Respiration in extreme

condition
Dr Renu Yadav
Physiology
 Learning Objectives
At the end of the class students will be able to

 Define hypoxia
 List out the types of hypoxia and its effect
 Understand the altitude sickness
 Describe the effect of exercise on respiratory
mechanism
 Describe the mechanism of high-pressure effect
and deep-sea diving on respiratory system
 Hypoxia

Definition: Inadequate oxygenation of the blood.

Various causes leads to hypoxia-
Pulmonary disease
Venous-to-arterial shunts (“right-to-left” cardiac shunts)
Inadequate oxygen transport to the tissues by the blood
Inadequate tissue capability of using oxygen
 Types of Hypoxia

1.Hypoxic hypoxia

2.Anemic hypoxia

3.Stagnant hypoxia

4.Histotoxic hypoxia
 Hypoxic hypoxia

Altitude Barometric PO2 in air Breathing air

(ft/meters) Pressure (mm Hg) PO2 in alveoli
(mm Hg ) (mmHg)

0 (sea level) 760 (20%) 159 104 (104)

10,000 / 3048 523 ( 20%) 110 67 (77)

20,000 / 6096 349 (20%) 73 40 (53)

Partial pressure of oxygen decreases-Dissolved oxygen

 2. Anemic hypoxia
Anemic hypoxia
a. Anemia or abnormal hemoglobin
b. Carbon monoxide poisoning
c. Altered hemoglobin e.g. (methemoglobin)

PO2 – Normal , Saturation remains normal

decrease in oxygen carrying capacity of blood
T/t-blood transfusion, hyperbaric oxygen (100%), Bone marrow transplant
 Anemic Hypoxia

Oxygen transported at various hemoglobin concentration at 760 mmHg

pressure (Anemia)
Hemoglobin Po2 (mmHg) Oxygen transported (ml/100ml) of blood
g/100ml Saturation Volume of O2 Dissolved Total
(appro) By Hb form

15 100 100 15 x 0.3 20.4

1.34=20.1
10 100 100 10 x 0.3 13.7
1.34=13.4

5 100 100 5 x 1.34=6.7 0.3 7

 Anemic hypoxia….CO poisoning

• Carbonmonoxide poisoning……..
• Carbonmonoxide (average- 210 )times affinity towards
hemoglobin.
• Acts like sufficient Hb is not available for tissue oxygenation
• Curve shift to left, increases the affinity of O2 for Hb.
• Decreases the release of oxygen from available hemoglobin
• Release of oxygen from hemoglobin is very slow
• Hemoglobin saturated with oxygen is reduced but not the
PO2(normal)
• forms carbon-monoxy hemoglobin or carboxy hemoglobin
(COHb)- (bright red colour/cherry red colour)
 Anemic hypoxia

Content of O2 has been reduced

Hyperbaric oxygenation is useful in this condition.

 3. Stagnant hypoxia

Hypoxia due to sluggish blood flow &

Decrease perfusion to tissue

a)Heart failure
b)Shock
c)Vascular obstruction

PO2 and oxygen saturation remains normal

4. Histotoxic hypoxia
 Cyanosis

Cyanosis
• Hypoxic Hypoxia-cyanosis
• Anemia cyanosis

• Bluish discoloration of skin in presence of more than 5 g deoxygenated

hemoglobin/ 100 ml of blood

• Deoxygenated hemoglobin- blue

• Peripheral cyanosis – Stasis of blood in skin capillaries. –cold

• Sites –lips, nail beds, ear lobes, cheeks and mucous membrane of the oral cavity

• Severe anemics never suffer from Cyanosis (<5 gm/dl)normal 12-14 gm/dl
 Hypoxia and oxygen therapy

2. Anemic hypoxia Yes-mild and Yes

moderate anemia
No-Severe anemia
Pulmonary system in stressful condition
High altitude
 Immediate response of Respiratory System
At 3000m (∼10,000 ft) above sea level, the alveolar PO2 is about 60 mm Hg and
there is hypoxia and stimulation of the chemoreceptors under normal breathing
to cause increased ventilation.

