Question 6

College Answer

Candidates who used a structured approach of using formulae that describe resistance fluid 
flow scored well. Poiseuille’s law describes the determinates of resistance to laminar fluid flow 
and provides a useful answer structure. The most common mistakes were confusion between 
resistance and compliance as well as failure to describe turbulent as well as laminar flow. 

Discussion

The question asked specifically for airways resistance, and the candidates would have probably not earned any marks if they discussed other contributing elements (eg. inertance, tissue resistance and the effect of gas compression). Ergo, only airway stuff is listed here:

A main determinant of airway resistance is whether the flow is laminar or turbulent. This depends on the Reynolds number, which is a dimensionless metric determined by:

• Tube diameter
• Tube length
• Flow rate
• Gas density
• Gas viscosity

Thus, the factors which affect airway resistance are:

• Gas properties which affect the type of flow
  • Gas density (increased density leads to increased turbulence and hence increased resistance)
  • Gas viscosity (increased viscosity promotes laminar flow and hence decreases resistance)
• Factors which affect airway diameter
  • Lung volume (resistance decreases with higher volume)
  • Physiological variation in airway diameter
  • Pathological conditions which affect airway diameter:
    • Increased smooth muscle tone
      • Bronchospasm
      • Irritants, eg. histamine
      • Parasympathetic nervous system agonists
    • Decreased smooth muscle tone
      • Bronchodilators
      • Sympathetic nervous system agonists
    • Decreased internal crossection
      • Oedema
      • Mucosal or smooth muscle hypertrophy
      • Encrusted secretions
    • Mechanical obstruction or compression
      • Extrinsic, eg. by tumour
      • Dynamic compression, eg. due to gas trapping or forceful expiratory effort
      • Artificial airways and their complications, eg. endotracheal tube becoming kinked 
  • Factors which affect airway length
    • Lung volume (increasing volume stretches and elongates the bronchi)
    • Artificial airways  (increase the length in the case of an ETT, or decrease it in the case of a tracheostomy)
  • Factors which affect flow rate
    • Respiratory rate (increased respiratory rate produces an increase in the flow rate for each breath) 
    • Inspiratory and expiratory work (eg. voluntary forced expiration for spirometry)
    • Inspiratory flow pattern generated by a mechanical ventilator

Kaminsky, David A. "What does airway resistance tell us about lung function?." Respiratory care 57.1 (2012): 85-99.

Macklem, PETER T., and Jere Mead. "Resistance of central and peripheral airways measured by a retrograde catheter." Journal of Applied Physiology 22.3 (1967): 395-401.

Briscoe, William A., and Arthur B. Dubois. "The relationship between airway resistance, airway conductance and lung volume in subjects of different age and body size." The Journal of clinical investigation 37.9 (1958): 1279-1285.

Hoppin Jr, FREDERIC G., M. A. L. C. O. L. M. Green, and MICHAEL S. Morgan. "Relationship of central and peripheral airway resistance to lung volume in dogs." Journal of Applied Physiology 44.5 (1978): 728-737.

Nakagawa, Misa, et al. "Effect of increasing respiratory rate on airway resistance and reactance in COPD patients." Respirology 20.1 (2015): 87-94.

Bruno Marciniak, in A Practice of Anesthesia for Infants and Children (Sixth Edition), 2019