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Author: Thomas Sisson, MD, 2009

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Pulmonary Blood Flow

           M1 – Cardiovascular/Respiratory
                     Sequence
                Thomas Sisson, MD

Winter, 2009
Objectives
•  The student will know the structure, function, distribution
   and control of pulmonary blood supply
    –  Compare pulmonary and bronchial circulation
    –  Compare and contrast pulmonary and systemic
       circulation
    –  Describe and explain the effects of cardiac output and
       lung volume on pulmonary vascular resistance
    –  Describe the effects of hypoxia on pulmonary
       vascular resistance
    –  Describe the effects of gravity of pulmonary blood
       flow
    –  Explain Starling’s equation
    –  Describe the mechanisms of pulmonary edema
Two Circulations in the Lung
•  Pulmonary Circulation.
  – Arises from Right Ventricle.
  – Receives 100% of blood flow.


•  Bronchial Circulation.
  – Arises from the aorta.
  – Part of systemic circulation.
  – Receives about 2% of left ventricular output.
Bronchial Circulation


                          Image of bronchial
                             circulation
                              removed



   United States government
Pulmonary Circulation




United States government




                            Source Undetermined
Pulmonary Circulation




 Patrick J. Lynch, wikimedia commons
Pulmonary Circulation
•  In series with the systemic circulation.

•  Receives 100% of cardiac output (3.5L/min/m2).

•  RBC travels through lung in 4-5 seconds.

•  280 billion capillaries, supplying 300 million
   alveoli.
   –  Surface area for gas exchange = 50 – 100 m2
Alveolar Architecture




  Source Undetermined
Alveolar Airspace                         Alveolar Airspace




                    Source Undetermined
Functional Anatomy of the
      Pulmonary Circulation
•  Thin walled vessels at all levels.

•  Pulmonary arteries have far less smooth
   muscle in the wall than systemic arteries.

•  Consequences of this anatomy - the
   vessels are:
  – Distensible.
  – Compressible.
Pulmonary Circulation Pressures




       Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Pulmonary Vascular Resistance

                         input pressure - output pressure
 Vascular Resistance =
                                   blood flow


     PVR = k • mean PA pressure - left atrial pressure
                     cardiac output (index)


         mean PA pressure - left atrial pressure = 10 mmHg

        mean aorta pressure - right atrial pressure = 98 mmHg


                  Therefore PVR is 1/10 of SVR
Vascular Resistance is Evenly Distributed in
         the Pulmonary Circulation




     West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
Reasons Why Pressures Are Different in
Pulmonary and Systemic Circulations?

•  Gravity and Distance:
   –  Distance above or below the heart adds to, or
      subtracts from, both arterial and venous pressure
   –  Distance between Apex and Base

        Systemic                     Pulmonary
Aorta        100 mmHg         Main PA     15 mmHg

Head          50 mmHg         Apex           2 mmHg

Feet          180 mmHg        Base           25 mmHg
Reasons Why Pressures Are Different in
   Pulmonary and Systemic Circulations?

•  Control of regional perfusion in the systemic circulation:
   –  Large pressure head allows alterations in local vascular resistance to
      redirect blood flow to areas of increased demand (e.g. to muscles
      during exercise).

   –  Pulmonary circulation is all performing the same job, no need to
      redirect flow (exception occurs during hypoxemia).

•  Consequences of pressure differences:
   –  Left ventricle work load is much greater than right ventricle
   –  Differences in wall thickness indicates differences in work load.
Influences on Pulmonary Vascular
               Resistance
Pulmonary vessels have:
  -Little vascular smooth muscle.
  -Low intravascular pressure.
  -High distensiblility and compressiblility.

Vessel diameter influenced by extravascular forces:
  -Gravity
  -Body position
  -Lung volume
  -Alveolar pressures/intrapleurql pressures
  -Intravascular pressures
Influences of Pulmonary Vascular Resistance
   •  ransmural pressure = Pressure Inside – Pressure
    T
   Outside.
      – ncreased transmural pressure-increases vessel diameter.
        I
      –  ecreased transmural pressure-decreased vessel diameter
        D
      (increase in PVR).
      –  egative transmural pressure-vessel collapse.
        N



                          Pi        Poutside




   •  ifferent effects of lung volume on alveolar and
    D
   extraalveolar vessels.
Effect of Transmural Pressure on Pulmonary
               Vessels During Inspiration




           Negative Pressure


                                                                           Elongate and
Distend
                                                                              Narrow

↓Resist.
           Negative Pressure                                                ↑Resist.




               Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
                                  Resistance ∝ Length and Resistance ∝ 1/(Radius)4
Effect of Lung Volume on PVR




      Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Pulmonary Vascular Resistance
        During Exercise
•  During exercise cardiac output increases (e.g. 5-fold), but
   with little change in mean pulmonary artery pressure
    –  How is this possible?
                            input pressure - output pressure
   Vascular Resistance =
                                      blood flow


•  ΔPressure= Flow x Resistance
•  If pressure does not change, then PVR must decrease with
   increased blood flow
        •  Passive effect (seen in isolated lung prep)
   –  Recruitment: Opening of previously collapsed capillaries
   –  Distensibility: Increase in diameter of open capillaries.
Recruitment and Distention in Response
to Increased Pulmonary Artery Pressure




          Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Control of Pulmonary Vascular Resistance
 •  Passive Influences on PVR:

           Influence                Effect on PVR             Mechanism
  ↑ Lung Volume          (above                             Lengthening and
                                        Increase
                FRC)                                         Compression
  ↓ Lung Volume          (below                             Compression of
                                        Increase
                FRC)                                      Extraalveolar Vessels
                                                            Recruitment and
    ↑ Flow, ↑Pressure                   Decrease
                                                              Distension
                                  Decrease in Dependent     Recruitment and
               Gravity
                                        Regions               Distension

  ↑ Interstitial Pressure               Increase             Compression

    Positive Pressure                                      Compression and
                                        Increase
       Ventilation                                          Derecruitment

   T. Sisson
Regional Pulmonary Blood Flow Depends
  Upon Position Relative to the Heart



                                                                      Main PA                    15 mmHg
                                                                          Apex                   2 mmHg
                                                                          Base                   25 mmHg




      West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
Gravity, Alveolar Pressure and Blood Flow

•  Pressure in the pulmonary arterioles depends on both mean
   pulmonary artery pressure and the vertical position of the vessel in
   the chest, relative to the heart.

•  Driving pressure (gradient) for perfusion is different in the 3 lung
   zones:

    –  Flow in zone may be absent because there is inadequate pressure to
       overcome alveolar pressure.

    –  Flow in zone 3 is continuous and driven by the pressure in the
       pulmonary arteriole – pulmonary venous pressure.

    –  Flow in zone 2 may be pulsatile and driven by the pressure in the
       pulmonary arteriole – alveolar pressure (collapsing the capillaries).
Gravity, Alveolar Pressure, and Blood Flow



                                                                 Alveolar Dead Space




            West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008


         Typically no zone 1 in normal healthy person
      Large zone 1 in positive pressure ventilation + PEEP
Gravity Influences Pressure




          Adrian8_8 (flickr)
Control of Pulmonary Vascular Resistance
•  Active Influences on PVR:
              Increase                Decrease
     Sympathetic Innervation   Parasympathetic Innervation

       α-Adrenergic agonists          Acetylcholine

         Thromboxane/PGE2         β-Adrenergic Agents

              Endothelin                 PGE1

              Angiotensin             Prostacycline

              Histamine                Nitric oxide

                                       Bradykinin



  T. Sisson
Hypoxic Pulmonary Vasoconstriction

•  Alveolar hypoxia causes active vasoconstriction at level of pre-
   capillary arteriole.

•  Mechanism is not completely understood:
    –  Response occurs locally and does not require innervation.
    –  Mediators have not been identified.
    –  Graded response between pO2 levels of 100 down to 20 mmHg.

•  Functions to reduce the mismatching of ventilation and perfusion.

•  Not a strong response due to limited muscle in pulmonary
   vasculature.

•  General hypoxemia (high altitude or hypoventilation) can cause
   extensive pulmonary artery vasoconstriction.
Barrier Function of Alveolar Wall

•  Capillary endothelial cells:
  – permeable to water, small molecules, ions.
  – barrier to proteins.

•  Alveolar epithelial cells:
  – more effective barrier than the endothelial
    cells.
  – recently found to pump both salt and water
    from the alveolar space.
Alveolar airspace
                                          Alveolar airspace




                    Source Undetermined
Fluid Movement Due to Osmotic Pressure




                    Concentrated                         Dilute
                       solute
                                                         solute
             H 2O                                 H 2O



                Water moves through the semi-permeable membrane
                 down a concentration gradient to dilute the solute.


