General Goal: To describe the concept that non-uniformity between alveoli with regard to cause arterial hypoxemia.

Specific Objectives: The student should: 1. be able to describe the effect of an infinite ratio on and of a single alveolus. ratio can

2. be able to describe the effect of a

ratio of zero on

and

of a single alveolus.

3. be able to differentiate between uniformity of ventilation, uniformity of blood flow, and uniformity of ratio in terms of the conditions necessary for ideal gas exchange. 4. be able to describe how ventilation, blood flow, and of the normal, upright lung. 5. be able to describe how alveolar gas tensions ( the normal upright lung. and ratios change from the top to the bottom

) change from the top to the bottom of

6. be able to list the expected changes in

non-uniformity of ratios.

, and

when disease causes increased

7. be able to describe the relationship between physiological deadspace and high relationship between venous admixture and low 8. be able to calculate an A-a O2 gradient ( alveoli.

alveoli and the

) using the modified ideal alveolar air equation.

9. be able to describe the clinical use of the (A-a) O2 difference and the a/A O2 ratio including normal values and the choice of index in patients receiving oxygen supplementation.

10. be able to differentiate between the physiological consequences of hypoventilation, diffusion

abnormalities, shunt, and Resources: Lecture: Reading: Forster, RE, AB DuBois, WA Briscoe, and AB Fisher. The Lung -- Physiological Basis of Pulmonary Function Tests. Year Book Med. Pub., 1986. Chapter 7. West, JB. Respiratory Physiology--The Essentials (4th Ed.). Chapter 5. Dr. Baer

Respiratory Physiology Page 74

I.

EFFECT OF CHANGING A. Definitions 1. 2.

IN A SINGLE HOMOGENEOUS LUNG UNIT

B. C.

Normally the overall

of the lung is (4 L/min)/(5 L/min) = 0.8 and in an alveolus and its

Since there is normally no diffusion impairment the end capillary blood are usually the same as each other.

D.

The extreme conditions of

Figure 1

1.

2.

Ventilation-Perfusion Ratio Page 75

E.

Diagram. Intermediate composition.

ratios also affect alveolar (end capillary) gas

Figure 2

1.

2.

3.

4.

F.

Low units affect blood more than alveolar air. We divide their partially arterialized blood into two conceptual portions:
1.

2.

G.

High units affect alveolar air more than arterial blood. We divide their partially utilized alveolar air into two conceptual portions:

Respiratory Physiology Page 76 1.

2.

II.

EFFECT OF DIFFERENT A.

RATIOS IN DIFFERENT PARTS OF THE LUNG . When two units of a lung

Uniform ventilation; uniform blood flow; uniform

have equal ventilations, equal blood flows, and equal

. This is the ideal.

, their

equals their

Ventilation-Perfusion Ratio Page 77

A Mixed Venous O2 Saturation (%) Mixed Venous O2 Tension (mmHg) Alveolar Ventilation (l/min) Pulmonary Blood Flow (l/min) Ventilation/Blood Flow Ratio Alveolar O2 Tension (mmHg) Capillary (arterial) O2 Tension (mmHg) Arterial O2 Saturation (%) 75.0 40.0 2.0 2.5 0.8 104.0 104.0 97.4

B 75.0 40.0 2.0 2.5 0.8 104.0 104.0 97.4

A+B 75.0 40.0 4.0 5.0 0.8 104.0 104.0 97.4

Figure 3. Ideal case with uniform ventilation and uniform blood flow to all parts of the lungs.

B.

Non-uniform distribution of ratios results in arterial hypoxemia even if total alveolar ventilation or total capillary blood flow are the same. Extreme example. If a person's left lung got all the ventilation and his right lung got all the blood flow he would die of asphyxia.

C.

Non-uniform distribution of ventilation with uniform blood flow. Total alveolar ventilation and capillary flow are the same as IIA:
A Mixed Venous O2 Saturation (%) Mixed Venous O2 Tension (mmHg) Alveolar Ventilation (l/min) Pulmonary Blood Flow (l/min) Ventilation/Blood Flow Ratio Alveolar O2 Tension (mmHg) 75.0 40.0 3.2 2.5 1.3 116.0 B 75.0 40.0 0.8 2.5 0.3 66.0 A+B 75.0 40.0 4.0 5.0 0.8 106.0

Respiratory Physiology Page 78

Capillary (arterial) O2 Tension (mmHg) Arterial O2 Saturation (%)

116.0 98.2

66.0 91.7

84.0 95.0

Figure 4. Effect of nonuniform distribution of air in a patient with uniform blood flow such as might occur in asthma. Uneven ventilation results in an alveolar-arterial PO2 difference of 22.

1.

2. -

3.

Ventilation-Perfusion Ratio Page 79 4. -

5.

6.

D. Non-uniform blood flow distribution with uniform ventilation. Total alveolar ventilation and capillary blood flow as in IIA. The result is similar to that seen with non-uniform ventilation. and will fall and will rise with respect to IIA.
A Mixed Venous O2 Saturation (%) Mixed Venous O2 Tension (mmHg) Alveolar Ventilation (l/min) Pulmonary Blood Flow (l/min) Ventilation/Blood Flow Ratio Alveolar O2 Tension (mmHg) Capillary (arterial) O2 Tension (mmHg) Arterial O2 Saturation (%) 75.0 40.0 2.0 4.0 0.5 85.0 85.0 95.7 B 75.0 40.0 2.0 1.0 2.0 125.0 125.0 98.5 A+B 75.0 40.0 4.0 5.0 0.8 105.0 90.0 96.2

Respiratory Physiology Page 80

Figure 5. Effect of nonuniform distribution of blood in a patient with uniform distribution of air, as might occur following partial obstruction of a right or left pulmonary artery.

