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ABG - Interpretation PDF
ABG - Interpretation PDF
Interpretation
Information in this slide presentation is adapted from All You Really Need to Know to Interpret
Arterial Blood Gases (2nd ed.), by Lawrence Martin, MD, Lippincott, Williams, Wilkins
Normal Arterial Blood Gas Values*
pH 7.35 - 7.45
PaCO2 35 - 45 mm Hg
PaO2 70 - 100 mm Hg **
SaO2 93 - 98%
HCO3¯ 22 - 26 mEq/L
%MetHb < 2.0%
%COHb < 3.0%
Base excess -2.0 to 2.0 mEq/L
CaO2 16 - 22 ml O2/dl
Condition State of
PaCO2 in blood alveolar ventilation
> 45 mm Hg Hypercapnia Hypoventilation
35 - 45 mm Hg Eucapnia Normal ventilation
< 35 mm Hg Hypocapnia Hyperventilation
Hypercapnia
VCO2 x 0.863
PaCO2 = ------------------
VA VA = VE – VD
VCO2 x 0.863
PaCO2 = ------------------
VA VA = VE – VD
PaCO2 = 71.9 mm Hg
2. VA = VE - VD
= 10(600) - 10(150) = 6 - 1.5 = 4.5 L/min
200 ml/min x .863
PaCO2 = ---------------------- = 38.4 mm Hg
4.5 L/min
PaCO2 and Alveolar Ventilation:
Test Your Understanding
Where PAO2 is the average alveolar PO2, and PIO2 is the partial
pressure of inspired oxygen in the trachea
* Note: This is the “abbreviated version” of the AG equation, suitable for most clinical purposes. In the longer version, the
multiplication factor “1.2” declines with increasing FIO2, reaching zero when 100% oxygen is inhaled. In these exercises
“1.2” is dropped when FIO2 is above 60%.
Alveolar Gas Equation
4. The PAO2 on the summit of Mt. Everest is calculated just as at sea level,
using the barometric pressure of 253 mm Hg.
a) PAO2 = .21 (253 - 47) - 1.2 (40) = - 5 mm Hg
b) PAO2 = 1.00 (253 - 47) - 40 = 166 mm Hg
c) PAO2 = .21 (253 - 47) - 1.2 (10) = 31 mm Hg
P(A-a)O2
P(A-a)O2 is the alveolar-arterial difference in partial pressure of
oxygen. It is commonly called the “A-a gradient,” though it does
not actually result from an O2 pressure gradient in the lungs.
Instead, it results from gravity-related blood flow changes within
the lungs (normal ventilation-perfusion imbalance).
PAO2 is always calculated based on FIO2, PaCO2, and barometric
pressure.
PaO2 is always measured on an arterial blood sample in a “blood
gas machine.”
Normal P(A-a)O2 ranges from @ 5 to 25 mm Hg breathing room
air (it increases with age). A higher than normal P(A-a)O2 means
the lungs are not transferring oxygen properly from alveoli into the
pulmonary capillaries. Except for right to left cardiac shunts, an
elevated P(A-a)O2 signifies some sort of problem within the lungs.
Physiologic Causes of Low PaO2
NON-RESPIRATORY P(A-a)O2
RESPIRATORY P(A-a)O2
(continued)
P(A-a)O2: Test Your Understanding -
Answers to #3 (cont)
a) PAO2 = .80 (713) - 40 = 530 mm Hg (Note that the factor 1.2 is dropped
since FIO2 is above 60%)
P(A-a)O2 = 530 - 350 = 180 mm Hg
P(A-a)O2 is increased. Despite a very high PaO2, the lungs are not
transferring oxygen normally.
e) PAO2 = .21 (713) - 1.2 (72) = 150 - 86 = 64 mm Hg; P(A-a)O2 = 64 - 80 =
-16 mm Hg
A negative P(A-a)O2 is incompatible with life (unless it is a transient
unsteady state, such as sudden fall in FIO2 -- not the case here). In this
example, negative P(A-a)O2 can be explained by any of the following:
incorrect FIO2, incorrect blood gas measurement, or a reporting or
transcription error.
SaO2 and Oxygen Content
[HCO3-]
pH = pK + log ----------------
.03 [PaCO2]
HCO3-
pH ~ ---------
PaCO2
pH is inversely related to [H+]; a pH change
of 1.00 represents a 10-fold change in [H+]
pH [H+] in nanomoles/L
7.00 100
7.10 80
7.30 50
7.40 40
7.52 30
7.70 20
8.00 10
Acid-base Terminology
Acidemia: blood pH < 7.35
Acidosis: a primary physiologic process that, occurring alone,
tends to cause acidemia. Examples: metabolic acidosis from
decreased perfusion (lactic acidosis); respiratory acidosis from
hypoventilation. If the patient also has an alkalosis at the same
time, the resulting blood pH may be low, normal, or high.
Alkalemia: blood pH > 7.45
Alkalosis: a primary physiologic process that, occurring alone,
tends to cause alkalemia. Examples: metabolic alkalosis from
excessive diuretic therapy; respiratory alkalosis from acute
hyperventilation. If the patient also has an acidosis at the
same time, the resulting blood pH may be high, normal, or low.
Acid-base Terminology (cont.)
Primary acid-base disorder: One of the four acid-base
disturbances that is manifested by an initial change in HCO3- or
PaCO2. They are: metabolic acidosis (MAc), metabolic alkalosis
(MAlk), respiratory acidosis (RAc), and respiratory alkalosis (RAlk).