 T. Sisson
Osmotic Pressure Gradient Can Move
 Fluid Against Hydrostatic Pressure


      Glass tube




                                    Permeable
                                    membrane




T. Sisson
                   Before   After
Osmotic Gradient Counteracts
      Hydrostatic Gradient
•  Hydrostatic pressure in the pulmonary capillary
   bed > hydrostatic pressure in the interstitium
  –  hydrostatic pressure drives fluid from the capillaries
     into the pulmonary interstitium


•  Osmotic pressure in the plasma > osmotic
   pressure in the interstitium
  –  osmotic pressure normally would draw fluid from the
     interstitial space into the capillaries
Starling’s Equation

             Q=K[(Pc-Pi) – σ(πc-πi)]

            Q = flux out of the capillary
            K = filtration coefficient
            Pc and Pi = capillary and interstitial hydrostatic
                           pressures
            πc and πi = capillary and interstitial
            osmotic       pressures
            σ = reflection (sieving) coefficient


T. Sisson
Normally Starling’s Forces Provide
            Efficient Protection
•  Normal fluid flux from the pulmonary capillary bed is
   approximately 20 ml/hr.
    –  recall that cardiac output through the pulmonary
       capillaries at rest is ~5 l/min.
    –  < 0.0066% leak.

•  Abnormal increase in fluid flux can result from:
    –  Increased hydrostatic pressure gradient (cardiogenic
       pulmonary edema).
    –  Decreased osmotic pressure gradient (cirrhosis,
       nephrotic syndrome).
    –  Increased protein permeability of the capillary wall
       (ARDS).
Additional Source Information
                           for more information see: http://open.umich.edu/wiki/CitationPolicy

Slide 5: Original source, https://eapbiofield.wikispaces.com/file/view/illu_bronchi_lungs.jpg
Slide 6: Bronchial Circulation, Wikipedia, http://en.wikipedia.org/wiki/File:Illu_bronchi_lungs.jpg
Slide 7: Pulmonary circuit, Wikipedia, http://en.wikipedia.org/wiki/File:Illu_pulmonary_circuit.jpg
Slide 7: Source Undetermined
Slide 8: Patrick J. Lynch, Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Bronchial_anatomy_with_description.png, CC:BY 2.5,
    http://creativecommons.org/licenses/by/2.5/deed.en; Original source,
    http://www.virtualmedicalcentre.com/uploads/VMC/DiseaseImages/2293_alveoli_450.jpg
Slide 10: Source Undetermined
Slide 10: Source Undetermined
Slide 13: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Slide 15: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
Slide 20: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Slide 21: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Slide 23: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
Slide 24: Thomas Sisson
Slide 25: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
Slide 27: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
Slide 28: Adrian8_8, flickr, http://www.flickr.com/photos/26349479@N07/3656385690/ , CC: BY http://creativecommons.org/licenses/by/2.0/deed.en
Slide 29: Thomas Sisson
Slide 32: Source Undetermined
Slide 33: Thomas Sisson
Slide 34: Thomas Sisson
Slide 36: Thomas Sisson

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11.17.08(c): Pulmonary Blood Flow

