Acid Base Disturbances and

Arterial Blood Gas Analysis

Yvonne Bettina E. Montejo, M.D., DPCP, FPCCP

Internal Medicine
Adult Pulmonology
Indications

1.  Acid-base status

2.  Ventilatory status
3.  Oxygenation status
Normal ABG Values

pH 7.35 – 7.45
pCO2 35 – 45
HCO3 22 – 26
pO2 80 -100
Steps in the Interpretation of an ABG
1.  Is the patient acidemic or alkalemic?
2.  Is the disturbance respiratory or metabolic?
3.  Is it acute or chronic?
4.  Is there secondary compensation?
5.  Is there hypoxemia or not?
a. if hypoxemic, is it uncorrected, corrected or
overcorrected?
b. If non-hypoxemic, is oxygenation adequate or more
than adequate?
4 Main Acid-Base Disturbances

Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Acid Base Primary Secondary
Disturbance Abnormality Compensation

METABOLIC
acidosis loss of base, hyperventilation
(pH <7.35) increased acid CO2
HCO3- (<22)

alkalosis increased base hypoventilation

(pH >7.45) HCO3- (>26) CO2
Acid Base Primary Secondary
Disturbance Abnormality Compensation

RESPIRATORY
acidosis hypoventilation HCO3 generation
(pH <7.35) CO2 (>45) HCO3-

alkalosis hyperventilation HCO3 consumption

(pH >7.45) CO2 (<35) HCO3-
Etiologies of Metabolic acidosis

Anion gap Non-anion gap

Renal failure GI or HCO3 loss
Ketoacidosis RTA
Drugs or poisons C-anhydrase inhibitors
Lactic acidosis Compensation for
respiratory alkalosis
Ureteral diversions
Hyperalimentation
Etiologies of Metabolic alkalosis
Extracellular Volume Extracellular Fluid
Loss Volume Excess
Gastric fluid loss Potassium depletion
Vomiting Primary
Congenital Chloride Hyperaldosteronism
diarrhea Cushing’s syndrome
Diuretic use Milk alkali syndrome
Post hypercapnea
Bartter’s syndrome
Metabolic acidosis
Expected PCO2
= (1.5 x actual HCO3) + 8 ± 2

Metabolic alkalosis
Expected PCO2
= (0.75 x actual HCO3) + 20 ± 5
Sample Computation for Expected pCO2 in
Metabolic Disturbances

Metabolic Acidosis
Example
pH 7.23, pCO2 25, HCO3 11, pO2 80
Expected pCO2 = (1.5 x 11) + 8 + 2
= 24.5 + 2 (22.5-26.5)
Metabolic Alkalosis
Example
pH 7.47, pCO2 47, HCO3 34, pO2 90
Expected pCO2 = (0.75 x 34) + 20 + 5
= 45.5 + 5 (40.5-50.5)
 METABOLIC:

v If actual PCO2 is within calculated range:

purely Metabolic acidosis/alkalosis

v If actual PCO2 is > expected range:

underlying Respiratory acidosis
Sample Computation for Expected pCO2 in
Metabolic Disturbances

Combined Metabolic and Respiratory Acidosis

Example
pH 7.23, pCO2 30, HCO3 11, pO2 80
Expected pCO2 = (1.5 x 11) + 8 + 2
> = 24.5 + 2 (22.5-26.5)
Mixed Metabolic Alkalosis and Respiratory Acidosis
Example
pH 7.47, pCO2 55, HCO3 34, pO2 90
Expected pCO2 = (0.75 x 34) + 20 + 5
> = 45.5 + 5 (40.5-50.5)
 METABOLIC:

v If actual PCO2 is within calculated range:

purely Metabolic acidosis/alkalosis

v If actual PCO2 is < expected range:

underlying Respiratory alkalosis
Sample Computation for Expected pCO2 in
Metabolic Disturbances

Mixed Metabolic Acidosis and Respiratory Alkalosis

Example
pH 7.23, pCO2 18, HCO3 11, pO2 80
Expected pCO2 = (1.5 x 11) + 8 + 2
< = 24.5 + 2 (22.5-26.5)
Combined Metabolic and RespiratoryAlkalosis
Example
pH 7.47, pCO2 35, HCO3 34, pO2 90
Expected pCO2 = (0.75 x 34) + 20 + 5
< = 45.5 + 5 (40.5-50.5)
Clinical Applications

Metabolic acidosis or alkalosis

-  replace or increase excretion of HCO3

Correction of Metabolic Acidosis

Bicarbonate deficit
= (body wt in Kg) (0.4) x [desired (HCO3)-measured (HCO3)]
Etiologies of Respiratory Acidosis

CNS depression
Chest Wall restriction
Airway Obstruction
Neuromuscular disorder
Severe Pulmonary Restrictive
Disease
 Respiratory Acidosis