E.

Non-uniform ventilation; non-uniform blood flow; non-uniform ratios. Total alveolar ventilation and total capillary blood as in IIA. Again and would fall and would rise with respect

to the values shown in IIA.

F. Non-uniform ventilation; non-uniform blood flow; but uniform ratios. Total alveolar ventilation and capillary flow as in IIA.

Ventilation-Perfusion Ratio Page 81

A Mixed Venous O2 Saturation (%) Mixed Venous O2 Tension (mmHg) Alveolar Ventilation (l/min) Pulmonary Blood Flow (l/min) Ventilation/Blood Flow Ratio Alveolar O2 Tension (mmHg) Capillary (arterial) O2 Tension (mmHg) Arterial O2 Saturation (%) 75.0 40.0 3.0 3.75 0.8 104.0 104.0 97.4

B 75.0 40.0 1.0 1.25 0.8 104.0 104.0 97.4

A+B 75.0 40.0 4.0 5.0 0.8 106.0 104.0 97.4

Figure 6. Both ventilation and blood flow are nonuniform, but ventilation and blood flow are increased in proportion to each other in alveoli A and decreased in proportion to each in alveoli B. Despite the nonuniformity there is no alveolar-arterial PO2 difference because ventilation blood flow ratios are equal through the lungs.

1.

2.

3.

Respiratory Physiology Page 82

G.

Carbon dioxide exchange and non-uniform 1.

2.

3. -

Figure 7. V/Q imbalance and the dissociation curves for carbon dioxide and oxygen. v/Q represents low V/Q units and V/ Q represents high V/Q units. See text for discussion.

4.

III.

VENTILATION/PERFUSION RATIOS IN REAL LUNGS A. Normal lungs (upright position)

Ventilation-Perfusion Ratio Page 83

Figure 8

1.

2.

3.

Respiratory Physiology Page 84 B. Regional blood gases (upright lung).

Figure 9

1.

2.

C.

Non-uniform

distributions in the normal lung only cause A-a

gradients of
ratio

about 5-20 mmHg depending on age. This normally corresponds to an a/A above 0.74. the normal lung. D. In disease the 1. -

may be considered to be relatively uniform in the various alveoli of

ratios become far more non-uniform.

2.

Ventilation-Perfusion Ratio Page 85 IV. CLINICALLY, A DECREASE IN (OR AN INCREASE A-A 0GRADIENT) IS

MOST COMMONLY CAUSED BY NON-UNIFORMITY LUNG. CAUSES OF HYPOXEMIA

RATIOS WITHIN THE

Figure 10

A.

Hypoventilation. When alveolar ventilation ( mixed venous arterial 1. and alveolar are similarly reduced.

) decreases, alveolar

falls toward . Alveolar and

rises toward mixed venous

Respiratory Physiology Page 86 2.

B.

Anatomical shunt. Hypoxemia results when venous blood bypasses ventilated alveoli and mixes with oxygenated blood. 1. -

2.

3.

4.

C.

Diffusion impairment. Diffusion impairment prevents the partial pressure of oxygen in end capillary blood ( ) from equilibrating with alveolar . 1.

2. 3.

4.

Ventilation-Perfusion Ratio Page 87

5.

D.

Non-uniformity of Ventilation/Perfusion ( 1.

).

2.

3.

4.

5.

6.

Respiratory Physiology Page 88

Study Questions for Ventilation-Perfusion Ratio

1. In which part of the normal, upright lung is ventilation greatest? Blood flow greatest? greatest? 2. Assume that an alveolus is ventilated with room air at sea level and gets venous blood with and ? What values would and and

ratio

approach if ventilation but not blood flow were

stopped? What values would

approach if blood flow but not ventilation were stopped?

3. If a lung disease were to cause an increased non-uniformity of ventilation but not blood flow, what would happen to, , and ? 4. If a lung disease were to cause an increased non-uniformity of blood flow but not ventilation, what would happen to , and ? 5. If the distribution of ratios become more non-uniform due to lung disease, how would physiological dead space change? How would venous admixture change? 6. If there were a similar decrease in ventilation and blood flow to every alveolus in the lung, how would change? (Assume no change in the composition of mixed venous blood.) 7. How might hypoxemia due to true shunt be distinguished clinically from that due to non-uniform ratios? 8. How might hypoxemia due to diffusion abnormalities be distinguished clinically from that due to non-uniform ratios?

Ventilation-Perfusion Ratio Page 89

Summary of rules for

examples

1. Blood oxygen from multiple units mix as contents or saturations; NOT as partial pressures. 2. Alveolar oxygen from multiple units mixes as partial pressures. 3. Alveolar in a single unit is determined by the unit's approaching inspired air. Low in a single unit usually equals alveolar ratio in a complex manner. High units have approaching mixed

units have venous blood. 4. End capillary

because diffusion problems rarely are

enough to prevent equilibrium during a single pass of red cells through the capillary. 5. The end capillary saturation of an individual unit is determined by reading the oxygen saturation corresponding to end capillary off an oxygen dissociation curve. 6. End capillary values of different units may differ if they have different ratios.

7. The mixed alveolar partial pressure of oxygen is determined as a ventilation weighted mean of individual units partial pressures.

8. The oxygen saturation of arterial blood (mixture of end capillary bloods) is determined from a blood flow (perfusion) weighted average of the end capillary saturations for the individual units.

9. Arterial

is determined by reading

corresponding to the arterial blood saturation off the

oxygen dissociation curve. It can NOT be determined from the weighted average of end capillary from individual units Note that the content of low units was above the average.