Ventilation Perfusion Mismatch

Alveolar gas exchange depends not only on ventilation of the alveoli but also on circulation of blood through the alveolar capillaries. In other words it depends both on ventilation and perfusion. This makes sense. You need both oxygen in the alveoli, and adequate blood flow past alveoli to pick up oxygen, other wise oxygen cannot be delivered. When the proper balance is lost between ventilated alveoli and good blood flow through the lungs, ventilation perfusion mismatch is said to exist.

The ventilation/perfusion ratio is often abbreviated V/Q. V/Q mismatch is common and often effects our patient’s ventilation and oxygenation. There are 2 types of mismatch: dead space and shunt.

Imbalance between perfusion and ventilation is called ventilation perfusion mismatch. This illustration compares shunt, the perfusion of poorly ventilated alveoli; and Physiologic dead space: the ventilation of poor perfused alveoli.

Shunt is perfusion of poorly ventilated alveoli. Physiologic dead space is ventilation of poor perfused alveoli.

This article will describe how dead space is different from shunt. It will help you understand how you can use these concepts to care for your patient.

What Is The Importance Of Dead Space?

One important contributor to ventilation perfusion mismatch is dead space. Dead space is the portion of the respiratory system where tidal volume doesn’t participate in gas exchange: it is ventilated but not perfused. There are three types of dead space: anatomic, physiologic, and that dead space belonging to any airway equipment being used to assist ventilation. They all impact how well a patient ventilates.

Anatomic Dead Space

Anatomic deadspace consists of the parts of the respiratory tract that are ventilated but not perfused. It consists of conducting airways such as the trachea, bronchi, and bronchioles —structures that don’t have alveoli. It’s called anatomic because it’s fixed by anatomy and doesn’t change.

About a third of each normal breath we take is anatomic dead space, which means that a third of each breath is essentially wasted. Dead space is age dependent. It’s highest in the infant at 3 ml/kg ideal body weight and is about 2 ml/kg in older children and adults. An adequate tidal volume must include enough volume to also fill the deadspace, otherwise not enough air enters the alveoli and the patient hypoventilates.

A healthy teenage boy weighing 60 kg (132 lb) will have about 360 ml of alveolar ventilation . A healthy infant weighs about 2.7 kg (6 lb) will have about 22 ml alveolar ventilation. In terms of liquid volume, that’s a can of soda vs. about a tablespoon — an impressive difference. Let’s look at an example of how anatomic deadspace impacts adequacy of breathing.

Illustration comparing dead space in a teenager vs a healthy infant

Anatomic dead space is an important concept in determining if tidal volume is adequate.

Our teenager will have an anatomic dead space of 120ml (2 ml/kg X 60 kg), which means that of his 480 ml breath, roughly 360 reaches the alveoli and 120 doesn’t participate in exchange gas at all. For our baby, the anatomic dead space is 8 (3 X 2.7). So again that’s 14 ml of air reaching the alveoli and 8 ml being effectively wasted.

Let’s say our baby is sick with nausea, vomiting, and a fever of 101F (38C) . She starts to hypoventilate and is now breathing tidal volumes of 10 ml. She’s still moving 10 ml of gas in and out of her mouth and you can feel her breathing and see her chest move, even though it looks shallow. Her dead space is still 8 so now the amount of gas reaching her alveoli is 2 ml (10 ml – 8 ml). That’s not enough.

Remember, oxygenation and ventilation are different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body. If you breathe a high concentration of oxygen, but don’t increase or decrease your respiratory rate, your arterial oxygen content (PaO2) will greatly increase, but your PaCO2 won’t change.

Oxygenation mostly changes PaO2. Ventilation mostly changes PaCO2.

If you’re providing our baby with extra oxygen, she may not become hypoxic right away because enough oxygen will still reach her alveoli to maintain her oxygen saturation for a while. However, she is barely moving her dead space gas back and forth so her ventilation is poor. As a result, her carbon dioxide starts to rise. Hypoventilation leads to increased PaCO2.

