Essential Anatomy and Physiology of the Respiratory System and the Pulmonary Circulation

  • J. Michael Jaeger
  • Randal S. Blank


Knowledge of the clinical anatomy and function of the respiratory system is essential for the safe, efficient, and appropriate perioperative management of intubation, mechanical ventilation, and anesthesia for the thoracic surgical patient. The lung has ten (third generation airway) bronchopulmonary segments on the right and eight segments on the left that are readily identifiable by fiberoptic bronchoscopy (two segmental bronchi on the left are considered “fused”). The anesthetic employed, both general and regional, will impact the control of respiration, reactivity of the airways, and the patient’s ability to maintain their airway, take a deep breath, and cough. Dynamic influences of ventilatory pattern, posture, body habitus, agitation or pain, and inflammation can cause “air trapping” and drastically reduce alveolar ventilation. The compliance and resistance of the respiratory system will change during the course of surgery, especially those procedures requiring one-lung ventilation, and may necessitate frequent adjustments of the ventilator to optimize gas exchange and reduce lung injury. Many drugs employed during cardiothoracic surgery will impact the lung’s intrinsic mechanisms to match ventilation to perfusion matching either directly on hypoxic pulmonary vasoconstriction (HPV) or indirectly by altering cardiac output or vascular resistance.


Chest Wall Lung Volume Pulmonary Vascular Resistance Functional Residual Capacity Pulmonary Blood Flow 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1.  1.
    Hudgel DW, Hendricks C. Palate and hypopharynx – sites of inspiratory narrowing of the upper airway during sleep. Am Rev Respir Dis. 1988;138:1542–7.PubMedCrossRefGoogle Scholar
  2.  2.
    Wheatley JR, Kelly WT, Tully A, Engel LA. Pressure-diameter relationships of the upper airway in awake supine subjects. J Appl Physiol. 1991;70(5):2242–51.PubMedGoogle Scholar
  3.  3.
    Spann RW, Hyatt RE. Factors affecting upper airway resistance in conscious man. J Appl Physiol. 1971;31(5):708–12.PubMedGoogle Scholar
  4.  4.
    Bartlett D. Respiratory function of the larynx. Physiol Rev. 1989;69:33–57.PubMedGoogle Scholar
  5.  5.
    Gal TJ. Anatomy and physiology of the respiratory system and the pulmonary circulation. In: Kaplan JA, Slinger PD, editors. Thoracic anesthesia. 3rd ed. Philadelphia, PA: Churchill Livingstone; 2003. p. 57–70.Google Scholar
  6.  6.
    Voynow JA, Rubin BK. Mucins, mucus, and sputum. Chest. 2009;135:505–12.PubMedCrossRefGoogle Scholar
  7.  7.
    Foster WM, Langenback E, Bergofsky EH. Measurement of tracheal and bronchial mucus velocities in man: relation to clearance. J Appl Physiol. 1980;48(6):965–71.PubMedGoogle Scholar
  8.  8.
    Gonda I. Particle deposition in the human respiratory tract. In: Crystal RG, West JB, Weibel ER, Barnes PJ, editors. The lung: scientific foundations. 2nd ed. Philadelphia, PA: Lipincott-Raven; 1997. p. 2289–308.Google Scholar
  9.  9.
    Gibson GJ, Pride NB, Empey DW. The role of inspiratory dynamic compression in upper airway obstruction. Am Rev Respir Dis. 1973;108:1352–60.PubMedGoogle Scholar
  10. 10.
    Vincken WG, Gauthier SG, Dollfuss RE, Hanson RE, Darauay CM, Cosio MG. Involvement of upper-airway muscles in extrapyramidal disorders. N Engl J Med. 1984;311:438–42.PubMedCrossRefGoogle Scholar
  11. 11.
    Phipps PR, Gonda I, Bailey DC, Borham P, Bautovich G, Anderson SD. Comparison of planar and tomographic gamma scintography to measure the penetrating index of inhaled aerosols. Am Rev Respir Dis. 1989;139:1516–23.PubMedGoogle Scholar
  12. 12.
    Crapo JD, Harmsen AG, Sherman MP, et al. Pulmonary immunobiology and inflammation in pulmonary diseases. Am J Respir Crit Care Med. 2000;162:1983–6.PubMedGoogle Scholar
  13. 13.
    Johnston RB. Monocytes and macrophages. N Engl J Med. 1988;318:747–52.PubMedCrossRefGoogle Scholar
  14. 14.
