Departemen/SMF Anestesiologi dan Reanimasi

FK-USU/RSUP.H. ADAM MALIK

M E D A N
VENTILATION PERFUSION
RELATION SHIPS
PROSES PERNAFASAN
Gabungan mekanisme yang berperan
dalam suplai oksigen keseluruh sel
dan eliminasi karbon dioksida
KOMPONEN YANG BERPERAN
Ventilasi
Difusi
Perfusi
3 Processes:
1. Ventilation - movement of air in & out --
depends on system of open (clear) airways
& movement of respiratory muscles,
primarily the diaphragm which is innervated
by the phrenic nerve.

2. Diffusion - exchange & transport gases
(need perfusion/pulmonary circulation)

3. Perfusion
HUBUNGAN VENTILASI/PERFUSI
1. Ventilasi : jumlah dari semua volume udara
yang diekshalasi dalam 1 menit
Minute Volume = VT X Frek. Nafas
Ventilasi Alveolar = Frek. Nafas x (VT VD)
DEAD SPACE
Non Respirasi (Anatomik Dead Space)
Non Perfusi (Alveolar Dead Space)
Physiological
Dead
Space
VENTILASI
Jumlah udara / gas yang mengadakan
pertukaran dalam alveoli setiap menit
Dipengaruhi oleh :
Patensi jalan nafas

Posisi tubuh

Volume paru

Dead space

Shunting
Patensi Jalan Nafas :
obstruksi
Infeksi
tumor
Volume Paru :
otot pernafasan
penyakit paru
space occupying lesion
tekanan intra abdominal
nyeri, obat
Posisi Tubuh :
tegak
terlentang
miring
VENTILATION
Proses transport gas antara alveolus dan atsmosfir
Pertukaran gas ini akan berkurang pada ;
obstructive
restrictive
combined ventilation disorders
Contoh :
Laparotomi abdomen atas
COPD (Chronic Obstructive Pulmonary Disease)
Status Asthmaticus
CNS dan obat- obatan : sedation, intoxication
Neuromuscular : myasthenia gravis, muscle relaxant
PERFUSION
Aliran darah paru yang bertanggung jawab
membawa CO
2
ke alveoli dan sebaliknya
membawa O
2
dari alveoli ke jantung

Perfusion disorder :
Pulmonary embolism
Sumbatan pada mikrosirkulasi paru
karena agregasi platelet dan granulosit :
septicemia
peritonitis
acute pancreatitis
Extra pulmonary : reduced CO pada gagal
jantung, atau pada kondisi syok
Pori-pori
Kohn
Alveoli
Bronkiolus
respiratorius
Bronkiolus
terminalis
SIRKULASI PULMONER
Sifat :
Tekanan pembuluh darah rendah, MAP 8 - 15
mmHg
Mudah mengembang (distensible)
Resistensi rendah

Dalam keadaan istirahat, perfusi pulmoner, sekitar
= 70 ml x 80 x / mnt = 5,6 L / mnt

Pintasan Fisiologis = jumlah darah yang melintas
dari kanan ke kiri tanpa mendapat oksigenisasi dan
dekarboksilasi paru (sekitar 5 % curah jantung)
The three-zone model of the lung. A: Upright position. B: Supine position.
Diffusion
Transport of gases between the alveoli and
(pulmonary) capillaries and eventually from
the capillaries to the tissues

diffusion dependent on perfusion and the
partial pressure (pp) exerted by each gas (each
gas in a mixture of gases exerts a partial
pressure, a property determined by the
concentration of the gas)

gases diffuse from area of conc. (pp) to
conc. (pp)
concentration pp of gas
diffusion

CO
2
more soluble than O
2
, therefore
it diffuses faster

MEMBRAN ALVEOLO-KAPILER: - adalah
permukaan antar alveoli dan endotel kapiler
- Tempat O
2

