Ventilation/Perfusion

Matching
Thomas H. Sisson, M.D.
 Objectives
• To recognize the importance of matching
ventilation and perfusion
– To explain the consequences of mismatched
ventilation and perfusion
– To define shunt and dead space physiology
– To be able to determine the alveolar pO2
– To be able to determine the A-a O2 gradient and
understand the implications of an increased gradient
– To explain and understand the consequences of
regional differences in ventilation and perfusion due to
effects of gravity
Ventilation and Perfusion at the
Level of the Whole Lung

BY: University of Michigan Medical School

[Link]
Gas Composition in the 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.

BY: University of Michigan Medical School

[Link]
 Alveolar Gas Equation
PAO2 = (PiO2) – (PaCO2/R).

PaCO2 approximates PACO2 due to the rapid

diffusion of CO2

R = Respiratory Quotient (VCO2/V02) = 0.8

In a normal individual breathing room air:

PAO2 = 150 – 40/0.8 = 100 mmHg

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.

BY: University of Michigan Medical School

[Link]
 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
BY: University of Michigan Medical School
[Link]
How Can We Tell if Alveolar
Ventilation is Adequate?
 PaCO2 and Alveolar Ventilation
• PaCO2 is:
– directly related to CO2
production (tissue
metabolism). VCO 2
– Inversely related to PaCO 2 
alveolar ventilation. VA
• Increased PaCO2
(hypercarbia) is always a
reflection of inadequate
alveolar ventilation (VA).
 Alveolar Hypoventilation
Suppose a patient hypoventilates, so that the PCO2 rises to 80 mmHg.
We can estimate the PAO2 based on the alveolar gas equation.

PAO2 = 150 – 80/0.8 = 50 mmHg

Thus even with perfectly

efficient lungs, the PaO2
would be 50, and the patient
would be severely
hypoxemic. Therefore,
hypoventilation results in
hypoxemia.

BY: University of Michigan Medical School

[Link]
 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
 Two Lungs, Not One
• Suppose the left lung is ventilated but not
perfused (dead space).

• Suppose the right lung is perfused but not

ventilated (shunt).

• Total V/Q = 1, but there is no gas

exchange (V/Q must be matched at level
of alveoalr unit).
Low V/Q Effect on Oxygenation
One lung unit has
normal ventilation and
perfusion, while the
has inadequate ventilation

 PCO2
Normal Low  PO2
V/Q

PO2 50

PO2 114 PO2 ?

 Mixing Blood
• What is the PO2 of a mixture of two
volumes of blood with different initial PO2?
• Determined by interaction of oxygen with
hemoglobin.
– the partition of oxygen between plasma (and
thus the pO2) and bound to hemoglobin is
determined by the oxyhemoglobin
dissociation curve.
Oxyhemoglobin Dissociation Curve
CO2=(1.3 x HGB x Sat) + (.003 x PO2)
100 20

Oxygen Content (ml/100 ml)

% Hemoglobin Saturation

80 16
Oxygen Combined
With Hemoglobin
60 12

40 8

20
Dissolved Oxygen 4

0
0
0 20 40 60 80 100

PO mmHg
2
Low V/Q Effect on Oxygenation
One lung unit has
normal ventilation and
perfusion, while the
has inadequate ventilation

 PCO2
Normal Low  PO2
V/Q

PO2 50

PO2 114 PO2 ?

Oxyhemoglobin Dissociation Curve and
O2 Content
Total Oxygen

100 20

Oxygen Content (ml/100 ml)

% Hemoglobin Saturation

80 16
Oxygen Combined
With Hemoglobin
60 12

40 8

20 4

0 0
0 20 40 60 80 100 600
PO mmHg
2
 Low V/Q Effect on Oxygenation
One lung unit has
normal ventilation and
perfusion, while the
has inadequate ventilation

PO2 50 mmHg
Normal Low O2sat 80%
V/Q O2 content 16ml/dl

PO2 50

PO2 114 mmHg PO2 114

O2sat 100%
O2 content 20ml/dl
Oxyhemoglobin Dissociation Curve and
O2 Content
Total Oxygen
100

Oxygen Content (ml/100 ml)

20
% Hemoglobin Saturation

80 16
Oxygen Combined
With Hemoglobin
60 12

40 8

20 4

0 0
0 20 40 60 80 100 600
PO mmHg
2
 Low V/Q Effect on Oxygenation
One lung unit has
normal ventilation and
perfusion, while the
has inadequate ventilation

