I now have comprehensive content from authoritative textbooks (Costanzo Physiology, Guyton & Hall, Ganong's Review). Let me compile the complete respiratory physiology notes.
🫁 Respiratory System - Complete Physiology Notes (Exam Focused)
Sources: Costanzo Physiology 7th Ed., Guyton & Hall Medical Physiology, Ganong's Review of Medical Physiology
📌 OVERVIEW
The respiratory system has two main goals:
- Deliver O₂ from the atmosphere to the tissues
- Remove CO₂ from the tissues to the atmosphere
At rest: 12-15 breaths/min × ~500 mL = 6-8 L/min inspired air. O₂ uptake = 250 mL/min; CO₂ output = 200 mL/min.
1. LUNG VOLUMES AND CAPACITIES
🔑 Four Basic Volumes (measured by spirometry)
| Volume | Abbreviation | Normal Value | Description |
|---|
| Tidal Volume | TV/Vt | 500 mL | Air moved per normal breath |
| Inspiratory Reserve Volume | IRV | 3000 mL | Extra air inspired above TV |
| Expiratory Reserve Volume | ERV | 1200 mL | Extra air expired below TV |
| Residual Volume | RV | 1200 mL | Air remaining after maximal expiration |
⚠️ Exam Tip: RV cannot be measured by spirometry (cannot be exhaled). Lung capacities that include RV (FRC, TLC) also cannot be directly measured by spirometry.
🔑 Four Capacities (each = sum of 2+ volumes)
| Capacity | Formula | Normal Value |
|---|
| Inspiratory Capacity (IC) | TV + IRV | 3500 mL |
| Functional Residual Capacity (FRC) | ERV + RV | 2400 mL |
| Vital Capacity (VC) | IC + ERV | 4700 mL |
| Total Lung Capacity (TLC) | VC + RV | 5900 mL |
FRC = equilibrium volume of the lungs after a normal tidal expiration. It is the balance point between lung elastic recoil (inward) and chest wall recoil (outward).
Measuring FRC (RV-containing volumes)
- Helium dilution: closed-circuit, measures communicating lung spaces
- Body plethysmography (gold standard): measures total thoracic gas volume including trapped gas
2. MECHANICS OF BREATHING
Pressures in the Respiratory System
| Pressure | Normal Value | Significance |
|---|
| Intra-alveolar (Palv) | 0 (atmospheric) at rest | Drives air in/out when it changes |
| Intrapleural (Ppl) | -5 cmH₂O at rest | Always negative (sub-atmospheric); keeps lungs expanded |
| Transpulmonary (PL) | +5 cmH₂O | = Palv - Ppl; keeps lungs open against elastic recoil |
Inspiration: Diaphragm contracts → thoracic volume ↑ → Ppl becomes more negative → alveolar pressure drops below atmospheric → air flows IN.
Expiration (at rest): Passive - elastic recoil of lung forces air out.
Compliance
Compliance = ΔVolume / ΔPressure
- High compliance = easy to stretch (emphysema - destruction of elastic tissue)
- Low compliance = stiff lungs (pulmonary fibrosis, pulmonary edema, infant RDS)
Hysteresis: The inflation and deflation limbs of the pressure-volume loop follow different paths. This occurs because surface tension forces differ during inspiration vs. expiration (related to surfactant action).
Surfactant
- Produced by Type II alveolar cells (pneumocytes)
- Composition: mostly dipalmitoylphosphatidylcholine (DPPC)
- Function: Reduces surface tension of the alveolar air-liquid interface → prevents alveolar collapse (atelectasis)
- La Place's Law: P = 2T/r (pressure inside a bubble = 2 × tension / radius)
- Without surfactant, small alveoli (small r) would have higher internal pressure and would empty into larger ones → collapse
- Surfactant lowers T proportionally more in small alveoli → stabilizes them
⚠️ Exam Tip: Deficiency in premature neonates → Infant Respiratory Distress Syndrome (IRDS/RDS) - lungs are stiff, compliance is low, atelectasis occurs.
