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Pulmonary
Circulation
Jason Ryan, MD, MPH
Pulmonary Circulation
• Low pressure system
• Systemic: 120/80
• Pulmonary artery: 24/12
• Walls of pulmonary artery very thin
• Little smooth muscle AfraTafreeh.com
• Low resistance to flow
• Very distensible (compliant)
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Blood Oxygen Content

• Systemic circulation
• ↓ O2 level (PaO2) leads to vasodilation (↑blood flow)
• Pulmonary circulation
• ↓ O2 level (PaO2) leads to vasoconstriction (↓blood flow)
• “Hypoxic vasoconstriction”
• Shunts blood away from poorly ventilated areas
• More blood to well ventilated areas
• Key for fetal circulation
• Low O2 constricts pulmonary arteries in womb
• At birth, arteries receive O2 and dilate
Blood O2 Content
Lungs
Blood Flow

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Systemic

PaO2
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Gas Exchange

Inspired Air
(humidified, tracheal)
PO2 150mmHg Alveoli
PCO2 0 mmHg PAO2 100 mmHg
PACO2 40 mmHg
O2 CO2

Venous Blood Arterial Blood

PvO2 40mmHg PaO2 90mmHg
PvCO2 46mmHg PaCO2 40mmHg
Gas Exchange
• Gasses classified by limiting factor for gas transfer
• Perfusion limited
• Gas transport limited by perfusion (blood flow)
• More blood flow → more uptake of gas
Venous blood
• Diffusion limited AfraTafreeh.com
• Gas transport limited by diffusion
Delivered to lung
(perfusion)

Gas diffusion

Equilibrium with alveoli

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Gas Exchange
N2O
PA
N2O: Perfusion limited
CO: Diffusion limited
Partial Pressure

CO

Length along capillary

Gas Exchange: Oxygen
100 Normal
Healthy Lung Perfusion limited
Partial Pressure

Disease
Fibrosis Diffusion limited
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40

Length along capillary

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Gas Exchange: Oxygen

High Altitude
Partial Pressure

Hypoxemia
60

40

Length along capillary

Gas Exchange: Carbon Dioxide
Partial Pressure

Normally perfusion limited

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40

Length along capillary

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DLCO
Diffusing capacity of carbon monoxide

• Measures ability of lungs to transfer gas

• Patient inhales small amount (not dangerous) CO
• CO uptake is diffusion limited
• Amount taken up ≈ diffusion capacity of lungs
• Machine measures CO exhaled
• Normal = 75 – 140 % predicted
• Severe disease <40% predicted
Low DLCO Disorders
• Emphysema
• Destruction of alveoli
• Decreased surface area
• Fibrosis or pulmonary edema
• Diffusion distance (thickness) increases
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Resistance to Blood Flow

Pulmonary Vascular Resistance

• Two vessels types:

• Alveolar: capillaries
• Extra-alveolar: arteries and veins
• Increased lung volumes:
• Crushes alveolar vessels → high resistance
• Pulls extra-alveolar vessels open

Artery Capillary Vein

Pulmonary Vascular Resistance
Resistance to blood flow

Pulmonary Exhale Inhale

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Vascular
Resistance

FRC
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Pulmonary Hypertension
• Normal PA pressure
• 24/12
• Mean 10-14mmHg
• Pulmonary hypertension
• Mean pressure >25mmHg
• Loud P2 = pulmonary hypertension
• “Accentuated” or “loud” second heart sound
• Left upper sternal border
Pulmonary Hypertension
• Main symptom is dyspnea
• Untreated can lead to “cor pulmonale”
• Chronic high pressure in right ventricle
• Right ventricle hypertrophies
• Eventually dilates and fails
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• Jugular venous distension
• Lower extremity edema
• Hepatomegaly
• Death from heart failure or arrhythmia
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Pulmonary Hypertension
• Gold standard diagnosis: right heart catheterization
• Non-invasive diagnosis by echocardiography
• Estimate PA pressure
• Visualize right heart structures
Pulmonary Hypertension
• Arteriosclerosis
• Thickening of arterial walls
• Proliferation smooth muscle cells
• Thickening media
• Narrowing of the lumenAfraTafreeh.com

Medial Hypertrophy Normal

Slideshare/Public Domain
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Pulmonary Hypertension
High PVR
“Pulmonary Arterial HTN”
Primary or Secondary

PPA = CO * PVR + PLA

High LA Pressure
Most common cause PHTN
“Pulmonary Venous HTN”
Heart Failure
Valve Disease
Left Heart Disease
Pulmonary Venous Hypertension

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O2 CO2
Pulmonary Artery Pulmonary Vein
PA: 25/12 mmHg 5 mmHg

Left Atrium
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Left Heart Disease

• Most common cause of pulmonary hypertension
• “Pulmonary venous hypertension”
• Any cause of high left atrial pressure
• Heart failure
• Mitral stenosis
• Mitral regurgitation
High PVR
Pulmonary Arterial Hypertension

• Hypoxemia → vasoconstriction
• COPD, other chronic lung diseases
• Sleep apnea or high altitude (chronic hypoxia)
• Chronic pulmonary emboli
• Decreased area for blood flow
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Blood Vessel
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PAH
Pulmonary Arterial Hypertension

• High pulmonary vascular resistance

• No chronic lung disease or thrombosis
• Key associations:
• Connective tissue disease (scleroderma)
• Human immunodeficiency virus
• Congenital heart disease (shunts)
• Schistosomiasis
• Drugs (amphetamines, cocaine)
Idiopathic PAH
• Rare disease
• Classically affects young women
• High pulmonary vascular resistance
• Increased activity vasoconstrictors
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• Endothelin
• Decreased activity vasodilators
• Nitric oxide
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Plexiform Lesions
• Unique to idiopathic PAH
• Endothelial proliferation forms multiple lumens
• Small arteries branch points from medium arteries

Yale Rosen/Flikr
BMPR2 gene mutations
• Bone morphogenetic protein receptor type II
• Inhibits smooth muscle proliferation
• Mutations → abnormal growth (endothelium, smooth muscle)
• Up to 25% of idiopathic cases
• Up to 80% familial cases
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PAH Treatments
• All lower PVR
• Epoprostenol: Prostacyclin (IV)
• PGI2
• Potent vasodilator
• Bosentan:
• Antagonist endothelin-1 receptors (PO)
• Sildenafil:
• Inhibits PDE-5 in smooth muscle of lungs (PO)