Ventilation Perfusion

Ratio
Dr K Mubaslat
Case History

• 65-year-old man who was admitted to the hospital with dyspnea,

weakness and cyanosis.
He suffered with angina on Isosorbide mononitrate 180mg/day

Physical exam was unremarkable except for cyanosis.

Chest Xray, Echo: Normal

Differential diagnosis excluded:

Acute and chronic pulmonary and cardiovascular disease.

• Saturation measured with a finger pulse oximeter was 89%.

• Despite administration of oxygen through a nasal cannula,
saturation measured with a pulse . . oximeter did not change.

• Arterial blood gas analysis revealed a saturation of:

ABG: SaO2 of 97.9%, PaO2 of 100 mm Hg, PaCO2 of 35 mm Hg, HCO3 of 3.4 mmol/l, pH of
7.44.
• Clinical cyanosis and low measured oxygen saturation in the presence of normal arterial
oxygen PO2 tension was highly suggestive of methemoglobinemia ("saturation gap").

• Methemoglobin level: Elevated at 16%.

Episode resolved spontaneously.

Pulse Oximetry (measured oxygen saturation)

• Pulse oximetry is based on measurement of:

Ratio of light absorption by tissues at:
Red wavelength (660 nm)-OxyHb absorbs infrared
Infrared wavelength (940 nm)-deoxyHb absorbs red light

• Uses empirically derived calibration curves

that converts ratio of oxy to deoxyHb into %saturation
Abnormalities Of V/Q Ratio

Ventilation without perfusion = dead space

Perfusion without ventilation = shunt

Normally

Physiological Dead space upper lobe: VQ Ratio 2.6

Physiological shunt lower lobe: VQ = 0.6

Pathologic:
COPD: Dead space-Bronchitis
Shunt -Emphysema
Factors Affecting O2 Dissociation curve

Oxygen-hemoglobin dissociation curve is shifted to left or right by various

factors:

1. Shift to left indicates acceptance (association) of oxygen by hemoglobin

2. Shift to right indicates dissociation of oxygen from hemoglobin.
Shift to right:
Oxygen-hemoglobin dissociation curve is shifted to right in the following conditions:

i. Decrease in partial pressure of oxygen

ii. Increase in partial pressure of carbon dioxide-Bohr Effect

ili. Increase in hydrogen ion concentration and decrease in pH (acidity)

iv. Increased body temperature

v. Excess of 2,3-diphosphoglycerate (DPG) in RBC.

2. Shift to left
Oxygen-hemoglobin dissociation curve is shifted to left in the following conditions:

i. In fetal blood, fetal hemoglobin has got more affinity for oxygen than the adult hemoglobin

ii. Decrease in hydrogen ion concentration and increase in pH (alkalinity).

pH

A decrease in pH (acidity) shifts the dissociation curve to the right.

Tissue metabolizes glucose and oxygen into CO2 and organic acids.

Therefore, as the pH decreases, and the CO2 increases, the hemoglobin affinity for oxygen will decrease.

This inverse relationship is known as the Bohr effect

Carbon Dioxide

Carbon dioxide affects the curve in two ways:

The Bohr effect

The accumulation of carbamino compounds that are generated by chemical interactions.

Carbaminohemoglobin+

The bicarbonate buffer system+++

Diphosphoglycerate (DPG)

2,3-Diphosphoglycerate (DPG)

The relationship of hydrogen ions is inversely proportionate with levels of 2,3 DPG.

Example: High altitudes where lower oxygen levels induce hyperventilation.

Temperature

Oxygen unloading is favored at higher temperatures which will cause a rightward shift.

Example: Exercise
Carbon Monoxide

Hemoglobin binds carbon monoxide (CO) 200 to 300 times more than with oxygen-carboxyhemoglobin

A pulse oximeter would usually be normal

Fetal Hemoglobin

It is composed of two alpha and two gamma chains.

This state is advantageous in the Uterus, as the fetus can pull oxygen from maternal circulation with greater ease.

At the level of the placenta, 2,3-DPG interacts more readily with adult hemoglobin, inducing oxygen unloading. Whereas, fetal hemoglobin
is unaffected by the 2,3-DPG and can bind oxygen easily.
Thank you