CURSO DE PNEUMOLOGIA PARA A ATENÇÃO BÁSICA

Fisiologia básica do
sistema respiratório
Alexandre Kawassaki

Doutor em Pneumologia
Médico da disciplina de Pneumologia – Hospital das Clínicas –
Faculdade de Medicina da Universidade de São Paulo
Parte I
 Introdução
• Fisiologia básica

• Mecânica
• Dinâmica – vias aéreas

• Química
• Troca de gases - pulmonar
Conceitos
• Anatomia básica
• Mecânica pulmonar
– Fluxo aéreo
– Mecanismos de resistência e complacência/elastância
• Troca gasosa
• Relação entre ventilação e perfusão
• Oxigênio e gás carbônico
• Algumas aplicações práticas
Anatomia básica
Anatomia básica
Respiração normal

medtube.net
16 Volumes
CHAPTER 2 pulmonares

8
Paper
Papel

Total
Capacidade
6 lung
pulmonar Spirometer
Espirômetro
capacity
total
Vital
Capacidade
capacity
vital
Liters
Litros

Caneta
Tidal
Volume Pen
corrente
volume

2
Functional
Capacidade
residual
residual Residual
Volume
capacity
funcional volume
residual
0

Figure 2.2. Lung volumes. Note that the total lung capacity, functional residual
 and forward (Figure 7.2). When they contract, the ribs are pulled upward
and forward, causing an increase in both the lateral and the anteroposte-
rior diameters of the thorax. The lateral dimension increases because of the
Mecânica pulmonar
“bucket-handle” movement of the ribs. The intercostal muscles are supplied
by intercostal nerves that come off the spinal cord at the same level. Paralysis
• Características
of da via
the intercostal muscles aéra
alone does not seriously affect breathing at rest
because the diaphragm is so effective.
• Caixa torácica
The accessory muscles of inspiration include the scalene muscles, which ele-
• vate the first two ribs,
Propriedades doandparênquima
the sternomastoids, which raise the sternum. There
pulmonar
is little, if any, activity in these muscles during quiet breathing, but during

Inspiração
Inspiration

Diafragma
Diaphragm
Expiração
Expiration
Músculos
Abdominal
abdominais
muscles

Força ativa
Active
Força passiva
Passive

Figure 7.1. On inspiration, the dome-shaped diaphragm contracts, the abdominal

contents are forced down and forward, and the rib cage is widened. Both increase the
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0.1
0
Volume
(l)
pressão negativa 0.2
0.3
0.4
P1 A
–5 Pressão
Intrapleural
pleural
pressure
–6 (cm H2 O)
–7 B

P2 –8 B' C
+0.5 Fluxo
Flow
(l / s)
0

– 0.5
Pressão
+1 Alveolar
alveolar
pressure
(cm H2 O)
0

–1

Figure 7.13. Pressures during the breathing cycle. If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0.1
0
Volume
(l)
pressão negativa 0.2
0.3
0.4
Pressão se transfere para P1
–5
A Pressão
Intrapleural
espaço pleural, para as vias –6
pleural
pressure
(cm H2 O)

aéreas intratorácicas e os –7 B

alvéolos P2 –8
+0.5
B'
Fluxo
Flow
C

(l / s)
0

– 0.5
Pressão
+1 Alveolar
alveolar
pressure
(cm H2 O)
0

–1

Figure 7.13. Pressures during the breathing cycle. If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0.1
0
Volume
(l)
pressão negativa 0.2
0.3
0.4
Pressão se transfere para P1
–5
A Pressão
Intrapleural
espaço pleural, para as vias –6
pleural
pressure
(cm H2 O)

aéreas intratorácicas e os –7 B

alvéolos P2 –8
+0.5
B'
Fluxo
Flow
C

(l / s)

Reacomodação do sistema 0

– 0.5
Pressão
+1 Alveolar
alveolar
pressure
(cm H2 O)
0

–1

Figure 7.13. Pressures during the breathing cycle. If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0.1
0
Volume
(l)
pressão negativa 0.2
0.3
0.4
Pressão se transfere para P1
–5
A Pressão
Intrapleural
espaço pleural, para as vias –6
pleural
pressure
(cm H2 O)

aéreas intratorácicas e os –7 B

alvéolos P2 –8
+0.5
B'
Fluxo
Flow
C

(l / s)

