Dr.

Fachrul Jamal, SpAn KIC

SMF ANESTESIOLOGI & ICU
FK-UNSYIAH/BPK RSUZA
BANDA ACEH

Respiratory System
Functions:
Remove CO2 & replace O2 needed for
metabolism
Maintain acid - base balance (pH)
Maintain body H2O & heat balance
Production of speech
Facilitate the sense of smell

SISTIM RESPIRASI
SSPusat (medula)
SSPerifer (n.frenikus)
Otot-otot pernafasan
Dinding dada
Paru
Jalan nafas atas
Cabang-cabang bronkus
Alveolus
Pembuluh darah paru

Control of Ventilation
Achieved by a complex network of
chemoreceptors that send message to the
brain, which in turn activates the muscles of
breathing via the phrenic nerve
**central chemoreceptors in medulla
oblongata & brain stem which are sensitive
to rising H+ concentration in the CSF (CO2
levels provide a stimulus to breathe)

 Peripheral chemoreceptors in the

carotid bodies and aortic bodies which
are sensitive to O2 levels (hypoxia
provides a stimulus to breath)
especially prominent in those with
chronic CO2 retention, for example,
those with COPD (over time medulla
no longer responds, depend on
HYPOXIC DRIVE )

Ventilation
The respiratory center
and
Central receptors

Peripheral receptors

Sistim respirasi

The respiratory tract

The upper airway

The lower airways

Alveolus

Respiratory Tract
Upper airway
nose
sinuses
pharynx
larynx

Lower airway
trachea
(windpipe)
bronchial tree
gas-exchanging
lung units (e.g.,
alveolar ducts,
alveolar sacs, &
alveoli)

The upper airway

The lower airways

Larynx

Trachea

Respiration
O2
CO2

Mechanisms of Ventilation:
1. Inspiration
Active process
- diaphragm contracts and lowers
- external intercostals contract, elevating the ribs
Result
- diameter and longitudinal dimensions of the thorax,
decreasing the intrapulmonic pressure
(now atmospheric pressure > intrapulmonicpressure)
air flows in from the atmosphere until pressures are =

Mechanisms of Ventilation:
2. Expiration
Passive process
- diaphragm relaxes
- this relaxation, along with lung elasticity (a property
of healthy lungs), increases the intrapulmonic
pressure and forces air out of the lungs (now
intrapulmonic pressure > atmospheric pressure)
- becomes an active process with disease & exercise

External intercostal muscles

The mechanics of breathing

Diaphragm

Inspiration

Diaphragm

Expiration

Spontaneous breathing

Pressure
kPa

Intrapulmonary pressure
0

Intrapleural pressure

-1

Insp.

Exp.

Insp.

Exp.

Time

Controlled
ventilation
Pressure
kPa

+1

Intrapulmonary pressure
0

Intrapleural pressure
-1

Insp.

Exp.

Insp.

Exp.

Time
s

Pressure
kPa

Spontaneous breathing
Intrapulmonary pressure

Intrapleural pressure

-1
Insp.

Pressure
kPa

Exp.

Insp.

Exp.

Time

Controlled ventilation

+1
Intrapulmonary pressure

0
s

Intrapleural pressure

-1
Insp.

Exp.

Time
Insp.

Exp.

Volume

Static lung volumes

6
IRV

IC VC TLC

5
4
3

VT
ERV

2
1
0

FRC
RV

Time
s

3 Processes:
1. Ventilation - movement of air in & out -depends on system of open (clear)
airways & movement of respiratory
muscles, primarily the diaphragm which
is innervated by the phrenic nerve.
2. Diffusion - exchange & transport gases
(need perfusion/pulmonary circulation)
3. Perfusion

PROSES PERNAFASAN
Gabungan mekanisme yang berperan
dalam suplai oksigen keseluruh sel
dan eliminasi karbon dioksida

KOMPONEN YANG BERPERAN

1.
2.
3.

