Ventilation and Perfusion

dr. Sri Lestari Sulistyo Rini, MSc

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 TERM
• VENTILATION :
– the rate at which blood is supplied with O2
• PERFUSION :
– the rate at which O2 is removed (blood flow)
• Ventilation/perfusion ratio :
– Ratio of ventilation to blood flow for a single alveolus
(VA/Q), or entire lung (VA/Qt)

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Anatomical DEAD SPACE
Tidal volume is distributed into dead
space (VD) and alveolar volume (VA)

The oropharynx, trachea and Conducting

upper airways in the lung, which airways

do not participate in gas

exchange, comprise VD Gas exchange
airways
Alveoli comprise the gas
exchange compartment or
respiratory zone, VA

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 Anatomical Dead Space
• Normally represents 20-30% of the minute
ventilation
• Influenced by
– Size
– Age : neonates 3.3 ml/kg, adults 2 ml/kg
– Posture : supine < standing - tidal volume
– Head and neck position - respiratory rate
– Tracheal intubation/ tracheostomy
– Bronchodilating/constricting drugs

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 
Total minute
VT VT f
ventilation
How much of total
minute ventilation is

Dead space VD V "wasted"?
Df
ventilation

Alveolar A
V (V )f
T-VD
ventilation

Dead space can be measured by two methods:

Fowler's single breath N2 washout
Bohr's method

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 Alveolar Dead Space
• Volume of alveoli that is ventilated but not
perfused
• Usually negligible, unless
– Low cardiac output
– Pulmonary embolism
– Posture

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 Physiology Dead Space
• Anatomic + Alveolar Dead Space
• In healthy individu represents 25-35% of the
minute ventilation
• Factors influencing
– Age : increases with age
– Sex : slightly higher in men
– Body size : app 2 mL/kg
– Posture : due to anat dead space
– Pathology : pulmonary embolism, smoking

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• Anatomic and physiologic dead space
are essentially equal in the normal lung
• Normal values for VD/VT = 0.20-0.35
(or 20-35%)

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Alveolar ventilation

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 Minute volume = VExp = VT x f

Alveolar ventilation rate = VA = (VT -VD) x f

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Ventilation-perfusion ratio (V/Q)
It is the ratio of alveolar ventilation to pulmonary
blood flow per minute. The alveolar ventilation at
rest (4.2L/min) and is calculated as:
Alveolar ventilation = respiratory rate x (tidal volume –
dead space air).
The pulmonary blood flow is equal to right ventricular
output per minute (5L/min).

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Let’s assume that there is a blockage of one
alveolar region

VA
<< 0.8 VA
~ 0.8
Q
Q 13
• Normally the V/Q ratio is closer to 0.8.
• If V/Q ratio is 1
– capillary PO2 will reach equilibrium with alveolar PO2
– there will be no alveolar arterial PO2 difference.
• If V/Q ratio is Zero :
– alveolar pO2 and pCO2 = mixed venous blood (shunt)
• If V/Q ratio is Infinity :
– alveolar pO2 and pCO2 = inspired gasses (alveolar dead
space)
• where ventilation and perfusion have normal matching, the PO2
will be about 100 and the PCO2 will be about 40 torr.
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This value is an average value across the lung.
At the apex, V/Q ratio = 3.
At the base, V/Q ratio = 0.6.
So the apex is more ventilated than perfused, and the
base is more perfused than ventilated.
During exercise, the V/Q ratio becomes more
homogenous among different parts of the lung.

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Regional Gas Exchange in the
Lung
• Even in normal healthy individuals there is a V/Q
heterogeneity.
• produced by an uneven distribution of ventilation and
perfusion among regions of the lung.
• Ventilation is greater in the lower (caudal) region of the
lung than in the upper (cranial) region
• Blood flow is also greater in the caudal compared with
the cranial region of the lung

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Regional heterogeneity in ventilation
• Single-breath 133Xe test
• Xe has very low water solubility, so remains within the airspace;
imaged using external detectors
•
• Regional VA is indeed greater at the base of the lung in an
upright individual

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 PO2 = 40
PCO2 = 45
PO2 = 100
50 PCO2 = 40
.
Low VA/Q Base
PCO2 (mm Hg)

.
Normal VA/Q
PO2 = 150
PCO2 = 0

Apex

.
High VA/Q
50 100 150
PO2 (mm Hg) 18
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 perfusion
Zone 1
PA
Pa Pv PA>Pa>Pv
Low Flow

PA Zone 2
Pa Pv
Pa>PA>Pv
Waterfall

PA Zone 3
Pa Pv Pa>Pv>PA
Hi Flow Zones of the lung
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• The lung may be
considered to comprise 3
compartments:
– Ventilated but unperfused
alveoli
• Alveolar dead space
– Perfused but unventilated
alveoli
• Intrapulmonary shunt
– Ideally perfused &
ventilated alveoli

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Characteristics of the Pulmonary Circulation

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“Special” Characteristics of the Pulmonary Circulation

Systemic Circ. Pulmonary Circ.