If HCO3- changes first, the disorder is either MAc (reduced HCO3-
and acidemia) or MAlk (elevated HCO3- and alkalemia). If PaCO2
changes first, the problem is either RAlk (reduced PaCO2 and
alkalemia) or RAc (elevated PaCO2 and acidemia).
Compensation: The change in HCO3- or PaCO2 that results from
the primary event. Compensatory changes are not classified by the
terms used for the four primary acid-base disturbances. For
example, a patient who hyperventilates (lowers PaCO2) solely as
compensation for MAc does not have a RAlk, the latter being a
primary disorder that, alone, would lead to alkalemia. In simple,
uncomplicated MAc the patient will never develop alkalemia.
Primary Acid-base Disorders:
Respiratory Alkalosis
HCO3- ↓HCO3-
↑ pH ~ ------- ↑ pH ~ --------
↓ PaCO2 ↓ PaCO2
Primary Acid-base Disorders:
Respiratory Acidosis
HCO3- ↑ HCO3-
↓ pH ~ --------- ↓ pH ~ ---------
↑PaCO2 ↑ PaCO2
Primary Acid-base Disorders:
Metabolic Acidosis
↑ HCO3- ↑HCO3-
↑ pH ~ ------------ ↑ pH ~ ---------
PaCO2 ↑PaCO2
Anion Gap
Note: CO2 in this equation is the “total CO2” measured in the chemistry lab as part of
routine serum electrolytes, and consists mostly of bicarbonate. Normal AG is typically
12 ± 4 mEq/L. If AG is calculated using K+, the normal AG is 16 ± 4 mEq/L. Normal
values for AG may vary among labs, so one should always refer to local normal values
before making clinical decisions based on the AG.
Metabolic Acid-base Disorders:
Some Clinical Causes
METABOLIC ACIDOSIS ↓HCO3- & ↓ pH
- Increased anion gap
• lactic acidosis; ketoacidosis; drug poisonings (e.g., aspirin,
ethylene glycol, methanol)
- Normal anion gap
• diarrhea; some kidney problems (e.g., renal tubular acidosis,
interstitial nephritis)
TIP 1. Do not interpret any blood gas data for acid-base diagnosis
without closely examining the serum electrolytes: Na+, K+, Cl-,
and CO2.
• A serum CO2 out of the normal range always represents some type of
acid-base disorder (barring lab or transcription error).
• High-serum CO2 indicates metabolic alkalosis &/or bicarbonate retention
as compensation for respiratory acidosis.
• Low-serum CO2 indicates metabolic acidosis &/or bicarbonate excretion
as compensation for respiratory alkalosis.
• Note that serum CO2 may be normal in the presence of two or more
acid-base disorders.
Tips to Diagnosing Mixed Acid-base
Disorders (cont.)
ACUTE CHRONIC
Resp Acidosis
pH ↓ by 0.07 pH ↓ by 0.03
HCO3- ↑ by 1* HCO3- ↑ by 3 - 4
Resp Alkalosis
pH ↑ by 0.08 pH ↑ by 0.03
HCO3- ↓ by 2 HCO3- ↓ by 5
3. a) false
b) true
c) true
d) true
e) false
f) true
g) false
Summary:
Clinical and Laboratory Approach to
Acid-base Diagnosis
Examine pH, PaCO2, and HCO3- for the obvious primary acid-
base disorder and for deviations that indicate mixed acid-base
disorders (TIPS 2 through 4).
Summary:
Clinical and Laboratory Approach to
Acid-base Diagnosis (cont.)
Use a full clinical assessment (history, physical exam, other lab
data including previous arterial blood gases and serum
electrolytes) to explain each acid-base disorder. Remember
that co-existing clinical conditions may lead to opposing acid-
base disorders, so that pH can be high when there is an
obvious acidosis or low when there is an obvious alkalosis.
Treat the underlying clinical condition(s); this will usually suffice
to correct most acid-base disorders. If there is concern that
acidemia or alkalemia is life-threatening, aim toward correcting
pH into the range of 7.30 - 7.52 ([H+] = 50-30 nM/L).
Case 2 - Discussion
OXYGENATION: The PaO2 is lower than expected for someone
hyperventilating to this degree and receiving supplemental oxygen, and
points to significant V-Q imbalance. The oxygen content is adequate.
Case 3 - Discussion
OXYGENATION: The patient's PaO2 is reduced for two reasons -
hypercapnia and V-Q imbalance - the latter apparent from an elevated P(A-
a)O2 (approximately 27 mm Hg).
ACID-BASE: The low pH, high PaCO2, and slightly low calculated HCO3- all point to
combined acute respiratory acidosis and metabolic acidosis. Anion gap is elevated
to 30 mEq/L indicating a clinically significant anion gap (AG) acidosis, possibly from
lactic acidosis. With an of AG of 30 mEq/L, his serum CO2 should be much lower, to
reflect buffering of the increased acid. However, his serum CO2 is near normal,
indicating a primary process that is increasing it, i.e., a metabolic alkalosis in addition
to a metabolic acidosis. The cause of the alkalosis is as yet undetermined. In
summary: this patient has respiratory acidosis, metabolic acidosis, and metabolic
alkalosis.
Arterial Blood Gas
Interpretation
The End