Reacomodação do sistema 0

– 0.5

Fluxo de ar inspiratório +1
Pressão
Alveolar
alveolar
pressure
(cm H2 O)
0

–1

Figure 7.13. Pressures during the breathing cycle. If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0
0.1
Volume
(l)
pressão negativa 0.2
0.3
0.4
Pressão se transfere para P1
–5
A Pressão
Intrapleural
espaço pleural, para as vias –6
pleural
pressure
(cm H2 O)

aéreas intratorácicas e os –7 B

alvéolos P2 –8
+0.5
B'
Fluxo
Flow
C

(l / s)

Reacomodação do sistema 0

– 0.5

Fluxo de ar inspiratório +1
Pressão
Alveolar
alveolar
pressure
(cm H2 O)
0
Quando o diafragma relaxa
–1
pressão alveolar fica positiva
Figure 7.13. Pressures during the breathing cycle. If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
 driving pressure (Figure 7.12). Indeed, the extent of the fall depend
flow rate and the resistance of the airways. In normal subjects, the c
alveolar pressure is only 1 cm water or so, but in patients with airway
tion, it may be many times that.
Respiração espontânea
Inspiração Expiração
Inspiration Expiration
Musculatura diafragmática gera 0
0.1
Volume
(l)
pressão negativa 0.2
0.3
0.4
Pressão se transfere para P1
–5
A Pressão
Intrapleural
espaço pleural, para as vias –6
pleural
pressure
(cm H2 O)

aéreas intratorácicas e os –7 B

alvéolos P2 –8
+0.5
B'
Fluxo
Flow
C

(l / s)

Reacomodação do sistema 0

– 0.5

Fluxo de ar inspiratório +1
Pressão
Alveolar
alveolar
pressure
(cm H2 O)
0
Quando o diafragma relaxa
Saída passiva de ar –1
pressão alveolar fica positiva Pressão
Figure 7.13. Pressures duringsobre ascycle.
the breathing VVAA If there was no airway res
alveolar pressure would remain at zero, and intrapleural pressure would follow
Vias aéreas
Fluxo
 21

respira
Transi
ducts
22
Alveolar
Fluxo sacs
23

500
• Velocidade do fluxo aéreo
reduz à medida que se
aproxima dos alvéolos 400

2 ) 2)
( cm(cm
• Componente de

aéreas
resistência

das viasarea
300
– Zona de condução

totalsection
• Complacência

Total cross
200 Conducting
Zona de Respiratory F
– Zona respiratória zone Zona
zone t
condução

Área transversal
– ΔV/ΔP respiratória in
t
– Inverso da elastância 100
z
a
Bronquíolos
Terminal o
bronchioles
terminais b
r
0 5 10 15 20 23 b
d
Segmentação aérea
Airway generation m
Recolhimento elástico e complacência
Elastância e complacência

Recolhimento
elástico
MECHANICS OF BREATHING

P=0 P = –5 P=0
P=0 P=0
P=0

Normal
Normal Pneumothorax
Pneumotórax
Figure 7.10. The tendency of the lung to recoil to its deflated volume is balanced
inside a jar (Figure 7.3). When the pressure within the jar is reduced below
atmospheric pressure, the lung expands, and its change in volume can be mea-
sured with a spirometer. The pressure is held at each level, as indicated by the
points, for a few seconds to allow the lung to come to rest. In this way, the
Elastância e complacência
pressure-volume curve of the lung can be plotted.
In Figure 7.3, the expanding pressure around the lung is generated by a
pump, but in humans, it is developed by an increase in volume of the chest
cage. The fact that the intrapleural space between the lung and the chest wall
• Recolhimento elástico pulmonar
is much smaller than the space between the lung and the bottle in Figure 7.3
makes no essential difference. The intrapleural space contains only a few mil-
• Diversas variáveis
liliters of fluid.
Figure 7.3 shows that the curves that the lung follows during inflation and
– Volume pulmonar
deflation are different. This behavior is known as hysteresis. Note that the lung
volume at any given pressure during deflation is larger than is that during
– Tensão alveolar (surfactante)
inflation. Note also that the lung without any expanding pressure has some
air inside it. In fact, even if the pressure around the lung is raised above atmo-
• Curva P-V
spheric pressure, little further air is lost because small airways close, trapping
gas in the alveoli (compare Figure 7.9). This airway closure occurs at higher
lung volumes with increasing age and also in some types of lung disease.