    Bienenstock J. Bronchus-associated lymphoid tissue. Int Arch Allergy Appl Immunol. 1985;76:62–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Richardson JB, Ferguson CC. Neuromuscular structure and function in the airways. Fed Proc. 1979;38:292–308.Google Scholar
  16. 16.
    Guyenet PG. The 2008 Carl Ludwig Lecture: retrotrapezoid nucleus, CO2 homeostasis, and breathing automaticity. J Appl Physiol. 2008;105:404–16.PubMedCrossRefGoogle Scholar
  17. 17.
    Barnes PJ. Neural control of airway smooth muscle. Chapter 91. In: Crystal RG, West JB, Barnes PJ, Weibel ER, editors. The lung: scientific foundations. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1997. p. 1269–85.Google Scholar
  18. 18.
    Caulfield MP. Muscarinic receptors, characterization, coupling and function. Pharmacol Ther. 1993;58:319–79.PubMedCrossRefGoogle Scholar
  19. 19.
    Barnes PJ. Modulation of neurotransmission in airways. Physiol Rev. 1992;72:699–729.PubMedGoogle Scholar
  20. 20.
    McKenzie DK, Gandevia SC. Skeletal muscle properties: diaphragm and chest wall. In: Crystal RG, West JB, Weibel ER, Barnes PJ, editors. The lung: scientific foundations. 2nd ed. Philadelphia, PA: Lipincott-Raven; 1997. p. 981–91.Google Scholar
  21. 21.
    Levine S, Kaiser L, Leferovich J, et al. Cellular adaptations in the diaphragm in chronic obstructive pulmonary disease. N Engl J Med. 1997;337:1799–806.PubMedCrossRefGoogle Scholar
  22. 22.
    Leith DE, Mead J. Mechanisms determining residual volume of the lungs in normal subjects. J Appl Physiol. 1967;23:221–7.PubMedGoogle Scholar
  23. 23.
    Colin AA, Wohl MEB, Mead J, et al. Transition from dynamically maintained to relaxed end-expiratory volume in human infants. J Appl Physiol. 1989;67:2107–11.PubMedGoogle Scholar
  24. 24.
    Milic-Emili J, Henderson JAM, Dolovich MB, et al. Regional distribution of inspired gas in the lung. J Appl Physiol. 1966;21:749–59.PubMedGoogle Scholar
  25. 25.
    West JB, Dollery CT. Distribution of blood flow and ventilation-perfusion ratio in the lung, measured with radioactive carbon dioxide. J Appl Physiol. 1960;15:405–10.PubMedGoogle Scholar
  26. 26.
    Bake B, Wood L, Murphy B, et al. Effect of inspiratory flow rate on regional distribution of inspired gas. J Appl Physiol. 1974;37:8–17.PubMedGoogle Scholar
  27. 27.
    Widdicombe J. Anatomy and physiology of the airway circulation. Am Rev Respir Dis. 1992;146:S3–7.PubMedGoogle Scholar
  28. 28.
    Galvin I, Drummond GB, Nirmalan M. Distribution of blood flow and ventilation in the lung: gravity is not the only factor. Br J Anaesth. 2007;98:420–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Hughes M, West JB. Point: Gravity is the major factor determining the distribution of blood flow in the human lung. J Appl Physiol. 2008;104:1531–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Glenny RW. Counterpoint: Gravity is not the major factor determining the distribution of blood flow in the healthy human lung. J Appl Physiol. 2008;104:1533–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Glenny RW, Bernard S, Robertson HT. Gravity is an important but secondary determinant of regional pulmonary blood flow in upright primates. J Appl Physiol. 1999;86:623–32.PubMedGoogle Scholar
  32. 32.
    Robertson HT, Hlastala MP. Microsphere maps of regional blood flow and regional ventilation. J Appl Physiol. 2007;102: 1265–72.PubMedCrossRefGoogle Scholar
  33. 33.
    Prisk GK, Guy HJB, Elliott AR, et al. Inhomogeneity of pulmonary perfusion during sustained microgravity on SLS-1. J Appl Physiol. 1994;76:1730–8.PubMedGoogle Scholar
  34. 34.
    Prisk GK, Guy HJB, Elliott AR, et al. Ventilatory inhomogeneity determined from multiple-breath washouts during sustained microgravity on Spacelab SLS-1. J Appl Physiol. 1995;78:597–607.PubMedGoogle Scholar
  35. 35.
