Quantitative Gas Exchange Physiology. VQ Relationships
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1 Quantitative Gas Exchange Physiology VQ Relationships
2 Traditional Mechanisms of Hypoxemia: 1.Altitude 2.Shunt 3.VQ mismatching 4.Diffusion Impairment 5. Hypoventilation How does one explain worsened hypoxemia related to: Exercise in COPD Anemia Fever Exercise in CHF Pulm HTN
3 Questions : What are the factors which determine ABG composition? How does the ABG depend upon overall VO 2, VCO 2, cardiac output, overall minute ventilation, & the VQ distribution? How are these factors inter-related? Goal: to understand ABG composition at a more fundamental and quantitative level.
4 CaO 2 Mass Conservation: Rate of O 2 entering unit = Rate of O 2 leaving unit Recall: concentration = amount / volume So, amount = volume * concentration So, Transport Rate = amount / minute = ( volume/minute ) * concentration
5 CaO 2 Rate of O 2 entering unit = Rate of O 2 leaving unit VI * FIO 2 + Q * CvO 2 = Q * CaO 2 + VA * FAO 2
6 The complete solution requires a computer. However, algebra provides an approximate solution : CaO 2 = CvO 2 + V/Q * (FIO 2 FAO 2 ) * k CaCO 2 = CvCO 2 - V/Q * FACO 2 * k So, the ABG of the single unit depends fundamentally upon only 4 things: 1. the mixed venous composition 2. the VQ ratio of the unit 3. the FiO 2 4. the hemoglobin dissociation and CO 2 solubility curves
7 Back to the real lung 500,000 alveolar ducts each has its own VQ ratio each unit drains ultimately into the left atrium, & mixes in proportion to its perfusion to form the arterial blood But, each receives the same mixed venous blood, and has the same FiO 2 (and dissociation curve). So each unit shares 3 of the 4 determinants of gas exchange; only the VQ ratio differs. So, the determinants of ABG composition in the lung are identical to those of the single unit, with the VQ distribution taking the place of the VQ ratio.
8 Determinants of ABG composition Single Unit Patient 1. Mixed venous composition VO 2, VCO 2, Cardiac Output, Ve 2. VQ ratio VQ distribution 3. FiO 2 FiO 2 4. Hg dissociation curve Hg dissociation curve
9 How is the ABG formed in vivo? A simple example: Imagine a lung with only 3 regions. VQ % Q top middle bottom Suppose the mixed venous PO 2 is normal and FiO 2 =0.21. What is the arterial PO 2?
10 CaO 2 = CvO 2 + V/Q * (PIO 2 PAO 2 ) * k Start with the mixed venous composition PvO2 = 40 CvO2 = 15.6 mls O2/100 mls blood 20 O 2 Content PO 2
11 CaO 2 = V/Q * (150 PAO 2 ) * k Solve earlier equations for O 2 contents for each region : VQ %Q CcO 2 top middle bottom Mix blood coming from each region in proportion to its perfusion: 20.9 (ml O 2 /100cc) = 41.8 mls O mls mls 1000 cc mls O ml O 2 /100cc this is the arterial O 2 content Look up PO 2 using the O 2 dissociation curve
12 Look up PO 2 using the O 2 dissociation curve O 2 Content PO 2 97 mmhg
13 A real life example -- a normal medical student
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16 Determinants of ABG composition CaO 2 = CvO 2 + V/Q * (PIO 2 PAO 2 ) * k CaCO 2 = CvCO 2 - V/Q * PACO 2 * k Single Unit Patient 1. Mixed venous composition VO 2, VCO 2, Cardiac Output, Ve 2. VQ ratio VQ distribution 3. FiO 2 FiO 2 4. Hg dissociation curve Hg dissociation curve
17 Inter-relationships of VO 2, VCO 2, cardiac output & VE - Example: Exercise in the normal patient. A stepwise investigation of the sequence of the normal response to exercise 1. increase VO 2 and VCO 2 by factor of two 2. increase cardiac output appropriately 3. increase VE proportionally to cardiac output 4. increase VE further to drive PCO 2 = 40
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20 Results Isolated effect of increasing VO 2 and VCO 2 X 2 PvO 2, PvCO 2 PaO 2, PaCO / 89 / / 78 / 50 Next increase cardiac output to from 5.0 to 6.5 L /min holding Ve constant at resting value
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22 Results 1. isolated effect of increasing VO 2 and VCO 2 PvO 2, PvCO 2 PaO 2, PaCO / 89 / / 78 / effect of increased cardiac output alone mixed venous improves (7.22 / 85 / 29) mean VQ no change in ABGs (7.23 / 76 / 53) Next, Increase VE proportionally to cardiac output to restore mean VQ (VE 5.8 L)
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24 Results: 1. isolated effect of increasing VO 2 and VCO 2 PvO 2, PvCO 2 PaO 2, PaCO / 89 / / 78 / effect of increased cardiac output alone : mixed venous improves mean VQ no change in ABGs 3. Increase VE proportionally to cardiac output to restore mean VQ: Incomplete effect: ABG: 7.23 / 60 / 68 Last step: Increase VE to drive PCO 2 to 40
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26 Inter-relationships of VO 2, VCO 2, cardiac output & VE - Exercise in the normal patient CaO 2 = CvO 2 + V/Q * (PIO 2 PAO 2 ) * k 1. isolated effect of increasing VO 2 and VCO 2 PvO 2, PvCO 2 PaO 2, PaCO / 89 / / 78 / effect of increased cardiac output alone : mean VQ no significant change in ABGs 3. Increase VE proportionally to cardiac output to restore mean VQ: (VE 5.6 L) Incomplete effect: ABG: 7.23 / 60 / Increase VE to drive PCO 2 to 40 (VE 9.0 L) Major effect: mean VQ to 1.4, ABG: 7.40 / 40 / 91 notice mixed venous: 7.37 / 48 / 33
27 VO 2 VCO 2 CO VE mixed venous ABG /44/ /39/ /89/ /78/ /85/ /76/ /68/ /60/ /48/ /40/91 Question : Why does a 27% increase in cardiac output require a 95% increase in VE to achieve the same ABG?