Volume (l)
Volume 1.0

Bomba
Pump

0.5

Pressure
Pulmão
Lung
Pressão

0 – 10 –2 0 – 30
Pressure around lung (cm water)
Pressão ao redor do pulmão
Measurement of the pressure-volume curve of(cmH
20)
Figure 7.3. excised lung. The lung
is held at each pressure for a few seconds while its volume is measured. The curve
is nonlinear and becomes flatter at high expanding pressures. Note that the inflation
Histerese
• Complacência pulmonar diferente entre ins e expiração
• Característica relacionada ao surfactante
Insuflação Capacidade
de salina pulmonar
total

Insuflação
de ar
Volume (ml)

Volume
residual

Pressão (cmH20)
Alvéolo
• Surfactante “corrige” uma característica física
• Homogeneizar os volumes alveolares
– Durante inspiração
Capacidade
pulmonar
total

Insuflação
de ar
Volume (ml)

Volume Alvéolos
residual colapsados

Pressão (cmH20)
Alvéolo
• Surfactante “corrige” uma característica física
• Homogeneizar os volumes alveolares
– Durante inspiração
Capacidade
pulmonar
total

Insuflação
de ar
Volume (ml)

Volume Início do
residual recrutamento

Pressão (cmH20)
Alvéolo
• Surfactante “corrige” uma característica física
• Homogeneizar os volumes alveolares
– Durante inspiração => facilita abertura de unidades alveolares
Capacidade
pulmonar
total

Insuflação
de ar
Volume (ml)

Início do
recrutamento

Pressão (cmH20)
Alvéolo
• Surfactante “corrige” uma característica física
• Homogeneizar os volumes alveolares
– Durante expiração => evita colapso de unidades alveolares

Unidades
alveolares
continuam
abertas Insuflação
de ar
Volume (ml)

Início do
recrutamento

Pressão (cmH20)
 Alvéolo
• Unidades alveolares maiores têm menor tensão na
parede

P P r

bubble P= 4T
r
 Alvéolo
• Unidades alveolares maiores têm menor tensão na
parede => maior recolhimento elástico

T Tensão Tensão

P P r

bubble P= 4T
r
 Alvéolo
• Unidades alveolares menores têm maior tensão na
parede e maior tendência para colapso

T Tensão Tensão

P
P PP r

bubble P= 4T
r
 Alvéolo
• Unidades alveolares maiores “roubam” ar das unidades
menores

T Tensão Tensão

P
P PP r

bubble P= 4T
r
 Alvéolo
• O surfactante corrige esse desbalanço

T Tensão Tensão
T

P P r

bubble P= 4T
r
 Alvéolo
• Redução da tensão na parede de alvéolos menores
• Garantindo uma troca gasosa adequada

T Tensão T

P
P r PP r

bubble T 4 4T
Pr == P elbbu
r
CURSO DE PNEUMOLOGIA PARA A ATENÇÃO BÁSICA

Obrigado!

alexandre@cdra.com.br
CURSO DE PNEUMOLOGIA PARA A ATENÇÃO BÁSICA

Fisiologia básica do
sistema respiratório
Alexandre Kawassaki

Doutor em Pneumologia
Médico da disciplina de Pneumologia – Hospital das Clínicas –
Faculdade de Medicina da Universidade de São Paulo
Conceitos
• Anatomia básica
• Mecânica pulmonar
– Fluxo aéreo
– Mecanismos de resistência e complacência/elastância
• Troca gasosa
• Relação entre ventilação e perfusão
• Oxigênio e gás carbônico
• Algumas aplicações práticas
Parte II
near resting levels. Third, the lung is the only organ that
receives all of the blood pumped from the heart and thus
Lung Structure Suits Function
must accommodate the entire increase in cardiac output The structure of the pulmonary circulation is aimed at
during exercise. This huge increase in blood flow has the preserving a low vascular resistance and providing the
Parede alveolar
potential to substantially increase pulmonary vascular
pressures, thereby increasing the load placed on the right
maximum alveolar–capillary surface area for diffusion
(Fig. 8.12). To this end, vessels in the lung are thin-walled,