3. VENTILATION & DEAD SPACE
Minute Ventilation
V̇E = TV × Respiratory Rate = 500 mL × 12 = 6000 mL/min
Dead Space (ventilated but no gas exchange)
| Type | Description | Normal |
|---|
| Anatomical dead space | Conducting airways (nose → bronchioles) | ~150 mL |
| Alveolar dead space | Alveoli ventilated but not perfused | ~0 mL (healthy) |
| Physiological dead space | Anatomical + Alveolar | ~150 mL (healthy) |
Bohr Equation (calculates physiological dead space):
VD = VT × (PaCO₂ - PECO₂) / PaCO₂
Alveolar Ventilation
V̇A = (VT - VD) × RR
The Alveolar Ventilation Equation (most important relationship):
PACO₂ = (V̇CO₂ × K) / V̇A
- If V̇A doubles → PACO₂ halves (inverse hyperbolic relationship)
- CO₂ crosses the blood-alveoli barrier perfectly → PACO₂ ≈ PaCO₂ = 40 mmHg
4. GAS EXCHANGE & DIFFUSION
Partial Pressures of Gases (at sea level, 760 mmHg)
| Location | PO₂ | PCO₂ |
|---|
| Dry inspired air | 159 mmHg | 0.3 mmHg |
| Humidified tracheal air | 149 mmHg | 0.3 mmHg |
| Alveolar air (PAO₂) | 100 mmHg | 40 mmHg |
| Systemic arterial blood | 95 mmHg | 40 mmHg |
| Mixed venous blood | 40 mmHg | 45 mmHg |
| Tissues | 20-40 mmHg | 45-50 mmHg |
Alveolar Gas Equation:
PAO₂ = PIO₂ - (PACO₂ / RQ) where RQ (respiratory quotient) = 0.8
Factors Affecting Diffusion (Fick's Law)
Rate of diffusion ∝ (Area × ΔP × Solubility) / (Distance × √MW)
- Area: ↑ in exercise (more capillaries recruited); ↓ in emphysema, fibrosis
- Partial pressure gradient: driving force
- Thickness of membrane: ↑ in pulmonary edema, fibrosis → impairs diffusion
- Solubility: CO₂ is 20× more soluble than O₂ (CO₂ diffuses much more easily)
- Diffusion-limited vs. Perfusion-limited gases:
- O₂ is normally perfusion-limited (equilibrates before blood leaves capillary)
- O₂ becomes diffusion-limited in disease or at high altitude
- CO₂ is always perfusion-limited (highly soluble)
- CO is always diffusion-limited (binds hemoglobin so fast, gradient is never lost)
A-a Gradient (Alveolar-arterial O₂ difference)
Normal: <15 mmHg (young), increases with age
- Causes of elevated A-a gradient: V/Q mismatch, diffusion impairment, shunt
- Normal A-a gradient in hypoxemia → suggests hypoventilation (e.g., opioids, CNS depression)
5. OXYGEN TRANSPORT
Oxygen in Blood - Two Forms
| Form | Amount | Details |
|---|
| Dissolved in plasma | 0.3 mL O₂/100 mL blood (3%) | Very small amount |
| Bound to hemoglobin | ~20 mL O₂/100 mL blood (97%) | Main transport form |
Hemoglobin (Hb)
- Each Hb molecule has 4 heme groups, each binds 1 O₂
- 15 g Hb/100 mL blood × 1.34 mL O₂/g Hb = 20.1 mL O₂/100 mL (20 vol%)
- O₂ saturation (SpO₂): % of Hb binding sites carrying O₂
