Work of breathing (WOB) is the energy expended to inhale and exhale a breathing gas. It is usually expressed as work per unit volume, for example, joules/litre, or as a work rate (power), such as joules/min or equivalent units, as it is not particularly useful without a reference to volume or time. It can be calculated in terms of the pulmonary pressure multiplied by the change in pulmonary volume, or in terms of the oxygen consumption attributable to breathing. In a normal resting state the work of breathing constitutes about 5% of the total body oxygen consumption. It can increase considerably due to illness or constraints on gas flow imposed by breathing apparatus, ambient pressure, or breathing gas composition.
Mechanism of breathing The normal relaxed state of the lung and chest is partially empty. Further exhalation requires muscular work. Inhalation is an active process requiring work. Some of this work is to overcome frictional resistance to flow, and part is used to deform elastic tissues, and is stored as potential energy, which is recovered during the passive process of exhalation, Tidal breathing is breathing that does not require active muscle contraction during exhalation. The required energy is provided by the stored elastic energy. When there is increased gas flow resistance, the optimal respiratory rate decreases.
Work against elastic recoil This work (generally during the inhalation phase) is stored as potential energy which is recovered during exhalation.
Work against non-elastic resistance A pressure difference is required to overcome the frictional resistance to gas flow due to viscosity, inertial resistance due to density, and to provide non-elastic components of movement of the airway tissues to accommodate pulmonary volume change.
Dynamic airway compression Dynamic airway compression occurs when intrapleural pressure equals or exceeds alveolar pressure, which causes dynamic collapsing of the lung airways. It is termed dynamic given the transpulmonary pressure (alveolar pressure − intrapleural pressure) varies based on factors including lung volume, compliance, resistance, existing pathologies, etc. It occurs during forced expiration when intrapleural pressure is greater than atmospheric pressure (positive barometric values), and not during passive expiration when intrapleural pressure remains at subatmospheric pressures (negative barometric values). Clinically, dynamic compression is most commonly associated to the wheezing sound during forced expiration such as in individuals with chronic obstructive pulmonary disorder (COPD). The density of the gas also influences the pressure reduction in the airways, and a higher density causes a greater drop in pressure for a given volumetric flow rate, which has consequences in ambient pressure diving, and can limit ventilation at densities over 6g/litre. It can be exacerbated by a negative static lung load. The effect is modeled by the Starling resistor
Mechanics Work is defined as a force applied over a distance. The SI unit of work is the Joule, equivalent to a force of 1 Newton exerted along a distance of 1 metre. In gas flow across a constant section this equates to a volume flowing against a pressure: Work = Pressure x Volume and Power = Work / time with SI units for Power: Watts = Joules per second The term "work of breathing" should be more accurately referred to as the "power of breathing," unless it is in reference to the work associated with a specific number of breaths or a given interval of time. It is important to differentiate between the terms "breathing rate" and "breathing frequency." Although the two are frequently used interchangeably, "breathing rate" refers to the respiratory rate and is described in breaths per minute (BPM). On the other hand, "breathing frequency" refers to the frequency composition of a single breath and is described in hertz.
Clinical signs of increased work of breathing Because measuring the work of breathing requires complex instrumentation, measuring it in patients with acute serious illness is difficult and risky. Instead, physicians determine if the work of breathing is increased by gestalt or by examining the patient looking for signs of increased breathing effort. These signs include nasal flaring, the contraction of sternomastoid, and thoraco-abdominal paradox.
Work of breathing in ambient pressure diving Work of breathing is affected by several factors in underwater diving at ambient pressure. There are physiological effects of immersion, physical effects of ambient pressure and breathing gas mixture, and mechanical effects of the gas supply system.
Immersion effects The properties of the lung can vary if a pressure differential exists between the breathing gas supply and the ambient pressure on the chest. The relaxed internal pressure in the lungs is equal to the pressure at the mouth, and in the immersed diver, the pressure on the chest may vary from the pressure at the mouth depending on the attitude of the diver in the water. This pressure difference is the static lung load or hydrostatic imbalance. A negative static lung load occurs when the gas supply pressure is lower than the ambient pressure at the chest, and the diver needs to apply more effort to inhale. The small negative pressure differential inside the air passages induces blood engorgement of the distensible lung blood vessels, reducing the compliance of the lung tissue and making the lung stiffer than normal, therefore requiring more muscular effort to move a given volume of gas through the airways. This effect can occur in an upright open-circuit diver, where the chest is deeper than the regulator, and in a rebreather diver if the chest is deeper than the counterlung and will increase the work of breathing and in extreme cases lead to dynamic airway compression. The effects of positive static lung load in these circumstances have not been clearly demonstrated, but may delay this effect.
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