Cardiovasculair stelsel ademhaling nier en urinewegen
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Cardiovasculair stelsel ademhaling nier en urinewegen
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2023-2024 Fysiologie van het
ademhalingsstelsel
Cardiovasculair stelsel, ademhaling, nier
en urinewegen
Emma Degroote
2DE BACH GENEESKUNDE
,Inhoudsopgave
Algemene inleidende begrippen ..................................................................................................................... 5
De inwendige en uitwendige ademhaling .......................................................................................................... 5
Geleidingszone en uitwisselingszone .................................................................................................................. 6
Geleidingszone............................................................................................................................................... 6
Uitwisselingszone .......................................................................................................................................... 6
Func8onele aspecten van de luchtwegenstructuur ............................................................................................ 6
LuchtstroomkarakterisCeken ......................................................................................................................... 6
Klaring van luchtwegen .................................................................................................................................. 7
Aerodynamische filtraCe ........................................................................................................................... 7
Mucociliair transport ................................................................................................................................ 7
Chronische ontstekingen ...................................................................................................................... 8
Belangrijke fysische aspecten van gassen ...................................................................................................... 8
Het begrip parCële druk of spanning ........................................................................................................ 8
BevochCgde lucht...................................................................................................................................... 8
ParCële druk van een gas in een vloeistof................................................................................................. 8
Gasvolumes en correcCefactoren ............................................................................................................. 8
OmzeQng tussen types voorwaarden.................................................................................................. 9
Longven2la2e ............................................................................................................................................... 10
De adembeweging ............................................................................................................................................ 10
Longen in rust en de funcConele residuele capaciteit (FRC)........................................................................ 10
Subatmosferische of negaCeve druk ....................................................................................................... 10
Pathologie ............................................................................................................................................... 10
De inademing ............................................................................................................................................... 11
De uitademing ............................................................................................................................................. 11
Opmerking: ............................................................................................................................................. 11
Drukveranderingen in de thorax als gevolg van de adembewegingen ........................................................ 11
Intrapulmonale of alveolaire druk .......................................................................................................... 12
Intrapleurale druk ................................................................................................................................... 12
Transmurale druk .................................................................................................................................... 12
Regionale verschillen in venClaCe (ongelijkmaCge venClaCe) ..................................................................... 13
Liggende houding .................................................................................................................................... 13
Staande houding ..................................................................................................................................... 13
Pathologie ............................................................................................................................................... 13
Longvolumes, longcapaciteiten en spirometrie ................................................................................................ 13
De vier klassieke longvolumes ..................................................................................................................... 13
Meten van residueel volume .................................................................................................................. 13
Verdunningsmethode ......................................................................................................................... 13
Totale lichaamsplethysmograaf .......................................................................................................... 14
De longcapaciteiten ..................................................................................................................................... 14
Longvolumes zijn verschillend ................................................................................................................ 14
Dynamische parameters .............................................................................................................................. 14
De 1-secondewaarde en Tiffeneau index ................................................................................................ 14
De piekstroom ......................................................................................................................................... 15
Maximale voluntary venClaCon (MVV) ................................................................................................... 15
Dode ruimte en alveolaire venClaCe ........................................................................................................... 15