As one ascends high altitude, alveolar PO2 fallsless rapidly and the alveolar
PCO2 declines faster because of the hyperventilation. The resultant fall in arterial
PCO2 produces respiratory alkalosis.

Number of compensatory mechanisms operate over a period of time to increase

altitude tolerance (acclimatization)
 Acclimatization to high altitude

PO2
 Acclimatization (high altitude)

1. Increased ventilation
2. Increased RBC and Hb con-, 20g/dl Hb, 20-30% BV.
3. Increased diffusing capacity-BV
4. Angiogenesis
5. Rt Ventricular muscle mass increased
6. Cellular acclimatization -↑ mitochondria
Acclimatized to high altitude
 Hypoxia
A) Acute effect (8,000 ft-rapid ascend)
1. drowsiness, lassitude, muscle &
mental fatigue
2. headache, nausea, euphoria
3. decreased mental proficiency,
judgement
3. twitchings, seizure
4. coma, death
 Acute Responses in high altitude
 This acute changes develops 8–24 hrs after arrival at altitude and
lasts for 4–8 days.
 It is characterized by headache, irritability, insomnia, breathlessness,
and nausea and vomiting.

 The low PO2 at high altitude causes systemic arteriolar dilataion, and
if cerebral autoregulation does not compensate this, there is an increase
in capillary pressure that favors increased transudation of fluid into
brain tissue.
 Two more serious syndromes that are associated with high-altitude illness:
high-altitude cerebraledema (HACE) and high-altitude pulmonaryedema
(HAPE).
 Acute Responses in high altitude
❖high-altitude cerebral edema, the capillary leakagein
mountain sickness progresses tofrank brain swelling,
with ataxia, disorientation, and in casescomaand
death due to herniation of the brain through the
tentorium.

❖High-altitude pulmonaryedema is a patchy edema of

the lungs that is related to the marked pulmonary
hypertension that develops at high altitude.
 Acute mountain sickness
1. Acute cerebral edema (HACE)
vasodilation(Hypoxia)

increased blood flow

increased hydrostatic pressure

fluid leak to cerebral tissues

cerebral symptoms develop

 Cont…

2. Acute pulmonary edema (HAPE)

vasoconstriction(Hypoxia)

blood flow to unconstricted area

high pressure leads fluid in tissues (hydrostatic pressure)

spreading of fluid in pulmonary tissues

pulmonary edema & hypertension

 Chronic mountain sickness
• Extreme polycythemia
• Pulmonary arterial pressure elevated
• Right side of the heart enlargement
• Peripheral arterial pressure fall
• Congestive heart failure
Monge’s Disease- Long term resident of high altitude
 Chronic mountain sickness
Excessively increased RBC pul vasoconstriction

• Viscosity increases pul hypertension

(congestive) rt sided heart failure

 Deep Sea Diving
In Fresh water every 10.4 m deep increase 1 atm pressure.
In Sea water every 10 m (33feet) deep increase 1 atm pressure.

Effects of high atm pressure

1. Volume ∞ 1/ atm pressure
2. Increase in atm pressure, increase the partial pressure of N 2, O2 & CO2 and equalize
the increase pressure on chest wall and abdomen.
Partial pressure of gaseous before & after decompression
 Deap sea
• Deap sea is a high pressure area; Thus inside the
sea divers have to inhale high pressure gas even if
it is through tank.
• Air inside the tank which is high pressure gas
enters the lung (require to counter balance the
outer pressure).
• The mixure of gas in tank is: 20% O2 , 80% N2
• There is no CO2
Partial pressure of gaseous before & after decompression
 Symptoms in deep sea
1. O2 toxicity

Nausea, twitching, irritability, disorientation, seizure, coma, death

Lung congestion, pulmonary edema

Excess of oxygen
 2. Nitrogen Narcosis

If a diver breaths compressed air, the increase pN2 can cause N2

narcosis, also known as “Rapture of the depths”.

