Fisiologi Batuk

Ikhlas Muhammad Jenie

Central nervous system

Afferent fibers

Efferent fibers

Receptor

Effector

Reflex arc

Physiologic mechanism to maintain the tracheobronchila tree

1. Respiratory movement (passive or active) 2. The secretion from the bronchial glands 3. The ciliary activity of the epithelium lining the trachea and bronchi 4. The cough reflex or the act of coughing

Reseptor Batuk

Mekanoreseptor

Chemoreseptor

Intrapulmoner

Ekstrapulmoner

Slowly adapting receptor (SAR)

Rapidly adapting receptor (RAR)

Mekanoreseptor
Low threshold mechanoreceptor Activated by one or more mechanical stimuli Generally do not respond directly to chemical stimuli, unless the stimulus acts upon airway structural cells to result in mechanical distortion

SAR and RAR

Originate in the nodose ganglia of the vagus nerve Terminate in the intrapulmonary airways and lung parenchyma Conduct AP in the A-range (10-20 m/s)

SAR and RAR

Sensitive to:
Lung inflation (changes in lung volumes) Bronchospasm (contraction of the smooth muscle cells) Airway wall oedema

SAR
Display slowly adaptation --- a slow reduction in the number of action potential Active during tidal inspiration, peaking just prior to the initiation of expiration Involved in the Hering-Breuer reflex, which terminates inspiration and initiates expiration when the lungs are adequately inflated Antagonize cholinergic drive to the airway smooth muscle, resulting in a reduction in airway tone

RAR
Display rapidly adaptation --- a rapid reduction in the number of action potential during sustained lung inflation Active during both inflation and deflation of the lungs (including lung collapse) Evokes tachypnea and airway smooth muscle contraction (bronchospasm)

Extrapulmonary low threshold mechanoreceptors

Sensitive to punctate mechanical stimuli (such as touch) Insensitive to:
Physiologically-relevant tissue stretching Changes in luminal pressure Airway smooth muscle contraction

Slower conduction velocity (5 m/sec) in the range of A-nerve fiber

Extrapulmonary low threshold mechanoreceptors

Originate also from the nodose ganglia of the vagus nerve Located in the extrapulmonary airways:
Larynx Trachea Large bronchi

May not be activated during normal breathing

Chemoreceptors
Generally quiescent in the normal airways, becoming recruited during airways inflammation or irritation Derived from both the nodose and jugular vagal ganglia, as well as from the dorsal root ganglia conduct action potentials in the C and A-fiber range Sometime, it is called high threshold mechanoreceptors

Afferent fibers of coughing reflex

From the receptors in the pharynx, the impulse is propagated along the afferent fibers of the glossopharyngeal nerve (the IXth cranial nerve) From the receptors in the larynx, trachea, and larger bronchi, the impulse is propagated along the afferent fibers of the vagus (the xth cranial nerve) [and also through n.laryngeus superior] The ascending impulse is to reach the nucleus of tractus solitarius (NTS)

Cough Center
Medulla oblongata (brain stem) near the respiratory center Receptors in MO:
Opioid receptors 5-hydroxytryptamine receptors (5HT1A) GABA receptors NMDA antagonist (N-methyl-D-asparate)

Efferent fibers of coughing reflex

The descending fibers arising from NTS to the spinal primary motor neurons and n.laryngeus recurrence.

Effectors
Laryngeal muscles Diaphragm The intercostal muscles The abdominal muscles

The action of cough

The air is inspired (2.5 L) The epiglottis is closed, and the vocal cords shut tightly to entrap the air within the lungs The abdominal muscle contract forcefully, pushing against the diaphragm, while other expiratory muscle contract forcefully the pressure in the lungs > 100 mmHg

The action of cough (2)

The vocal cords and epiglottis suddenly opened widely, so that the air under pressure in the lungs explodes outward (velocity 75 100 miles/ hour) The rapidly moving air usually carries with it any foreign matter that is present in the bronchi or trachea

The act of cough

Deep inspiration Glottis is closed Forced expiratory effort against the closed glottis Raised intrathoracic & intraabdominal pressure Glottis is suddenly opened A drop in intralaryngeal pressure Increased air flow (axial & radial) Brief violent rush of air out of trachea (800 km/h)

Sites for eliciting cough

The origins of cough are part of respiratory tract:
Pharynx Larynx (the endings of n.laryngeal superior) Trachea (at the bifurcation or carina) Segmental bronchi Others:
External ear Pleura Esophagus Abdominal organs

Stimulus for cough

Abnormal secretion within respiratory tract Edema or ulceration of respiratory mucous membrane Irritation produced by foreign bodies Pressure from outside of respiratory tract (mediastinal tumor, aortic aneurysms, Hodgkins disease) Pressure upon the recurrent laryngeal nerve Irritation of the pleural surface (pleurisy, effusion)

Clinical cough
Acute and chronic non-asthmathic cough Postnasal drip syndrome Asthma Gastro-esophageal reflux Chronic bronchitis Angiotensin-converting enzyme inhibitors (ACE inhibitors)

Clinical cough (2)

Others:
Pharyngitis Pulmonary congestion Pulmonary tuberculosis Intrathoracal malignancies Pleural effusion Pleurisy