Advertisement

Gas-exchange in mechanically ventilated patients

Part of the Topics in Anaesthesia and Critical Care book series (TIACC)

Abstract

Adequate management of patients with respiratory failure requires proper assessment of pulmonary gas exchange. Partial pressures of arterial blood gases (PaO2 and PaCO2) and pH are the directly measurable variables used by most clinicians for this purpose. Although arterial blood gases have become increasingly easy to obtain in both intensive care and medical care settings, often the interpretation of the pathophysiologic determinants of abnormal PaO2 and/or PaCO2 in the clinical arena is not straightforward. This is because arterial blood gases reflect not only the functional conditions of the lung as a gas exchanger, thereby their intrapulmonary determinants (i.e. ventilation-perfusion heterogeneities, intrapulmonary shunt and alveolar to end-capillary diffusion limitation for oxygen), but also the conditions under which the lung operates, namely the composition of inspired gas and mixed venous blood (i.e. extrapulmonary factors) [1–6].

Keywords

Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome Patient Noninvasive Positive Pressure Ventilation Control Mechanical Ventilation Intrapulmonary Shunt 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    West JB (1969) Ventilation-perfusion inequality and overall gas exchange in computer models of the lung. Respir Physiol 7:88–110PubMedCrossRefGoogle Scholar
  2. 2.
    West JB (1977) Ventilation-perfusion relationships. Am Rev Respir Dis 116:919–943PubMedGoogle Scholar
  3. 3.
    Roca J, Wagner PD (1993) Contribution of multiple inert gas elimination technique to pulmonary medicine (1): principles and information content of the multiple inert gas elimination technique. Thorax 49:815–824CrossRefGoogle Scholar
  4. 4.
    West JB, Wagner PD (1977) Pulmonary gas exchange. In: West JB (ed) Bioengineering aspects of the lung, 1st ed. Marcel Dekker, New York, pp 361–457Google Scholar
  5. 5.
    Dantzker DR (1983) The influence of cardiovascular function on gas exchange. Clin Chest Med 4:149–159PubMedGoogle Scholar
  6. 6.
    Wagner PD (1982) Ventilation-perfusion inequality in catastrophic lung disease. In: O Prakash (ed) Applied physiology in clinical respiratory care. Martinus Nijhoff, The Hague, pp 363–379Google Scholar
  7. 7.
    Light RB (1988) Intrapulmonary oxygen consumption in experimental pneumococcal pneumonia. J Appl Physiol 64:2490–2495PubMedGoogle Scholar
  8. 8.
    Wagner PD, Saltzman HA, West JB (1974) Measurements of continuous distributions of ventilation-perfusion ratios: theory. J Appl Physiol 36:588–599PubMedGoogle Scholar
  9. 9.
    Wagner PD, Naumann PF, Laravuso RB, West JB (1974) Simultaneous measurement of eight foreign gases in blood by gas chromatography. J Appl Physiol 36:600–605PubMedGoogle Scholar
  10. 10.
    Evans IW, Wagner PD (1977) Limits on VA/Q distributions from analysis of experimental inert gas elimination. J Appl Physiol 36:600–605Google Scholar
  11. 11.
    Wagner PD (1979) Susceptibility of different gases to ventilation-perfusion inequality. J Appl Physiol 46:372–386PubMedGoogle Scholar
  12. 12.
    Wagner PD, Laravuso RB, Uhl RR, West JB (1974) Continuous distributions of ventilation-perfusion ratios in normal subjects breathing air and 100% O2. J Clin Invest 54:54–68PubMedCrossRefGoogle Scholar