At pressure 4-5 atm, 80% N2 produce definite Euphoria (joviality)

and at high atm pressure symptoms like alcohol intoxication.

N2 get dissolve in fatty tissues and in neuronal membrane and

reduce the excitability of the nerve

dissolve in body fluids

 Decompression Sickness
When the diver ascends from deep drive, N2 diffuse out from the
tissues in to the lungs along the partial pressure gradient.

N2 escapes from solutions and bubbles are formed in the tissues and
blood if the ascend is very rapid,

If the ascend is slow, there is no harmful effects on the body.

These bubbles in the tissues cause joint pain & neurological symptoms
like itching, paralysis, spinal cord damage & ultimately respiratory
failure.

It also known as “Caisson Disease” or “The Bends”.

 Decompression Sickness

Bubbles in blood (air embolism) in the pulmonary capillary cause

dyspnoea (also called chokes) and in coronary artery causes
myocardial damage.

Treatment: prompt recompression in a pressure chamber followed

by slow decompression.
The problem of N2 narcosis can be avoided by breathing mixture
of O2 & Helium..
 Decompression table prepared by US Navy
10 minutes at 50 feet depth
17 minutes at 40 feet depth
19 minutes at 30 feet depth
50 minutes at 20 feet depth
84 minutes at 10 feet depth
Note: This table is for a diver who is breathing at a depth of 190 feet
for 60 min.
SCUBA Diving

Developed by: Jacques

Cousteau in 1943

Basic Principle: to carry

compressed air (more
compressed air in less
volume/area)
S = Self
C = Contained
U = Underwater
B = Breathing
A = Apparatus
 2. Mechanical ventilator

Positive pressure Negative pressure

endotracheal intubation, tracheostomy tube

respiration is maintained
Resuscitator
• Pressures are adjusted so that the negative pressure that causes
inspiration falls to -10 to -20 cm H2O.

• and the positive pressure rises to 0 to +5 cmH2O.

• Not more than 30 mm Hg positive pressure (significant

reduction of venous return)
 Reference books required

• USMLE Step 1 Lecture notes (Kaplan medical physiology)-2021

• Ganong's Review of Medical Physiology 26th ed 2019

• Guyton and Hall Physiology 13th Ed 2016

• BRS Physiology (Linda S Costanza, 7th Edition)

• Understanding medical Physiology (Bijlani, 4th edition)

Practice Quizzes
A 54-year-old man sustains third degree burns in a house fire. His respiratory rate is 25/min, Hb =14
g/dL, arterial PO2 is 95 mm Hg, and arterial O2 saturation is 50%. The most likely causative factor of
his low oxygen saturation of Hb is…
a. Airway obstruction
b. Carbon monoxide poisoning
c. Cyanide poisoning
d. pulmonary edema
e. fever
Which points on the figure represent arterial blood in a severely anemic person who has 6 gm/dl of hemoglobin and
breathing at sea level in normal atmospheric air pressure (760 mmHg)?
Top graph Bottom graph
a) D D
b) E E
c) D E
d) E D
e) D B
A 17-year-old male places a paper bag over his mouth and
breathes in and out of the bag. As he continues to breathe
into this bag, his rate of breathing continue to increase.
Which of the following is primarily responsible for the
increased ventilation?
A) Increased alveolar Po2
B) *Increased alveolar Pco2
C) Decreased arterial Pco2
D) Increased pH
E) Increased HCO3
At a depth of 66 feet in sea water, air breathed from a scuba tank as
air enters the diver's lungs is how much denser than air breathed at
sea level?
a. same density
b. Twice as dense
c. Three times
d. Four times
e. Depends on the air left in the tank
N2 escapes from solutions and bubbles are formed in the tissues and blood if
ascent is very rapid, is called as;
a. Rapture in depth
b. N2 narcosis
c. Alcohol intoxication
d. Compression sickness
e. Decompression sickness
Thank u Answers: B, D, B, C, E