    Glenny RW, Lamm WJ, Bernard SL, et al. Selected contribution: redistribution of pulmonary perfusion during weightlessness and increased gravity. J Appl Physiol. 2000;89:1239–48.PubMedGoogle Scholar
  36. 36.
    Weibel ER. Fractal geometry: a design principle for living organisms. Am J Physiol Lung Cell Mol Physiol. 1991;261:L361–9.Google Scholar
  37. 37.
    Glenny RW. Blood flow distribution in the lung. Chest. 1998;114:8S–16.PubMedCrossRefGoogle Scholar
  38. 38.
    Altemeier WA, McKinney S, Glenny RW. Fractal nature of regional ventilation distribution. J Appl Physiol. 2000;88:1551–7.PubMedGoogle Scholar
  39. 39.
    Hughes JMB, Glazier JB, Maloney JE, et al. Effect of lung volume on the distribution of pulmonary blood flow in man. Respir Physiol. 1968;4:58–72.PubMedCrossRefGoogle Scholar
  40. 40.
    West JB. Regional differences in gas exchange in the lung of erect man. J Appl Physiol. 1962;17:893–8.PubMedGoogle Scholar
  41. 41.
    Wagner PD, Dantzker DR, Dueck R, et al. Ventilation-perfusion inequality in chronic obstructive pulmonary disease. J Clin Invest. 1977;59:203–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Bradford J, Dean H. The pulmonary circulation. J Physiol. 1894;16:34–96.PubMedGoogle Scholar
  43. 43.
    Von Euler U, Liljestrand G. Observations on the pulmonary arterial pressure in the cat. Acta Physiol Scand. 1946;12:301–20.CrossRefGoogle Scholar
  44. 44.
    Duke HN. Pulmonary vasomotor responses of isolated perfused cat lungs to anoxia and hypercapnia. Q J Exp Physiol. 1951;36:75–88.Google Scholar
  45. 45.
    Bergofsky EH, Haas F, Porcelli R. Determination of the sensitive vascular sites from which hypoxia and hypercapnia elicit rises in pulmonary arterial pressure. Fed Proc. 1968;27:1420–5.PubMedGoogle Scholar
  46. 46.
    Domino KB, Wetstein L, Glasser SA, et al. Influence of mixed venous oxygen tension (PvO2) on blood flow to atelectatic lung. Anesthesiology. 1983;59:428–34.PubMedCrossRefGoogle Scholar
  47. 47.
    Marshall C, Marshall BE. Influence of perfusate PO2 on hypoxic pulmonary vasoconstriction in rats. Circ Res. 1983;52:691–6.PubMedGoogle Scholar
  48. 48.
    Marshall BE, Marshall C, Benumof J, et al. Hypoxic pulmonary vasoconstriction in dogs: effects of lung segment size and oxygen tension. J Appl Physiol. 1981;51:1543–51.PubMedGoogle Scholar
  49. 49.
    Naeije R, Lejeune P, Leeman M, et al. Pulmonary vascular responses to surgical chemodenervation and chemical sympathectomy in dogs. J Appl Physiol. 1989;66:42–50.PubMedGoogle Scholar
  50. 50.
    Lejeune P, Vachiaery JL, Leeman M, et al. Absence of parasympathetic control of pulmonary vascular pressure-flow plots in hyperoxic and hypoxic dogs. Respir Physiol. 1989;78:123–33.PubMedCrossRefGoogle Scholar
  51. 51.
    Robins ED, Theodore J, Burke CM, et al. Hypoxic vasoconstriction persists in the human transplanted lung. Clin Sci. 1987;72:283–7.Google Scholar
  52. 52.
    Aaronson PI, Robertson TP, Knock GA, et al. Hypoxic pulmonary vasoconstriction: mechanisms and controversies. J Physiol. 2006;570:53–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Sommer N, Dietrich A, Schermuly RT, et al. Regulation of hypoxic pulmonary vasoconstriction: basic mechanisms. Eur Respir J. 2008;32:1639–51.PubMedCrossRefGoogle Scholar
  54. 54.
    Waypa GB, Chandel NS, Schumacker PT. Model for hypoxic pulmonary vasoconstriction involving mitochondrial oxygen sensing. Circ Res. 2001;88:1259–66.PubMedCrossRefGoogle Scholar
  55. 55.
    Evans AM, Dipp M. Hypoxic pulmonary vasoconstriction: cyclic adenosine diphosphate-ribose, smooth muscle Ca2+ stores and the endothelium. Respir Physiol Neurobiol. 2002;132:3–15.PubMedCrossRefGoogle Scholar
  56. 56.
