VQ mismatch & A-a O2
gradient
27 Juli 2016
• Shunt (V/Q = 0) : pulmonary (pathological), cardiac, anatomical, brain, etc
• Hypoxia vasocontriction to ventilated alveoli
• Giving 100% FiO2 doesn’t improve (refractory hypoxemia) require
positive pressure
• Dead space (V/Q = ~) : physiological / total (anatomical + alveolar)
• Anatomical in conducting airways no gas exchange
• Alveolar ventilated alveoli without perfusion no gas exchange
• Increase in some lung disease to V/Q missmatch
Normal, Decreased, and Increased V/Q Ratios
- A normal V/Q ratio is around 0.80.
- This means that roughly 4 liters of oxygen pass through the lungs
each minute while 5 liters of blood pass through the lungs.
A decreased V/Q ratio occurs when either there is decreased
ventilation in the lungs or increased perfusion (more blood flow
through the lungs)
Conditions which may result in a decreased V/Q ratio include:
- Chronic bronchitis:
- The combination of bronchospam, mucus plugs, inflammation, and
airway obstruction all add up to worsen ventilation and thus
decrease the ratio of ventilation to perfusion.
- Asthma
- Pulmonary edema
- Airway obstruction (foreign body aspiration)
An increased V/Q ratio occurs when there is either increased ventilation or
decreased perfusion (blood flow to the lungs.)
An increased V/Q ratio may be seen with:
- Pulmonary embolism:
- A pulmonary embolism is a blood clot in the lungs which usually begins as
a blood clot in the legs which breaks off and travels to the lungs. If it is
large enough, a clot can clog a complete blood vessel resulting in no
perfusion to some areas of the lung that are getting ventilation. Therefore
V/Q increases because the ventilation (V) stays the same and the
perfusion (Q) goes down. On the V/Q scan, there will be evidence that
segments of the lung in the distribution of the affected blood are not being
perfused.
- Emphysema: Emphysema can also cause an elevated V/Q ratio. Due to
damaged and destroyed alveoli in the lungs, the surface area available for
transfer of oxygen and carbon dioxide goes down. Ventilation, therefore,
goes up, leading to an increased V/Q ratio.
[Link]
Intracardiac shunt
- The A–a gradient is useful in determining the source of
hypoxemia.
- The measurement helps isolate the location of the problem
as either:
- intrapulmonary (within the lungs)
- extrapulmonary (somewhere else in the body).
- It is used in diagnosing the source of hypoxemia.
- It helps to assess the integrity of alveolar capillary unit.
- For example, in high altitude, the arterial oxygen PaO2 is low
but only because the alveolar oxygen (PAO2) is also low.
- However, in states of ventilation perfusion mismatch, such
as pulmonary embolism or right-to-left shunt, oxygen is not
effectively transferred from the alveoli to the blood which
results in elevated A-a gradient
- A normal A–a gradient for a young adult non-smoker
breathing air, is between 5–10 mmHg.
- Normally, the A–a gradient increases with age.
- For every decade a person has lived, their A–a gradient is
expected to increase by 1 mmHg.
- A conservative estimate of normal A–a gradient is less than
[age in years/4] + 4]
- Thus, a 40-year-old should have an A–a gradient less than
14.
PAO2 - PaO2
= [(760 - 47)*FiO2 - PaCO2/0.8] - PaO2
Kl Room air --> FiO2 21%(0.21)
= [(760-47) 0.21 - PaCO2/0.8] - PaO2
= [150 - PaCO2/0.8] - PaO2
Normal A-a is less than 10 mmHg, but can range from 5-20
mmHg.
gradient can also be widened under normal conditions of age,
obesity, fasting, supine position, and heavy exercise.
Interpretation: Calculating a normal A-a Gradient
A-a Gradient = (Age/4) + 4
Young person at sea level
A-a increases 5 to 7 mmHg for every 10% increase FIO2
Room Air: 10 to 20 mmHg
100% oxygen: 60 to 70 mmHg
Increased age affects A-a Gradient (at sea level)
Age 20 years: 4 to 17 mmHg
Age 40 years: 10 to 24 mmHg
Age 60 years: 17 to 31 mmHg
Age 80 years: 25 to 38 mmHg
Interpretation: Hypoxemia causes differentiated by A-a Gradient
Increased A-a Gradient
Right to Left Intrapulmonary Shunt (due to fluid filled alveoli)
Congestive Heart Failure
Adult Respiratory Distress Syndrome (ARDS)
Lobar Pneumonia
V/Q Mismatch (due to lung dead space)
Pulmonary Embolism
Atelectasis
Pneumonia
Obstructive Lung Disease (e.g. Asthma, COPD)
Pneumothorax
Alveolar hypoventilation
Interstitial Lung Disease
Normal A-a Gradient
Neuromuscular disorders
Central nervous system disorder
Low inspired FiO2 (e.g. high altitude)
Thankiu