  13. 13.
    West JB (1985) Ventilation-blood flow and gas exchange, 4th ed. Blackwell Scientific Publications, OxfordGoogle Scholar
  14. 14.
    Gale GE, Torre-Bueno J, Moon RE, Salzman HA, Wagner PD (1985) Ventilation-perfusion inequality in normal humans during exercise. J Appl Physiol 58:978–988PubMedGoogle Scholar
  15. 15.
    Wagner PD, Gale GE, Torre-Bueno JE, Stoip BW, Saltzman HA (1986) Pulmonary gas exchange in humans exercising at sea level and simulated altitude. J Appl Physiol 61:260–270PubMedGoogle Scholar
  16. 16.
    Hammond MD, Gale GE, Kapitan KS, Ries A, Wagner PD (1986) Pulmonary gas exchange in humans during normobaric hypoxic exercise. J Appl Physiol 60:1590–1598PubMedGoogle Scholar
  17. 17.
    Hammond MD, Gale GE, Kapitan KS, Ries A, Wagner PD (1985) Pulmonary gas exchange in humans during normobaric hypoxic exercise. J Appl Physiol. 58:978–988Google Scholar
  18. 18.
    Cardus J, Burgos F, Diaz O, Roca J, Barberä JA, Marrades RM, Rodriguez-Roisin R, Wagner PD (1997) Increase in pulmonary ventilation-perfusion inequality with age in healthy individuals. Am J Resp Grit Care Med 156(2):648–653Google Scholar
  19. 19.
    West JB (1971) Causes of carbon dioxide retention in lung disease. New Engl J Med 284:1232–1236PubMedCrossRefGoogle Scholar
  20. 20.
    Weinberger SE, Wchwartzstein RM, Weis JW (1989) Hypercapnia. New Engl J Med 321:1223–1231PubMedCrossRefGoogle Scholar
  21. 21.
    Agusti AG, Roca J, Rodriguez-Roisin R, Gea J, Xaubet A, Wagner PD (1991) Mechanisms of gas exchange impairment in idiopathic pulmonary fibrosis. Am Rev Respir Dis 143:219–225PubMedGoogle Scholar
  22. 22.
    Rodriguez-Roisin R, Agusti AG, Roca J (1992) The hepatopulmonary syndrome: new name, old complexities (Editorial). Thorax 47:897–902PubMedCrossRefGoogle Scholar
  23. 23.
    Hansen JE, Clausen JL, Levy SE, Möhler IG, Van Kessel AL (1986) Proficiency testing materials for pH and blood gases. The California Thoracic Society Experience. Chest 89:214–217PubMedCrossRefGoogle Scholar
  24. 24.
    Brimouille S, Kahn RJ (1990) Effects of metabolic acidosis on pulmonary gas exchange. Am Rev Respir Dis 141:1185–1189Google Scholar
  25. 25.
    Brimouille S, Vachiery JL, Lejeune P, Leeman M, Melot C, Naeije R (1991) Acid-base status affects gas exchange in canine oleic acid pulmonary edema. Am J Physiol 260:H1080-H1086.Google Scholar
  26. 26.
    Torres A, Reyes A, Roca L Wagner PD, Rodriguez-Roisin R (1989) Ventilation-perfusion mismatching in chronic obstructive pulmonary disease during ventilator weaning. Am Rev Respir Dis. 140:1246–1250PubMedCrossRefGoogle Scholar
  27. 27.
    Lemaire F, Teboul JL, Cinotti L et al (1988) Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation. Anesthesiology 69:171–179PubMedCrossRefGoogle Scholar
  28. 28.
    Froese AB, Bryan AB (1974) Effect of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology 41:242–245PubMedCrossRefGoogle Scholar
  29. 29.
    Modell HI, Cheney FW (1979) Effects of inspiratory flow pattern on gas exchange in normal and abnormal lung. J Appl Physiol 46:1103–1107PubMedGoogle Scholar
  30. 30.
    Al-Saad N, Bennet ED (1985) Decelerating inspiratory flow waveform improves lung mechanics and gas exchange in patients on intermittent positive-pressure ventilation. Intensive Care Med 11:68–75Google Scholar
  31. 31.
