Blood gas workshop

How do we interpret the results ?

Josep Roca
Hospital Clínic
Universitat de Barcelona
Spain
 AGENDA

 DIAGNOSTIC AND MONITORING TECHNIQUES

 THE BASICS

 PHYSIOLOGICAL BACKGROUND

 CLINICAL SCENARIO

 CONCLUSIONS
ERS 2006, Munich
 clinical diagnosis & assessment

 RESPIRATORY BLOOD GAS MEASUREMENTS

monitoring techniques
 PULSE OXIMETRY

 END-TIDAL O2 & CO2

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 TRANSCUTANEOUS DE O2 & CO2 MEASUREMENTS

 Future challenges

Assessment of tissue hypoxia

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mitochondrial respiration
 Near-Infrared Spectroscopy (NIRS)
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 Nitroso-RedoxBalance
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 AGENDA

 DIAGNOSTIC AND MONITORING TECHNIQUES

 THE BASICS

 PHYSIOLOGICAL BACKGROUND

 CLINICAL SCENARIO

 CONCLUSIONS
ERS 2006, Munich
 Arterial blood gas measurements

 PULMONARY GAS EXCHANGE

PaO2
PaCO2

 ACID – BASE STATUS

pH
PaCO2
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Base excess
 Arterial blood gas measurements
FIO2 0.21 & BP 760 mmHg

 PULMONARY GAS EXCHANGE

PaO2 90-95 mmHg
PaCO2 35-45 mmHg

 ACID – BASE STATUS

pH 7.38 – 7.42
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PaCO2 respiratory component

Base excess - 2 to + 2 metabolic component

 Arterial blood gas measurements
FIO2 0.21 & BP 760 mmHg

 HYPOXEMIA

PaO2 < 80 mmHg

 RESPIRATORY FAILURE (hypoxemic)

PaO2 < 60 mmHg

 RESPIRATORY FAILURE (hypercapnic)

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PaCO2 > 50 mmHg

 Oxy-haemoglobin dissociation

% SaO2 100

75

60 mmHg
50

25
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0
P50 PaO2 (mmHg)
 Arterial blood gas measurements
FIO2 0.21 & BP 760 mmHg

 PULMONARY GAS EXCHANGE

PaO2
PaCO2

 ACID – BASE STATUS

pH
respiratory alcalosis (low PaCO2)
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PaCO2
or acidosis (high PaCO2)

Base excess metabolic alcalosis (positive BE)

or alcalosis (negative BE)
 Arterial blood gas measurements

 REDUNDANT VARIABLES
CO2 content
Actual bicarbonate
Standard bicarbonate
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 Arterial blood gas measurements

 ADDITIONAL INFORMATION REQUESTED

Barometric pressure (BP)

FIO2 or low flow oxygen therapy

Patient temperature
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inspiratory O2 partial pressure (PIO2) depends

on BP and FIO2
 AGENDA

 DIAGNOSTIC AND MONITORING TECHNIQUES

 THE BASICS

 PHYSIOLOGICAL BACKGROUND

 CLINICAL SCENARIO

 CONCLUSIONS
ERS 2006, Munich
ERS 2006, Munich

v
.
I

.
VA/Q

PaO2
16
 FACTORS GOVERNING PaO2 & PaCO2

INSPIRED
OXYGEN
VENTILATION-PERFUSION
ALVEOLAR IMBALANCE
VENTILATION

SHUNT

CARDIAC DIFFUSION
OUTPUT
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OXYGEN
UPTAKE
 Protective Ventilatory Strategy in ARDS

Open lung minus baseline differences

300 r 2 = 0.77 10 r 2 = 0.79

250 5
∆ PaO2 (mmHg)

200 0

D Shunt %
150 -5
100 -10
50 -15
0 -20
-50 -25
-100 -30
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0 100 200 300 400 500 0 100 200 300 400 500

Recruited Volume (ml) Recruited Volume (ml)

 FACTORS GOVERNING PaO2 & PaCO2

INSPIRED
OXYGEN
VENTILATION-PERFUSION
ALVEOLAR IMBALANCE
VENTILATION

SHUNT

CARDIAC DIFFUSION
OUTPUT
ERS 2006, Munich

OXYGEN
UPTAKE
 FACTORS GOVERNING PaO2 & PaCO2

INSPIRED
OXYGEN
VENTILATION-PERFUSION
ALVEOLAR IMBALANCE
VENTILATION

SHUNT

CARDIAC DIFFUSION
OUTPUT
ERS 2006, Munich

OXYGEN
UPTAKE
 INTERACTION MIXED VENOUS AND ARTERIAL PO2
Healthy
subjects
0.3 0.6
100

90
0.9

COPD
Arterial PO2 (mm Hg)

80 1.2
patients
1.5
70 1.8

60

50

40
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30

15 20 25 30 35 40 45

Mixed venous PO2 (mm Hg) 32

 DETERMINANTS OF HYPOXEMIA IN
COPD EXACERBATION
Low Mixed Ventilation-Perfusion
Venous PO2 Worsening

26% 46%

28%
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Increased Oxygen
Consumption
Barberà JA et al. ERJ 1997; 10: 1285
19
 AGENDA

 DIAGNOSTIC AND MONITORING TECHNIQUES

 THE BASICS

 PHYSIOLOGICAL BACKGROUND

 CLINICAL SCENARIO

 CONCLUSIONS
ERS 2006, Munich
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS

PaO2 90 normoxemia

PaCO2 37 normocapnia

normal BE
Base excess 0
normal pH
pH 7.40
ERS 2006, Munich
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS

PaO2 90 normoxemia

PaCO2 37 normocapnia

normal BE
Base excess 0
normal pH
pH 7.40
ERS 2006, Munich
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS
FIO2 0.21 & BP 760 mmHg

PaO2 90 normoxemia

PaCO2 37 normocapnia

normal BE
Base excess 0
normal pH
pH 7.40
ERS 2006, Munich
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS
FIO2 0.21 & BP 760 mmHg

PaO2 55 respiratory failure

PaCO2 50 hypercapnia

metabolic alcalosis
Base excess +6
normal pH
pH 7.38
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  PULMONARY GAS EXCHANGE & ACID – BASE STATUS
FIO2 0.21 & BP 760 mmHg

PaO2 55 respiratory failure

PaCO2 54 hypercapnia

normal BE
Base excess 0
low pH
pH 7.34
ERS 2006, Munich
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS
FIO2 0.21 & BP 760 mmHg

PaO2 70 55
PaCO2 25 40
Base excess -10 0
pH 7.31 7.39
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 Alveolar Gas Equation

PACO2
PAO2 = (BP - PH2O) x FIO2 -
RER

AaPO2 = PAO2 - PaO2

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  PULMONARY GAS EXCHANGE & ACID – BASE STATUS
FIO2 0.21 & BP 760 mmHg

PaO2 70 55
PaCO2 25 40
Base excess -10 0
pH 7.31 7.39
48 44
ERS 2006, Munich

AaPO2
  PULMONARY GAS EXCHANGE & ACID – BASE STATUS

FIO2 0.21 1.0

PaO2 50 55
PaCO2 35 36
Base excess -3 -3
pH 7.43 7.42
ERS 2006, Munich
ERS 2006, Munich