Oxygen-Hemoglobin Dissociation Curve
The classic sigmoid (S-shaped) curve:
| Point | PO₂ | SpO₂ | Clinical meaning |
|---|
| Arterial blood (lungs) | 95 mmHg | 97% | Near-fully saturated |
| Venous blood (tissues) | 40 mmHg | 75% | ~25% O₂ unloaded |
| P50 (normal) | 26.5 mmHg | 50% | PO₂ at half-saturation |
Right Shift of Dissociation Curve (↓ affinity, ↑ O₂ delivery to tissues)
Mnemonic: CADET - Right shift = unloading
- ↑ CO₂ (Bohr effect)
- ↑ Acid (↓ pH)
- ↑ 2,3-DPG (exercise, chronic hypoxia, anemia)
- ↑ Exercise/Temperature
Left Shift (↑ affinity, less O₂ released)
- ↓ CO₂, ↑ pH, ↓ temperature, ↓ 2,3-DPG
- Fetal hemoglobin (HbF): higher O₂ affinity than HbA (extracts O₂ from maternal blood)
- CO poisoning: COHb left-shifts + blocks binding sites
⚠️ Bohr Effect: ↑ PCO₂ / ↓ pH → RIGHT shift → more O₂ released at tissues
6. CO₂ TRANSPORT
CO₂ is transported in three forms:
| Form | Percentage | Mechanism |
|---|
| As bicarbonate (HCO₃⁻) | 70% | CO₂ + H₂O ↔ H₂CO₃ ↔ H⁺ + HCO₃⁻ (carbonic anhydrase in RBCs) |
| As carbaminohemoglobin | 20-23% | CO₂ binds amine groups of Hb directly |
| Dissolved in plasma | 7-10% | Small but physiologically important |
Chloride Shift (Hamburger Shift): HCO₃⁻ formed in RBCs exits into plasma in exchange for Cl⁻ entering the RBC via Band-3 protein (anion exchanger).
Haldane Effect: Oxygenation of Hb decreases its affinity for CO₂ (and vice versa). In the tissues, deoxygenated Hb picks up more CO₂ (facilitating CO₂ transport). In the lungs, oxygenation of Hb releases CO₂ for excretion.
7. VENTILATION-PERFUSION (V/Q) RELATIONSHIPS
Normal V/Q ratio = 0.8 (V̇A = 4 L/min; Q̇ = 5 L/min)
Regional V/Q Differences (upright person)
| Zone | Location | Blood flow | Ventilation | V/Q ratio |
|---|
| Apex (top) | Zone 1 | Least (gravity) | Highest relative | >0.8 (dead space-like) |
| Base (bottom) | Zone 3 | Greatest | Less relative | <0.8 (shunt-like) |
Hypoxic Pulmonary Vasoconstriction (HPV): Low alveolar O₂ → vasoconstriction of local pulmonary arterioles → diverts blood away from poorly ventilated areas → optimizes V/Q matching. (Opposite to systemic circulation!)
Clinical Extremes of V/Q
| Scenario | V/Q | Alveolar air | Arterial blood | Example |
|---|
| Perfect match | 0.8 | PO₂=100, PCO₂=40 | Normal | Normal |
| Shunt (airway obstruction) | 0 (no ventilation) | Like mixed venous blood | PaO₂=40, PaCO₂=46 | Atelectasis, pneumonia |
| Dead space (PE) | ∞ (no perfusion) | Like inspired air | No exchange | Pulmonary embolism |
⚠️ Key clinical point: V/Q mismatch is the most common cause of hypoxemia in clinical practice. Shunt does NOT correct with 100% O₂; dead space does.