    Smith RA, Venus B (1988) Cardiopulmonary effect of various inspiratory flow profiles during controlled mechanical ventilation in a porcine lung model. Crit Care Med 16:769–772PubMedCrossRefGoogle Scholar
  32. 32.
    Dantzker DR, Brook L, DeHart P, Lynch J, Weg J (1979) Ventilation-perfusion distribution in the adult respiratory distress syndrome. Am Rev Respir Dis 120:1039–1052PubMedGoogle Scholar
  33. 33.
    Matamis D, Lemaire F, Harf A, et al (1984) Redistribution of pulmonary blood flow induced by positive end-expiratory pressure and dopamine infusion in acute respiratory failure. Am Rev Respir Dis 129:39–44PubMedGoogle Scholar
  34. 34.
    Ralph DD, Robertson HT, Weaver LJ et al (1985) Distribution of ventilation and perfusion during positive end-expiratory pressure in the adult respiratory distress syndrome. Am Rev Respir Dis 131:54–60PubMedGoogle Scholar
  35. 35.
    Coffey RL, Albert RK, Robertson HT (1983) Mechanism of physiological dead space response to PEEP after acute oleic acid lung injury. J Appl Physiol Respir Environ Exer Physiol 55:1550–1557Google Scholar
  36. 36.
    Ranieri MV, Giuliani R, Fiore T, Dambrosio M, Milic-Emili J (1994) Volume-pressure curve of the respiratory system predicts effects of PEEP in ARDS: “occlusion” versus “constant flow” technique. Am J Respir Grit Care Med 149:19–27Google Scholar
  37. 37.
    Hopewell PC, Murray JF (1975) Effects of continuous positive-pressure ventilation in experimental pulmonary edema. J Appl Physiol 39:672–679Google Scholar
  38. 38.
    Dantzker DR, Wagner PD, West JB (1975) Instability of lung units with low VA/Q ratios during O2 breathing. J Appl Physiol 38:886Google Scholar
  39. 39.
    Rodriguez-Roisin R (1994) Effect of mechanical ventilation on gas exchange. In: Tobin MJ (ed) Principles and practice of mechanical ventilation, 1st ed. McGraw-Hill, New York, pp 673–693Google Scholar
  40. 40.
    Pepe PP, Marini JJ (1982) Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction. Am Rev Respir Dis 126:166–170PubMedGoogle Scholar
  41. 41.
    Rossi A, Gottfried SB, Zocchi L, Higgs BD, Lennox S, Calverley PMA, Begin P, Grassino A, Milic-Emili J (1982) Measurement of static compliance of the total respiratory system in patients with acute respiritory failure during mechanical ventilation. Am Rev Respir Dis 131:672–677Google Scholar
  42. 42.
    Kimball WR, Leith DE, Robins AG (1982) Dynamic hyperinflation and ventilator dependence in chronic obstructive pulmonary disease. Am Rev Respir Dis. 126:991–995PubMedGoogle Scholar
  43. 43.
    Guy PC, Rodarte JR, and Hubmayr RD (1987) The effect of positive-expiratory pressure on isovolume and dynamic hyperinflation in patients receiving mechanical ventilation. Am Rev Respir Dis 139:621–626Google Scholar
  44. 44.
    Tuxen DV (1989) Detrimental effects of positive end expiratory pressure during controlled mechanical ventilation. Am Rev Respir Dis 140:5–9PubMedCrossRefGoogle Scholar
  45. 45.
    Rossi A, Brandolese R, Milic-Emili J, Gottfried SB (1990) The role of PEEP in patients with chronic obstructive pulmonary disease during assisted ventilation. Eur Respir J 3:818–822PubMedGoogle Scholar
  46. 46.
    Ranieri VM, Giuliani R, Cinnella G, Pesce C, Brienza N, Ippolito EL, Pomo Y, Fiore T, Gottfried SB, Brienza A (1993) Physiologic effects of positive end-expiratory pressure in patients with chronic obstructive pulmonary disease during acute ventilatory failure and controlled mechanical ventilation. Am Rev Respir Dis 177:5–13CrossRefGoogle Scholar
