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Dr.Gyanendra
Gyanendra Agrawal
SeniorResident
DeptofPulmonaryMedicine
OXYGENANDCARBONDIOXIDE
CASCADE
Introduction
Introduction
Oxygen indispensableforlife
Substrateusedinthegreatestquantity
Substrate used in the greatest quantity
Nostoragesystem
Continuoussupplyrequired
C i
l
i d
Carbondioxide majorbyproductofenergy
metabolism
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
perfusion
Alveolar ventilation
Alveolarventilation
Dependsonrateofbreathingandtidal
volume(V
volume
(VT)
Hyperbolicrelationshipbetweenalveolar
venttn andP
d PAO2
Affectedbydisordersofrespiratorycentre
andrespiratorymuscles
Highfrequencyventilationallowslowertidal
volumes while maintaining MV
volumeswhilemaintainingMV
Largequantitiesofmoresolublegasreplacesmaller
q
quantitiesoflesssolublenitrogen
g
Diffusionfromalveolitopulmonary
Diffusion
from alveoli to pulmonary
capillaries
p
O2 diffusion=
diffusion
K x S/d x P
KxS/dxP
Diffusionfromalveolitopulmonary
Diffusion
from alveoli to pulmonary
capillaries
p
PAO2 ismaindeterminantofPaO2
(Aa)gradientdescribestheoverallefficiency
of oxygen uptake
ofoxygenuptake
Capillarybloodisfullyoxygenatedbefore
traversingdistanceofalveolarcapillary
g
p
y
interface
V/Q matching
V/Qmatching
Trueshuntv/s
effectiveshunt
Clinicalcorrelates
Cli i l
l
HighPEEPstrategy
Prone ventilation
Proneventilation
BMJ1998;317:13026
Hypoxemia
Hypoxemia
BMJ1998;317:13026
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
Carriage of O2 inblood
CarriageofO
in blood
2%inplasma
98%inhemoglobin
Hemoglobin saturation
Hemoglobinsaturation
ExtenttowhichtheHb
iscombinedwithO
is
combined with O2
DependsonPO2 ofthe
blood
Phenomenonof
cooperativity
ti it
P50~28mmHg
Rapidandreversible
reaction
Oxygenhemoglobindissociationcurve
Oxygen
hemoglobin dissociation curve
(Oxyhemoglobin equilibriumcurve)
PCO2
Temperature
2,3DPG
PercentageoffetalHb
Chest2005;128:554S560S
Bohr Effect
BohrEffect
ChristianBohr(1855
Christian Bohr (1855
1911)
EffectofP
Eff t f PCO2 onOEC
OEC
Conceptofpermissive
hypercapnia
2 3 Diphosphogleycerate
2,3
FormedintheRapoportLuebering shuntof
theglycolytic
the
glycolytic pathway
DPGmutase activityincreasedathighpH
DecreasedDPG instoredblood
Increasedin anemia
highaltitude
CaO
C O2=20vol
20 l %
%
C O2 =15vol
CvO
15 l %
O2contentdecreasedin
Hypoxemia(lowPO
yp
(
2)
Anemia(lowHb)
Hypercarbia,acidemia,hyperthermia(lowSaO
yp
,
, yp
(
2))
carryingcapacityof
blood& O2 content
CarbonMonoxide
affinityforHb 250fold
relativetoO
relative
to O2
CompeteswithO2 binding
Lshift interferewithO2
unloadingattissues
Severetissuehypoxia
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
minute O2 deliveryorflux
minute
delivery or flux
EqualtocardiacoutputXarterialoxygen
content
t t
DO2 isapproximately1000mL/min
NormalrestingO
g 2 consumption~250mL/min
p
/
inadulthumans
OER=VO2/DO2
Reducedextractionof
oxygenbytissues
Doesnotplateau
(consumptionremains
supply dependent even
supplydependenteven
atsupranormallevels
of DO2)
ofDO
CriticallevelofDO
ca e e o O2 rangefrom
a ge o
2.1to6.2mL/min/kg
BMJ1998;317:13026
Mechanismscausingfailureofglobal
Mechanisms
causing failure of global
oxygendelivery
yg
y
Reductionincardiacoutput
Reduction in cardiac output
Fallinhemoglobinconcentration
Failureofoxygenuptake
byblood
y
DO2 duringexercise
during exercise
Duringexercise
O2 requirementmaybe20times
q
y
Bloodremainsincapillaryblood<Ntime
Butsaturationnotaffected
FullsaturationinfirstofNtime
Increaseddiffusioncapacity
Additionalcapillariesopenup
V/Qratioimproves
