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Volledige samenvatting ademhalingsfysiologie (prof. Neyrinck)
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ADEMHALING FYSIOLOGIE1 Organisatie vh respiratoir systeem ............................................................................. 5
1.1 Definitie vh respiratoir systeem ..................................................................................... 5
1.2 Samenstelling van lucht ................................................................................................. 5
1.2.1 Bloedgaswaarden ............................................................................................................................... 5
1.2.2 Vochtige lucht vs droge lucht ............................................................................................................. 5
1.3 De alveool: funtionele unit............................................................................................. 6
1.4 Meer dan alleen maar ademhaling ................................................................................. 6
1.5 Spirogram...................................................................................................................... 6
2 Statische mechanica vd ventilatie ............................................................................... 7
2.1 Balans tussen long en thoraxwand ................................................................................. 7
2.1.1 Intrapleurale ruimte ........................................................................................................................... 7
2.2 Inademen ...................................................................................................................... 7
2.3 Uitademen .................................................................................................................... 8
2.4 Druk-volume relatie vd long ........................................................................................... 8
2.4.1 Compliantie afgeleid van PV-relatie ................................................................................................... 8
2.5 Transmurale & transpulmonale druk .............................................................................. 9
2.6 Waarom heeft long neiging om plat te vallen? ................................................................ 9
2.6.1 Oppervlaktespanning.......................................................................................................................... 9
3 Dynamische mechanica vd ventilatie ........................................................................ 10
3.1 Soorten luchtstroomen in een buis ............................................................................... 10
3.1.1 Reynolds getal................................................................................................................................... 10
3.2 Weerstand bepaald door… ........................................................................................... 10
3.2.1 Luchtstroom & stromingstype .......................................................................................................... 11
3.2.2 Regulatie AZS .................................................................................................................................... 11
3.2.3 Regulatie door humorale factoren ................................................................................................... 11
3.2.4 Effect van longvolume zelf ............................................................................................................... 11
3.3 Longziektes.................................................................................................................. 11
3.3.1 Obstructieve ..................................................................................................................................... 11
3.3.2 Restrictieve ....................................................................................................................................... 11
3.4 Ademcyclus ................................................................................................................. 11
3.5 Dynamische compressie ............................................................................................... 12
4 O2 en CO2 transport in bloed .................................................................................... 13
4.1 Transport van O2 ......................................................................................................... 13
4.1.1 O2 kan zich oplossen in plasma ........................................................................................................ 13
1
, 4.1.2 Hoeveel O2 verbruiken wij? ............................................................................................................. 13
4.1.3 Hemoglobine .................................................................................................................................... 13
4.1.3.1 Wat is hemoglobine (niet op examen) .................................................................................... 13
4.1.3.2 Verschillende hemoglobine moleculen ................................................................................... 13
4.1.3.3 Belang van hemoglobine in de kliniek ..................................................................................... 13
4.1.4 Hoeveel O2 gebonden aan hemoglobine? ....................................................................................... 14
4.1.4.1 O2 capaciteit: 1,39 ml O2/gram Hb ......................................................................................... 14
4.1.4.2 Saturatie van Hb ...................................................................................................................... 14
4.1.5 Hb-O2 dissociatie curve .................................................................................................................... 14
4.1.5.1 Oxygen content ........................................................................................................................ 14
4.1.5.2 4 facotren bepalen shift van curve .......................................................................................... 15
4.2 Transport van CO2 ....................................................................................................... 15
4.2.1 Hoofdzakelijk onder vorm van HCO3- .............................................................................................. 15
4.2.2 Verschil arterieel en veneus ............................................................................................................. 15
4.2.3 CO2 dissociatiecurve......................................................................................................................... 15
5 Gasuitwisseling id long: diffusie................................................................................ 16
5.1 Wet van Fick ................................................................................................................ 16
5.1.1 DL bepaald door ................................................................................................................................ 16
5.1.2 Formule ............................................................................................................................................. 16
5.1.3 Diffusie van O2 is complexer: redenen: ........................................................................................... 16
