Pathology of Respiration

24 March 2015
 Respiratory failure
Lungs are unable to provide:
an adequate supply of O2
and/or to remove CO2 efficiently

In arterial blood: pO2 - 95 - 100 mm Hg

pCO2 - 43 - 46 mm Hg

Classification:
 Acute failure – minutes to hours (bronchial asthma
attack, acute pneumonia).
 Subacute –days to weeks (pneumonia, bronchitis).
 Chronic – months to years (emphysema of lungs,
disseminated lung fibrosis).
Respiratory failure classification
Type 1 – hypoxia without hypercapnia
 low oxygen in the air

 ventilation/perfusion mismatch

 pnemonia, lung edema

 gases diffusion disturbances

Type 2 – hypoxia with hypercapnia

 reduced breathing effort;

 increased resistance to breathing (asthma);

  in the area of the lung that is not available

for gas exchange (COPD,emphysema).
Reasons of respiratory failure
Disturbances of lungs function
 ventilation,

 perfusion,

 alveolar ventilation-perfusion ratio,

 gases diffusion through alveolar-

capillary membrane.
Reasons of respiratory failure
Extra-lungs disturbances of:
 nervous regulation of respiration (brain
stroke or trauma, tumour, drugs overdose),
 respiratory muscles function (myasthenia,
poliomyelitis),
 chest respiratory movements (fracture of
ribs or spinal column, chest wall deformities),
 blood circulation in the lungs (cardiac
failure, severe anemia).
 Disturbances of alveolar
ventilation
MIXED
OBSTRUCTIVE RESTRICTIVE

VIOLATIONS OF RESPIRATION

Alveolar hypoventilation

EXTRA-LUNGS REASONS

depression disorders of thoracic cage

of respiratory center respiratory muscles disorders
 Obstructive lung disorders
Obstruction of the upper respiratory ways:
 embolism (foreign substance),
 compression (tumour),
 spasm of larynx (neurogenous, inflammatory).

Decreased permeability of the lower respiratory

ways:
 increased bronchial muscles tonus (bronchospasm),
 embolism of bronchi:
 edema of bronchial mucous membranes
 hypersecretion of mucus by bronchial glands
(inflammation, asthma).
Violation of bronchi flexibility
 lungs emphysema.
 Restrictive lung diseases
Disturbances of lung’s expansion
Pulmonary reasons:
  area of lung (resection, tuberculosis)
  elasticity of lung tissue
(pneumosclerosis, lung fibrosis,
sarcoidosis)
 Alveolar or interstitial lung edema

 Acute respiratory distress syndrome

(ARDS).
 Deficiency of surfactant (premature
infants)
 Restrictive lung diseases
Extrapulmonary reasons:
 Changes in pleura and mediastinum
(exudative pleurisy, pneumothorax,
cardiomegaly).
 Changes of thorax and respiratory
muscles (deformation of thorax,
paralysis of diaphragm).
 Changes of abdominal cavity organs
(hepatomegaly, ascites).
 Disorders of perfusion
Hyperperfusion
 Local - pneumonia.
 Total - stress reaction or asphyxia.

