Lung ventilation, natural and

mechanical

2019-07-08
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 Inhaltsverzeichnis

Inhaltsverzeichnis
1. Overview  4

2. What to learn  5

3. Basic elements  6

4. Pressure  7

5. Pressure gradient  8

6. Gas volume (V)  9

7. Gas flow  10

8. Resistance  11

9. Compliance  12

10. Time constant  13

11. Why is respiration necessary?  14

12. Anatomy of airway and lungs  15

13. A simple model to demonstrate lung ventilation  16

14. Natural lung ventilation  17

15. Artificial lung ventilation  18

16. Conclusion  19

17. Test  20

Glossar  21

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 1. Overview

1 Overview
Lung Ventilation, Natural and Mechanical

Mechanical ventilation is a respiratory therapy that is becoming increasingly popular around the
world.

When applied appropriately, mechanical ventilation is a very powerful and effective means of
saving lives – a lot of lives, because it maintains vital breathing functions in an artificial manner.

However, if applied inappropriately, mechanical ventilation may be equally powerful and effective
in harming patients.

Mechanical ventilation might be the most challenging of all clinical therapies – not only because the
therapy itself is complicated, but because the therapeutic tool, the ventilator system, is
complicated, as well. This is a fact which is not often recognized.

The outcome of mechanical ventilation depends, to a great extent, on the specialist knowledge of
the clinicians in charge. It is generally the case that the more the clinicians know, the better the
outcome.

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 2. What to learn

2 What to learn
This learning unit is one of the most critical in this education program. After studying the material
in it, you should be able to explain:
¡ What pressure, pressure gradient, volume, and flow mean.
¡ What respiration really means.
¡ How lungs are ventilated naturally.
¡ How lungs are ventilated artificially or mechanically.

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 3. Basic elements

3 Basic elements
Mechanical ventilation is closely related to, and is dependent on, pneumatics which is a branch of
physics.

So if you want to know about mechanical ventilation better, this means, not only what to do, and
how to do it, but also why things are as they are or will be, you must thoroughly understand the
basic terms and principles of:
¡ Pressure
¡ Pressure gradient
¡ Volume
¡ Gas flow
¡ Resistance
¡ Compliance
¡ Time constant

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 4. Pressure

4 Pressure
Pressure is a force against resistance or a force applied uniformly over a unit area of surface. Gas
pressure can be expressed in various units. The most commonly used units in mechanical ventilation
include bar, millibar (mbar), centimeter of water (cmH2O), kilopascal (kPa), hectopascal (hPa) and
pound per square inch (PSI).

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 5. Pressure gradient

5 Pressure gradient
Pressure gradient refers to the difference between the pressure at area A and the pressure at area
B. If both areas are connected with a tube, the pressure gradient drives the air or gas to move from
the high pressure area to the low pressure area. The gas movement is flow.

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 6. Gas volume (V)

6 Gas volume (V)

Gas volume is a measure of the space occupied by a quantity of gas at a given pressure. Tidal
volume and minute volume are two typical examples of gas volume. Volume is expressed in litres (L)
or millilitres (ml).

Gas is compressible. Under various pressures, the volume of a given quantity of gas varies.
Therefore, a vast amount of gas can be compressed into a small gas cylinder.

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 7. Gas flow

7 Gas flow
Gas flow refers to the movement of gas volume over time. Gas flow has two essential properties:
direction of flow and rate of flow. Flow direction is determined by the pressure gradient only, while
flow rate is determined by both the pressure gradient and the resistance encountered.

Inspiratory flow refers to the gas flow towards the patient, usually expressed in positive values.
Expiratory flow refers to the gas flow from the patient, usually expressed in negative values.

The rate of gas flow is usually expressed in liter per minute (L/min) or milliliter per second (ml/s).
One liter per minute (L/min) is equal to 16.7 milliliters per second (ml/s).

At a low flow rate, gas tends to move smoothly. The resulting pattern is called laminar flow. At a
high flow rate, gas tends to move unevenly. The resulting pattern is called turbulent flow.

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 8. Resistance

8 Resistance
Resistance is defined as a force that tends to oppose or retard gas movement. Resistance is flow
dependent. Whenever a gas moves through a tube, a given resistance is generated.

Resistance is usually expressed in millibars per litre per minute (mbar/L/min).

The level of resistance is determined by three factors:

The first factor is flow rate. The higher the flow rate, the greater the resistance, and vice versa. If
the flow rate drops to zero, resistance disappears.

The second factor is the physical properties of the tube, including its length, internal diameter,
inner surface, curvature, and so on.

The third factor is the physical properties of the passing gas, including its density and viscosity.
Heliox is a gas mixture of helium and oxygen. It has a lower density than air. Passing through a
narrowed airway, Heliox generates less resistance than air, resulting in a higher gas flow. This fact
forms the foundation of Heliox therapy.

The relationship between pressure gradient, flow, and resistance is described by Ohm’s law: flow
equals to pressure gradient divided by resistance (flow = ΔP/R). So, flow increases when the
pressure gradient increases and/or resistance decreases.

