VENTILATION PERFUSION

RELATION SHIPS

Dr.Hasanul Arifin SpAn

Departemen/SMF Anestesiologi dan
Reanimasi
FK-USU/RSUP.H. ADAM MALIK
MEDAN

PROSES PERNAFASAN
Gabungan mekanisme yang berperan
dalam suplai oksigen keseluruh sel
dan eliminasi karbon dioksida
KOMPONEN YANG BERPERAN
Ventilasi
Difusi
Perfusi

Processe
s:
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)

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)
Non Respirasi (Anatomik Dead Space)

DEAD SPACE

Physiological
Dead
Non Perfusi (Alveolar Dead Space)
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

Posisi Tubuh : Volume Paru :

tegak
terlentang
miring

otot pernafasan
penyakit paru
space occupying
lesion
tekanan intra
abdominal
nyeri, obat

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,

PERFUSION
Aliran darah paru yang bertanggung
jawab
membawa CO2 ke alveoli dan sebaliknya
membawa O2 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

Bronkiolu
s
terminali
s
Bronkiolu
s
respiratori
us

Alveol
i
Poripori
Kohn

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

The three-zone model of the lung. A: Upright position. B: Supine position.

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)

 concentration pp of gas

diffusion
CO2 more soluble than O2,
therefore it diffuses faster

MEMBRAN ALVEOLO-KAPILER: adalah permukaan antar alveoli dan

endotel kapiler
- Tempat O2
berdifusi
dari alveoli
ke kapiler
darah /CO2
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 (CO2

PERTUKARAN
GAS

Oxygenation
UDARA BEBAS:
PiO2

21% x 760 = 160 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg

PiN2

ALVEOLUS

: 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg

N2

H2O

PAN2:
573 mmHg

PROSES DIFUSI

PAO2:
104 mmHg

Pulmonary Artery O2
PvO2:
40
mmHg

O2

CO2

PAH2O:
47 mmHg
PACO2:
40 mmHg

CO2

KAPILER PARU

Pulmonary Vein

PaO2
O2

CO2

PcCO2: 45
PcCO2: 40
PcO2: 100
mmHg
mmHg
mmHg

PAO2 PcO2

SHUNT DAN DEAD

SPACE

Airwa
y
Alveol
i

VENTIL
ASI

DIFUSI

Kapiler darah

PERFU
SI

Airway

Sumbata
n

Alveoli

No
VENTILASI
PERFUS
I

Blood
flow

Kapiler
darah
SHUNT UNIT
(PERFUSION WITHOUT
VENTILATION)

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
Bronchial
Pleural
Thabesian
CHD (Congenital Heart
Disease)
Tumor Paru
Arteriovenous
Anastomosis

FUNCTIONAL
Atelectasis
Pneumothorax
Hematothorax
Pleural effusion
Pulmonary edema
Pneumonia
Acute Respiratory
Failure (ARDS)

SHUNT %
2-3%10%
un
t

500

200

No
rm
al

PaO2 300

sh

400

30%

100
0

20%

21

50%
40 60 80 100
FiO2

DEAD
SPACE

Volume udara yang di hirup dalam

satu kali bernafas yang tidak turut
berdifusi dalam alveolus

FUNCTIONAL DEAD
SPACE
ANATOMICAL

ALVEOLAR

Airwa
y

VENTILASI

Alveoli

NO
PERFUSI
No Blood flow

Kapiler
darah
DEAD SPACE UNIT
(VENTILATION WITHOUT

DEAD SPACE UNIT

Hubungan Ventilasi (V) dan Perfusi (Q)

ANATOMICAL
DEAD SPACE

TRAKEA

KAPILER
PARU

PHYSIOLOGICAL
DEAD SPACE

V/Q =

V/Q > 1

ALVEOLAR
DEAD SPACE

MECHANICAL
DEAD SPACE:
TUBE

V/Q = 1

NORMAL

CONNECTOR
ET CO2
BREATHING
CIRCUIT

V/Q < 1

VENOUS ADMIXTURE
(SHUNT)
V/Q = 0

~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

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

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
In
areascardiogenic
where both shock).
perfusion
infarct,
and ventilation are limited or
absent, a silent unit exists (e.g.,
pneumothorax, severe ARDS).