1.Acute Respiratory Acidosis:

for every 10 mmHg increase in PCO2, pH should
decrease by 0.08 units
Expected pH
= 7.4 – [ 0.008 x (actual PCO2 – 40) ]

2.Chronic Respiratory acidosis:
for every 10 mmHg increase in PCO2, pH should
decrease by 0.03 units
Expected pH
= 7.4 – [ 0.003 x (actual PCO2 – 40) ]
Sample Computation for Expected pH in RAc

Example
pH =7.25, pCO2 = 75 mmHg, pO2=95, HCO3= 30, O sat = 94%
Acute Respiratory Acidosis
Expected pH = 7.4 – [ 0.008 (75-40) ]
= 7.12
Chronic Respiratory Acidosis
Expected pH = 7.4 – [0.003 (75-40)]
= 7.29
Expected pH range 7.12 – 7.29 à compare with actual pH
Respiratory Acidosis

If pH is within calculated range: purely

Resp. Acidosis

If pH is > calculated range: with

underlying Met. Alkalosis (Mixed
disorder)
Sample Computation for Expected pH in RAc

Example
pH =7.32, pCO2 = 75 mmHg, pO2=95, HCO3= 30, O sat = 94%
Acute Respiratory Acidosis
Expected pH = 7.4 – [ 0.008 (75-40) ]
= 7.12
Chronic Respiratory Acidosis
Expected pH = 7.4 – [0.003 (75-40)]
= 7.29
Expected pH range 7.12 – 7.29 à actual pH >expected pH
Mixed respiratory acidosis and metabolic alkalosis
Respiratory Acidosis

If pH is within calculated range: purely

Resp. Acidosis

If pH is < calculated range: with

underlying Met. Acidosis (Mixed
disorder)
Sample Computation for Expected pH in RAc

Example
pH =7.10, pCO2 = 75 mmHg, pO2=95, HCO3= 30, O sat = 94%
Acute Respiratory Acidosis
Expected pH = 7.4 – [ 0.008 (75-40) ]
= 7.12
Chronic Respiratory Acidosis
Expected pH = 7.4 – [0.003 (75-40)]
= 7.29
Expected pH range 7.12 – 7.29 à actual pH < expected pH
Combined respiratory and metabolic acidosis
Etiologies of Respiratory alkalosis

CNS events
Hypoxia
Drug use
Pulmonary Diseases
Hepatic Failure
Sepsis, Hypotension
 Respiratory Alkalosis
1.Acute Respiratory Alkalosis:
for every 10 mmHg decrease in PCO2, pH should
increase by 0.08 units
Expected pH
= 7.4 + [ 0.008 x (40 - actual PCO2) ]
2.Chronic Respiratory Alkalosis:
for every 10 mmHg decrease in PCO2, pH should
increase by 0.03 units
Expected pH
= 7.4 + [ 0.003 x (40 – actual PCO2) ]
 Sample Computation for Expected pH in RAl

Example
pH= 7.47, pCO2 = 20 mmHg, pO2 = 98, HCO3=22, O2 sat = 94%
Acute Respiratory Alkalosis
Expected pH = 7.4 + [ 0.008 (40-20)]
= 7.5
Chronic Respiratory Alkalosis
Expected pH = 7.4 + [ 0.003 (40-20) ]
= 7.46
Expected pH range 7.46 – 7.50 à compare with actual
pH
Respiratory Alkalosis

If pH is within calculated range: purely

Resp alkalosis

If actual pH is > expected range: with

underlying Met alkalosis (Mixed disorder)
 Sample Computation for Expected pH in RAl

Example
pH= 7.55, pCO2 = 20 mmHg, pO2 = 98, HCO3=22, O2 sat = 94%
Acute Respiratory Alkalosis
Expected pH = 7.4 + [ 0.008 (40-20)]
= 7.5
Chronic Respiratory Alkalosis
Expected pH = 7.4 + [ 0.003 (40-20) ]
= 7.46
Expected pH range 7.46 – 7.50 àActual pH >expected pH
Combined respiratory and metabolic alkalosis
Respiratory Alkalosis

If pH is within calculated range: purely

Resp alk

If actual pH is < expected range: with

underlying Met acidosis (Mixed disorder)
 Sample Computation for Expected pH in RAl

Example
pH= 7.43, pCO2 = 20 mmHg, pO2 = 98, HCO3=22, O2 sat = 94%
Acute Respiratory Alkalosis
Expected pH = 7.4 + [ 0.008 (40-20)]
= 7.5
Chronic Respiratory Alkalosis
Expected pH = 7.4 + [ 0.003 (40-20) ]
= 7.46
Expected pH range 7.46 – 7.50 àActual pH <expected pH
Mixed respiratory alkalosis and metabolic acidosis
Clinical Applications