Erythrocytes have less time for normal

gas exchange hypoxemia.
 The diffusion of CO2– not altered.
 Type 1 respiratory failure
 Disorders of perfusion
Hypoperfusion
 heart pathology (heart failure, valvular
disorders)
 vessels pathology (atherosclerosis,
thromboembolism).
Pathogenetic mechanisms:
 low cardiac output
 opening of shunts between arteries and
veins of pulmonary circulation
 obstruction of lung vessels
 Type 1 respiratory failure
 Mismatching of ventilation and
perfusion
 Ventilation/perfusion ratio differs in lungs
physiologically
 Reason of pathological mismatch:
 Problems with ventilation
 Collapsed airways (emphysema)
 Bronchoconstriction (COPD, asthma)
 Inflammation (bronchitis, pneumonia)
 Lung diseases (fibrosis, pulmonary vascular
congestion)
 Low oxygen in alveoli  perfusion
 Carbon dioxide is increased
 Type 2 respiratory failure
 Diffusion impairment
  distance for diffusion (lung edema,
inflammation, fibrous changes).
  permeability of the alveolar
capillary membrane ( ARDS,
pulmonary edema, emphysema).
Type 1 respiratory failure
 Manifestations
of respiratory failure
 Hypoxemia - pO2 < 50 mm Hg
 Hypercapnia - pCO2 >50 mm Hg.
Hypoxemia Manifestations.
 resulting from impaired function of
vital centers
 resulting from activation of
compensatory mechanisms
 Hypoxemia Manifestations
 impairment of mental performance
and behavior
 peripheral vasoconstriction
 diaphoresis (sweating)
 central or peripheral cyanosis
  blood pressure
  heart rate, hyperventilation
Hypercapnia Manifestations
  pH and respiratory acidosis
 compensated by renal bicarbonate
retention
 vasodilating effect of CO2 :
 increase in cerebral blood flow and cerebral
spinal fluid pressure (headache);
 hyperemic conjunctivae;
 warm and flushed skin.
 Nervous system effects of CO2
-progressive somnolence, disorientation,
coma.
 Acute respiratory distress
syndrome (ARDS)
Causes
 aspiration of gastric contents, toxic
gases
 trauma (with or without fat emboli),

 sepsis

 acute pancreatitis

 pneumonia, alveolar bleedings

 reactions to drugs and toxins.

 ARDS pathogenesis and clinics
• Injuryand 
permeability of the
alveolar-capillary
membrane lung
edema
•Neutrophils - inactivate
surfactant and  damage
of the alveolar cells.
• lung becomes harder
ARDS clinical manifestation
 rapid onset, 12 to 18 hours after
initial event
  in respiratory rate
 signs of respiratory failure
 diffuse bilateral consolidation of the
lung tissue
 marked hypoxemia
 multiple organ failure (kidneys, GIT,
CNS, and cardiovascular system)
 Pulmonary edema
 cardiogenic (left-sided heart failure)
Non-cardiogenic pulmonary edema

 alveolar walls damage by toxic compounds

(Phosporus), proteolytic enzymes (a.
pancreatitis)
 microbe affection of lungs (local – bacterial
pneumonia, systemic – sepsis)
 quick intravenous infusion of big amount of
fluid (physiological solution, blood substitutes)
– due to ”blood dilution”
 anaphylactic allergic reaction – due to BAS
influence
  catecholamines – generalized
vasoconstriction lung hypertension and
blood congestion.
 Pulmonary edema symptoms
Acute Chronic
 nocturia (frequent
 difficult breathing
urination at night)
 coughing up blood  orthopnea (inability to
 excessive sweating lie down flat due to
 anxiety breathlessness)
 paroxysmal nocturnal
 pale skin
dyspnea (episodes of
 coma and death severe sudden
from acute breathlessness at night).
hypoxia
 Pulmonary edema
symptoms
Chronic pulmonary edema:
 nocturia (frequent
urination at night),
 ankle edema

