THE RESPIRATORY SYSTEM

Emphysema with Respiratory Failure

A 60-year-old woman is in the intensive care unit for treatment of respiratory tract failure. Her underlying
disease is emphysema, caused by years of smoking. Her trachea is intubated, and the tube is connected to a
mechanical ventilator that has taken over her breathing. The fraction of inspired oxygen is 0.6. The
machine-delivered tidal volume is 700 ml and the rate is 12 breaths/minute. She is afebrile and has normal
blood pressure. The following data are obtained:

1. Write the formula you would use to calculate the following:

a. Arterial oxygen content

b. Arterial oxygen delivery
c. Venous oxygen content
d. Oxygen uptake
e. Venous oxygen delivery

a. Arterial blood oxygen content (CaO2) = (SaO2 x Hb x 1.34) + (0.003 x PaO2)

b. Arterial oxygen delivery = CaO2 x cardiac output
c. Venous blood oxygen content (CVO2) = (SVO2 x Hb x 1.34) + (0.003 x PVO2)
d. Oxygen uptake = (CaO2 - CVO2) x cardiac output*
*This important relationship is also known as the Fick Equation.
e. Venous oxygen delivery = arterial oxygen delivery - oxygen uptake

2. Assuming that all other factors remain the same, explain the result of each of the following changes on
her arterial oxygen content and arterial oxygen delivery. In each instance where the HbO2 equilibrium
curve is altered, state whether the P50 is lower or higher than normal.

a. Increase in PaCO2 to 50 mm Hg
b. Increase in body temperature to 101 0F
c. Increase in pH to 7.58
d. Increase in PaO2 to 80 mm Hg
e. Increase in hemoglobin to 12 g/dl blood

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 f. Decrease in cardiac output to 4 L/min

a.-b. Both a high PaCO2 and a high temperature will shift the HbO2 equilibrium curve to the right,
thereby causing decreased oxygen uptake in the pulmonary capillaries and a reduced SaO 2. Because
oxygen content is directly related to SaO 2, oxygen content will fall. Because arterial oxygen delivery is
directly related to oxygen content, it too will fall. Note that the higher the PaO 2, the flatter the curve;
compared to changes in the steep part of the curve, right and left shifts in the flat region affect
pulmonary capillary oxygen uptake relatively slightly. The P 50 of a right-shifted curve is higher than
normal.

Changes that shift the curve toward the right while causing reductions in pulmonary capillary oxygen
uptake, arterial oxygen content, and arterial oxygen delivery also cause oxygen to be unloaded more
easily from the venous end of the systemic capillaries, where PO2 is low. Thus, although there may be
less oxygen delivered to the systemic capillaries per minute, it is released to the tissues more easily; as
a result, there may be no net reduction in oxygen actually delivered to the tissue cells.

c. An increase in pH shifts the HbO2 equilibrium curve to the left; the P50 will be reduced. Blood
changes that shift the HbO2 equilibrium curve toward the left lead to a higher SaO2 at the pulmonary
capillary level, although for reasons previously stated, the increase is slight in the flat portion of the
curve. In this example, where pH changes from 7.5 to 7.58, SaO2 increases only from 92% to 94%.
This increase will lead to a modest increase in arterial O2 content and delivery, which may be offset by
the fact that oxygen will be held more tightly by hemoglobin at low PO2 values (i.e., in the systemic
capillaries).

d. A 20 mm Hg increase in PaO 2 (a 33% increase over baseline) increases SaO 2 a small amount,
approximately 4%. Because this patient's baseline pH is 7.5, the left-shifted (solid black line) curve in
the figure more closely approximates her curve than the standard (red line) curve of pH 7.4. As a result
of increased SaO2, arterial oxygen content and arterial oxygen delivery will increase slightly. A change
in PaO2 by itself will not alter the position of the curve, so P50 will not change.

e. Increasing hemoglobin from 9 to 12 g/dl provides a 33% increase in hemoglobin-bound oxygen

content, and a corresponding increase in arterial oxygen delivery. Clearly, in the region of the flat part
of the HbO2 equilibrium curve, raising a low hemoglobin content can have a more profound effect on
oxygen content and delivery than increasing PaO2.

f. A 20% decrease in cardiac output from 5 to 4 L/min will have no effect on oxygen content (assuming
nothing else changes) but will reduce systemic oxygen delivery by the same degree, 20%. The position
of the HbO2 equilibrium curve, and hence the P50' will be unaffected. (When cardiac output falls, the
body usually compensates by increasing the percentage of oxygen extracted at the tissue level.)

3. Based on the information provided:

a. Approximately what percentage of oxygen delivered to the systemic tissue capillaries is taken up and
metabolized by the tissues?

b. Approximately what percentage of oxygen delivered to the systemic tissue capillaries returns to the
right heart?

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a. The percentage of oxygen taken up is the difference between arterial and venous oxygen contents
divided by arterial oxygen content:

(CaO2 ¨C CvO2)/CaO2

Oxygen content = (HbO2 saturation x Hb content x 1.34) + dissolved oxygen.

If you used a normal hemoglobin content of 15 g/dl blood when you did the calculation, you would find
the following values (approximate):

CaO2 = 20 ml O2/dl

CvO2 = 15 ml O2/dl

In this manner the percentage of oxygen uptake is 5/20 = 25%. Note that the content can be stated
as ml O2/dl or ml O2/L; either way the percentage of uptake is the same.

Because hemoglobin content is the same in arterial and venous blood, and dissolved oxygen is a very
small amount in both arterial and venous blood, the difference in oxygen saturations also reflects the
difference in contents. Normally, arterial oxygen saturation is 98% and mixed venous saturation is
75%. This difference reflects the fact that approximately 25% of arterial oxygen delivery is taken up by
the tissues.

In this patient the difference in oxygen saturation (92% - 72%) indicates that about 20% of the
delivered oxygen is metabolized by the tissues (i.e., about the normal amount).

b. The percentage of total arterial oxygen delivery that returns to the right heart is 100 minus the
percentage of oxygen uptake, or approximately 75%.

These values¨C25% oxygen uptake, 75% oxygen return to the right heart¨Care normal for
resting individuals. The percentage of delivered oxygen used by the tissues increases in anemia,
exercise, or heart failure.