  • 1. Author: Thomas Sisson, MD, 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Non-commercial–Share Alike 3.0 License: http://creativecommons.org/licenses/by-nc-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  • 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Pulmonary Blood Flow M1 – Cardiovascular/Respiratory Sequence Thomas Sisson, MD Winter, 2009
  • 4. Objectives •  The student will know the structure, function, distribution and control of pulmonary blood supply –  Compare pulmonary and bronchial circulation –  Compare and contrast pulmonary and systemic circulation –  Describe and explain the effects of cardiac output and lung volume on pulmonary vascular resistance –  Describe the effects of hypoxia on pulmonary vascular resistance –  Describe the effects of gravity of pulmonary blood flow –  Explain Starling’s equation –  Describe the mechanisms of pulmonary edema
  • 5. Two Circulations in the Lung •  Pulmonary Circulation. – Arises from Right Ventricle. – Receives 100% of blood flow. •  Bronchial Circulation. – Arises from the aorta. – Part of systemic circulation. – Receives about 2% of left ventricular output.
  • 6. Bronchial Circulation Image of bronchial circulation removed United States government
  • 7. Pulmonary Circulation United States government Source Undetermined
  • 8. Pulmonary Circulation Patrick J. Lynch, wikimedia commons
  • 9. Pulmonary Circulation •  In series with the systemic circulation. •  Receives 100% of cardiac output (3.5L/min/m2). •  RBC travels through lung in 4-5 seconds. •  280 billion capillaries, supplying 300 million alveoli. –  Surface area for gas exchange = 50 – 100 m2
  • 10. Alveolar Architecture Source Undetermined
  • 11. Alveolar Airspace Alveolar Airspace Source Undetermined
  • 12. Functional Anatomy of the Pulmonary Circulation •  Thin walled vessels at all levels. •  Pulmonary arteries have far less smooth muscle in the wall than systemic arteries. •  Consequences of this anatomy - the vessels are: – Distensible. – Compressible.
  • 13. Pulmonary Circulation Pressures Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
  • 14. Pulmonary Vascular Resistance input pressure - output pressure Vascular Resistance = blood flow PVR = k • mean PA pressure - left atrial pressure cardiac output (index) mean PA pressure - left atrial pressure = 10 mmHg mean aorta pressure - right atrial pressure = 98 mmHg Therefore PVR is 1/10 of SVR
  • 15. Vascular Resistance is Evenly Distributed in the Pulmonary Circulation West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
  • 16. Reasons Why Pressures Are Different in Pulmonary and Systemic Circulations? •  Gravity and Distance: –  Distance above or below the heart adds to, or subtracts from, both arterial and venous pressure –  Distance between Apex and Base Systemic Pulmonary Aorta 100 mmHg Main PA 15 mmHg Head 50 mmHg Apex 2 mmHg Feet 180 mmHg Base 25 mmHg
  • 17. Reasons Why Pressures Are Different in Pulmonary and Systemic Circulations? •  Control of regional perfusion in the systemic circulation: –  Large pressure head allows alterations in local vascular resistance to redirect blood flow to areas of increased demand (e.g. to muscles during exercise). –  Pulmonary circulation is all performing the same job, no need to redirect flow (exception occurs during hypoxemia). •  Consequences of pressure differences: –  Left ventricle work load is much greater than right ventricle –  Differences in wall thickness indicates differences in work load.
  • 18. Influences on Pulmonary Vascular Resistance Pulmonary vessels have: -Little vascular smooth muscle. -Low intravascular pressure. -High distensiblility and compressiblility. Vessel diameter influenced by extravascular forces: -Gravity -Body position -Lung volume -Alveolar pressures/intrapleurql pressures -Intravascular pressures
  • 19. Influences of Pulmonary Vascular Resistance •  ransmural pressure = Pressure Inside – Pressure T Outside. – ncreased transmural pressure-increases vessel diameter. I –  ecreased transmural pressure-decreased vessel diameter D (increase in PVR). –  egative transmural pressure-vessel collapse. N Pi Poutside •  ifferent effects of lung volume on alveolar and D extraalveolar vessels.
  • 20. Effect of Transmural Pressure on Pulmonary Vessels During Inspiration Negative Pressure Elongate and Distend Narrow ↓Resist. Negative Pressure ↑Resist. Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003 Resistance ∝ Length and Resistance ∝ 1/(Radius)4
  • 21. Effect of Lung Volume on PVR Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
  • 22. Pulmonary Vascular Resistance During Exercise •  During exercise cardiac output increases (e.g. 5-fold), but with little change in mean pulmonary artery pressure –  How is this possible? input pressure - output pressure Vascular Resistance = blood flow •  ΔPressure= Flow x Resistance •  If pressure does not change, then PVR must decrease with increased blood flow •  Passive effect (seen in isolated lung prep) –  Recruitment: Opening of previously collapsed capillaries –  Distensibility: Increase in diameter of open capillaries.
  • 23. Recruitment and Distention in Response to Increased Pulmonary Artery Pressure Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003
  • 24. Control of Pulmonary Vascular Resistance •  Passive Influences on PVR: Influence Effect on PVR Mechanism ↑ Lung Volume (above Lengthening and Increase FRC) Compression ↓ Lung Volume (below Compression of Increase FRC) Extraalveolar Vessels Recruitment and ↑ Flow, ↑Pressure Decrease Distension Decrease in Dependent Recruitment and Gravity Regions Distension ↑ Interstitial Pressure Increase Compression Positive Pressure Compression and Increase Ventilation Derecruitment T. Sisson