8. CONTROL OF BREATHING
Brain Stem Centers
| Center | Location | Function |
|---|
| Dorsal Respiratory Group (DRG) | Medulla (inspiratory center) | Controls basic rhythm of breathing; sends output via phrenic nerve to diaphragm |
| Ventral Respiratory Group (VRG) | Medulla (expiratory center) | Active during forced/exercise breathing |
| Pneumotaxic Center | Pons (upper) | Limits inspiration (switches off inspiration) → controls inspiratory duration |
| Apneustic Center | Pons (lower) | Prolongs inspiration; inhibited by pneumotaxic center |
Chemoreceptors
Central Chemoreceptors
- Location: medulla oblongata (ventral surface)
- Stimulus: CO₂ / H⁺ (indirectly via CO₂ crossing the blood-brain barrier → forms H⁺ in CSF)
- NOT directly sensitive to O₂
- Most powerful driver of ventilation under normal conditions
- CO₂ rises → ↑ H⁺ in CSF → ↑ ventilation
Peripheral Chemoreceptors
- Carotid bodies (at carotid bifurcation, CN IX) - primary for humans
- Aortic bodies (aortic arch, CN X) - less important
- Stimulated by: ↓ PaO₂ (< 60 mmHg), ↑ PaCO₂, ↓ pH
- Hypoxemia is sensed HERE (not in the medulla)
⚠️ Exam Tip: The peripheral chemoreceptors only significantly respond to PO₂ below 60 mmHg (steep part of the O₂-Hb curve). Above this, they contribute little to ventilatory drive.
Lung Receptors
| Receptor | Location | Stimulus | Response |
|---|
| Stretch receptors (slowly adapting) | Airway smooth muscle | Lung inflation | Inhibit inspiration (Hering-Breuer reflex) |
| Irritant receptors (rapidly adapting) | Airway epithelium | Smoke, dust, cold air | Cough, bronchoconstriction, hyperpnea |
| J receptors (juxtacapillary) | Alveolar walls | Pulmonary edema, PE | Rapid, shallow breathing, dyspnea |
Hering-Breuer Reflex: Inflation of lungs → stretch receptors activated → inhibit further inspiration (prevents over-inflation). Important in neonates; less important in adults at normal tidal volumes.
9. ACID-BASE AND RESPIRATION
| Condition | pH | PaCO₂ | HCO₃⁻ | Cause |
|---|
| Respiratory acidosis | ↓ | ↑ | ↑ (compensatory) | Hypoventilation |
| Respiratory alkalosis | ↑ | ↓ | ↓ (compensatory) | Hyperventilation |
| Metabolic acidosis | ↓ | ↓ (compensatory) | ↓ | Diarrhea, DKA, renal failure |
| Metabolic alkalosis | ↑ | ↑ (compensatory) | ↑ | Vomiting, diuretics |
Henderson-Hasselbalch Equation:
pH = 6.1 + log ([HCO₃⁻] / 0.03 × PCO₂)
Normal ABG: pH = 7.4, PaCO₂ = 40 mmHg, PaO₂ = 95 mmHg, HCO₃⁻ = 24 mEq/L
10. PULMONARY CIRCULATION
- Low pressure circuit: Normal pulmonary artery pressure = 25/10 mmHg (mean ~15 mmHg)
- Much lower resistance than systemic circulation
- Blood flow distribution: At the base of upright lungs (gravity) > apex
- Hypoxic vasoconstriction (unique to pulmonary): ↓ O₂ → vasoconstriction (opposite of systemic)
- Bronchial circulation: Supplies conducting airways; a small fraction of total pulmonary blood flow
Zones of the Lung (West Zones)
| Zone | Pressure relationship | Blood flow |
|---|
| Zone 1 (apex) | PA > Pa > Pv | None to minimal |
| Zone 2 (middle) | Pa > PA > Pv | Intermittent |
| Zone 3 (base) | Pa > Pv > PA | Continuous, largest |