    Yamamoto Y, Nakano H, Ide H, et al. Role of airway nitric oxide on the regulation of pulmonary circulation by carbon dioxide. J Appl Physiol. 2001;91:1121–30.PubMedGoogle Scholar
  57. 57.
    Talbot NP, Balanos GM, Dorrington KL, et al. Two temporal components within the human pulmonary vascular response to 2 h of isocapnic hypoxia. J Appl Physiol. 2005;98:1125–39.PubMedCrossRefGoogle Scholar
  58. 58.
    Weissmann N, Zeller S, Schafer RU, et al. Impact of mitochondria and NADPH oxidases on acute and sustained hypoxic pulmonary vasoconstriction. Am J Respir Cell Mol Biol. 2006;34:505–13.PubMedCrossRefGoogle Scholar
  59. 59.
    Nunn JF. Factors influencing the arterial oxygen tension during halothane anaesthesia with spontaneous respiration. Br J Anaesth. 1964;36:327–41.PubMedCrossRefGoogle Scholar
  60. 60.
    Brismar B, Hedenstierna G, Lundquist H, et al. Pulmonary densities during anesthesia with muscular relaxation – a proposal of atelectasis. Anesthesiology. 1985;62:422–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Lundquuist H, Hedenstierna G, Strandberg A, et al. CT-assessment of dependent lung densities in man during general anesthesia. Acta Radiol. 1995;36:626–32.CrossRefGoogle Scholar
  62. 62.
    Reber A, Bein T, Hogman M, et al. Lung aeration and pulmonary gas exchange during lumbar epidural anaesthesia and in the lithotomy position in elderly patients. Anaesthesia. 1998;53:854–61.PubMedCrossRefGoogle Scholar
  63. 63.
    Tenling A, Joachimsson PO, Tyden H, et al. Thoracic epidural anesthesia as an adjunct to general anesthesia for cardiac surgery: effects on ventilation-perfusion relationships. Anesthesiology. 1987;66:157–67.CrossRefGoogle Scholar
  64. 64.
    Magnusson L, Spahn DR. New concepts of atelectasis during general anaesthesia. Br J Anaesth. 2003;91:61–72.PubMedCrossRefGoogle Scholar
  65. 65.
    Froese AB, Bryan AC. Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology. 1974;41:242–55.PubMedCrossRefGoogle Scholar
  66. 66.
    Warner DO, Warner MA, Ritman EL. Atelectasis and chest wall shape during halothane anesthesia. Anesthesiology. 1996;85:49–59.PubMedCrossRefGoogle Scholar
  67. 67.
    Reber A, Nylund U, Hedenstierna G. Position and shape of the diaphragm: implications for atelectasis formation. Anaesthesia. 1998;53:1054–61.PubMedCrossRefGoogle Scholar
  68. 68.
    Loring SH, Butler JP. Gas exchange in body cavities. In: Farhi LE, Tenney SM, editors. Handbook of physiology. Section 3. The respiratory system. Volume 4, gas exchange. Bethesda, MD: American Physiological Society; 1987. p. 283–95.Google Scholar
  69. 69.
    Joyce CJ, Baker AB, Kennedy RR. Gas uptake from an unventilated area of the lung: computer model of absorption atelectasis. J Appl Physiol. 1993;74:1107–16.PubMedGoogle Scholar
  70. 70.
    Joyce CJ, Williams AB. Kinetics of absorption atelectasis during anesthesia: a mathematical model. J Appl Physiol. 1999;86:1116–25.PubMedGoogle Scholar
  71. 71.
    Rothen HU, Sporre B, Engberg G, et al. Influence of gas composition on recurrence of atelectasis after a re-expansion maneuver during general anesthesia. Anesthesiology. 1995;82:832–42.PubMedCrossRefGoogle Scholar
  72. 72.
    Domino KB, Borowec L, Alexander CM, et al. Influence of ­isoflurane on hypoxic pulmonary vasoconstriction in dogs. Anesthesiology. 1986;64:423–9.PubMedCrossRefGoogle Scholar
  73. 73.
    Abe K, Mashimo T, Yoshiya I. Arterial oxygenation and shunt fraction during one-lung ventilation: a comparison of isoflurane and sevoflurane. Anesth Analg. 1998;86:1266–70.PubMedGoogle Scholar
  74. 74.
