Case 7

Chair: Sami
Learning Objectives:

1. Blood supply to the lungs (Bronchial and pulmonary circulation, hemodynamic properties of
the pulmonary circulation)

2. Ventilation/perfusion ration relationship between alveolar oxygen and carbon dioxide and
the factors affecting ventilation/perfusion ration (posture, exercise and gender)

3. Loss of ventilation (ventilation/perfusion mismatch effect and its consequences and shunt)

4. Loss of perfusion, its consequences with the focus on anatomical and physiological dead

5. Anatomy of the airway (where the foreign object fell)

6. General understanding of diagnostic possibilities for pulmonary embolism (CT-angiography

and ventilation/perfusion scan, D-dimer test and use heparin and coumarins and anti-coagulant)
1. Blood supply to the lungs
(Bronchial and pulmonary circulation, hemodynamic
properties of the pulmonary circulation)
 Pulmonary and Bronchial circulation
differences between the pulmonary and Bronchial circulation

Pulmonary and Bronchial circulation 4

2. Ventilation/perfusion ratio relationship between
alveolar oxygen and carbon dioxide and the factors
affecting ventilation/perfusion ratio
(posture, exercise and gender)
Revision of the Concept of Ventilation/Perfusion Ratio
Ventilation Perfusion V/Q Ratio
The movement of air into and out The blood flow through the The ratio of ventilation to
of the alveoli, facilitating the capillaries surrounding the perfusion, which determines the
exchange of gases. alveoli, allowing for the transfer efficiency of gas exchange in the
of oxygen and carbon dioxide. lungs.
Factors Affecting Ventilation/Perfusion Ratio
Gravity Lung Diseases Blood Flow
1 2 3
The effect of gravity on blood flow Conditions that impair ventilation Changes in cardiac output and
and air movement in the lungs. or perfusion, leading to V/Q vascular resistance affecting
mismatch. perfusion.

Airway Resistance
4
Increased resistance to airflow, altering the distribution of ventilation.
Role of Alveolar Oxygen Concentration
Alveolar O₂
Higher alveolar oxygen levels lead to constriction of the pulmonary arterioles, reducing perfusion.

Ventilation
Ventilation is not directly affected by alveolar oxygen concentration.

V/Q Ratio
The V/Q ratio increases as alveolar oxygen concentration rises, improving gas exchange efficiency.
Influence of Alveolar Carbon Dioxide Concentration
Alveolar CO₂
Higher alveolar carbon dioxide levels stimulate the respiratory center, increasing ventilation.

Ventilation
Ventilation increases in response to elevated alveolar carbon dioxide concentrations.

V/Q Ratio
The V/Q ratio may rise or fall depending on the relative changes in ventilation and perfusion.
Physiological Mechanisms Regulating
Ventilation/Perfusion Ratio
Neural Control
1
The respiratory center in the brainstem regulates ventilation in response to changes in blood
gases and pH.

Vascular Responses
2
Pulmonary arterioles constrict in response to low oxygen levels, redirecting blood flow to
better-ventilated areas.

Homeostatic Regulation
3

Physiological mechanisms work to maintain a normal V/Q ratio, ensuring efficient gas exchange.
Strategies for Optimizing Ventilation/Perfusion
Ratio
Body Positioning Ventilator Settings
Adjusting the patient's position can help improve V/Q Optimizing ventilator parameters can help balance
matching. ventilation and perfusion.

Oxygen Therapy Pharmacological Interventions

Supplemental oxygen can improve oxygenation and Certain medications can help modulate ventilation
V/Q relationships. and perfusion.
: Alveolar ventilation (V)
The amount of air that reaches alveoli in the lungs, measured in
.liters/minute (L/min)

: Perfusion (Q)
The pulmonary blood flow, or cardiac output, that reaches the
arteries, and specifically the capillaries, surrounding the alveoli, also
.measured in L/min

:When the lungs are upright and at rest

In an upright position, gravity dramatically affects both ventilation and perfusion across
all three zones, and overall the V/Q ratio progressively decreases from zone 1 to zone 2
.and finally to zone 3

In zone 1, the flow of air and blood is the

lowest with ventilation of around 0.25 L/min,
and perfusion of around 0.07 L/min;
.generating a V/Q ratio of 3.6

In zone 2, ventilation is equal to perfusion;

.generating a V/Q ratio of about 1

In zone 3, the flow of air and blood is the

highest with ventilation of around 0.8 L/min,
and perfusion of around 1.3 L/min;
.generating a V/Q ratio of 0.6

So the V/Q ratio varies depending on which part of the lung is involved,
but the overall ratio is an average of the three zones and works out to be
.0.8
The ratio of V to Q influences how efficiently gases,
specifically O2 and CO2 , are exchanged in the lungs.