PO2 50 mmHg
Normal Low O2sat 80%
V/Q O2 content 16ml/dl

PO2 50

PO2 114 mmHg PO2 114

O2sat 100% PO2 60mmHg
O2 content 20ml/dl
 PCO2 in V/Q Mismatch
• Increased
80
ventilation can

CO2 CONTENT (ml/100 ml)

compensate for 60
low V/Q units.
– Shape of CO2 40

curve
20
• Total ventilation
(VE) must 0 20 40 60 80
increase for this
P
CO2 (mmHg)
compensation.
 Extremes of V/Q Inequality
• Shunt
– Perfusion of lung units without ventilation
• Unoxygenated blood enters the systemic circulation
• V/Q = 0

• Dead space
– Ventilation of lung units without perfusion
• Gas enters and leaves lung units without contacting blood
• Wasted ventilation
• V/Q is infinite
 Effect of Changing V/Q Ratio on
Alveolar PO2 and PCO2

Shunt Dead
Space

BY: University of Michigan Medical School

[Link]
Effects of V/Q Relationships on
Alveolar PO2 and PCO2

BY: University of Michigan Medical School

[Link]
 Shunt Physiology
PO2 40
One lung unit has
O2sat 50%
normal ventilation and
perfusion, while the
has no ventilation

Normal Shunt
PO2 40 mmHg
O2sat 50%
PO2 40

PO2 114 mmHg PO2 114 PO2 49

O2sat 100% O2sat 75%
Response to Breathing 100% Oxygen
• Alveolar hypoventilation or V/Q mismatch responds to
100% oxygen breathing.

• Nitrogen will be washed out of low ventilation lung units

over time.

• PaO2 will rise to > 550 mmHg.

• Limited response to oxygen in shunt.

• Use this characteristic to diagnose shunt.

 Shunt Calculation
• Qt x CaO2 = total volume of oxygen per time
entering systemic arteries
– Qt = total perfusion
– Qs = shunt perfusion
– CaO2, Cc’O2, CvO2 are oxygen contents of arterial,
capillary and venous blood
• (Qt-Qs) x Cc’O2 = oxygen coming from normally
functioning lung units
• Qs x CvO2 = oxygen coming from shunt blood
flow
Shunt

BY: University of Michigan Medical School

[Link]
 Shunt Equation

Qt x CaO2 = [(Qt – Qs) x CcO2] + [Qs x CvO2]

Qs Cc' O 2  CaO 2

Qt Cc' O 2  CvO2
 Causes of Shunt
• Physiologic shunts:
– Bronchial veins, pleural veins

• Pathologic shunts:
– Intracardiac
– Intrapulmonary
• Vascular malformations
• Unventilated or collapsed alveoli
Detecting V/Q Mismatching and Shunt

• Radiotracer assessments of regional

ventilation and perfusion.

• Multiple inert gas elimination.

– Takes advantage of the fact that rate of
elimination of a gas at any given V/Q ratio
varies with its solubility.

• A-aO2 Gradient.
V/Q Relationships

Source: Pulmonary Physiology, The McGraw-Hill Companies, Inc., 2007

Multiple Inert Gas Elimination

 A-a O2 gradient
• In a totally efficient lung unit with matched V/Q, alveolar
and capillary PO2 would be equal.

• Admixture of venous blood (or of blood from low V/Q lung

units) will decrease the arterial PaO2, without effecting
alveolar O2 (PAO2).

• Calculate the PAO2 using the alveolar gas equation, then

subtract the arterial PaO2: [(PiO2) – (PaCO2/R)] –PaO2.

• The A-a O2 gradient (or difference) is < 10-15 mmHg in

normal subjects
– Why is it not 0?
 Apical and Basilar Alveoli in the
Upright Posture
• Elastic recoil of the individual alveoli is similar throughout the
normal lung.

• At end expiration (FRC) apical alveoli see more negative

pressure and are larger than basilar alveoli.

• During inspiration, basilar alveoli undergo larger volume

increase than apical alveoli.

• Thus at rest there is more ventilation at the base than the apex.

• Also More Perfusion to Lung Bases Due to Gravity.

Effects of Gravity on Ventilation
and Perfusion

Source: Pulmonary Physiology, The McGraw-Hill Companies, Inc., 2007

Effects of Gravity on Ventilation
and Perfusion Matching

BY: University of Michigan Medical School

[Link]
 Causes of Abnormal Oxygenation

• Hypoventilation
• V/Q mismatch
• Shunt
• Diffusion block
 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.