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 9. Compliance

9 Compliance
A balloon and human lungs have one thing in common: both are elastic, hollow and gas tight
structures. Their volumes change at different levels of internal pressures. Compliance is a measure
to express the pressure-volume relationship of such structures.

A simple physical model can help our understanding.

Here we have two balloons made of the same elastic material. The wall of one balloon is slightly
thicker than that of the other. Using a T-piece equipped with a valve, we connect the two balloons
to a source of high pressure gas. In this arrangement, the internal pressure of the two balloons
remains identical at all times.

Now we gradually open the valve, causing gas to flow into the both balloons and the internal
pressure to increase. As a consequence, both balloons begin to expand. Unsurprisingly, the balloon
with thin wall expands faster than that with the thick wall.

If we measure the internal pressure and balloon volumes simultaneously, and then plot the
readings on a graph, we get two different pressure‐volume curves. These two curves have different
angles to the horizontal. These different angles show the different levels of compliance of the two
balloons.

In principle, compliance is a static property, and should be measured in conditions of zero flow.

Compliance is expressed in milliliters per centimeter of water (ml/cmH2O) or liters per centimeter of
water (L/cmH2O).

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 10. Time constant

10 Time constant
Flow is defined as change of volume over time. Keep in mind that it takes time to complete a
course of volume change, such as in the process by which lungs are inflated or deflated.

If the time available for lung inspiration (or inflation) is shorter than required, the realized tidal
volume decreases.

If the time available for lung exhalation (or deflation) is shorter than required, a part of the gas
volume that should be expired is trapped in the lungs. This results in higher alveolar pressure at the
end of expiration than would otherwise be the case.

This phenomenon is called “autoPEEP”. The length of time required to complete a volume change
varies, depending on clinical conditions.

The question is: “Is there any possible way for us to know or estimate objectively and individually
the required time to complete a course of volume change?”

Yes. The tool we use is the time constant.

The time constant parameter is the product of the monitored compliance (C) and resistance (R) of
a respiratory system.

Time constant (RC) = respiratory resistance (R) x respiratory compliance (C)

Therefore, the time constant increases when resistance and/or compliance increase.

In a passive lung model, the volume change of inspiration or expiration is exponential. This means,
the change is maximal at beginning, and then slows down.

The time constant is expressed in second. However, it does NOT directly indicate the length of time
required to complete a flow course. Instead, it must be factored. In theory,
¡ after one time constant (1 x RC), 63% of the volume change is complete;
¡ after two time constants (2 x RC), 86.5% is complete;
¡ after three time constants (3 x RC), 95% is complete;
¡ after four time constants (4 x RC), 98% is complete, and
¡ after five time constants (5 x RC), 99% is complete.

It is generally agreed that adequate inspiratory time should be at least 3 inspiratory time constants
long, while adequate expiratory time at least 3 expiratory time constants long.

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 11. Why is respiration necessary?

11 Why is respiration necessary?

An adequate and continuous supply of energy is vital for life. Energy is produced in all living cells
through a biochemical process called “metabolism”. This is comparable to burning fuel in a stove.
During the process, oxygen (O2) is consumed and carbon dioxide (CO2) produced.

Respiration is the process of moving O2 towards, and CO2 away from living cells. The process has
four parts:

1 Lung ventilation. This means the replacement of stale gases in the lungs with fresh gases from
the environment.

2 Gas diffusion at alveoli. This means moving O2 from the alveoli to the pulmonary capillaries,
and moving CO2 from the pulmonary capillaries to the alveoli. O2 diffusion is driven by the
difference between the O2 partial pressure in the alveoli and that in the surrounding capillaries.
The same principle is true for CO2 diffusion, but in opposite direction.

3 Blood circulation to transport O2 and CO2 between living cells and the lungs.

4 Gas diffusion at tissues. This time is the moving of O2 from tissue capillaries to supplied cells,
and the moving of CO2 from cells to tissue capillaries. Again, gas diffusion is driven by the
differences of O2 and CO2 partial pressures between the living cells and the supplying
capillaries.

Human respiration is so precisely regulated that the partial pressures of O2 and CO2 in arterial
blood, PaO2 and PaCO2, are stabilized within a narrow normal range, even under a wide range of
physiological conditions. The term “respiratory failure” describes that the respiratory function is so
inadequate that PaO2 and/or PaCO2 can no longer be maintained within their normal physiological
ranges.

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 12. Anatomy of airway and lungs

12 Anatomy of airway and lungs

Respiratory system refers to the organs serving for respiration. The lungs, airway and chest wall are
essential parts of a respiratory system. They are responsible for lung ventilation and gas diffusion at
alveoli.

Functionally, the airway‐lung structure may be divided roughly into three parts.

The first part is the upper airway, including the nose, nasal cavity, mouth, pharynx, larynx and
trachea.

The second part is the low airway, including everything from the primary bronchi and bronchial tree
to the small bronchioles.