berdifusi dari
alveoli ke
kapiler darah
/CO
2
berdifusi
dari kapiler ke
alveol
Factors Affecting Diffusion
surface area in the lung (e.g., lobectomy,
atelectasis, emphysema)
thickness of alveolar-capillary membrane
(e.g., edema, pneumonia)
differences in partial pressure of gases on
either side
Characteristics of the gas (CO
2
diffuses
faster)
PERTUKARAN GAS
ALVEOLUS
KAPILER PARU
UDARA BEBAS:
PiO
2
: 21% x 760 = 160 mmHg
PiCO
2
: 0.04 % x 760 = 0.3 mmHg
PiN
2
: 78.6 % x 760 = 597mmHg
PiH
2
O : 0.46 % x 760 = 3.5 mmHg
N
2
H
2
O
O
2
PAO
2
:
104 mmHg
CO
2
PACO
2
:
40 mmHg
O
2
PvO
2
:
40 mmHg
O
2
PcO2: 100
mmHg
CO
2
PcCO
2
: 45
mmHg
CO
2
PcCO
2
: 40
mmHg
PROSES DIFUSI
PAN
2
:
573 mmHg
PAH
2
O:
47 mmHg
PAO
2
PcO
2
PaO
2
Pulmonary Artery
Pulmonary Vein
Oxygenation
SHUNT DAN DEAD SPACE
VENTILASI
DIFUSI
PERFUSI
Airway
Alveoli
Kapiler darah
No VENTILASI
PERFUSI
Airway
Alveoli
Kapiler darah
Blood flow
SHUNT UNIT (PERFUSION
WITHOUT VENTILATION)
Sumbatan
SHUNT UNIT
The distribution of / ratios for the whole lung (A) and according to height (B) in the upright position.
Note that blood flow increases more rapidly than ventilation in dependent areas.
(Reproduced, with permission, from West JB: Ventilation/Blood Flow and Gas Exchange, 3rd ed.
Blackwell, 1977.)
A three-compartment model of gas exchange in the lungs, showing dead space ventilation,
normal alveolarcapillary exchange, and shunting (venous admixture).(Modified and
reproduced, with permission, from Nunn JF: Applied Respiratory Physiology, 5th ed. Lumb
A [editor]. Butterworth-Heinemann, 2000.)
SHUNTING
(Intrapulmonary Right-to-Left Shunt)
ANATOMICAL FUNCTIONAL
Bronchial
Pleural
Thabesian
CHD (Congenital Heart Disease)
Tumor Paru
Arteriovenous Anastomosis
Atelectasis
Pneumothorax
Hematothorax
Pleural effusion
Pulmonary edema
Pneumonia
Acute Respiratory
Failure (ARDS)
SHUNT %

0
FiO
2
PaO
2
100
50%
20%
30%
10%
2-3%
100
200
300
400
500
21 40 60 80
DEAD SPACE
Volume udara yang di hirup dalam
satu kali bernafas yang tidak turut
berdifusi dalam alveolus
FUNCTIONAL DEAD SPACE
ANATOMICAL
ALVEOLAR
VENTILASI
NO PERFUSI
Airway
Alveoli
Kapiler darah
No Blood flow
DEAD SPACE UNIT
(VENTILATION WITHOUT PERFUSION)
DEAD SPACE UNIT
ANATOMICAL
DEAD SPACE
ALVEOLAR
DEAD SPACE
PHYSIOLOGICAL
DEAD SPACE
VENOUS ADMIXTURE
(SHUNT)
V/Q =
V/Q > 1
V/Q = 1
V/Q < 1
V/Q = 0
Hubungan Ventilasi (V) dan Perfusi (Q)
TRAKEA
KAPILER
PARU
MECHANICAL
DEAD SPACE:
TUBE
CONNECTOR
ET CO2
BREATHING
CIRCUIT
NORMAL
~0.8
Optimum gas exchange
requires:
Ventilation/perfusion match (high V/Q ratio)
In healthy lungs this ratio is close to 1:1
Perfusion greater in dependent areas of the
lung
Ventilation also greater in dependent areas of
the lung
Measure adequacy of V/Q match through ABGs
V/Q mismatches
In areas where perfusion > ventilation,
a shunt exists. Blood bypasses the
alveoli without gas exchange occurring
(e.g., pneumonia, atelectasis, tumor,
mucus plug)