  47. 47.
    Ross A, Santos C, Roca J, Torres A, Félez MA, Rodriguez-Roisin R (1994) Effects of PEEP on (VA/Q) mismatching in ventilated patients with chronic airflow obstruction. Am J Respir Crit Care Med 149:1077–1084Google Scholar
  48. 48.
    Marcy TW (1994) Inverse ratio ventilation. In: Tobin MJ (ed) Principles and practice of mechanical ventilation, 1st ed. McGraw-Hill, New York, pp 319–331Google Scholar
  49. 49.
    Gattinoni L, Marcolin R, Caspani M, Fumagali R, Mascheroni D, Pesenti A (1985) Constant mean airway pressure with different patterns of positive pressure breathing during the adult respiratory distress syndrome. Bull Eur Physiopathol Respir 21:275–279PubMedGoogle Scholar
  50. 50.
    Duncan S, Rizk N, Raffm T (1987) Inverse ratio ventilation. PEEP in disguise? Chest 92:390–391PubMedCrossRefGoogle Scholar
  51. 51.
    East T, Böhm S, Wallace J, Clemmer T, Weaver L, Orme J, Morris A (1992) A successful computerized protocol for clinical management of pressure control inverse ratio ventilation in ARDS patients. Chest 101:697–710PubMedCrossRefGoogle Scholar
  52. 52.
    Brandolese RC, Broseghini C, Polese G, Bernasconi M, Brandi G, Milic-Emili J, Rossi A (1992) Effects of intrinsic PEEP on pulmonary gas exchange in mechanically-ventilated patients. Eur Respir J 6:358–363Google Scholar
  53. 53.
    Bernard G, Artigas A, Brighman K, Carlet J, Falke K, Hudson L, Lamy M, Legall J, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  54. 54.
    Hubmayr R, Abel M, Rehder K (1990) Physiologic approach to mechanical ventilation. Crit Care Med 18:103–113PubMedCrossRefGoogle Scholar
  55. 55.
    Manthous C, Schimidt G (1993) Inverse ratio ventilation in ARDS. Improved oxygenation without Auto PEEP. Chest 103:953–954PubMedCrossRefGoogle Scholar
  56. 56.
    Marini JJ (1994) Ventilation of the acute respiratory distress syndrome. Looking for Mr. Goodmode. Anesthesiology 80:972–975PubMedCrossRefGoogle Scholar
  57. 57.
    Gurevitch M, Van Dyke J, Young E, Jackson K (1986) Improved oxygenation and lower peak airway pressure in severe adult respiratory distress syndrome. Treatment with inverse ratio ventilation. Chest 89:211–213PubMedCrossRefGoogle Scholar
  58. 58.
    Tharratt R, Allen R, Albertson T (1988) Pressure controlled inverse ratio ventilation in severe adult respiratory failure. Chest 94:755–762PubMedCrossRefGoogle Scholar
  59. 59.
    Lain D, Di Benedetto R, Morris S, Van Nguyen A, Saulters R, Causey D (1989) Pressure control inverse ratio ventilation as a method to reduce peak inspiratory pressure and provide adequate ventilation and oxygenation. Chest 95:1081–1088PubMedCrossRefGoogle Scholar
  60. 60.
    Abraham E, Yoshihara G (1989) Cardiorespiratory effects of pressure controlled inverse ratio ventilation in severe respiratory failure. Chest 96:1356–1359PubMedCrossRefGoogle Scholar
  61. 61.
    Poelaert J, Vogelaers D, Colardyn F (1991) Evaluation of the hemodynamic and respiratory effects of inverse ratio ventilation with a right ventricular ejection fraction catheter. Chest 99:1444–1450PubMedCrossRefGoogle Scholar
  62. 62.
    Chan K, Abraham E (1992) Effects of inverse ratio ventilation on cardiorespiratory parameters in severe respiratoryfailure. Chest 102:1556–1561PubMedCrossRefGoogle Scholar
  63. 63.