28 Gas Transport vs VQ ratio
29 Inter-relationships of VO 2, VCO 2, cardiac output & VE - 2 nd Example: fever in the ICU in a patient with COPD and CHF 1. Increase body temp to Increase VO 2, VCO 2 by factor of 2 3. Increase cardiac output and increase VE proportionally - Let s begin with the baseline
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31 FIO 2 = 0.3 Temp = 37
32 Temp = 39
33 Results: - 2 nd Example: fever in the ICU in a patient with COPD and CHF 1. Increase body temp to 39 PO 2 rises from 70 to 76 why? Next : Increase VO 2, VCO 2 by factor of 2 in response to metabolic effect of fever
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35 Results: - 2 nd Example: fever in the ICU in a patient with COPD and CHF Baseline ABG: 7.29 / 60 / Increase body temp to 39 R shift dissociation curve PO 2 rises from 70 to Increase VO 2, VCO 2 by factor of 2 in response to metabolic effect of fever PO 2 plummets, PCO 2 explodes ABG: 7.11 / 120 / 54 Next : Increase both cardiac output and VE 40% (no in mean VQ)
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37 Results: - 2 nd Example: fever in the ICU in a patient with COPD and CHF Baseline ABG: 7.29 / 60 / Increase body temp to 39 R shift dissociation curve PO 2 rises from 70 to Increase VO 2, VCO 2 by factor of 2 in response to metabolic effect of fever PO 2 plummets, PCO 2 explodes ABG: 7.11 / 120 / Increase both cardiac output and VE 40% (no in mean VQ) ABG improves 7.20 / 86 / Increase VE to drive PCO 2 back to baseline ( mean VQ)
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39 Results: - 2 nd Example: fever in the ICU in a patient with COPD and CHF Baseline ABG: 7.29 / 60 / Increase body temp to 39 R shift dissociation curve PO 2 rises from 70 to Increase VO 2, VCO 2 by factor of 2 in response to metabolic effect of fever PO 2 plummets, PCO 2 explodes ABG: 7.11 / 120 / Increase both cardiac output and VE 40% (no in mean VQ) ABG improves 7.20 / 86 / Increase VE to drive PCO 2 back to baseline ( mean VQ) ABG improves 7.30 / 60 / 66
40 Inter-relationships of VO 2, VCO 2, cardiac output & VE - 3 rd Example: CO 2 retention in advanced COPD on O 2 1. Baseline 2. Increase work of breathing VCO 2 VO 2 3. Increase FiO 2 to 75% 4. Release hypoxic pulmonary vasoconstriction 5. Increase VE to drive PCO 2 to baseline - Let s begin with the baseline
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43 Results - 3 rd Example: CO 2 retention in advanced COPD on O 2 1. Baseline : 7.29 / 62 / 53 mixed venous: 7.28 / 67 / Increase work of breathing VCO 2 VO / 77 / 35 mixed venous: 7.23 / 85 / 18 Now put on high flow oxygen FiO 2 75%
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45 Results - 3 rd Example: CO 2 retention in advanced COPD on O 2 1. Baseline : 7.29 / 62 / Increase work of breathing VCO 2 VO / 77 / Increase FiO 2 to 75%: 7.21 / 81 / Why? 4. Now release hypoxic vasoconstriction, increasing perfusion of low VQ regions, making the lung a poorer gas-exchanger
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47 Results - 3 rd Example: CO 2 retention in advanced COPD on O 2 1. Baseline : 7.29 / 62 / Increase work of breathing VCO 2 VO / 77 / Increase FiO 2 to 75%: 7.21 / 81 / 429 (Haldane effect) 4. Release hypoxic pulmonary vasoconstriction : broaden VQ 7.12 / 89 / Now increase VE to drive PCO 2 to baseline - if you can
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49 Results - 3 rd Example: CO 2 retention in advanced COPD on O 2 1. Baseline : 7.29 / 62 / Increase work of breathing VCO 2 VO / 77 / Increase FiO 2 to 75%: 7.21 / 81 / 429 (Haldane effect) 4. Release hypoxic pulmonary vasoconstriction : broaden VQ 7.12 / 89 / Increase VE to drive PCO 2 back to baseline : VE : L/min What if airflow obstruction prevents this? ventilatory reserve
50 Summary : Determinants of ABG composition Single Unit Patient 1. Mixed venous composition VO 2, VCO 2, Cardiac Output, Ve 2. VQ ratio VQ distribution 3. FiO 2 FiO 2 4. Hg dissociation curve Hg dissociation curve
51 Summary of effects on gas exchange: 1. VO 2, VCO 2 alters mixed venous gases 2. cardiac output shifts overall VQ distribution, alters mixed venous gases 3. VE shifts overall VQ distribution, alters mixed venous gases secondarily. Important for both PCO 2 and PO 2 4. Differing shapes of O 2 and CO 2 are responsible for differing gas transport properties Discover the effects of P50, anemia, etc, on your own ( only with Internet Explorer )
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