 orthopnea (inability to lie

down flat due to
breathlessness)
 paroxysmal nocturnal
dyspnea (episodes of
severe sudden
breathlessness at night).
 Short breath (dyspnea)
 violation of frequency, depth, rhythm
of breath
 changes of respiratory movements
 “air hunger”
 Dyspnea classification
According to pathogenesis
 Cerebral dyspnoea (central) - violation of
respiratory center or cortex function.
 Lung dyspnoea– diseases of lungs,
bronchi, pleura.
 Cardiac dyspnoea - heart diseases with
cardiac failure.
 Hematic dyspnoea -  in blood oxygen
capacity (anaemia), acidosis.
 Dyspnea classification
Due to dyspnea character:
 Hyperpnea
 Tachypnea
 Bradypnea
 Apnoea
Due to altered phase of respiration:
 Inspiratory dyspnea
 Expiratory dyspnea
 Mixed dyspnoea
 Dyspnoe mechanisms
 Humoral – increase of pCO2 and
decrease of pO2, shift of pH to the
acid side.
 Neuroregulatory – violated
impulsion from chemoreceptors
and baroreceptors.
 Central – dysfunction of respiratory
center, or cortex neurons.
 Cerebral dyspnea
 Excitation of respiratory centre - frequent
deep respiration.
 Inhibition of respiratory center - frequent
superficial respiration.
 Periodic breathing appears at brain
affections by:
 trauma
 stroke
 tumour
 inflammation
 endogenous and exogenous intoxications
 Cheyne-Stokes respiration
 failure of the respiratory center
 bigger concentrations of CO2 are needed
for the excitation of respiratory centre.
 causes: strokes, head injuries or brain
tumors, congestive heart failure, morphine
administration.
 Bioth's respirations
 cluster respiration.
 damage to the medulla oblongata
(stroke, trauma, compression).
 poor prognosis.
 Kussmaul breathing
 The cause of Kussmaul breathing is
respiratory compensation for a
metabolic acidosis (ketoacidosis,
uremia).
 low pCO2 due to deep breathing.
 Agonal respiration
 shallow, irregular inspirations followed by
irregular pauses.

 gasping, labored breathing, accompanied

by strange vocalizations and myoclonus.
 Causes
 cerebral ischemia
 extreme hypoxia or anoxia
 Other dyspnea types
 Lungs dyspnea
 Embolism or narrowing of upper respiratory
ways (stenotic breath)
 bronchial asthma (expiratory dyspnoea)
 pneumonia, pleurisy
 Cardiac dyspnea
 cardiac failure, heart valves pathology
 Hematic dyspnea
 anemia
 metHb formation (CO poisoning).
 Asphyxia
a condition of severe deficiency of oxygen
supply with severe disorders of nervous
system, respiration and circulation of the
blood
Causes:
Insufficient environmental oxygen:
 Inhalation of non-oxygen gases (helium,
CO2 fire).
 Loss of aircraft cabin pressure;
 Exposure to a vacuum.
 Asphyxia causes
Physical obstruction of air flow
 Compressive asphyxia
 Drowning (water or other liquids).
 Choking due to object in the airways or inhalation
of vomit.
 Narrowing of the airways (anaphylaxis, asthma).

Disturbances of respiration
 CO inhalation.
 Pulmonary agents (phosgene),blood agents
(cyanide).
 Drug overdose.
 Asphyxia stages
 1st stage -  frequency of breathing, BP and
heart rate - phase of inspiratory dyspnea –
compensation of acute hypoxia.
 2nd stage- more rare respiration with enforced
expiration, slowing-down of heart rate and BP -
phase of expiratory dyspnea.
 3rd stage - temporary (from several seconds to
several minutes) stopping of breathing
(preterminal pause); low BP, reflexes, loss of
consciousness.
 4th stage - terminal or agonal breathing (rare
deep convulsive «sighs» during several
minutes); respiratory centre paralysis and
death.
 Lung volumes
measurement

 Forced expiratory volume in one second

(FEV1) is the 1-s-volume exhaled with forceful
pressure from maximal inspiration.
 Forced vital capacity (FVC) is the maximum
amount of air forcibly expired after maximum
inspiration.
 Total lung capacity (TLC) is the total volume of
air in the lungs, when they are maximally
inflated.
 Residual volume (RV) the volume of air left in
the lungs after a maximal expiration.
 Difference between obstructive,
restrictive and mixed disorders
Measure Obstructive Restrictive Mixed
Disorders Disorders Disorders
FEV1/FVC  Normal or  

FEV1  Normal   

FVC Normal or   

TLC Normal or   

RV Normal or   Normal 
