Blood Gas Analysis :

Application in Respiratory Failure

Dicky Soehardiman
Interventional Pulmonology & Respiratory Care Medicine Division
Pulmonology & Respiratory Medicine Department
Faculty of Medicine
Universitas of Indonesia – Persahabatan Hospital
 Blood Gas Analysis (BGA)
• A blood test that is performed using blood from an
artery.
• ACID: a substance that can donate a hydrogen ion.
• BASE: a substance that can accept a hydrogen ion.
 pH

Respiratory Metabolic

pCO2 SID ATOT

- Na+, K+ - Albumin
- Ca2+, Mg2+ - Globulin
- Cl- - Phosphate
- Lactate
- Ketoacids
- SO42-

Stewart
Vet Clin Pathol. 2000;29:115-128.
 Acid Base Disorders
• Henderson-Hasselbach • Stewart
• Anion gap • SID
• pCO2 : respiratory disorder • pCO2 : respiratory disorders
• Metabolic disorders:
• HCO3 : metabolic disorder
• SID: water (Na+), Cl - , UA,
• nonvolatile weak acid (albumin &
phosphate)
Stewart Acid Base Disorders

Fencl V. Am J Respir Crit Care Med 2000;162:2246-51

ACIDOSIS ALKALOSIS
ACID BASE DISORDERS
Henderson-Hasselbach

35<pCO2<45

RESPIRATORY

METABOLIC

7,35 7,45

22<HCO3<26
 ACIDOSIS ALKALOSIS

pCO2>45

pCO2<35

RESPIRATORY

METABOLIC 7,35 7, 45

HCO3<22

HCO3>26
 Respiratory System

Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott Williams & Wilkins; 2006.
RESPIRATORY ACIDOSIS

Respiratory acidosis is caused by disorders in:

1. Respiratory controller:
• Automatic controller
• Behaviour controller

2. Ventilatory pump problem:

• Chest wall muscles
•
•
pCO > 45
Chest wall skeleton
2
Chest wall connective tissue
• Airways
• Pleura
• Spinal cord & peripheral nerves
Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott Williams & Wilkins; 2006.
Ventilatory Pump

Schwartsein RM, Parker MJ. Respiratory physiology: a clinical approach. Philadelphia: Lippincott Williams & Wilkins; 2006.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 Treatment
• Treat the underlying disease
• Oxygen therapy
 RESPIRATORY ACIDOSIS
ALKALOSIS

pCO2 < 45
Respiratory alkalosis is caused by disorders in gas exchanger:
•Ventilation – perfusion mismatch: dead space & shunt
•Diffusion abnormalities
Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott Williams & Wilkins; 2006.
 Respiratory System

Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott Williams & Wilkins; 2006.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
Gas Exchanger
 Dead Space

Shunt

Anatomical shunt
Shapiro BA, Peruzzi WT, Templin R. Clinical application of blood gas. St. Louis: Mosby; 1994.
 Treatment
• Treat the underlying disease
• Oxygen therapy
 ACIDOSIS ALKALOSIS

pCO2>45

pCO2<35

RESPIRATORY

METABOLIC 7,35 7, 45

HCO3<22

HCO3>26
 Terapi Oksigen

• Pemberian oksigen tambahan untuk koreksi atau

mencegah terjadinya hipoksemia.

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
Oxygen = obat
• Dosis toksik

• Lama pemberian

• Indikasi
• Jenis

• Kontraindikasi

• Efek samping

• Dosis
http://balabasnia.narod.ru/optimal/
 PaO2 and SaO2 value in adult

PaO2 SaO2 (%)

Normal ≥ 80 ≥ 95
Hipoksemia < 80 < 95
Ringan 60 –79 90 – 94
Sedang 40 – 59 75 – 89

Berat <40 < 75

 Menghitung kebutuhan oksigen
1. PAO2=(PB-PH2O)x FiO2 – (1,25 xPaCO2 AGD)

= (760-47) x FiO2 – (1.25 xPaCO2 AGD)

PAO2 = (713x FiO2) – (1.25 xPaCO2 AGD)

2. PaO2 AGD = PaO2 target

PAO2 yg didapat PAO2 baru

3. Selanjutnya bila sudah didapat PAO2 baru, cari FiO2 baru dengan rumus (1)
FiO2= [PAO2+(1,25xPaCO2)]
713
 Deteksi hipoksemia
Alveolar-arterial oxygen gradient (AaDO2) :
• < 20 mmHg: normal
• 20-40 mmHg: V/Q mismatch
• 40-60 mmHg: shunt
• > 60 mmHg: gangguan difusi
 Tujuan Terapi Oksigen

Meningkatkan:

• PaO2 > 60 mmHg, atau

• Saturasi O2 > 90 %

dg memberikan dosis O2 terendah

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 BTS
Adakah hiperkapnia kronik?