As the names imply, the upper and lower airways are gas passageways between the environment
and the alveoli.

The third part is the alveoli. These are miniature gas sacs, each with a thin wall coated with blood
capillaries. A normal human being has millions of alveoli in the lungs so that the gas-blood
interface is huge. The special structure makes gas exchange particularly easy.

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 13. A simple model to demonstrate lung ventilation

13 A simple model to demonstrate lung ventilation

Explaining the complicated mechanism of lung ventilation in an easily understandable way is a
challenge. A simple and intuitive physical model can help.

A fireplace bellows can serve the purpose well. However, we must make two modifications to the
normal design.

First, the one‐way valve for gas entry must be closed, so that the nozzle becomes the one and only
gas passageway.

Second, a spring must be added between the two handles to mimic the elastic lung‐chest wall. The
elastic recoil force brings the extended bellows back to its resting position whenever external force
is removed.

We will often use this model to visualize the pneumatic mechanism of various forms of lung
ventilation.

And with our specially adapted bellows model, we are prepared to go on…

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 14. Natural lung ventilation

14 Natural lung ventilation

Natural lung ventilation

A. Inspiration

Natural and quiet inspiration begins with downward movement of diaphragm, causing the alveolar
pressure (Palv) to drop below the airway opening pressure (Pao) which is equal to atmosphere
pressure. Following the gradient, the air is sucked into the lungs.

With the Inspiratory flow over time, the lungs are inflated and the alveolar pressure increases,
gradually. Finally, inspiratory flow stops when alveolar pressure (Palv) and airway opening pressure
(Pao) becomes equal.

Natural lung inflation results from contraction of inspiratory muscles, mainly the diaphragm. It is an
active, energy‐consuming process. The muscle work must be sufficient to overcome the airway
resistance (the nozzle in the bellows model) as well as the elastic recoil force of the respiratory
system (the spring in the bellows model).

The respiratory muscular work is called “work of breathing” (WOB). The muscular work required
for the inspiration of normal quiet breaths is as low as 3 to 5% of total body energy expenditure.
However, this work can increase dramatically under abnormal conditions such as asthma or acute
respiratory distress syndrome (ARDS).

B. Expiration

Natural and quiet expiration begins with relaxation of diaphragm. The elastic recoil force of the
lungs and chest wall brings the enlarged lungs back to their resting position, which is called
residual functional capacity or FRC. Natural and quiet expiration is passive, consuming no energy.

In our bellows model, the spring, which was loaded during the inspiration, generates a positive
internal pressure, pushing the gas out until the bellows is back to its original position.

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 15. Artificial lung ventilation

15 Artificial lung ventilation

Artificial lung Artificial lung ventilation can be achieved in three ways:
ventilation ¡ Intermittent positive pressure ventilation or IPPV,

¡ intermittent negative pressure ventilation or INPV, and

¡ high frequency ventilation or HFV.
Most modern ventilators are based on IPPV. From now on, when talking about mechanical
ventilation, we mean mechanical ventilation with IPPV.

To keep our explanation simple, we assume that the ventilated patient is totally passive.

A. Inspiration

When artificial inspiration begins, the ventilator system raises the airway opening pressure (Pao)
from the pressure baseline to the peak pressure, generating a temporary gradient where the airway
opening pressure is higher than the alveolar pressure. The gas is pushed into the lungs.

With inspiratory flow over time, the lungs are inflated and the alveolar pressure (Palv) rises
exponentially. At end of the inspiration, both the airway opening pressure (Pao) and the alveolar
pressure (Palv) are equal at peak pressure level. The inspiratory flow stops.

B. Expiration

When artificial expiration begins, the ventilator system lowers suddenly the airway opening
pressure (Pao) from the peak pressure level to the pressure baseline, generating a temporary
gradient where airway opening pressure (Pao) is lower than the alveolar pressure (Palv). The elastic
recoil force of the lung‐chest wall pushes the gas out of the lungs. In our bellows model, the
spring, which is loaded during the inspiration, represents the recoil force.

With expiratory flow over time, the lungs are deflated and the alveolar pressure (Palv) drops
exponentially. At end of the expiration, the alveolar pressure (Palv) and the airway opening pressure
(Pao) are equal at the pressure baseline. The expiratory flow stops.

Similarly to natural expiration, such an artificial expiration is passive, consuming no energy.

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 16. Conclusion

16 Conclusion
Conclusion

To understand comprehensively how a ventilator system works, it is at least necessary to know well
7 physical terms and principles.

The primary function of respiratory system is to transport oxygen (O2) to and carbon dioxide (CO2)
away from living cells of the human body.

Complete respiration has 4 sequenced steps. Lung ventilation is one of the four.

Lung ventilation is realized by intermittent changes, naturally or artificially, in gradient between

airway opening pressure (Pao) and alveolar pressure (Palv).

The pressure gradients may be generated with three driving forces, this means, respiratory muscle
contraction, a ventilator system and elastic recoil force of lungs and chest wall.

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