Transport and storage of O2 is mediated by two proteins in our body:

Hemoglobin (SaO2) & Myoglobin

Oxygen is also carried dissolved in the blood's plasma (PO2)

Hb is a conjugated protein of 4 globin chains, each with one heme group

Each Heme group is a complex of ferrous iron (Fe2+ ) and protoporphyrin IX

Each heme group carries one molecule

of O2 (Hb + 4O2)

CaO2 = [Hb x 1.34 x (SaO2 /100)] + (PaO2 x 0.003)

 Curve demonstrates binding ability of Hb with O2 at different partial
pressures of O2 (pO2)
Flat upper portion of the curve shows that saturation is minimally affected
by reasonable decreases in PaO2
The steep lower part of the curve allows the tissues to extract a large
amount of O2 with only a small decrease in PaO2
PO2 (mmHg) SO2 (%)
10 13.5
20 35.0
30 57.0
40 75.0
50 83.5
60 90.0
70 92.7
80 94.5
90 96.5
100 97.5
 pO2 in the lung capillary = 100mmHg

pO2 of tissue capillaries = 40 mmHg

pO2 in capillary bed of active muscle = 20 mmHg

pO2 of muscle under severe physical exercise = 5mmHg

In the lungs (pO2 is high) : Hb gets fully loaded with O2.

At the tissue level (pO2 is low): Oxyhemoglobin releases its O2 for

cellular respiration

The P50 is the PO2 at which hemoglobin is 50% saturated and correlates
with PO2 of 27 mm Hg normally.
Standard O2-Hb dissociation applies under the exact following conditions:

Human Hb type A, pH = 7.4, PCO2 = 40 mmHg, Temp = 37C (98.6F), 2,3-DPG

concentration = 15 micromoles/gram Hb.

Standard O2-Hb dissociation applies under the exact following conditions:

Human Hb type A, pH = 7.4, PCO2 = 40 mmHg, Temp = 37C (98.6F), 2,3-DPG

concentration = 15 micromoles/gram Hb.

Standard O2-Hb dissociation applies under the exact following conditions:

Human Hb type A, pH = 7.4, PCO2 = 40 mmHg, Temp = 37C (98.6F), 2,3-DPG

concentration = 15 micromoles/gram Hb.

 When the curve shifts to the left or right, it alters the P50 (oxygen tension at
which hemoglobin is 50% saturated).
Shift to the left P50 decreases (i.e. lower PO2 needed to saturate 50% of
the hemoglobin)
Shift to the right P50 increases (i.e. higher PO2 needed to saturate 50% of
the hemoglobin).
CADET, face Right!
Left Shift Right Shift CO2, Acid, 2,3-DPG, Exercise &
Alkalosis Acidosis Temperature
Decreased PCO2 Increased PCO2
right A CITE
Hypothermia Hyperthermia Acidosis
Decreased 2,3-DPG Increased 2,3-DPG CO2
Carboxyhemoglobin Increased 2,3-DPG
Methemoglobin Temperature
Abnormal & fetal Hb Exercise
 The binding of O2 to Hb decreases with:

increasing H+ conc. (low pH i.e. Acidosis): Bohr Effect

increased partial pressure of CO2 (pCO2): Haldane effect

Enhances oxygenation of the blood in the lungs and promotes release of O2

from the blood in the tissues

Increase or decrease in pH of 0.10 causes a fall or rise (i.e., an opposite

change) in the PaO2 of about 10%
Blood stored in a blood bank tends, with time, to become relatively
depleted of 2,3-diphosphoglycerate. What effect does this have on the
hemoglobin-oxygen dissociation curve?

A. Shifts the curve to the left, so that the hemoglobin has a decreased
oxygen affinity

B. Shifts the curve to the left, so that the hemoglobin has an increased
oxygen affinity

C. Shifts the curve to the right, so that the hemoglobin has a decreased
oxygen affinity

D. Shifts the curve to the right, so that the hemoglobin has an increased
oxygen affinity

E. Does not change the dissociation curve

Blood stored in a blood bank tends, with time, to become relatively
depleted of 2,3-diphosphoglycerate. What effect does this have on the
hemoglobin-oxygen dissociation curve?

A. Shifts the curve to the left, so that the hemoglobin has a decreased
oxygen affinity

B. Shifts the curve to the left, so that the hemoglobin has an increased
oxygen affinity

C. Shifts the curve to the right, so that the hemoglobin has a decreased
oxygen affinity

D. Shifts the curve to the right, so that the hemoglobin has an increased
oxygen affinity

E. Does not change the dissociation curve

 2,3 BPG : created in RBCs during glycolysis

Binds to deoxyHb and decreasing its affinity for oxygen

Facilitates the release of O2 at the partial pressure found in the

tissues, thus enhancing the ability of RBCs to release oxygen near tissues
that need it most

Levels of 2,3 BPG are related to tissue demands of O2 supply.