C.O. (L/min) 6.0 ≈ 5.9

Arterial B.P. (mm Hg) 100 >> 15

Venous B.P. (mm Hg) 2 “≈” 5

Vascular resistance (∆P/flow) 100-2/6=16.3 > 15-5/5.9=1.7

Vascular compliance (∆V/∆P) Csystemic << Cpulm

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Special Characteristics of the Pulmonary Circulation: high compliance

Ability to promote a decrease in resistance as blood pressure rises

viscosity length

8hl
Remember that resistance to Flow = R=
pr4 25
radius
Special characteristic of blood vessels surrounding alveoli:
hypoxic vasoconstriction
When PO2 within the alveoli decreases there is a decrease in blood
flow to that alveolus
This is called hypoxic vasoconstriction

Thought to be the result of O2-sensitive K+ channels in the smooth

muscle membrane. At low O2 the K+ channels close, the Em rises,
and the cell reaches threshold and depolarizes and contracts.

This phenomenon is just the opposite of

the response to hypoxia you get with
arteriole smooth muscle in the systemic
circulation, but it is an important feature
of the pulmonary circulation that helps to
match perfusion with ventilation
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Pulmonary blood vessels are much more compliant than systemic blood vessels.
Also the system has a remarkable ability to promote a decrease in resistance as the
blood pressure rises.

Two reasons are responsible:

Recruitment: opening up of previously closed vessels
Distension: increase in caliber of vessels

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 Gas exchange at alveolar and systemic capillaries
Inspired air:
Expired air:
PO2 = 158 mm Hg
PO2 = 116 mm Hg
PCO2 = 0.3 mm Hg
PCO2 = 32 mm Hg

Right Heart Left Heart

Arterial blood
PO2 = 95 mm Hg
PCO2 = 41 mm Hg
(physiological shunt)

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Gas exchange is optimal when ventilation
and perfusion are going to the same places
and to the extent that they are not, gas
exchange suffers.

In an extreme case, if all the blood flow went

to the right lung and all the ventilation went
to the left, the person might have normal
cardiac output and normal alveolar
ventilation and no gas exchange.

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 Ventilation/perfusion
mismatch
• Main cause of hypoxemia in lung diseases

• O2 transport/perfusion inhomogeneity
probably also in other organs

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 Matching respiration & blood flow:
the Ventilation-Perfusion Ratio

Ventilation
Alveolar ventilation, VA
VA = (VT - VD) x resp. rate
= (0.5 - 0.15) x 12 = 4.2 L/min

Perfusion
Cardiac output = C.O. = Q
Q = stroke vol. x heart rate
= (0.086) x 70 = 6.0 L/min

VA
= ventilation/perfusion ~ 0.8
Q

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Pathological Examples of Altered Respiratory Mechanics

Normal Pulm.
Emphysema Asthma
Circ.

Capillary enlargement Longer paths

Exercise (e.g., Mitral Stenosis) for diffusion

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 SHUNTS
• the mixing of deoxygenated blood from systemic veins
with oxygenated blood coming from pulmonary
capillaries.
– Shunt occurs when blood flows from the venous
system to the arterial system without being
oxygenated.
• Shunts are classified as anatomic or physiologic; (a
small anatomic shunt [2-3%] is normal).
– Physiologic shunts are caused by alveolar collapse
or alveoli filled with a substance other than air.
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• Shunt (the maximal ventilation perfusion mismatch
[V/Q ratio of zero]) significantly reduces PaO2.
• Causes ;
– the Thebesian circulation which perfuses the left
ventricle and empties directly into the left ventricle
without passing through the lung.
– Lung tissue itself must be perfused (bronchial
circulation), and this blood empties into pulmonary
veins, mixing with pulmonary capillary blood.
– Congenital heart defects (Tetralogy of Fallot)
– Pulmonary pathology (Athelectasis/PNEUMONIA)
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Forced capacity (FVC & FEV1)
Normal ( N ) FEV1
( N ) VC

Obstructive  ( N ) FEV1

 or ( N ) VC

Restrictive  ( N ) FEV1
 or ( N ) VC
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 TIDAL FORCED
BREATHING EXPIRATION
NORMAL

FEV1 = 3.0L
FVC = 4.2L
FEV1
FEV1/FVC = 72%

OBSTRUCTIVE
FEV1
FEV1 = 0.9L
FVC = 2.3L
FEV1/FVC = 40%

RESTRICTIVE
FEV1
FEV1 =1.8L
FVC = 2.3L
FEV1/FVC = 78%

1 SECOND
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Terima kasih

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