0.5 µ

V
ALV
CAP

BM

EN EP
A B
FIGURE 8.12 A. The alveolar-capillary blood gas barrier and the alveolar-to-capillary diffusion pathway.
 DIFFUSION 29

In the last chapter, we looked at how gas is moved from the atmosphere to the

Difusão
alveoli, or in the reverse direction. We now come to the transfer of gas across
the blood-gas barrier. This process occurs by diffusion. Only 80 years ago, some
physiologists believed that the lung secreted oxygen into the capillaries, that is,
the oxygen was moved from a region of lower to one of higher partial pressure.
Such a process was thought to occur in the swim bladder of fish, and it requires
energy. But more accurate measurements showed that this does not occur in the
lung and that all gases move across the alveolar wall by passive diffusion.
Início do Final do
capilar capilar
LAWS OF DIFFUSION
Parede
Diffusion through tissues is described by Fick’s law (Figure 3.1). This states
alveolar
that the rate of transfer of a gas through a sheet of tissue like a postage stamp
Hemácia
is proportional to the tissue area and the difference in gas partial pressure
between the two sides, and inversely proportional to the tissue thickness.

Pressão parcial
As we have seen, the area of the blood-gas barrier in the lung is enormous
(50 to 100 square meters), and the thickness is only 0.3 μm in many places (Anormal)
Alvéolo
(Figure 1.1), so the dimensions of the barrier are ideal for diffusion. In addi-
tion, the rate of transfer is proportional to a diffusion constant, which depends
on the properties of the tissue and the particular gas. The constant is propor-
tional to the solubility of the gas and inversely proportional to the square root
of the molecular weight (Figure 3.1). This means that CO2 diffuses about
20 times more rapidly than does O2 through tissue sheets because it has a
much higher solubility but not a very different molecular weight.

P2 Vgas ∝ A . D . (P1 – P2 )
T

Are D∝
Solubility Tempo no capilar (s)
O2 a (A Mol. Wt
)
P1

CO2
Thickness (T)
Ventilação / Perfusão

Petterson J, Glenny RW. Eur Respir J, 2014

Circulação
2
Oxigênio
CHAPTER 6

100 20° 38°

43°
%
Sat
100 Temp
0
PO2 100
100
80 20
40
Saturação da hemoglobina (%)

%
Sat 70
% Hb saturation

60 PCO2
Temp DPG 0
PO2 100
+
PCO2 H
40 100
7.6
% 7.2
Sat 7.4
20
pH
0
PO2 100
0
0 20 40 60 80 100
PO2 (mm Hg)
+
igure 6.3. Rightward shift of the O2 dissociation curve by increase of H , PCO2,
 preparations that sensory afferents are not required for forma- The carotid chemoreceptors are small (1-mm diameter)
addition of abasic
tion of the signifi cant concentration
respiratory of carbon
pattern because dioxide
the respiratory- sinuslocated
organs nerve,bilaterally
a branchnear of the
the glossopharyngeal nerve (cranial
bifurcations of the com-
he like
bathing
rhythmmedium;
from thehence,
phrenicatnerve
least was
oneshown
type ofto sensory
persist monnerve IX),arteries
carotid to stimulate the and
(Fig. 8.3A) brainstem medullary
that respond quicklyrespiratory
t iswhen
required for rhythmic
the preparation respiratory
was fully motor
deafferented output. the
(4). However, to neurons
changes inandPO2, infl
PCOuence
, and pHmotor
of thenerve activity
arterial blood on tothe
the respira-
Gás carbônico
2
We rhythm of the in vitro
now describe twopreparation is absolutely
types of sensory dependent on
inputs—chemical way to the
tory brain. Sensory
muscles. These activity
organs isreceive
carried the
via the carotidblood flow
highest
mechanical—and leave consideration of sensorydioxide
the addition of a significant concentration of carbon inputs sinus nerve, a branch of the glossopharyngeal nerve (cranial
per gram of tissue of any organ and are especially important
in the bathing medium; hence, at least one
ed to locomotion to our later discussion of exercise type of sensory nerve IX), tothey
stimulate the brainstem medullary respiratoryfor rapidly
because are the only receptors responsible
input is required for rhythmic respiratory motor output. neurons and influence motor nerve activity to the respira-
erpnea. We now describe two types of sensory inputs—chemical
stimulating ventilation when oxygen availability is low. There
tory muscles. These organs receive the highest blood flow
and mechanical—and leave consideration of sensory inputs per gram of tissue of any organ and are especially important
CO + H O ó H CO ó H + HCO
related to locomotion
2 2toRT.our later discussion
2 3
+
of exercise because -
3 they are the only receptors responsible for rapidly
hyperpnea. CAROTID BODY OF THE CAT stimulating ventilation when oxygen availability is low. There
1 mm