Acute values above 50 mmHg are significant and require treatment, values above 70 mmHg can be life-threatening because of respiratory acidosis among other things. Each 10 mmHg change in PCO2 roughly changes your pH by 0.1. So all other things being equal,  a PCO2 of 70 is associated with a pH of 7.1. If carbon dioxide rises into the 70–80mmHg range it will also profoundly sedate the patient. This worsens hypoventilation, and increases carbon dioxide even more. Respiratory rate eventually slows and the patient can stop breathing.

It’s important to realize that by providing extra oxygen, a good practice, you delay the onset of hypoxia, but you may also delay the diagnosis of dangerous hypoventilation if you’re not looking for it. For another clinical explanation of how hypoventilation causes hypoxia and the difference between oxygenation and ventilation  click here.

Physiologic Dead Space

A second type of dead space, physiologic dead space, consists of alveoli that are ventilated but lack capillary blood flow to pick up oxygen and drop off carbon dioxide. In other words, they are not perfused.

One cause of ventilation perfusion mismatch is dead space. This illustration defines physiologic dead space

In physiologic dead space, alveoli are ventilated but not perfused. Physiologic dead space can change as lung perfusion changes.

However, unlike anatomic dead space, which is fixed, physiologic dead space can change from minute to minute with alterations in cardiac output and pulmonary blood flow. Many things can impair alveolar perfusion and increase physiologic dead space such as:

  • cardiovascular shock (blood flow to the lungs is decreased),
  • emphysema (lots of enlarged alveoli with less surface area and fewer alveolar capillaries)
  • pulmonary embolus (flow is blocked by clot).

Let’s go back to the baby in our clinical scenario. Perhaps the baby is hypoventilating because she is in shock from diarrhea. Now she has two reasons for respiratory failure:

She’s hypoventilating, and barely exceeding her anatomic dead space.

She’s in cardiovascular shock. Hypovolemia and acidosis is decreasing her cardiac output and lung perfusion. Her physiologic dead space has increased and she is not perfusing all of the alveoli that are still getting ventilated. Remember, hypovolemia and shock increases physiologic dead space. And this brings us to the concept of shunt.

What Is Pulmonary Shunt?

Another contributor to ventilation perfusion mismatch is shunt. Shunt is the opposite of dead space and consists of alveoli that are perfused, but not ventilated.

One cause of ventilation perfusion mismatch is shunt. This illustration defines pulmonary shunt

In pulmonary shunt, alveoli are perfused but not ventilated.

Blood flowing past poorly ventilated alveoli doesn’t pick up additional oxygen. This poorly oxygenated blood returns to the heart and mixes with oxygenated blood coming from other areas of the lungs that are ventilated. The mixture lowers the total oxygen content of the arterial blood, producing hypoxemia. The larger the shunt, the lower the oxygen content.

Giving a patient with an intrapulmonary shunt 100% oxygen to breathe won’t increase the PaO2 much, if at all, depending on the size of the shunt because the alveoli that are being ventilated are already filled with oxygen and the blood from the non-ventilated alveoli won’t pick up any more.

Common causes of shunt occur in lung tissue disease and include:

  • pneumonia and pulmonary edema: some alveoli filled with fluid
  • tissue trauma: alveolar wall swelling
  • atelectasis: collapse of alveoli from failure to expand, or absorbsion of the air out of the alveoli without replacing it
  • mucous plugging: air can’t get into the alveoli
  • pulmonary arteriovenous fistulas

You can also have certain defects in the heart that cause abnormal mixing of oxygenated and un-oxygenated blood, like a right to left shunt, but that’s a different mechanism from pulmonary shunt.