Anatomische en fysiologische dode ruimte ............................................................................................ 15
Bepalen fysiologische dode ruimte .................................................................................................... 15
Alveolaire venClaCe (VA) ......................................................................................................................... 16
Ademhalingsweerstanden en ademarbeid ....................................................................................................... 16
Dynamische of wrijvingsweerstand ............................................................................................................. 16
1
, Algemeen ................................................................................................................................................ 16
Het transmuraal drukgradiënt – dynamische luchtwegencompressie .................................................... 17
Invloed van transmuraal drukgradiënt ............................................................................................... 17
Gevolgen van dynamische luchtwegencompressie ............................................................................ 17
Veranderingen in tonus van de bronchomotoren ................................................................................... 18
EvaluaCe van luchtwegenweerstand ....................................................................................................... 18
StaCsche (of elasCsche) weerstand (complianCe) ....................................................................................... 19
ComplianCe van de long ......................................................................................................................... 19
Voordelen van surfactans ................................................................................................................... 19
Surfactans en prematuur.................................................................................................................... 20
ComplianCe van de thorax ...................................................................................................................... 20
Gasuitwisseling in de longen ......................................................................................................................... 21
Alveolaire lucht ................................................................................................................................................. 21
Bepalen van PAO2 en PACO2 uit alveolaire venClaCevergelijkingen: ............................................................. 21
Gasuitwisseling doorheen het alveolo-capillaire membraan............................................................................ 22
Zuurstof........................................................................................................................................................ 22
Koolstofdioxide ............................................................................................................................................ 22
Transport gassen doorheen alveolo-capillaire membraan ............................................................................... 22
Debiet- of diffusie-gelimiteerde opname..................................................................................................... 22
Opname van een gas ................................................................................................................................... 23
Drukgradiënt ................................................................................................................................................ 23
Klinische toepassing: ............................................................................................................................... 23
Longdiffusiecapaciteit .................................................................................................................................. 23
Determinanten van de longdiffusiecapaciteit van een gas ..................................................................... 23
Totaal oppervlak van de alveolo-capillaire membraan ....................................................................... 23
Eigenschappen van het gas ................................................................................................................ 24
Dikte van het membraan .................................................................................................................... 24
Bepalen van de longdiffusiecapaciteit .................................................................................................... 24
Het respiratoir quo8ënt .................................................................................................................................... 24
Longdoorbloeding – kleine bloedsomloop..................................................................................................... 25
Druk, volume en debiet in de longcircula8e ..................................................................................................... 25
Invloed van de zwaartekracht .......................................................................................................................... 25
Regula8e van de longcircula8e ........................................................................................................................ 26
Rechts-links shunt = veneuze bijmenging ......................................................................................................... 26
Opmerking: .................................................................................................................................................. 26
Transport ademhalingsgassen in het bloed.................................................................................................... 27
ZuurstoPransport ............................................................................................................................................. 27
Rol van hemoglobine in het transport van zuurstof .................................................................................... 27
Hemoglobine en oxyhemoglobine .......................................................................................................... 27
De O2-hemoglobine dissociaCecurve/ hemoglobine-desaturaCecurve .................................................. 27
Oxyhemoglobine-dissociaCecurve ..................................................................................................... 28
Verschuivingen in de dissociaCecurve .................................................................................................... 28
Methemoglobine .................................................................................................................................... 29
De zuurstofcascade in het organisme ..................................................................................................... 29