Dilatationofbothalveoliandcapillaries
OECshiftstoright
OEC shifts to right CO2,pH,temp,2,3DPG
CO2 pH temp 2 3 DPG
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
RegionaldistributionandOxygen
Regional
distribution and Oxygen
consumption
p
Perfusionpressureisanimportantdeterminant
Chest 2005; 128:554S560S
Chest2005;128:554S
560S
Oxygen Cascade
OxygenCascade
Uptakeinthelungs
Carryingcapacityofblood
Carrying capacity of blood
Globaldeliveryfromlungstotissue
Regionaldistributionofoxygendelivery
Diffusionfromcapillarytocell
Diffusion from capillary to cell
Cellularuseofoxygen
Canbeinhibitedbycellularmetabolicpoisons
b hb db
ll l
b l
Exogenous(e.g.cyanide)or
Endogenous(e.g.endotoxins insepticshock)
Dyspnea
Alteredmentalstate
Tachypnea orhypoventilation
Arrhythmias
y
Peripheralvasodilatation
Systemichypotension
y
yp
Coma
Cyanosis(unreliable)
y
(
)
Nausea,vomiting,andgastrointestinal
disturbance
Capillarymicrothrombosis afterendothelial
damage
CytokinesinduceddisorderedcellularO
Cytokines induced disordered cellular O2 use
AltereddissociationprofileofOEC
p
Acidosis,fever
Decreased2,3DPG
Decreased 2 3 DPG
precipitatedbyanemia
precipitated
by anemia
Subendocardial ischemiafromLVH
Compromisedmyocardialcontractilityfromthe
i d
di l
ili f
h
effectsofinflammatorycytokines
Inappropriateintravascularfluidstatus
CARBONDIOXIDE CASCADE
threeforms
CaCO2=48vol%CvCO2=52vol%
Eachtimebloodcirculatesthroughthebody,4vol%
g
y,
ofCO2 isremovedfromthetissuesanddeliveredto
thelungstobeexhaled
Dissolved CO2
DissolvedCO
Only5%oftotalarterialcontentispresentin
theformofdissolvedCO
the
form of dissolved CO2
0.3mlofCO2/100mlinabsoluteterms
Duringheavyexercisemayincreaseupto
sevenfold
fold)
Notpresentinplasma
7isozymes
y
CAIIinRBCsandCAIVmembranebound
isozyme presentinpulmonarycapillaries
present in pulmonary capillaries
Inhibitedbythiazides andacetazolamide
Chloride shift
Chlorideshift
Hamburgerin1918
HCO3 exchangewithCl
exchange with Cl ionsacrossRBC
ions across RBC
membrane
Passiveprocess
P i
Mediatedbymembraneboundproteinband3
Band3anchoringsiteforankyrin andspectrin
CO2 boundascarbamate
bound as carbamate
CO2 reactsdirectlywithHb
Reversiblereactionwithaloosebond
Reversible reaction with a loose bond
Dependson
O2 satn ofHb and2,3DPG(bindingtoHb)
H+ concn ((bothHb &plasmaproteins)
p
p
)
in opposite direction
inoppositedirection
Haldane Effect
HaldaneEffect
JBSHaldane[18921964]
ChristiansenJ,DouglasCG,HaldaneJS.JPhysiol 1914;48:24471
inturnassistingbloodtoload
moreCO
CO2 fromthetissues
f
h i
Haldane Effect
HaldaneEffect
BindingofO2 withhemoglobintendsto
releaseofCO22 inthelungs
ApproximatelydoublestheamountofCO
Approximately doubles the amount of CO2
releasedfromthebloodinthelungsandthat
pickedupinthetissues
i k d i th ti
Coupledtransportwithintheredcellin
Coupled
transport within the red cell in
p p
peripheraltissues
NEngJMed1998;338:23947
H+ removedbycombiningwithHCO
removed by combining with HCO3
IfH+ concentrationsbegintodrop,carbonicacid
dissociates releasing H+
dissociates,releasingH
Hypercapnia
Signsofventilatory failure:
Tachypnea
Acidemia
Increasedpulsus paradoxus
Hyperinflation
Somnolence/Decreasedmentalstatus
Hypercapnia
yp
p Etiologies
g
PaCO2
2
VCO2
RR(VT VD)
VCO2 (Hypermetabolism)
VT
Fever
Seizures
Sepsis
Hyperalimentation
Skeletalmuscleweakness
Impairedneuromusculartransmission
Lung/chestwallcompliance
Airwayobstruction
COPD
Asthma
Obstructivesleepapnea
Obst
uct e s eep ap ea
RR(Centralhypoventilation
(
yp
)
Drugs
Brainstemlesions
Obesityhypoventilationsyndrome
VD
ExcessivePEEP