Respiratory Acidosis
Increase the tidal volume
Decrease dead space
Increase the RR
Respiratory Alkalosis
Decrease the tidal volume
Increase the dead space
Decrease the RR
Steps in the Interpretation of an ABG
1.  Is the patient acidemic or alkalemic?
2.  Is the disturbance respiratory or
metabolic?
3.  Is it acute or chronic?
4.  Is there secondary compensation?
5.  Is there hypoxemia or not?
a. if hypoxemic, is it uncorrected, corrected or
overcorrected?
b. If non-hypoxemic, is oxygenation adequate or
more than adequate?
OXYGENATION
 INDICES OF OXYGENATION

1.  pO2
2.  P/F ratio
3.  O2 saturation
4.  aADO2
- difference in O2 in the alveolus and the arterial blood
pAO2 = 713 (FiO2) - pCO2
0.8
aADO2 = pAO2 – paO2
Normal ≤ 20
 OXYGENATION

Expected pO2 at room air

§  For age ≤ 60 years old = 80 – 100

§  For age > 60 years old = 80 - # yrs. above 60
ex. 70 y.o. = 80 - 10 = 70
OXYGENATION

At Room Air
Compare actual p02 to expected p02

 Actual < Exp. = HYPOXEMIC

 Actual > Exp.= NON-HYPOXEMIC/
NORMAL OXYGENATION
OXYGENATION

At Room Air
•  NORMAL OXYGENATION:
80-100mmHg
•  MILD HYPOXEMIA: 60-79mmHg
•  MODERATE HYPOXEMIA:
40-59mmHg
•  SEVERE HYPOXEMIA: <40mmHg
On Supplemental oxygen
pO2: 80-100 – corrected hypoxemia
pO2: <80 – uncorrected hypoxemia
pO2: >100 – overcorrected hypoxemia
ON SUPPLEMENTAL OXYGEN
FiO2 per nasal cannula
= (O2 liters/minute) x 4 + 20
e.g. O2 at 2LPM = 2 x 4 + 20
= 28% ≈ 0.28
 OXYGENATION

Actual P/F ratio

P/F = paO2 (actual from ABG)
FiO2 (expressed in decimal)

Example: 6lpm oxygen ARDS:

pO2: 60mmHg NORMAL: >300
MILD: 200-299
FIO2: 6 X 4 + 20 = 44% MODERATE: 100-199
PF ratio: 60/.44 = 136 SEVERE: <100
 Clinical Application

v Causes of Hypoxemia
v Central hypoventilation
v V/Q mismatch
v Shunt
v Low FIO2
v Low mixed venous O2
Problem #1
•  Metabolic acidosis
•  40M
•  Expected pCO2:
•  Room air = 1.5 x HCO3 + 8 + 2
•  pH = 7.20 = 1.5 x 10 + 8 + 2
•  pCO2 = 25 = 23 + 2 (21-25)
•  pO2 = 68 •  Purely metabolic acidosis
•  HCO3 = 10 •  Oxygenation at room air
Expected pO2 < 60y/o = 100 + 20
•  Hypoxemic at room air

Purely metabolic acidosis with

Mild Hypoxemia at room air
Problem #2
•  32M •  Respiratory acidosis
•  3 lpm by n.c. •  Expected pH
Acute: 7.4 – 0.008 x (80-40) = 7.08
•  pH - 7.06
Chronic: 7.4 – 0.003 x (80-40) = 7.28
•  pCO2 - 80 Expected pH range: 7.08 – 7.28
•  pO2 - 77 •  with underlying metabolic acidosis

•  HCO3 - 23 •  Actual P/F (FiO2 = 3 x 4 + 20 = 32)

= 77/0.32 = 240
Expected P/F in <60y/o = 400-500
•  Hypoxemic at 3 lpm, uncorrected

Combined Respiratory acidosis

And
metabolic acidosis with Uncorrected
Hypoxemia at 3 lpm O2
 Practice Exercises:
pH pC02 P02 HC03
1. 40/M 7.20 25 68 10
2. 32/M 7.08 80 77 26
@ 3lpm
3. 50/F 7.23 25 118 12
@ 5lpm
4. 26/M 7.44 23.7 42.5 16
@3 lpm
5. 70/F 7.48 36 215 30
@50%
Problem #3
Metabolic acidosis
Overcorrected hypoxemia at 5lpm
New FiO2 of 29% or 2.25 lpm

Problem #4
Respiratory alkalosis
With uncorrected hypoxemia at 3 lpm

Problem #5
Metabolic alkalosis
With underlying respiratory alkalosis
With more than adequate oxygenation at 50% FiO2
New FiO2 of 21%
Thank
you!!!