Transport van CO2 ............................................................................................................................................. 29
3 manieren van CO2 transport ..................................................................................................................... 29
Ven2la2e/perfusie verhouding ..................................................................................................................... 30
Invloed van houding op ven8la8e/perfusie verhouding ................................................................................... 30
2
, Invloed van V/Q op samenstelling van de alveolaire lucht ............................................................................... 30
Stoornissen van de V/Q verhouding.................................................................................................................. 30
V/Q stoornis door relaCef verminderde doorbloeding ................................................................................ 31
V/Q stoornis door relaCef verminderde (ongelijkmaCge) venClaCe ............................................................ 31
Oorzaken van verminderde venClaCe: .................................................................................................... 31
Gecompenseerde V/Q stoornis .................................................................................................................... 31
Fasen van compensaCe van de 𝑉𝐴𝑄 stoornissen ................................................................................... 31
IniCële theoreCsche fase .................................................................................................................... 31
Tweede fase: gecompenseerde V/Q stoornis ..................................................................................... 31
Derde fase: laaQjdige, niet-compenseerde 𝑉𝐴𝑄 stoornis ................................................................. 32
Evalueren van een ven8la8e/perfusie stoornis ................................................................................................. 32
Regula2e van de ademhaling ........................................................................................................................ 33
Algemeen.......................................................................................................................................................... 33
Ademhalingscentra in de hersenstam en ritmogenese..................................................................................... 34
Verschillende hersendelen en hun funcCe bij ademhaling .......................................................................... 34
Medulla ................................................................................................................................................... 34
Pons......................................................................................................................................................... 34
Cortex ...................................................................................................................................................... 34
SecCe op verschillende niveaus en hun effecten ......................................................................................... 34
Chemische regula8e van de ademhaling .......................................................................................................... 34
Chemoreceptoren ........................................................................................................................................ 35
Perifere chemoreceptoren ...................................................................................................................... 35
Centrale chemoreceptoren ..................................................................................................................... 35
Verband longvenClaCe en zuur-base evenwicht .......................................................................................... 35
VenClaCe stoornissen en respiratoire zuur-base stoornissen ................................................................. 35
Metabole stoornissen en venClaCeverandering ..................................................................................... 36
Invloed van CO2 en O2 op de venClaCe ........................................................................................................ 36
Invloed van CO2 ....................................................................................................................................... 36
Acuut effect ........................................................................................................................................ 36
Chronisch effect.................................................................................................................................. 36
Invloed van O2-tekort .............................................................................................................................. 36
Acuut effect ........................................................................................................................................ 36
Chronisch effect.................................................................................................................................. 36
Invloed van wijzigingen in PCO2 en PO2 .................................................................................................. 37
Neurogene regula8e van de ademhaling ......................................................................................................... 37
Invloed vanuit andere centra in het centraal zenuwstelsel ......................................................................... 37
Reflexen vanuit longen en luchtwegen en de intrapulmonale receptoren .................................................. 37
Stretchreceptoren en reflex van Hering en Breuer ................................................................................. 37
Irritant receptoren .................................................................................................................................. 38
J-receptoren ............................................................................................................................................ 38
Hoesten en niezen................................................................................................................................... 38
Andere ademhalingsreflexen ....................................................................................................................... 39
De ademhaling in speciale omstandigheden.................................................................................................. 40
Inspanning ........................................................................................................................................................ 40
Inspanning en venClaCe............................................................................................................................... 40