All cause obstruction in the distal
airways, decreasing ventilation
In areas where ventilation > perfusion,
dead space results. The alveoli do not have
an adequate blood supply for gas exchange
to occur (e.g., pulmonary emboli,
pulmonary infarct, cardiogenic shock).
In areas where both perfusion and
ventilation are limited or absent, a silent
unit exists (e.g., pneumothorax, severe
ARDS).
MEASURED
PARAMETERS
CALCULATED
PARAMETERS
Arterial Oxygen Tension (PaO
2
)
Arterial Carbon Dioxide Tension
(PaCO
2
)
Arterial Oxygen Saturation
(SaO
2
or SpO
2
)
Mixed Venous Oxygen Saturation
(SvO
2
)
Venous Oxygen Tension (PvO
2
)
Hemoglobin (Hgb)
Cardiac Output (CO)
Pulmonary Capillary Oxygen
Content (CcO
2
)
Arterial Oxygen Content (CaO
2
)
Venous Oxygen Content (CvO
2
)
Arterial-Venous Oxygen Content
Difference (Ca-vO
2
)
Oxygen Utilization Coefficient (OUC)
Oxygen Delivery Index (DO
2
I)
Oxygen Consumption Index (VO
2
I)
Intrapulmonary Shunt (Qs/Qt)
Cardiac Index (CI)
Nervous Syst
Humoral
Local Control

6 Key steps in oxygen cascade
Oxygenation
Carrying capacity
Cardiac Output
Autoregulation
Distance
Mitochondria
Uptake in the Lung
Delivery
Organ distribution
Diffusion
Cellular use
DO
2

PaO
2

SaO
2
- Ht
Flow rate -
O
2
Haemoglobin
CaO
2

Contraction
VO
2

TISSUE OXYGENATION
Oksigen ditranspor ke jaringan
dalam 2 bentuk
Terlarut dalam plasma

Berikatan dengan hemoglobin
OXYGEN DELIVERY
DO
2
= oxygen delivery
VO
2
= oxygen consumption
SaO
2
= arterial oxygen saturation
SvO
2
= mixed venous oxygen saturation
Q = cardiac output
Hb = hemoglobin concentration
PaO
2
= arterial oxygen tension
PvO
2
= mixed venous oxygen tension
DO2 = CO X CaO2
(ml / menit) (ml O2 / 100 ml Blood)
= 1000 ml O2 / menit

CaO2 = (SaO2 x Hb x 1,341) + (PaO2 x 0,0003)
= 20 ml O2 / 100 ml Blood
Oxygen Content dalam
darah
= Hb bound plus dissolved
CaO
2
= [Hb] x 1.34 x % saturation
+
PO
2
x 0.003 ml O
2
/ dl / mm Hg
Kurva Disosiasi Hemoglobin
Oxygen Dissociation Curve
Karena pengikatan oksigen jarang menimbulkan
masalah, maka perhatian khusus diarahkan
terhadap pelepasan oksigen oleh Hb di jaringan.

Acidemia, hiperkarbia, dan demam akan
menggeser kurva disosiasi ke kanan sehingga akan
memperbaiki / mempermudah pelepasan oksigen
di jaringan
O
2
Sat
(%)
PO
2
(mm Hg)
100
50
75
25
10 30 50 70 90 20 40 60 80 100
27, 50%
40, 75%
60, 90%
100, 97%
Oxygen Dissociation Curve
10 20 30 40 50 60 70 80 90 100
PO
2
(mm Hg)
O
2
Sat
(%)
100
80
60
40
20
flat portion of curve:
large changes of PO
2
result in
very small changes in oxygen
saturation or content.
10 20 30 40 50 60 70 80 90 100
PO2 (mm Hg)
O2 Sat
(%)
100
80
60
40
20
steep portion of curve:
small changes of PO
2
result in
large changes in oxygen
saturation or content.
Results in enhanced oxygen release.
Four Things Change
Oxyhemoglobin Affinity
Hydrogen Ion Concentration, [H
+
]
Carbon Dioxide Partial Pressure, PCO
2
Temperature
[2,3-DPG]
Hydrogen Ion
Better
Unloading
Inhibited
Unloading
Carbon Dioxide
Temperature
O
2
ER = 25%
Acute DO
2





VO
2
O
2
ER = 50%
O
2
return
500
SvO
2

50%
Anemia
CO
Hypoxemia
HR
If failed
TRAUMA
NARKOTIKA
DEPRESSANT / ANESTHETIC
INFEKSI , PERDARAHAN
GUILLAIN BARRE
POLIOMYELITIS , POLINEUROSIS
MYASTHENIA GRAVIS
TETANUS
RELAXANT / CURARE
OTAK
SYARAF
OTOT
ALVEOLI RONGGA THORAX
FRACTURE COSTAE
PNEUMOTHORAX
HEMATOTHORAX
EDEMA PARU
ATELEKTASIS
GANGGUAN SISTEM PERNAFASAN & PENYEBAB
JALAN NAFAS
ASTHMABRONCHIALE