Ya Tidak

Target SpO2= 88-92% Target SpO2= 94-98%

 ACIDOSIS ALKALOSIS

Gagal napas tipe 2

pCO2>45
Gagal napas tipe 1
- paCO2>45 mmHg - paO2<60 mmHg atau
- paO2<60 mmHg - SpO2<90%

RESPIRATORY

METABOLIC 7,35 7, 45

HCO3<22

HCO3>26
 Indikasi


• Koreksi hipoksemia
• Meningkatkan reabsorbsi pada rongga badan.

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 Efek samping

• Hipoventilasi dan CO2 narcosis

• Absorption atelectasis

• Pulmonary oxygen toxicity

• Retrolental fibroplasia

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 Pemberian Terapi O2

1. Low flow devices

1. Nasal kanul
2. Masker : - sederhana
- rebreathing mask (RM)
- nonrebreathing (NRM)

2. High flow devices

1. Venturi
 Nasal kanul
• Suatu pipa plastik lunak, ujung buntu ! dikaitkan ke
telinga & bawah leher

• Digunakan bayi, anak, dewasa

• Kecepatan aliran 1-6 L/mnt, FiO2 0,24-0,44

• Komplikasi : kerusakan kulit, kekeringan &

ketidaknyamanan
 Nasal kanul
• Untung:
• Murah
• Sederhana & nyaman
• Dpt makan dan minum
• PPOK
• Dpt menggunakan pelembab

• Rugi:
• Luka akibat tekanan
• Mukosa hidung kering &
iritasi

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 Masker

• Masker digunakan ! kadar O2 yang diberikan

lebih tinggi dibandingkan nasal kanul

• Perangkat dari plastik ringan menutupi hidung

& mulut
 Masker sederhana
(Simple mask)

➢ Masker ! digunakan pada wajah,

➢ Masker ! tidak menyebabkan tekanan yang

menyakitkan wajah, tulang pipi

➢ Kecepatan aliran 5-8 L/mnt, FiO2 0,4 – 0,6

 • Untung:
• Sederhana, ringan
• Dapat dilembabkan
• FiO2 sampai 0,6

• Rugi:
• Tdk nyaman bagi
pembicara yg senang
menyingkirkan masker
• Sulit buang dahak dan
makan
• Tdk nyaman pd trauma
wajah
• Mata kering/iritasi

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 Masker reservoir
2 jenis masker reservoir :

- Rebreathing mask

- Nonrebreathing mask

Masker ! ringan ! plastik transparan dengan

reservoir dibawah dagu

Kecepatan aliran 7 –15 L/mnt

 Rebreathing mask (RM)

• Untung • Rugi
• FiO2 sampai > 0,6
• Aliran yg kurang:
• Oksigen ekspirasi dr dead rebreathing CO2
space terjaga
• Claustrophobia

• Tdk bisa makan, minum &

buang dahak

• 15 L/m < sesak nps berat

• Mata kering/iritasi

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
Tanpa klep

Rebreathing mask

Tanpa klep
Nonrebreathing mask (NRM)

• Untung • Rugi
• FiO2 > 0,8 • Tdk nyaman
• Claustrophobia
• Tdk bisa makan,
minum & buang dahak
• Mata kering/iritasi
• Katup masker lengket

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
Klep 2 Masker

Klep 1

Selang O2

Non rebreathing mask

 High flow devices

Venturi

• Konsentrasi oksigen ! dalam masker dengan

udara didalamnya ! oksigen diberikan dengan
angka pasti

• Alat digunakan nonaerosol ! persen tetap

(24%, 28%, 31%, 36%, 40%, 50%)
Venturi mask
 Pemilihan jenis alat berdasarkan FiO2
No. Jenis alat Aliran (L/m) FiO2
1. Kanul hidung 1 0,24
2 0,28
3 0,32
4 0,36
5 0,40
6 0,44
2. Simple Mask 5-6 0,4
6-7 0,5
7-8 0,6
3. Rebreathing Mask 7 0,65
8-15 0,7-0,8
4. Nonrebreathing Mask Atur reservoir jgn 0,85-1,0
kempes

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
METABOLIC ACIDOSIS

Metabolic acidosis is caused by:

1.Loss of base
2.Accumulation of nonvolatile acid

HCO3 < 22
METABOLIC ACIDOSIS

No. Normal Anion Gap (HHARDUP) High Anion Gap (MUDPILES)