0 1 2 3 4 5 6 7 8 9 10

s
RT. CAROTID BODY OF THE CAT

inu
d ar t.
1 mm caroti

s
on
comm

id
dy

rot
d bo
0 1 2 3 4 5 6 7 8 9 10

ca
r t.
da
ti

s
caro

ti

u
r t.
rotid a

sin
aro on ca
t. c comm
tid
body

ex ro
ca

r t.
tid

da
caro

i
rot
t . ca
ex
.
ar t
t.
ar

otid
al

car
ge

55
.
ar t
an

int.
rt.
ar

otid

25
la
ph

Pa
a

CO
car
rve
ge

55 2
ing

Ventilation ( /min)
ne

int.
ra
nd

25
a
ph

g’s
ce

PaCO2 45
rve
as

ing

rin

Ventilation ( /min)
ne
nd

He

g’s
ce

45
as

rin

glionic N.
He

-gan
cervical post
occipital ar t.

-ganglionic N. 35
cervical post
.

occipital ar t.
lN

35
ia
an

.
lN
cr

ia
an
IX

cr
IX

5
N.
XII cranial anial N. 5
XII cr

40 40 100 100
A A B B PaO2 (mm O2 (mm Hg)
PaHg)

FIGURE
FIGURE 8.3 8.3 A. The
A. The intact
intact carotidchemoreceptor
carotid chemoreceptor ofofthe cat.
the Head
cat. is toisthe
Head to left
theand
leftheart
and to the right.
heart to theNote the Note the
right.
Aplicações práticas
• Espirometria

• Fisiologia da ventilação mecânica

• Relação V/Q
Curva Fluxo X Volume

• Volume corrente
• Inspiração forçada
• Expiração forçada
• Inspiração máxima
• Fluxo inspiratório X
Fluxo expiratório
Limitação ao Fluxo
 Doenças Pulmonares

• Resistência das VVAA

• Doença obstrutiva
• Redução precoce de
vias aéreas
– Calibre reduzido
– Menor sustentação
 Ventilação mecânica

Pressão
Pico

Platô

Peep

Tempo
Pressão

Fluxo zero

Tempo
 P = (R x Fluxo) + (V / C)
Pressão

Pressão
resistiva

Pressão
Elástica
Fluxo zero

Tempo
 1 R = Ppico – P platô
Fluxo
Pressão

Pressão
1 resistiva

Tempo
 2 C= Vol
P platô - Peep

Pressão

Pressão
2
Elástica

Tempo
Histerese

Hess DR. Respir Care, 2015

Ventilação / Perfusão
Bibliografia recomendada
• West JB, Luks AM. West’s Respiratory Physiology – The
essentials. 10th ed, 2016, Wolters Kluwer
• Romer LM, Sheel AW, Harms CG. The Respiratory
System. In: ACSM’s Advanced exercise physiology (2nd
ed), 2012, Wolters Kluwer
• Arthurs GJ, Sudhakar M. Carbon dioxide transport. Cont Educ
Anaest Crit Care Pain 2005; 5(6):207-210
• Cruickshank S, Hirschauer N. The alveolar gas equation.
Cont Educ Anaest Crit Care Pain 2004; 4(1):24-27
• West JB, Watson RR, Fu Z. The human lung: did evolution
get ir wrong?. Eur Respir J 2007;29:11-17
• Hess DR. Recruitment maneuvers and PEEP titration. Respir
Care, 2015;60(11):1688-1704
• Petterson J, Glenny RW. Gas exchange and ventilation-
perfusion relationships in the lung. Eur Respir J
2014;44(4):1023-41
CURSO DE PNEUMOLOGIA PARA A ATENÇÃO BÁSICA

Obrigado!

alexandre@cdra.com.br