In healthy lungs:

V/Q ratio = 0.8

At apex the ventilation is low but the perfusion is much

lower V/Q = 3 so it’s > 0.8, ( wasted ventilation ) why??

At base the ventilation is high but the perfusion is much

higher V/Q = 0.6 so it’s < 0.8 ( wasted perfusion ) why??
Lung zones
Zone 1: no blood flow
during all portions of cardiac cycle
The local alveolar air pressure (PALV) is greater than
.arterial pressure

Zone 2: intermittent flow

only during the peaks of pulmonary arterial blood
pressure
The systolic pressure is greater than alveolar air
pressure, but the diastolic blood pressure is lower than
.alveolar air pressure

Zone 3: continuous blood flow

The arterial pressure and pulmonary pressure (Ppc)
.remain greater than alveolar air pressure at all times
:Zone 1
As a result of gravitational effect ,arterial pressure (Pa) at the
apex of the lung may be lower than alveolar pressure (PA), which
.is approximately equal to atmospheric pressure

If Pa < PA, the pulmonary capillaries will be compressed by the

higher alveolar pressure outside of them, this will cause the
capillaries to close, reducing regional blood flow, normally in
zone 1, arterial pressure is just high enough to prevent this
.closure, and zone 1 is perfused, albeit at a low flow rate

If arterial pressure is decreased (e.g., due to hemorrhage) or if

alveolar pressure is increased (e.g., by positive pressure
?breathing) what happen

PA > Pa

.Blood vessels >> compressed and close

.zone 1 will be ventilated but not perfused

No perfusion = No gas exchange

:Zone 2

Because of the gravitational effect on hydrostatic pressure,

.Pa is higher in zone 2 than in zone 1 and higher than PA

Although compression of the capillaries does not present a

problem in zone 2, blood flow is driven by the difference
between arterial and alveolar pressure, not by the
difference between arterial and venous pressure (as it is in
.systemic vascular beds)
:Zone 3

The gravitational effect has increased arterial and venous

pressures, and both are now higher than alveolar
pressure. Blood flow in zone 3 is driven by the difference
between arterial pressure and venous pressure, as it is in
.other vascular beds

In zone 3, the greatest number of capillaries is open and

blood
.flow is highest
 Exercise
.In upper lobes, Va/Q is 2.5/3 times more than ideal value

?So physiological dead space or shunt

:During exercise
Blood flow to the upper part of lung increases ( higher Q )
Less V/Q
Less physiologic dead space occurs
Effectiveness of gas exchange is better

Women may experience greater pulmonary gas exchange

. impairment during exercise than men

Ventilation-perfusion inequality , values were slightly lower for

women under all conditions , but this did not significantly affect
. gas exchange
3. Loss of ventilation
(ventilation/perfusion mismatch effect and its
consequences and shunt)
4. Loss of perfusion, its consequences with the focus
on anatomical and physiological dead
Ventilation/Perfusion Ratio
Ideal ratio: 1

Normal ratio: 0.8

- 4 L/min air

- 5 L/min blood
Low perfusion = high V/Q ratio
Reduced perfusion compared to airflow

- Wasted ventilation

- Insufficient blood flow for gas

exchange

- Extreme increase in V/Q; if perfusion

reaches zero V/Q= infinity
5. Anatomy of the airway
(where the foreign object fell)
6. General understanding of diagnostic possibilities for
pulmonary embolism
(CT-angiography and ventilation/perfusion scan,
D-dimer test and use heparin and coumarins and
anticoagulant)
 :Diagnosis
D-dimer test

A blood test usually used to help check for or monitor blood

clotting problems. A positive test means the D-dimer level in
your body is higher than normal and suggests you might have
.blood clots

This test measures the amount of D-dimer, which is normally

.undetectable, in your blood

whether Blood clots form whenever a blood vessel is damaged,

that’s by an injury or by atherosclerosis, or when blood flow is
restricted, such as by a vessel being compressed for a long
.time

