Learning Objectives

Pulmonary Circulation and Ventilation/Perfusion Matching

By the end of this lecture the student should be able to Understand mechanism of blood flow to lungs Regional distribution of ventilation and perfusion due to effect of gravity in lungs Concept of physiological shunt Concept of physiological dead space Ventilation perfusion ratio in different parts of lungs in health and disease Partial pressures of oxygen and carbondioxide in physiological shunt and dead space RELATIONSHIP OF VENTILATION AND PERFUSION IN DIFFERENT AREAS OF LUNG

RELATIONSHIP OF VENTILATION AND PERFUSION IN DIFFERENT AREAS OF LUNG

Ventilation and Perfusion at the Level of the Whole Lung

Gas Composition in the Normal Alveolar Space

Trachea: partial pressure of CO2 is approximately 0 PiO2 = (barometric pressure-H2O vapor pressure)xFiO2 = (760 47) x 0.21 =150 mmHg In the alveolar space, oxygen diffuses into the blood and CO2 diffuses into the alveolus from the blood.

Consequences of Inadequate Ventilation

Apnea: PACO2 rises

PAO2 falls until there is no gradient for diffusion into the blood

Hypoventilation: Inadequate ventilation for perfusion PACO2 rises PAO2 falls, but diffusion continues

Abnormal V/Q in the Upper and Lower Normal Lung. In a normal person in the upright position, both pulmonary capillary blood flow and alveolar ventilation are considerably less in the upper part of the lung than in the lower part However, blood flow is decreased considerably more than ventilation is. Therefore, at the top of the lung,V/Q is as much as 2.5 times as great as the ideal value, which causes a moderate degree of physiologic dead space in this area of the lung. Abnormal V/Q in the Upper and Lower Normal Lung. At the bottom of the lung, there is slightly too little ventilation in relation to blood flow, with V/Q as low as 0.6 times the ideal value. In this area, a small fraction of the blood fails to become normally oxygenated, and this represents a physiologic shunt. Abnormal V/Q in the Upper and Lower Normal Lung. In both extremes, inequalities of ventilation and perfusion decrease slightly the lungs effectiveness for exchanging oxygen and carbon dioxide. However, during exercise, blood flow to the upper part of the lung increases markedly, so that far less physiologic dead space occurs, and the effectiveness of gas exchange now approaches optimum.

V/Q Matching
300 million alveoli.

 Different alveoli may have widely differing amounts of ventilation and of perfusion. Key for normal gas exchange is to have matching of ventilation and perfusion for each alveolar unit Alveoli with increased perfusion also have increased ventilation Alveoli with decreased perfusion also have decreased ventilation V/Q ratio = 1.0

Low V/Q Effect on Oxygenation

One lung unit has normal ventilation and perfusion, while the has inadequate ventilation

Normal

Low V/Q

PCO2 PO2

PO2 50 PO2 114 PO2 ?

Effects of V/Q Relationships on Alveolar PO2 and PCO2

Shunting of blood
Whenever V/Q is below normal, there is inadequate ventilation to provide the oxygen needed to fully oxygenate the blood flowing through the alveolar capillaries. Therefore, a certain fraction of the venous blood passing through the pulmonary capillaries does not become oxygenated. This fraction is called shunted blood.

Shunting of blood
Some additional blood flows through bronchial vessels rather than through alveolar capillaries Normally this is about 2 % of the cardiac output This is unoxygenated, shunted blood. The total quantitative amount of shunted blood per minute is called the physiologic shunt The greater the physiologic shunt, the greater the amount of blood that fails to be oxygenated as it passes through the lungs.

Causes of Shunt
Physiologic shunts: Bronchial veins, pleural veins Pathologic shunts: Intracardiac Intrapulmonary Vascular malformations Unventilated or collapsed alveoli

Effects of Gravity on Ventilation and Perfusion Matching

Key Concepts:
Ventilation and Perfusion must be matched at the alveolar capillary level. V/Q ratios close to 1.0 result in alveolar PO2 close to 100 mmHg and PCO2 close to 40 mmHg. V/Q greater than 1.0 increase PO2 and Decrease PCO2. V/Q less than 1.0 decrease PO2 and Increase PCO2.

 Shunt and Dead Space are Extremes of V/Q mismatching. A-a Gradient of 10-15 Results from gravitational effects on V/Q and Physiologic Shunt.

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