Ventilasi
Difusi
Perfusi

Ventilasi Semenit ( VE )
= Volume Tidal x Frekwensi
= 500 ml x 12 = 6 L/mnt

Ventilasi Alveolar ( VA )
= VE - Vent. Ruang Mati ( VD )
= 6 L/mnt - 1,8 L/mnt = 4,2 L/mnt
Kapasitas Residu Fungsional = Vol. udara dalam
paru pada akhir ekspirasi ,
sekitar 3300 ml, pada laki-laki
sekitar 2300 ml, pada wanita

VENTILASI
Jumlah udara/gas yang mengadakan
pertukaran dalam alveoli setiap menit
Dipengaruhi oleh :

Patensi jalan nafas

Posisi tubuh

Volume paru

Dead space

Shunting

Patensi Jalan Nafas :

obstruksi
Infeksi
tumor

Posisi Tubuh :
tegak
terlentang
miring

Volume Paru :

otot pernafasan
penyakit paru
space occupying lesion
tekanan intra abdominal
nyeri, obat

VENTILATION

Proses transport gas antara alveolus dan

atsmosfir
Pertukaran gas ini akan berkurang pada ;
obstructive
restrictive
combined ventilation disorders
Contoh :
Laparotomi abdomen atas
COPD (Chronic Obstructive Pulmonary Disease)
Status Asthmaticus
CNS dan obat- obatan : sedation, intoxication
Neuromuscular : myasthenia gravis,
muscle relaxant

PERFUSION

Aliran darah paru yang bertanggung jawab

membawa CO2 ke alveoli dan sebaliknya
membawa O2 dari alveoli ke jantung

Perfusion disorder :
Pulmonary embolism
Sumbatan pada mikrosirkulasi paru
karena agregasi platelet dan granulosit :
septicemia
peritonitis
acute pancreatitis
Extra pulmonary : reduced CO pada gagal
jantung, atau pada kondisi syok

SIRKULASI PULMONER
Sifat :

Tekanan pembuluh darah rendah, MAP 8 - 15

mmHg
Mudah mengembang (distensible)
Resistensi rendah

Dalam keadaan istirahat, perfusi pulmoner

sekitar
= 70 ml x 80 x/mnt = 5,6 L/mnt

Pintasan Fisiologis = jumlah darah yang melintas

dari kanan ke kiri tanpa mendapat oksigenisasi dan
dekarboksilasi paru (sekitar 5 % curah jantung)

SHUNTING
(Intrapulmonary Right-to-Left Shunt)
ANATOMICAL

FUNCTIONAL

Bronchial

Atelectasis

Pleural
Thabesian
CHD
(Congenital Heart Disease)
Tumor Paru
Arteriovenous Anastomosis

Pneumothorax
Hematothorax
Pleural effusion
Pulmonary edema
Pneumonia
Acute Respiratory
Failure (ARDS)

DEAD SPACE
Volume udara yang di hirup dalam
satu kali bernafas yang tidak turut
berdifusi dalam alveolus

FUNCTIONAL DEAD SPACE

ANATOMICAL

ALVEOLAR

Physiological
dead space

Ventilation
Alveolar dead space

Anatomical
dead space

Circulation - perfusion

Normal ventilation perfusion balance

Compensatory changes in perfusion for impaired

ventilation impaired ventilation is compensated for by a
reduction in blood flow to the poorly ventilated alveolus,
resulting in better oxygenation of the arterial blood.

Impaired ventilation impaired ventilation of

an alveolus leads to impaired oxygenation.
Physiological shunt.

Impaired perfusion
Normal ventilation of poorly perfused alveoli
results in a large dead space.

Optimum gas exchange

requires:
Ventilation/perfusion match (high V/Q
ratio)
In healthy lungs this ratio is close to 1:1
Perfusion greater in dependent areas of
the lung
Ventilation also greater in dependent
areas of the lung
Measure adequacy of V/Q match through
ABGs

V/Q mismatches
In areas where perfusion > ventilation, a
shunt exists. Blood bypasses the alveoli
without gas exchange occurring (e.g.,
pneumonia, atelectasis, tumor, mucus
plug)
All cause obstruction in the distal
airways, decreasing ventilation

 In areas where ventilation > perfusion,

dead space results. The alveoli do not
have an adequate blood supply for gas
exchange to occur (e.g., pulmonary emboli,
pulmonary infarct, cardiogenic shock).
In areas where both perfusion and
ventilation are limited or absent, a silent
unit exists (e.g., pneumothorax, severe
ARDS).