    Mercat A, Graïni L, Teboul J, Lenique F, Richard C (1993) Cardiorespiratory effects of pressure-controlled ventilation with and without inverse ratio in the adult respiratory distress syndrome. Chest 104:871–875PubMedCrossRefGoogle Scholar
  64. 64.
    Lessard M, Guérot E, Lorino H, Lemaire F, Brochard L (1994) Effects of pressure-con- troled with different I:E ratios versus volume-controlled ventilation on respiratory mechanics, gas exchange, and hemodynamics in patients with adult respiratory distress syndrome. Anesthesiology 80:972–975CrossRefGoogle Scholar
  65. 65.
    Cole A, Weiler S, Sykes M (1984) Inverse ratio ventilation compared with PEEP in adult respiratory failure. Intensive Care Med 10:227–232PubMedCrossRefGoogle Scholar
  66. 66.
    Zavala E, Ferrer M, Polese G, Masclans JR, Planas M, Milic-Emili J, Rodriguez-Roisin R, Roca J, Rossi A (1996) Effects of PEEPi generated by inverse I:E ratio ventilation on pulmonary gas exchange in ARDS. Am J Respir Crit Care Med 153:A374Google Scholar
  67. 67.
    Rossi A, Ranieri M (1994) Positive End-Expiratory Pressure. In: Tobin M (ed) Principles and practice of mechanical ventilation, 1st ed. Mc Graw-Hill, New York, pp 259–303Google Scholar
  68. 68.
    Brochard L, Isabey D, Piquet I, Amaro P, Mancebo J, Messadi AA, Brun-Buisson C, Rauss A, Lemaire F, Harf A (1990) Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. New Engl Med 323:1523–1530CrossRefGoogle Scholar
  69. 69.
    Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS (1995) Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 151:1799–1806PubMedGoogle Scholar
  70. 70.
    Appendini L, Patessio A, Zanaboni S, Carone M, Gukov B, Donner CF, Rossi A (1994) Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 149:1069–1076PubMedGoogle Scholar
  71. 71.
    Bott J, Carroll MP, Conway JH, Keüty SEJ, Ward EM, Brown AM, Paul EA, Elliott MW, Godfrey RC, Wedzicha JA, Moxham J (1993) Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet 341:1555–1557PubMedCrossRefGoogle Scholar
  72. 72.
    Hill NS (1993) Noninvasive ventilation. Does it work, for whom, and how? Am Rev Respir Dis 147:1050–1055PubMedGoogle Scholar
  73. 73.
    Roussos C (1985) Function and fatigue of respiratory muscles. Chest 88:1245–1315Google Scholar
  74. 74.
    Gay PC, Patel AM, Viggiano RW, Hubmayr RD (1991) Nocturnal nasal ventilation for treatment of patients with hypercapneic respiratory failure. Mayo Clin Proc 66:695–703PubMedGoogle Scholar
  75. 75.
    Möhr CH, Hill NS (1990) Long-term follow-up of nocturnal ventilatory assistance in patients with respiratory failure due to Duchenne-type muscular dystrophy. Chest 97:91–96PubMedCrossRefGoogle Scholar
  76. 76.
    Elliot MW, Mulvey DA, Moxham J, Green M, Bronthwaite MA (1991) Domiciliary nocturnal nasal intermittent positive pressure ventilation in COPD: mechanisms underlying changes in arterial blood gas tensions. Eur Respir J 4:1044–1052Google Scholar
  77. 77.
    Ferrer M, Iglesia R, Roca J, Escarrabil J, Farrero E, Gomez FP, Farré R, Barberä JA, Rodriguez-Roisin R (1998) Factors determining Pa02 during noninvasive ventilation in clinically stable chronic respiratory failure. Am J Respir Crit Care Med 157(3): A370Google Scholar

Copyright information

© Springer-Verlag Italia, Milano 1999

Authors and Affiliations

  • J. Roca

There are no affiliations available

Personalised recommendations