Many types of shunt can be improved with treatment. The most common example of shunt is atelectasis, which is collapse of alveoli. For example, taking deep breaths or sighs easily treats atelectasis, one of the most common day-to-day causes of shunt. We do this naturally several times an hour, often without even being aware of it. In contrast, patients who take very shallow breaths without sighing often develop atelectasis. Factors that can cause atelectasis to develop are:

  • painful breathing from surgery or trauma
  • depressed levels of consciousness such as from drug,  injury, or illness
  • the disease process itself

Ventilation Perfusion Mismatch

As you can see it’s possible, and quite common, for both deadspace and shunt to be present in the same patient. Looking back at our baby one more time her potential causes of hypoxemia/hypoxia include:

  • Hypoventilation: tidal volumes close to her anatomic dead space volume producing inadequate alveolar ventilation. If you think about it, this is producing poorly ventilated alveoli which are still being perfused- that’s shunt
  • Shock: increasing her physiologic dead space.
  • Fever of 101 which will increase her metabolic rate and cause her to need even more oxygen than normal

V/Q mismatch can lead easily lead to hypoxemia and hypercarbia. When treating hypoxia, it’s important for us to look for both shunt and dead space and treat them.

May The /Force Be With You

Christine Whitten MD,

Author Anyone Can Intubate: a Step by Step Guide, 5th Edition
Pediatric Airway Management: A Step by Step Guide

all illustrations copyright Christine Whitten MD

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20 thoughts on “Ventilation Perfusion Mismatch”

  1. Great review Christine! V/Q mismatch is an often forgotten issue that can sneak up on anyone in the OR or ICU. I practice proper recruitment maneuvers and avoid ZEEP (no PEEP) – especially in longer cases.

  2. As a first year med student I found this exceptionally easy to read and understand. Also really appreciated the Don’t Withhold Oxygen from a CO2 Retainer.

  3. Hi
    I have never found the answer to this question:
    V/Q mismatch includes both “Shunt” at one end of the spectrum, and “Dead Space” at the other end of the spectrum. Yet when the literature addresses the causes of hypoxia, there are in the list (amongst other causes) “Shunt” and “V/Q mismatch”. Why is that??? it should say “Shunts” and “Dead Space”

    1. While I can’t provide the definitive answer, I believe that the literature refers to V/Q mismatch, instead of dead space, because it better emphasizes the fact that the amount of impairment in ventilation/oxygenation due to dead space can change, depending on the status of the patient. Anatomical dead space is fixed. But anything that effects perfusion through the lungs actually increases or decreases physiologic dead space, and therefore can cause V/Q mismatch. Physiologic dead space changes with things like the position the patient (increases in the upright vs. decreasing with the supine position). Physiologic dead space also increases in the presence of shock.

  4. That was one of the clearest, most accurate and well informed article on V/Q mismatch.

    Thank you!

  5. I like your article. It has helped me grasp the concepts of pulmonary shunt, dead space and V/Q quite clearly. Thank you!

  6. Assuming that the ventilation pathology doesn’t involve the entire lung (e.g. foreign body inside a single bronchus), would the patient benefit from 100% oxygen? And why?

    Like wise, assuming that a pulmonary embolus doesn’t involve the entire lung (e.g. PE in a segmental artery), would the patient benefit from 100% oxygen? And why?

    It would be of great value if you could provide an answer using the concepts of perfusion-limited & diffusion-limited equilibration & provide examples in numbers such as PaO2.

    Thank you so much,

  7. Hi Christine
    Your post gives a good account of Riley & Cournand’s 3-compartment model of the lung but it doesn’t really address the issue of V/Q mismatch as a problem of poor overlap between the distribution of ventilation and blood flow in the manner pioneered by West and Wagner. Possibly too complicated for Medical Students but on the other hand, West’s book is a standard text in this area for students.
    Ben Korman

    1. Thanks for the feedback. I agree that my explanation is limited. My audience also consists of nurses, emergency medical workers and respiratory therapists who sometimes have less background in physiology than the medical students do. I often try to strike a balance in detail but will take your feedback into consideration for future discussions.

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