DETEKSI GANGGUAN PERTUKARAN GAS

Partial pulmonary failure

PaO2, PaCO2 (respiratory alkalosis)

Global pulmonary failure

PaO2 , PaCO2 (respiratory acidosis)

.Hypercapnia
Penyebab :
VT or f ( )

Drug
Anesthesia
CNS
Fatigue

.Hypercapnia
Penyebab lain
Tidak mampu merespon terhadap PaCO2
Obat-obatan
Alkalemia
COPD

Tidak mampu bernafas ok

Spinal cord injury

Neuromuscular blocker
Guillain-Barre` Syndrome
Myasthenia Gravis

Otot pernafasan yang lemah ok

Fatique, Malnutrition, Dystrophy

..Hypoxemia
P (A-a) O2 gradient
PAO2 = FiO2 ( PB - 47 ) ( 1.25 PACO2 )
PAO2 = PO2 alveolar
FiO2 = Oxygen Fraction
PB = Barometric Pressure

P (A-a) O2 Adult : < 10 torr (<1,3 kPa )

Umumnya : < 20 torr ( < 2,7 kPa )

HYPOXEMIA
Penyebab SHUNT EFFECT yang lain
Difusi () melalui alveolocapillary
membrane complex :
interstitial edema
inflammation
fibrosis, etc.

Alveolar hypoventilation
High Altitude

Diffusion
Transport of gases between the alveoli and
(pulmonary) capillaries and eventually from the
capillaries to the tissues
diffusion dependent on perfusion and the partial
pressure (pp) exerted by each gas (each gas in
a mixture of gases exerts a partial pressure, a
property determined by the concentration of the
gas)
gases diffuse from area of conc. (pp) to
conc. (pp)

 concentration pp of gas
diffusion
CO2 more soluble than O2, therefore it
diffuses faster

Factors Affecting Diffusion

surface area in the lung (e.g.,
lobectomy, atelectasis, emphysema)
thickness of alveolar-capillary membrane
(e.g., edema, pneumonia)
differences in partial pressure of gases
on either side
Characteristics of the gas (CO2 diffuses
faster)

Summary of gas exchange and gas transport

Pulmonary capillary
Alveolus

Artery

Cell
Tissue capillary

Summary of gas exchange and gas transport

Tissue capillary

Cell

Vein

Alveolus
Pulmonary capillary

Oxygenation
UDARA BEBAS:
PiO2

21% x 760 = 160 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg

PiN2

ALVEOLUS

: 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg

N2

H2O

PAN2:
573 mmHg

PROSES DIFUSI

PAO2:
104 mmHg

Pulmonary Artery O2
PvO2:
40
mmHg

O2

CO2

PAH2O:
47 mmHg
PACO2:
40 mmHg

CO2

KAPILER PARU

Pulmonary Vein

PaO2
O2

CO2

PcCO2: 45
PcCO2: 40
PcO2: 100
mmHg
mmHg
mmHg

PAO2 PcO2

Ventilation
The respiratory center
and
Central receptors

Peripheral receptors

Ventilation

The normal regulation of breathing

The blood

Receptors

Signal to the respiratory center

Muscular activity

Central

Low pH

Hyperventilation

Peripheral

High pH

Hypoventilation

PaCO2

The regulation of breathing in a patient with

Chronic lung disease
The blood

Receptors

PaCO2

Peripheral

Signal to the respiratory center

Muscular activity

Low PaO2

Hyperventilation

High PaO2

Hypoventilation

The normal regulation of breathing

Receptors

The blood

Signal to the respiratory center

Muscular activity

Central

Low pH

Hyperventilation

Peripheral

High pH

Hypoventilation

PaCO2

The regulation of breathing in a patient with

Chronic lung disease
Signal to the respiratory center

The blood
PaCO2

Receptors

Muscular activity

Low PaO2

Hyperventilation

High PaO2

Hypoventilation

Peripheral

GANGGUAN SISTEM PERNAFASAN & PENYEBAB

OTAK

SYARAF

OTOT

JALAN NAFAS
ASTHMABRONCHIALE

TRAUMA

NARKOTIKA
DEPRESSANT / ANESTHETIC
INFEKSI , PERDARAHAN
GUILLAIN BARRE

POLIOMYELITIS , POLINEUROSIS
MYASTHENIA GRAVIS

TETANUS

RELAXANT / CURARE

ALVEOLI

RONGGA THORAX

EDEMA PARU

FRACTURE COSTAE

ATELEKTASIS

PNEUMOTHORAX
HEMATOTHORAX