  • 25. Regional Pulmonary Blood Flow Depends Upon Position Relative to the Heart Main PA 15 mmHg Apex 2 mmHg Base 25 mmHg West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008
  • 26. Gravity, Alveolar Pressure and Blood Flow •  Pressure in the pulmonary arterioles depends on both mean pulmonary artery pressure and the vertical position of the vessel in the chest, relative to the heart. •  Driving pressure (gradient) for perfusion is different in the 3 lung zones: –  Flow in zone may be absent because there is inadequate pressure to overcome alveolar pressure. –  Flow in zone 3 is continuous and driven by the pressure in the pulmonary arteriole – pulmonary venous pressure. –  Flow in zone 2 may be pulsatile and driven by the pressure in the pulmonary arteriole – alveolar pressure (collapsing the capillaries).
  • 27. Gravity, Alveolar Pressure, and Blood Flow Alveolar Dead Space West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008 Typically no zone 1 in normal healthy person Large zone 1 in positive pressure ventilation + PEEP
  • 28. Gravity Influences Pressure Adrian8_8 (flickr)
  • 29. Control of Pulmonary Vascular Resistance •  Active Influences on PVR: Increase Decrease Sympathetic Innervation Parasympathetic Innervation α-Adrenergic agonists Acetylcholine Thromboxane/PGE2 β-Adrenergic Agents Endothelin PGE1 Angiotensin Prostacycline Histamine Nitric oxide Bradykinin T. Sisson
  • 30. Hypoxic Pulmonary Vasoconstriction •  Alveolar hypoxia causes active vasoconstriction at level of pre- capillary arteriole. •  Mechanism is not completely understood: –  Response occurs locally and does not require innervation. –  Mediators have not been identified. –  Graded response between pO2 levels of 100 down to 20 mmHg. •  Functions to reduce the mismatching of ventilation and perfusion. •  Not a strong response due to limited muscle in pulmonary vasculature. •  General hypoxemia (high altitude or hypoventilation) can cause extensive pulmonary artery vasoconstriction.
  • 31. Barrier Function of Alveolar Wall •  Capillary endothelial cells: – permeable to water, small molecules, ions. – barrier to proteins. •  Alveolar epithelial cells: – more effective barrier than the endothelial cells. – recently found to pump both salt and water from the alveolar space.
  • 32. Alveolar airspace Alveolar airspace Source Undetermined
  • 33. Fluid Movement Due to Osmotic Pressure Concentrated Dilute solute solute H 2O H 2O Water moves through the semi-permeable membrane down a concentration gradient to dilute the solute. T. Sisson
  • 34. Osmotic Pressure Gradient Can Move Fluid Against Hydrostatic Pressure Glass tube Permeable membrane T. Sisson Before After
  • 35. Osmotic Gradient Counteracts Hydrostatic Gradient •  Hydrostatic pressure in the pulmonary capillary bed > hydrostatic pressure in the interstitium –  hydrostatic pressure drives fluid from the capillaries into the pulmonary interstitium •  Osmotic pressure in the plasma > osmotic pressure in the interstitium –  osmotic pressure normally would draw fluid from the interstitial space into the capillaries
  • 36. Starling’s Equation Q=K[(Pc-Pi) – σ(πc-πi)] Q = flux out of the capillary K = filtration coefficient Pc and Pi = capillary and interstitial hydrostatic pressures πc and πi = capillary and interstitial osmotic pressures σ = reflection (sieving) coefficient T. Sisson
  • 37. Normally Starling’s Forces Provide Efficient Protection •  Normal fluid flux from the pulmonary capillary bed is approximately 20 ml/hr. –  recall that cardiac output through the pulmonary capillaries at rest is ~5 l/min. –  < 0.0066% leak. •  Abnormal increase in fluid flux can result from: –  Increased hydrostatic pressure gradient (cardiogenic pulmonary edema). –  Decreased osmotic pressure gradient (cirrhosis, nephrotic syndrome). –  Increased protein permeability of the capillary wall (ARDS).
  • 38. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 5: Original source, https://eapbiofield.wikispaces.com/file/view/illu_bronchi_lungs.jpg Slide 6: Bronchial Circulation, Wikipedia, http://en.wikipedia.org/wiki/File:Illu_bronchi_lungs.jpg Slide 7: Pulmonary circuit, Wikipedia, http://en.wikipedia.org/wiki/File:Illu_pulmonary_circuit.jpg Slide 7: Source Undetermined Slide 8: Patrick J. Lynch, Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Bronchial_anatomy_with_description.png, CC:BY 2.5, http://creativecommons.org/licenses/by/2.5/deed.en; Original source, http://www.virtualmedicalcentre.com/uploads/VMC/DiseaseImages/2293_alveoli_450.jpg Slide 10: Source Undetermined Slide 10: Source Undetermined Slide 13: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003 Slide 15: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008 Slide 20: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003 Slide 21: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003 Slide 23: Levitzky. Pulmonary Physiology, 6th ed. McGraw-Hill. 2003 Slide 24: Thomas Sisson Slide 25: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008 Slide 27: West. Respiratory Physiology: The Essentials 8th ed. Lippincott Williams & Wilkins. 2008 Slide 28: Adrian8_8, flickr, http://www.flickr.com/photos/26349479@N07/3656385690/ , CC: BY http://creativecommons.org/licenses/by/2.0/deed.en Slide 29: Thomas Sisson Slide 32: Source Undetermined Slide 33: Thomas Sisson Slide 34: Thomas Sisson Slide 36: Thomas Sisson