PA = alveolar pressure; Pa = pulmonary arterial pressure; Pv = pulmonary venous pressure
11. SPECIAL TOPICS
Exercise Physiology
- Ventilation ↑ dramatically (can reach 100-150 L/min in athletes)
- V̇O₂ and V̇CO₂ both ↑
- Cardiac output ↑ → pulmonary blood flow ↑ → more capillary beds perfused → V/Q matching improves → physiological dead space ↓
- O₂-Hb curve shifts RIGHT (↑ CO₂, ↓ pH, ↑ temperature, ↑ 2,3-DPG)
- Ventilatory threshold (anaerobic threshold): point at which VCO₂ increases disproportionately to VO₂ (lactic acid buffering adds extra CO₂)
High Altitude
At high altitude (↓ barometric pressure → ↓ PiO₂ → ↓ PAO₂ → hypoxemia):
Adaptive responses:
- Hyperventilation (↑ VA → ↓ PACO₂ → ↑ PAO₂)
- Polycythemia (↑ EPO from kidneys → ↑ RBCs → ↑ O₂ carrying capacity)
- Right shift of O₂-Hb curve (↑ 2,3-DPG in RBCs - hours to days)
- Increased cardiac output (early)
- Pulmonary hypertension (hypoxic vasoconstriction of pulmonary vessels)
- Renal HCO₃⁻ excretion (compensates for respiratory alkalosis from hyperventilation - takes days)
⚠️ PO₂ at 18,000 ft = (380 - 47) × 0.21 = 70 mmHg (vs. 150 mmHg at sea level)
Chronic Hypoxia (COPD "Blue Bloaters")
Long-standing hypercapnia (↑ CO₂) → central chemoreceptors desensitize → ventilatory drive shifts to hypoxic drive (peripheral chemoreceptors). This is why supplemental O₂ in severe COPD can paradoxically reduce ventilatory drive.
12. KEY SPIROMETRY VALUES (FEV₁/FVC)
| Pattern | FEV₁ | FVC | FEV₁/FVC | Examples |
|---|
| Normal | Normal | Normal | >0.75-0.80 | Healthy |
| Obstructive | ↓↓ | Normal or ↓ | <0.70 | Asthma, COPD |
| Restrictive | ↓ | ↓↓ | Normal or ↑ | Fibrosis, obesity, scoliosis |
- DLCO (diffusing capacity for CO): ↓ in emphysema & fibrosis; normal in asthma; ↑ in polycythemia, left-to-right shunt
- Flow-volume loop: Essential for identifying obstruction (concave expiratory limb = obstructive; reduced loop size = restrictive)
🔑 HIGH-YIELD SUMMARY TABLE
| Topic | Key Number/Fact |
|---|
| Normal PaO₂ | 95 mmHg |
| Normal PaCO₂ | 40 mmHg |
| Normal pH | 7.4 |
| Normal SpO₂ | 97-99% |
| P50 of Hb | 26.5 mmHg |
| FRC = ERV + RV | 2400 mL |
| Tidal Volume | 500 mL |
| Anatomical dead space | 150 mL (1 mL/pound ideal body weight) |
| Normal V/Q ratio | 0.8 |
| Normal FEV₁/FVC | >0.75 |
| O₂ carried by Hb | 97% |
| CO₂ as bicarbonate | 70% |
| Hypoxic vasoconstriction PO₂ threshold | <60 mmHg (peripheral chemoreceptors) |
| Bohr effect | ↑CO₂/↓pH → RIGHT shift → more O₂ unloaded |
| Haldane effect | O₂ binding → CO₂ released from Hb |
| Surfactant made by | Type II pneumocytes |
🧠 MNEMONICS
- "CADET Face Right" = Right shift of Hb curve: CO₂↑, Acid↑, DPG↑, Exercise, Temperature↑
- "The LUNGS CAN'T measure RV" = RV, FRC, TLC cannot be measured by spirometry alone
- Obstructive = Obstruct flow = FEV₁/FVC ↓ | Restrictive = Restrict volume = FVC ↓
- "Peripheral chemorec = PO₂; Central chemorec = PCO₂ via H⁺"
- "Shunt → No correction with O₂; Dead space → Corrects with O₂"
All values from: Costanzo Physiology 7th Ed. | Guyton & Hall Medical Physiology 14th Ed. | Ganong's Review of Medical Physiology 26th Ed.