1. Hypoaldosteronism Methanol use

2. Hyperosmolar nonketotic coma Uremia (renal failure)

HCO3 < 22
3. Acetazolamide Diabetic ketoacidosis

Poisons (paraldehyde,
4. Renal tubular acidosis
phenformin, propylene glycol)

5. Diarrhea Iron, INH

6. Uterosigmoidectomy, ileostomy Lactic acidosis

7. Pancreatic fistule Ethanol or ethylene glycol use

8. Salicylate use, starvation

Spector SA. Critical care companion. 2000

 Treatment
• Treat the underlying disease
• HCO3 corection???
 METABOLIC ACIDOSIS
ALKALOSIS

Metabolic alkalosis is caused by:

1.Loss of nonvolatile acid
2.Accumulation of base

HCO3 > 26
 METABOLIC ALKALOSIS
ACIDOSIS

Chloride responsive Chloride unresponsive

No.
metabolic alkalsosis metabolic alkalosis (D.VAGA)

1. Contraction alkalosis Diuretics

HCO3 > 26
2. Diuretics Vomiting

3. Villous adenoma Aldosteronism

Gastric loss from large volume

4. vomiting or continuous gastric Gastric drainage
suction

5. Alkali intake (antacids)

Spector SA. Critical care companion. 2000

 Treatment
• Treat the underlying disease
• Treat hypovolemia
• Treat hypokalemia,
• Treat hypochloride (if there is)
• Acetazolamide (500 mg every 6 hours)
 ACIDOSIS ALKALOSIS

pCO2<35

RESPIRATORY

METABOLIC
HCO3<22

Compensation
 ACIDOSIS ALKALOSIS

pCO2>45

RESPIRATORY

METABOLIC

HCO3>26

Compensation
 Prediction

PaCO2 pH HCO3

80 7,2 28
20 60 7,3 26

40 7,4 24

10 30 7,5 22

20 7,6 20

Shapiro BA, Peruzzi WT, Templin R. Clinical application of blood gas. St. Louis: Mosby; 1994.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 ACIDOSIS ALKALOSIS

Respiratory Controller + Ventilatory Pump

Gas Exchanger

RESPIRATORY

METABOLIC 7,35 7, 45
 Summary
• Respiratory acidosis is caused by disorder of
respiratory controller and ventilatory pump problems.
• Respiratory alkalosis is caused by gas exchanger
problems.
• Management of respiratory acidosis or alkalosis:
• treat the underlying disease
• oxygen therapy
Thank You
 Soal 1
• Datang ke IGD pasien usia 60 th dg keluhan sesak napas
mengi, batuk 1 minggu dan nyeri dada. Baru berhenti
merokok 1 bulan ini

• Sakit sedang, compos mentis.

• T: 120/70. N: 100 x/mnt. RR: 28 x/mnt. t: 38 oC. Nyeri dada

VAS 1. SpO2: 88%.

• Pemeriksaan paru: bronkovesikular, Rh +/+, Wh +/+

 AGD
• pH: 7,25 • pH: 7,30 • pH: 7,35

• pCO2: 55 mmHg • pCO2: 55 mmHg • pCO2: 55 mmHg

• HCO3: 25 meq/L • HCO3: 35 meq/L • HCO3: 35 meq/L

• Kesan: asidosis • Kesan: asidosis • Kesan: asidosis

respiratorik. respiratorik respiratorik
terkompensasi terkompensasi
sebagian. penuh.
 AGD
• pH: 7,1

• pCO2: 65 mmHg

• HCO3: 10 meq/L

• Kesan: asidosis
respiratorik dan
asidosis metabolik.
 Soal 2
• Datang ke IGD seorang laki2 65 th dg diantar oleh petugas
kepolisian dan ambulans. Pasien ditemukan di kawasan car
free day dlm keadaan tidak sadar.

• Apa yg anda lakukan?

• Keadaan sesak napas, apatis. T: 90/60. N: 110x/mnt. RR: 32

x/mnt. t: 36,8oC.

• Pemeriksaan paru: vesikular, Rh -/- wh -/-

• Apa yg anda lakukan

 AGD
• pH: 7,25 • pH: 7,25 • pH: 7,35

• pCO2: 35 mmHg • pCO2: 30 mmHg • pCO2: 25 mmHg

• HCO3: 15 meq/L • HCO3: 15 meq/L • HCO3: 15 meq/L

• Kesan: asidosis • Kesan: asidosis • Kesan: asidosis

metabolik. metabolik metabolik
terkompensasi terkompensasi
sebagian. penuh.
 AGD
• pH: 7,1

• pCO2: 65 mmHg

• HCO3: 10 meq/L

• Kesan: asidosis
metabolik dan
asidosis
respiratorik.