5.1.3.1 Reden 1: variatie van oppervlakte en dikte wand ................................................................... 16
5.1.3.2 Reden 2: variatie van PO2 en PCO2 in alveool (tijd en plaats) ................................................ 17
5.1.3.3 Reden 3: variatie van PO2 in capillair ...................................................................................... 17
5.2 ‘Eindresultaat’ = principe van Fick ................................................................................ 17
5.3 Diffusie-limitatie van gastransport/uptake over alveolaire wand .................................. 18
5.3.1 Beschrijven adhv CO inademen (0,1%)............................................................................................. 18
5.4 Perfusie-limitatie ......................................................................................................... 19
5.4.1 Beschrijven adhv N2O (lachgas) inademen ....................................................................................... 19
5.5 O2 en CO2 perfusie of diffusie limitatie ........................................................................ 19
5.5.1 Hevig sporten .................................................................................................................................... 20
5.5.2 Grote hoogte: diffusie-limitatie ........................................................................................................ 20
5.5.3 Pathologische omstandigheden: diffusie verminderen ................................................................... 20
6 Perfusie vh respiratoir systeem ................................................................................. 21
6.1 Pulmonale circulatie gekenmerkt door lage perfusiedrukken ........................................ 21
6.1.1 Als druk in rechter circulatie stijgt dan: ............................................................................................ 21
6.1.2 Pulmonaal circulatie vs systeem circulatie ....................................................................................... 21
6.1.3 Hoge compliantie in pulmonaal circulatie ........................................................................................ 21
6.1.4 Lage weerstand in pulmonaal circulatie ........................................................................................... 22
6.1.5 PVR is zeer onderhevig aan externe factoren .................................................................................. 22
6.1.5.1 Longvolume.............................................................................................................................. 22
6.1.5.2 Pulmonaal arteriële druk ......................................................................................................... 23
6.1.5.3 Recruitment en distentie ......................................................................................................... 23
6.1.5.4 Mediatoren: specifieke situaties/agentia ................................................................................ 24
6.1.5.5 PVR meten in klinische praktijk ............................................................................................... 25
2
, 6.2 Zijn er regionale verschillen id perfusie vd long? ........................................................... 25
6.2.1 Zwaartekracht en houding ............................................................................................................... 25
6.2.2 Zones van West................................................................................................................................. 25
6.2.2.1 Zone 1: top vd long: PA > PPA > PPV ........................................................................................... 26
6.2.2.2 Zone 2: apex tot midden long: PPA > PA > PPV ........................................................................... 26
6.2.2.3 Zone 3: Midden tot laag id long: PPA > PPV > PA ....................................................................... 26
6.2.2.4 Zone 4: uiterst basaal id long: PPA > PPV > PA ............................................................................ 27
6.3 Zien we ook regionale verschillen in ventilatie? ............................................................ 27
7 Ventilatie/perfusie-verhouding ................................................................................ 28
7.1 Ventilatie .................................................................................................................... 28
7.1.1 Alveolaire ventilatie vergelijking = totale ventilatie – dode ruimte ventilatie ................................. 28
7.1.1.1 Alveolaire PCO2 in alveool, is omgekeerd evenredig met ventilatie ...................................... 28
7.1.2 De alveolaire gas vergelijking ........................................................................................................... 29
7.1.3 Alveolaire ventilatie vgl en alveolaire gas vgl gecombineerd .......................................................... 29
7.1.3.1 Verband PCO2 en PO2 in alveool............................................................................................. 29
7.2 Ventilatie-perfusie verhouding..................................................................................... 29
7.2.1 Ventilatie en perfusie ....................................................................................................................... 29
7.2.2 Bepaald door effecten van zwaartekracht ....................................................................................... 30
7.2.2.1 Ventilatie/Perfusie verhouding varieert op verschillende hoogtes id long............................. 30
7.2.3 Alveolaire dode ruimte ventilatie ..................................................................................................... 31
7.2.3.1 1 vd 2 longen bloeddoorstroming aflsuiten ............................................................................ 31
7.2.4 Shunt: perfusie van alveolen die niet geventileerd zijn ................................................................... 32
7.3 Zuurstoftransportcascade ............................................................................................ 32
8 Controle vd ventilatie ............................................................................................... 33
8.1 Controle is cruciaal ...................................................................................................... 33
8.2 Componenten van ademcircuit om controle uit te voeren............................................. 33
8.2.1 Centrale controle .............................................................................................................................. 33
8.2.1.1 Ritmische output van CZS ........................................................................................................ 33
8.2.1.2 RRN........................................................................................................................................... 33
8.2.1.3 Eupnea ..................................................................................................................................... 33
8.2.2 Effectoren ......................................................................................................................................... 34
8.2.2.1 Uitademhalingsspieren ............................................................................................................ 34
8.2.2.2 Inademhalingsspieren .............................................................................................................. 34