    Pagel PS, Fu JL, Damask MC, et al. Desflurane and isoflurane produce similar alterations in systemic and pulmonary hemodynamics and arterial oxygenation in patients undergoing one-lung ventilation during thoracotomy. Anesth Analg. 1998;87:800–7.PubMedGoogle Scholar
  75. 75.
    Schwarzkopf K, Schreiber T, Preussler N-P, et al. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Cardiothorac Vasc Anesth. 2003;17:73–5.PubMedCrossRefGoogle Scholar
  76. 76.
    Benumof JL, Wahrenbrock EA. Local effects of anesthetics on regional hypoxic pulmonary vasoconstriction. Anesthesiology. 1975;43:525–32.PubMedCrossRefGoogle Scholar
  77. 77.
    Reid CW, Slinger PD, Lenis S. A comparison of the effects of propofol-alfentanil versus isoflurane anesthesia on arterial oxygenation during one-lung ventilation. J Cardiothorac Vasc Anesth. 1996;10:860–3.PubMedCrossRefGoogle Scholar
  78. 78.
    Beck DH, Doepfmer UR, Sinemus C, et al. Effects of sevoflurane and propofol on pulmonary shunt fraction during one-lung ventilation for thoracic surgery. Br J Anaesth. 2001;86:38–43.PubMedCrossRefGoogle Scholar
  79. 79.
    Ishibe Y, Shiokawa Y, Umeda T, et al. The effect of thoracic epidural anesthesia on hypoxic pulmonary vasoconstriction in dogs: an analysis of the pressure-flow curve. Anesth Analg. 1996;82:1049–55.PubMedGoogle Scholar
  80. 80.
    Parsons GH, Leventhal JP, Hansen MM, et al. Effect of sodium nitroprusside on hypoxic vasoconstriction in the dog. J Appl Physiol. 1981;51:288–92.PubMedGoogle Scholar
  81. 81.
    Casthely PA, Lear S, Cottrell JE, et al. Intrapulmonary shunting during induced hypotension. Anesth Analg. 1982;61:231–5.PubMedCrossRefGoogle Scholar
  82. 82.
    Kato R, Sato J, Hishino T. Milrinone decreases both pulmonary arterial and venous resistances in the hypoxic dog. Br J Anaesth. 1998;81:920–4.PubMedGoogle Scholar
  83. 83.
    Weissmann N, Gerigk B, Kocer O, et al. Hypoxi-induced pulmonary hypertension: different impact of iloprost, sidenafil, and nitric oxide. Respir Med. 2007;101:2125–32.PubMedCrossRefGoogle Scholar
  84. 84.
    Reichenberger F, Kohstall MG, Seeger T, et al. Effect of sildenafil on hypoxia-induced changes in pulmonary circulation and right ventricular function. Respir Physiol Neurobiol. 2007;159:196–201.PubMedCrossRefGoogle Scholar
  85. 85.
    Fesler P, Pagnamenta A, Rondelet B, et al. Effects of sildenafil on hypoxic pulmonary vascular function in dogs. J Appl Physiol. 2006;101:1085–90.PubMedCrossRefGoogle Scholar
  86. 86.
    Kiely DG, Cargill RI, Lipworth BJ. Angiotensin II receptor blockade and effects on pulmonary hemodynamics and hypoxic pulmonary vasoconstriction in humans. Chest. 1996;110:698–703.PubMedCrossRefGoogle Scholar
  87. 87.
    Cargill RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction in humans. Chest. 1996;109:424–9.PubMedCrossRefGoogle Scholar
  88. 88.
    McMurty IF, Petrun MD, Reeves JT. Lungs from chronically hypoxic rats have decreased pressor response to acute hypoxia. Am J Physiol. 1978;235:H104–9.Google Scholar
  89. 89.
    Weissmann N, Nollen M, Gerigk B, et al. Down-regulation of hypoxic vasoconstriction by chronic hypoxia in rabbits: effects of nitric oxide. Am J Physiol. 2003;284:H931–8.Google Scholar
  90. 90.
    Wagner PD, Laravuso B, Goldzimmer E, et al. Distributions of ventilation-perfusion ratios in dogs with normal and abnormal lungs. J Appl Physiol. 1975;38:1099–109.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • J. Michael Jaeger
    • 1
  • Randal S. Blank
    • 2
  1. 1.Department of Anesthesiology, Divisions of Critical Care Medicine and Cardiothoracic AnesthesiaUniversity of Virginia Health SystemCharlottesvilleUSA
  2. 2.Department of AnesthesiologyUniversity of VirginiaCharlottesvilleUSA

Personalised recommendations