MEASURED
PARAMETERS

CALCULATED
PARAMETERS

Arterial Oxygen Tension (PaO2)

Pulmonary Capillary Oxygen

Arterial Carbon Dioxide Tension

Content (CcO2)

(PaCO2)

Arterial Oxygen Content (CaO2)

Arterial Oxygen Saturation

Venous Oxygen Content (CvO2)

(SaO2 or SpO2)

Arterial-Venous Oxygen Content

Mixed Venous Oxygen Saturation

Difference (Ca-vO2)

(SvO2)

Oxygen Utilization Coefficient (OUC)

Venous Oxygen Tension (PvO2)

Oxygen Delivery Index (DO2I)

Hemoglobin (Hgb)
Cardiac Output (CO)

Oxygen Consumption Index (VO2I)

Intrapulmonary Shunt (Qs/Qt)
Cardiac Index (CI)

6 Key steps in oxygen cascade

O2
Uptake in the Lung

Oxygenation PaO2

CaO2

DO2

Haemoglobin

Carrying capacity SaO2 - Ht

Delivery

Cardiac Output Flow rate

Nervous Syst
Autoregulation

Organ distribution

Humoral
Local Control

Distance
TISSUE OXYGENATION

Diffusio
n
Cellular
use

Mitochondria

VO2

Contraction

Oksigen ditranspor ke
jaringan dalam 2 bentuk
Terlarut dalam plasma
Berikatan dengan hemoglobin

OXYGEN DELIVERY
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)

DO2 = oxygen delivery

Q
= cardiac output
= hemoglobin concentration
VO2 = oxygen
= consumption
20 ml O2 Hb
/PaO
100
ml Blood
=
arterial
oxygen tension
2
SaO2 = arterial oxygen saturation
PvO2 = mixed venous oxygen tensi
SvO2 = mixed venous oxygen saturation

Oxygen Content dalam darah

= Hb bound plus dissolved
CaO2 = [Hb] x 1.34 x % saturation

PO2 x 0.003 ml O2/ 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

Oxygen Dissociation Curve

100
60, 90%
75
O2 Sat
(%)

100, 97%

40, 75%

50

27, 50%

25

10 20

30 40

50 60

70 80

PO2 (mm Hg)

90 100

100
80

flat portion of curve:

large changes of PO2 result in
very small changes in oxygen
saturation or content.

O2 Sat 60
(%)

40
20
10

20

30

40

50

60

70

80

90

PO2 (mm Hg)

100

100
80

steep portion of curve:

small changes of PO2 result in
large changes in oxygen
saturation or content.
Results in enhanced oxygen release.

O2 Sat 60
(%)
40
20
10

20

30

40

50

60

70

80

PO2 (mm Hg)

90

100

Four Things Change

Oxyhemoglobin Affinity
Hydrogen Ion Concentration, [H+]
Carbon Dioxide Partial Pressure, PCO2
Temperature
[2,3-DPG]

Hydrogen Ion

Inhibited
Unloading

Better
Unloading

Carbon Dioxide

Temperature

Acute DO2
Anemia
Hypoxemia
CO

H
RIf failed
O2ER = 50%
25%

SvO2
50%

VO2

O2 return
500

ANGGUAN SISTEM PERNAFASAN & PENYEBAB

GANGGUAN
OTAK

SYARAF

OTOT

JALAN NAFAS
ASTHMABRONCHIALE

TRAUMA
NARKOTIKA
DEPRESSANT / ANESTHETIC
INFEKSI , PERDARAHAN

GUILLAIN BARRE
POLIOMYELITIS , POLINEUROSIS
MYASTHENIA GRAVIS

TETANUS
RELAXANT / CURARE

ALVEOLI
EDEMA PARU
ATELEKTASIS

RONGGA THORAX
FRACTURE COSTAE
PNEUMOTHORAX
HEMATOTHORAX

Thank you for

listening