1. 2,3-DPG: Hypoxaemia, chronic lung disease, anaemia, CHF

2. 2,3-DPG: Banked blood, chronic illness, septic shock

3. Fetal Hemoglobin : Binding of 2,3BPG to HbF is very weak. HbF has

higher affinity for O2. Its needed for transfer of O2 from the maternal
blood to the fetus.
 As temperature increases, Hb gives up O2 more readily, raising the PO2 in
the plasma.

For each 1C (1.8F) rise in temperature, the PaO2 rises about 5%

A 37-year-old HIV-infected man with a CD4 count of 13 cells/mm3 and a
HIV RNA greater than 1 million copies/ml presents with a 1-week history of
shortness of breath. The patient has a history of pulmonary Kaposis
sarcoma that previously responded to chemotherapy. He is dizzy and
unable to take more than three steps due to dyspnea, but denies fever,
cough, or chest pain. His current medications include tenofovir-
emtricitabine (Truvada), zidovudine, lopinavir-ritonavir (Kaletra), dapsone,
and weekly azithromycin, all of which were started 4 weeks ago. His
glucose 6-phosphate dehydrogenase (G6PD) screen was normal. On
examination, he is afebrile, but appears pale; his lips are a dark grayish-
brown color. His oxygen saturation on room air is 86%. His room air
arterial blood gas demonstrates the following: pH 7.54, PaCO2 32 mmHg,
Pa02 112 mmHg. The blood is a brownish color when drawn.
 Assuming that you will obtain the appropriate laboratory tests and confirm
the diagnosis, which of the following would be the most appropriate
intervention?

A Start IV pentamidine for presumptive Rx of Pneumocystis pneumonia.

B Stop zidovudine and adminster high-dose folic acid.

C Stop dapsone and administer intravenous methylene blue

D Administer high-dose corticosteroids for Kaposis sarcoma immune

reconstitution inflammatory syndrome.
 Assuming that you will obtain the appropriate laboratory tests and confirm
the diagnosis, which of the following would be the most appropriate
intervention?

A Start IV pentamidine for presumptive Rx of Pneumocystis pneumonia.

B Stop zidovudine and adminster high-dose folic acid.

C Stop dapsone and administer intravenous methylene blue

D Administer high-dose corticosteroids for Kaposis sarcoma immune

reconstitution inflammatory syndrome.
 Increased quantities of hemoglobin in which the iron of heme is oxidized to
the ferric (Fe3+) form.

Methemoglobin is useless as an oxygen carrier cyanosis.

Cyanosis does not improve with supplemental oxygen

Pulse oximeter will report a falsely elevated value for arterial oxygen
saturation percentage

More commonly from recreational amyl nitrate (poppers) use

Most common drugs: dapsone, local anesthetics, phenacetin, and

antimalarial drugs

Suspected in a patient who is cyanotic with normal PaO2 on ABG

Blood drawn will typically appear dark brown or chocolate-colored

During a bitterly cold winter, an elderly couple is found dead in their
apartment. All of their windows are closed and their leaky old furnace is
on full. Which of the following is the primary mechanism by which the
toxin involved led to the death of this couple?

A. Decreasing intracellular calcium

B. Inhibition of cytochrome oxidase

C. Inhibition of Na+/K+ ATPase

D. Binding to hemoglobin

E. Stimulation of cellular apoptosis

During a bitterly cold winter, an elderly couple is found dead in their
apartment. All of their windows are closed and their leaky old furnace is
on full. Which of the following is the primary mechanism by which the
toxin involved led to the death of this couple?

A. Decreasing intracellular calcium

B. Inhibition of cytochrome oxidase

C. Inhibition of Na+/K+ ATPase

D. Binding to hemoglobin

E. Stimulation of cellular apoptosis

 Binding affinity of normal adult hemoglobin for carbon monoxide is about
200-240 times that of oxygen.

CO displaces oxygen and shifts curve to the left.

Patient suffers from severe tissue hypoxia while maintaining a normal pO2

Carbon monoxide colorless, odorless gas

Fires, space heaters, wood-burning stoves, charcoal burning for heat, or

portable generators without adequate ventilation

Normal physiologic blood carbon monoxide levels ~1% in healthy

nonsmokers (smokers: up to 10%)

"flu-like" symptoms, headache most common complaint, cherry red oral

mucosa is rarely seen
 Des Jardins, T. (2008) Cardiopulmonary Anatomy & Physiology. 5th edn. NY:
Cengage Learning

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th edn.