8.2.3 Sensoren ........................................................................................................................................... 34
8.3 Central pattern generator (CPG) = plaats in centrale controle ....................................... 34
8.3.1 Inspiratoire en expiratoire neuronen id medulla ............................................................................. 34
8.3.2 Dorsale en Ventrale respiratoire groep ............................................................................................ 34
8.3.3 Neuronactiviteit in hersenstam ........................................................................................................ 34
8.4 Chemische controle van ventilatie................................................................................ 35
8.4.1 Perifere chemoreceptoren ............................................................................................................... 35
8.4.1.1 Verschillende plaatsen ............................................................................................................. 35
8.4.1.2 3 belangrijke parameters ......................................................................................................... 35
8.4.2 Centrale chemoreceptoren .............................................................................................................. 35
8.4.3 Integratie van receptoren ................................................................................................................. 35
3
, 8.4.3.1 Respons op hypercapnie beinvloed door hypoxie: ................................................................. 35
8.4.3.2 Respons op hypoxie beïnvloed door hypercapnie .................................................................. 36
8.5 Bijzondere adempatronen............................................................................................ 36
8.5.1 Apnea ................................................................................................................................................ 36
8.5.2 Sigh.................................................................................................................................................... 36
8.5.3 Cheyne-stokes ademhaling............................................................................................................... 36
8.5.4 Gasping ............................................................................................................................................. 36
8.5.5 Dyspnea ............................................................................................................................................ 36
9 Toegepaste fysiologie............................................................................................... 37
9.1 Hoelang kan je onder water blijven? ............................................................................ 37
9.1.1 Wat doen om langer onder water te blijven? .................................................................................. 37
9.1.2 Wat is de limiterende factor? ........................................................................................................... 37
9.2 Zuurstoftransportcascade ............................................................................................ 37
9.2.1 Hypoxie vs hypoxemie ...................................................................................................................... 37
9.2.2 Atelectase ......................................................................................................................................... 38
9.3 Restrictieve vs obstructieve longziekten ....................................................................... 38
9.3.1 Hoe longvolumes meten? ................................................................................................................. 38
9.3.2 Restrictief .......................................................................................................................................... 38
9.3.3 Obstructief ........................................................................................................................................ 38
9.4 Patiënt beademen ....................................................................................................... 39
9.4.1 Principes van ventilatie ..................................................................................................................... 39
9.4.2 Druk-volume relatie: volume- vs drukgestuurde ventilatie ............................................................. 39
9.4.2.1 Volumegestuurde beademing ................................................................................................. 39
9.4.2.2 Drukgestuurde beademing ...................................................................................................... 39
9.4.3 Ventileren van patiënt kan gevaarlijk zijn - PEEP-CPAP ................................................................... 40
9.4.3.1 Inflectie en deflectie punten op grafiek .................................................................................. 40
9.5 ARDS = adult respiratory distress syndrome ................................................................. 40
9.6 Prone vs spine position voor beademing ...................................................................... 41
9.6.1 Spine position ................................................................................................................................... 41
9.6.2 Prone position................................................................................................................................... 41
4
,1 ORGANISATIE VH RESPIRATOIR SYSTEEM
1.1 DEFINITIE VH RESPIRATOIR SYSTEEM
Externa ademhaling is de uitwisseling van O2 en CO2 tussen de atmosfeer en de mitochondria. In de
mitochondria vindt dan het proces van “interne ademhaling” plaats (oxidatieve fosforylatie).
Hierbij maakt het menselijk lichaam gebruik van belangrijke processen:
- Diffusie (over korte afstand): passief transport via concentratiegradiënt.
- Convectie (over langere afstand): vervoer van gassen in bulk via gesofisticeerde pomp en
transportsystemen.
- Oppervlakte (longresectie).
- Transportcapaciteit.
1.2 SAMENSTELLING VAN LUCHT
21% O2, de rest is stikstof.
159 mmHg O2 in lucht op zeeniveau = PO2 = partiële dampspanning van O2 id lucht.
1.2.1 BLOEDGASWAARDEN
1.2.2 VOCHTIGE LUCHT VS DROGE LUCHT
Waterdamp is geen gas, maar is fase van water. Voldoet dus niet
aan wet van Henry, Dalton… .
PO2 in mond en neus is direct veel lager omdat er waterdamp is
bijgekomen. Het neemt een partiele druk in.
PO2 lucht = 21% * (760 mmHg - 47 mmHg) = 150 mmHg
Koorts kan dampspanning van water laten toenemen!
5
, 1.3 DE ALVEOOL: FUNTIONELE UNIT
300 000 000 alveolen → totale opp = 50-
100m2
Oppervlak zo groot om diffusie te kunnen
gebruiken.
Zuurstofarm bloed komt toe → gemengd →
arterieel.
1.4 MEER DAN ALLEEN MAAR ADEMHALING
- Geurzin
- Processen van ingeademde lucht: verwarmen, bevochtigen, filteren.
- Bloedreservoir voor het linker hart (440mL).
- Filteren vh bloed.
- Metabole functies.
1.5 SPIROGRAM
IRV = inspiratoir reserve volume
ERV = expiratoir reserve volume
TV = teugvolume (ong 0,5L)
RV = rest volume (na max uitademen)
FRC = functioneel residuele capaciteit = rustvolume (3,5L)
IC = inspiratoire capaciteit
VC = vitale capaciteit (verschil tussen max in- en uitademen)
TLC = totale longcpaciteit (ong 6L)
6
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