.arm How it’s done? A blood sample is taken from a vein in your
 :Diagnosis

CT pulmonary angiography

CT scanning generates X-rays to produce cross-sectional

images of your body. CT pulmonary angiography ― also
called CT pulmonary embolism study ― creates 3D images
that can detect abnormalities such as pulmonary embolism
within the arteries in your lungs. In some cases, contrast
material is given intravenously during the CT scan to
.outline the pulmonary arteries
 :Diagnosis

Ventilation-perfusion scan (V/Q scan)

When there is a need to avoid radiation exposure or

contrast from a CT scan due to a medical condition, a V/Q
.scan may be performed

In this test, a tracer is injected into a vein in your arm. The

tracer maps blood flow (perfusion) and compares it with
the airflow to your lungs (ventilation) and can be used to
determine whether blood clots are causing symptoms of
.pulmonary hypertension
 :Diagnosis
Pulmonary angiogram

This test provides a clear picture of the blood flow in

the arteries of your lungs. It's the most accurate way to
diagnose pulmonary embolism, but because it requires
a high degree of skill to administer and has potentially
serious risks, it's usually performed when other tests
.fail to provide a definitive diagnosis

In a pulmonary angiogram, a flexible tube (catheter) is

inserted into a large vein — usually in your groin — and
threaded through your heart and into the pulmonary
.arteries

A special dye is then injected into the catheter, and

X-rays are taken as the dye travels along the arteries in
.your lungs
 :Treatment
Treatment of pulmonary embolism is aimed at keeping
the blood clot from getting bigger and preventing new
clots from forming. Prompt treatment is essential to
prevent serious complications or death

Oral Parenteral
 :Treatment
Parenteral

Parenteral Therapies are medications, nutrients, vitamins and other healing

substances administered by injection into the body.
The most common types of parenteral therapies are given intravenously, but
.some are administered into the muscles or under the skin

Blood thinners (anticoagulants)

Drugs prevent existing clots from enlarging and new clots
.from forming while your body works to break up the clots

Heparin is a frequently used anticoagulant that can be given

.through the vein or injected under the skin
It acts quickly and is often overlapped for several days with
an oral anticoagulant, such as warfarin, until it becomes
.effective, which can take days
 :Treatment
Oral

Medications taken orally by mouth, come as solid tablets, capsules,

chewable tablets or lozenges to be swallowed whole or sucked on, or as
.drinkable liquids such as drops, syrups or solutions

term Warfarin is commonly called a "blood thinner," but the more correct
is "anticoagulant." It helps to keep blood flowing smoothly in your body
by decreasing the amount of certain substances (clotting proteins) in
.your blood
Warfarin - with brand name, Coumadin, is a prescription drug used as an
anticoagulant to inhibit formation of blood clots, and so is a therapy for
.deep vein thrombosis and pulmonary embolism
Pre-Discussion of Case 8
Case 8: Impulse conduction in the heart

Tom shows his fellow students the ECGs that were made at Papendal National Sports Centre. It shows a
regular series of peaks. The students wonder what these peaks and curves are. They find a normal ECG on
the internet demonstrating the effect of exercise.

The intervals between the peaks seem to be shorter after exercise. What is the heart frequency before and
after exercise?

Fig. 1:
Text in figure:
Voor inspanning: Before exercise Na inspanning:
After exercise

“How does a heart muscle cell know when and how strong to contract?” Mohammed wants to know. How is
the electrical function of the heart linked with the contraction of the heart muscle cells?

Monique asks Tom: “Do you think the peaks in your ECG are larger than normal because you have an
enlarged heart?” They also wonder if ECGs in women differ from those in men. The students compare Tom’s
ECG with the normal ECG.

21
Fig. 2: Tom’s ECG: Three leads are shown, I, II and III. What is the heart frequency?

During the procedure, they placed 10 electrodes on his body: four on his extremities (arms and legs) and
six on his chest surrounding his heart (see figure 3).

Fig. 3.

The physician clarified that these make it possible to follow the electrical activity in different directions. This
is important to localise conduction disturbances. To explain this further, the physician drew Einthoven’s
triangle. Now the students finally understand what the Roman numbers for the different leads stand for in
Tom’s ECG.

When studying the conduction and different bundle branches at home, Tom wondered whether heart tones
ITM1102 43
(see task 1) would sound different if there was a bundle branch block. Would a left or right bundle branch
block lead to other tones?
Difficult Words:

Word Meaning or Definition

Problem Definition:

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Brain Storming:

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Learning Objectives:

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