Verband ademhaling en hypoxie ...................................................................................................................... 41
Hypox(em)ische hypoxie ................................................................................................................................... 41
Aanpassing aan de hoogte ........................................................................................................................... 41
HypervenClaCe (+tachycardie) ................................................................................................................ 41
AcCvaCe hypoxie-induceerbare factor 1 HIF-1........................................................................................ 42
3
, Hypox(em)ische hypoxie door ademhalingsproblemen (PaO2 < 60 mm Hg) ............................................... 42
HypovenClaCe (‘pompvalen’).................................................................................................................. 42
Diffusiestoornis (‘alveolo-capillair blok’) ................................................................................................. 42
Rechts-links shunt ................................................................................................................................... 42
Alveolaire hypovenClaCe ........................................................................................................................ 43
Opmerking .............................................................................................................................................. 43
Ademefficiën8e bij rokers ................................................................................................................................. 44
Effecten van hypox(em)ie en hypercapnie ........................................................................................................ 44
Hypox(em)ie ................................................................................................................................................ 44
Hypercapnie ................................................................................................................................................. 44
Behandeling van ademproblemen-toediening van zuurstof ............................................................................. 45
Toediening van zuurstof ............................................................................................................................... 45
Risico’s van O2-therapie .......................................................................................................................... 45
Hyperbare O2-therapie (3 atmosfeer) ..................................................................................................... 45
, Algemene inleidende begrippen
De inwendige en uitwendige ademhaling
Ademhaling in fysiologie = alle gasuitwisselingen tussen de cellen van het lichaam en de
buitenwereld:
- Inwendige ademhaling: gasuitwisseling tussen cel en extracellulair milieu
ñ Biochemische intracellulaire processen: aërobe energieproducDe
- Uitwendige ademhaling: uitwisseling O2 en CO2 tussen organisme en omgevingslucht
ñ Uitwisseling aangepast aan cel metabolisme: constante PO2 en PCO2 in
arterieel bloed
ñ 3 processen:
˃ LongvenDlaDe
˃ Gasuitwisseling thv longen
˃ Gastransport in bloed --> weefsel
Gasuitwisseling = passieve diffusie --> gasdrukgradiënt verzekeren door 2 pompen:
- Thoraxwand met ademspieren: O2-rijke/ CO2-arme lucht in longen
- Hart: O2-arme/CO2-rijke lucht in longen
Vereisten voor gezonde ademhaling:
- Goede venDlaDe: pompwerking van thorax en ademhalingsspieren
- Goede bloedstroom naar longen: pompwerking hart
- Goede gasuitwisseling: longziektes gasuitwisseling = verstoord
ñ Compensatoire venDlaDe toename => onvoldoende
˃ Hypoxemie en hypercapnie
FuncDes van longen:
- Verwijderen van giUige verbindingen
- Metabole acDviteit:
ñ InacDeve verbindingen --> acDeve stoffen (AG I --> AG II)
ñ InacDvaDe: serotonine, bradykinine, noradrenaline
- Filteren microtrombi
- Bloedreservoir
5
,Geleidingszone en uitwisselingszone
Luchtwegen onderverdelen in 2 zones:
- Geleidingszone: 25 cm
- Uitwisselingszone: 0,5 cm
Geleidingszone
= bovenste luchtwegen + onderste luchtwegen tot terminale bronchiolen
- Geen gasuitwisseling
- Volume = 150 ml <--> teugvolume = 500 ml
- Einde uitademing: 150 ml aan alveolaire lucht
ñ Alveolaire lucht = lucht dat heeU deelgenomen aan
gasuitwisseling in alveolen (-O2 + CO2)
ñ Inademen: eerste 150 ml alveolaire lucht in longalveolen
˃ 350 ml verste lucht per teug
- FuncDe: lucht geleiden --> uitwisselingszone + lucht
condiDoneren
ñ Lucht condiDoneren = opwarmen, filteren en
bevochDgen ingeademde lucht
ñ Tracheale lucht ≠ atmosferische lucht: parDële spanning
O2, N2, … ↓
Uitwisselingszone
= zone waar alveolo-capillaire membraan gasuitwisseling tussen lucht en bloed mogelijk is
- Alveole-capillaire membraan = 2 cellagen
ñ Epitheel alveool
ñ Endotheel capillair
- Grootste volume longen: 2,5 – 3 l
- Grote oppervlakte: 50 – 100 m2 => capillairen omspoelen
300 miljoen alveolen
ñ 1 alveool + capillaire omspoeling = respiratoire
eenheid
Func5onele aspecten van de luchtwegenstructuur
Luchtstroomkarakteris7eken
Trachea --> alveolaire zakken
- Diameter: kleiner
- Cross-secDonal area: ∅1 < ∅2 +∅3
ñ 2,5 cm2 --> 2,5 x 5000 cm2
6
, Gevolgen ↑ CSA:
- Luchtstroomsnelheid: geleidingszone >> uitwisselingszone
ñ Uitwisselingszone: gassen staan sDl => beweging moleculen door diffusie
ñ ConcentraDeverschillen weg binnen 1 seconde
˃ Snelheid diffusie
˃ Geringe afstanden
- Luchtstroomweerstand: geleidingszone >> uitwisselingszone
ñ Pathologie: verhoogde weerstand in bronchiolen
˃ Kleinere diameter => gemakkelijk verstopt
˃ Veel gladde spiercellen => makkelijker vernauwen
Aerodynamische filtra5e
Aerodynamische filtraDe op basis van inerDe stofdeeltjes en snelheid luchtstroom
- InerDe = traagheid: wat in beweging is wil in beweging blijven in dezelfde zin
ñ Hoe zwaarder voorwerp hoe groter inerDe
- Doel = lucht progressief zuiveren van stofdeeltjes => slijmvlies kleven
ñ Grote diameter/zwaardere stofdeeltjes: vliegen uit de bocht => nasofarynx
ñ Diameter 2-5 𝜇m: bronchiolen
ñ Diameter < 2 𝜇m: respiratoire bronchiolen en alveolen
˃ Opruimen door pulmonale alveolaire macrofagen --> lymfe
Aerosoltherapie afzehng parDkels aiankelijk van: diepste penetreren parDkels
- Grooje parDkels: klein
- Snelheid van luchtstroom: traag
- Diepte van in-en uitademen: diep inademen na maximale uitademing
Mucociliair transport
Muco-ciliair transport => 2 noodzakelijke onderdelen:
- Mucus uit 2 lagen: droge lucht => indikking
ñ Gel: oppervlakkig en kleverig
ñ Sol: dieper en minder viskeus
- Ciliair = trilharen: verplaatsen gellaag + parDkels --> epiglohs => inslikken
ñ Koude: vermindering van ciliaire beweging
ñ Volledige klaring in 24 uur
˃ Alveolen hebben geen trilhaar => parDkels opruimen door macrofagen
7
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