PULMONARY PHYSIOLOGY

OF THE NEWBORN

Dr Aditya Bhat
Basic Biochemistry of Respiration:

 Oxygen-----key requisite for human metabolism.

 Integral part of oxidative phosphorylation.
 electrons
Carbs-------- water + co2

oxygen
 Role of anerobic metabolism
Development of lung:
 Primary goal of lung organogenesis is expanding lung
surface area .

 Second goal is to minimize diffusing distance from

alveolus to rbc

 Third goal is production of a protective aqueous

barrier over alveoli while mitigating effects of
surface tension generated by this barrier, through
the production of surfactant.
Prenatal development of the lungs
Development:
 Embryonic phase ( weeks 3-6) :
- lung bud arises from foregut

 Pseudoglandular phase ( weeks 6-16):

-development of lower conducting airways

 Canalicular phase ( weeks 16-26)

- formation of acini

 Terminal sac phase( weeks 26-36)

-refinement of acini

 Alveolar phase( weeks 36- 3 years)

-alveolar proliferation and development
Surfactant:
 Complex mixture of phospholipids, neutral lipids, and proteins
synthesized by alveolar type 2 cells.
 Production starts by 26th week, stored in lamellar bodies.
 Composition:
-Lipid -90 %
Saturated phosphatidylcholine- 45 ,Unsaturated
phosphatidylcholine -25
Phosphatidylglycerol -5, Neutral lipids -10
-Protein -10%
 Surfactant proteins- 5, Serum proteins -5
 KEY component is SP-B…………….
Consequences of prematurity:
Event
Alveolarization
Type II cell differentiation
Hydrophobic surfactant
proteins (SP-B, SP-C)
Hydrophilic surfactant
proteins (SP-A, SP-D)
Clara cell differentiation
Respiratory drive
Fetal lung liquid
Potential Consequences
Reduced lung growth and lung surface
area with increased alveolar size;
impaired pulmonary function
RDS
RDS
Comprised host defense
Impaired antioxidant and antimicrobial
defenses
AOP
Hypoplasia
Transition at birth:
 Pulmonary gas exchange has to replace placental gas
exchange within minutes after birth.
 Key events that lead to this transition involve:
 Adjustments in circulation

 Pulmonary mechanics

 Gas exchange

 Acid–base status

 Respiratory control
Circulatory transition------
 closed

expand

Normal
open
Transition
of Circulation
from Pre- to
Post- natal
closed
Adaptations:
Gas transport:
 Gas flow is , gas exchange is not!

 Amount of gas inspired in a single breath is

Tidal volume
Minute ventilation Ve = V t x f

Wasted ventilation = Vds/ v

 Ventilation involves movement of gases by

 Convection
 Molecular diffusion
Dead space ventillation
 Area without gas exchange
 Includes physiological and anatomical dead space
 Increased dead space---- iatrogenic as well
 Normal adult values of 150ml, variable in newborn

 Va= (Tidal volume – dead space)x RR

 spontaneous breathing

active contraction of resp muscles

negative interpleural pressure

gas flow across pressure gradient

Inspired gas 168 torr -----alveolar gas----arterial gas--
 capillary---- ecf -- icf 10 torr
Mechanisms of gas transport:
 Convection
 Diffusion ---- Fick’s law
 Dependent on surface area, concentration
gradient and distance.
 Ocurrs at alveolocapillary membrane.

 Axial flow:
 Spiketheory of panting
 Useful in HFV
 Pendelluft theory:
 Concept in alveoli with unequal time constants
 “Fast” units

help
“slow”units
Diffusion:
 Role of respiratory membrane
 Components of respiratory membrane :
 A layer of fluid lining the alveolus
 The alveolar epithelium

 An epithelial basement membrane

 A thin interstitial space between the alveolar

epithelium and the capillary membrane
 A capillary basement membrane

 The capillary endothelial membrane

Respiratory unit:
 Diffusion depends on
 the thickness of the membrane
 the surface area of the membrane

 the diffusion coefficient of the gas

 the partial pressure difference of the gas between

the two sides of the membrane.

Oxygenation:
 Oxygen transport depends on blood flow and O2
carrying capacity.
 Carried in bound form and dissolved form
 Ca02 = (1.34 x Hb x Sao2) + (0.003 x Pa02)
Oxygen transport
Oxygen release:
Hb-O2 dissociation curve
Factors affecting oxygen release:

 Temperature
 Ph
 2,3 DPG
 Co2 levels
 Type of Hb
Alveolar gas equations:
 PAO2 = ( Barometric pressure – partial pressure of
water vapor) x FiO2) – PcO2/RQ
 Scenario---- a 1.5 kg neonate with suspected RDS
 FiO2- 0.7
 PCO2- 65mm

 Pa o2- 48

around- 420
PAO2--- CLINICAL USE

 Arterial- alveolar O2 tension ratio or the a/A

ratio
 close to 1 in healthy infant
 Less than 0.3 indicates severe resp disease.

 Alveolar- arterial gradient or A-a DO2

 Normally less than 20 mm

 Oxygenation index = Paw x Fio2 X100/ Pa o2

Carbon dioxide elimination:
Ventillator and oxygenation----
Lung volumes:
Normal lung volumes in newborn:
Ventilation:
 In diseased lung
 Dependent on local diferrences in compliance
 In healthy lung
 Gravity dependent

 --------
Perfusion:
 Depends on gravitational forces and other mediators.

 Flow  Flow 
-Increased Pao2/PAo2 - lung volumes / 
-optimal lung volumes - hypoxemia
-alkalosis - acidosis
-bradykinins/pg -shock
-NO - R->L shunts
-shunts L->R
 Pulmonary vessels include alveolar and extra-alveolar.

 Diameter of alveolar vessels is determined by

pressure differences between alveolus and vessel.

 Diameter of extra-alveolar vessels is determined by

lung inflation----best compliance at optimal volumes
 u shaped response of PVR to inflation.
 Regional hypoventillation reduces perfusion---- protective
Perfusion:
 Zone 1: No blood flow during all portions of the
cardiac cycle because the local alveolar

 Zone 2: Intermittent blood flow only during the

peaks of pulmonary arterial pressure

 Zone 3: Continuous blood flow because the alveolar

capillary pressure remains greater than alveolar air
pressure during the entire cardiac cycle
V/Q ratio
 Ventilation increases from apex to base
 Perfusion increases from apex to base

--------------- what happens to V/Q ratio….?

Key sources:
 Assisted ventilation of Neonate- Goldsmith
 Manual of Neonatal resp care- Donn
 Guyton’s textbook of Physiology
 Avery’s diseases of the newborn
Thank you