A Review of Arterial Blood Gas

Interpretation for Physiotherapists

Tania Larsen, PT PhD (c)
Western University
Physiotherapy Clinical Resource Specialist, London Health Sciences Centre

March 29th, 2018

Hosted by The Cardiorespiratory Division

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• This webinar is adapted from material in the
Cardiorespiratory Division course entitled
Foundations of Physiotherapy Practice ©
– Contributors of material to that course include:
• Anastasia Newman, PT
• Tania Larsen, PT
• Dr Deborah Lucy, PT

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 Objectives
1. Understand acid-base status in the blood and review
mechanisms that regulate pH in the body.
2. Describe the 4 primary acid-base disorders and the
methods of compensation
3. Interpret arterial blood gases and be able to identify
if primary acid-base disturbances are present and if
partial or complete compensation is occurring
4. Describe mechanisms of hypoxemia as they relate
to arterial blood gas interpretation.

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What is an Arterial Blood Gas Test?

Amounts of arterial gases such as oxygen and carbon dioxide are measured

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 Arterial Blood Gas (ABG) Values

• Normal Ranges:
– pH: 7.35 – 7.45
– PaO2: 80 – 100 mmHg
– PaCO2: 35 – 45 mmHg
– HCO3: 22 – 26 mmol/L
– SaO2: 95 – 100%

– Base Excess +/- 2mE/l

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 What can ABGs tell us?
Can provide information about:

1. About acid-base status of the blood

2. Gas exchange – demonstrates how well the

lungs are delivering oxygen to the blood?

3. Ventilation - demonstrates efficiency of the

lungs in eliminating CO2

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Objective #1

UNDERSTAND ACID-BASE STATUS IN THE

BLOOD AND REVIEW MECHANISMS THAT
REGULATE pH

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CO2 transport has a PROFOUND influence on
acid-base balance in the body !

CO2 + H2O  H2CO3  H+ + HCO3 -

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Understanding acid-base balance…

… calls for a chemistry refresher.

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 Introduction to Acid-Base Status

• water comprises > 60% of body mass

% Compartment

40 intracellular (ICF)

20 extracellular (ECF)  16% interstitial

 4% plasma

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 Water
H2O → H+ + OH-
forms the basis of the pH scale

• pure H2O is a neutral solution in which

[H+] = [OH -] = 1 x 10-7

• mathematically an awkward number to work with


pH = - log [H+] = 7
pure water is ‘neutral’ (7 on the pH scale)

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 Hydrogen Ion Relationship to pH

 H+   PH ( < 7.0 )  acid = PH < 7.0

 H+  PH ( > 7.0 )  alkaline = PH > 7.0

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 Acids & Bases: What are they?
• Acids: proton donor (solution can donate H+)

• Bases: proton acceptor (solution can accept H+)

• Conjugate Acid-Base Pair

– proton donor + corresponding proton acceptor

H2CO3  H+ + HCO3 -
Acid Base
Carbonic acid Bicarbonate

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 Strong vs Weak Acids & Buffers
• Strong Acid/Base
– completely ionized (i.e not a reversible reaction)
 poor buffer

• Weak Acid/Base
– forms a reversible reaction
 good buffer

• Buffer
– acqueous solutions that tend to resist changes in their PH
when small amounts of acid [H+]or base [OH -] are added

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 Body Acid-Base Status:
What acid is produced daily in the body?

Source Hydrogen [H+] Load

carbohydrates, fats, proteins 100 mEq/day

tissue metabolism 12,500 mEq/day

(CO2 + H2O  H2CO3)

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CO2 + H2O  H2CO3  H+ + HCO3 -
Carbonic Acid

Weak Acid
Good Buffer

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What determines the pH of blood?

Henderson-Hasselbach (H-H) Equation

PH = PK + log (Base)
(Acid)

Normal ration of
Base (HCO3-) to Acid (CO2) is 20:1

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 Blood pH

• Normal blood is slightly alkalemic

• Normal Arterial PH  7.35 - 7.45

Acidemia PH < 7.35

Alkalemia PH > 7.45

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 How is Acid-Base Balance Maintained?

Elimination of Metabolically Produced Acids

Volatile Acids
– those acids expelled in the gaseous form in the lungs

H+ + HCO3 -  H2CO3  H2O + CO2 (d)  CO2 (g)

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 How is Acid-Base Balance Maintained?

Elimination of Metabolically Produced Acids

Non-volatile Acids
– those acids eliminated in solution by the kidney

H2CO3  HCO3 - + H+

+
For each H+
NH3 secreted in the
urine, 1 HCO3-
 and 1 Na+ enter
the blood stream
NH4 + (ammonium) through the kidney

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How is Acid-Base Balance Maintained?

CO2 + H2O  H2CO3  H+ + HCO3 -

Kidneys
+
regulate base
(HCO3-)
Volatile acid expelled by through urine
lungs > 10,000 mEq/d NH3 production

Lungs regulate NH4 +

acid (CO2) via Non-volatile acid expelled by
kidney< 100 mEq/d
ventilation

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 Regulation of pH Balance

CO2 HCO3-
1 20

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Objective #2

DESCRIBE THE 4 PRIMARY ACID-BASE

DISORDERS AND THE METHODS OF
COMPENSATION

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 Clinical Importance of the H-H
Equation
The simple proportion in the equation

PH ~ HCO3 - (Base)
PaCO2 (Acid)

• Can be used to describe the 4 Primary Acid-

Base Disorders

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 Acid-Base Disorders

 BLOOD (EMIA)

Versus

 PATIENT (OSIS ie a physiologic process)

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• One of 4 acid-base disturbances manifested by
an initial change in either HCO3 - or PaCO2

• If HCO3 - changes 1st  metabolic disorder

• If PaCO2 changes 1st  respiratory disorder

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Acidemia a low blood pH (< 7.35)

Acidosis: a PRIMARY physiologic PROCESS that

occurring alone, tends to cause  pH (acidemia)

Metabolic Acidosis ( HCO3 - )

eg low perfusion lactic acidosis

Respiratory Acidosis ( PaCO2)

ie alveolar hypoventilation

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Alkalemia a high blood pH (>7.45)

Alkalosis a PRIMARY physiologic PROCESS that

occurring alone tends to cause  pH (alkalemia)

Metabolic Alkalosis ( HCO3 - )

eg vomiting, diuretics

Respiratory Alkalosis (PaCO2)

ie alveolar hyperventilation from hypoxemia,
anxiety etc

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 Compensation
• Secondary changes

• Occur AFTER the primary process have begun

• Occur solely as an attempt to correct the pH

change brought about by the primary disorder

• Compensatory changes are NOT termed

‘acidosis’ or ‘alkalosis’

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 Methods of Compensation
pH  Kidneys (slow)
Lungs (fast)

1. Buffer Systems (immediate)

– Bicarbonate-carbonic acid
2. Respiratory Regulation (minutes)
– ↑ or ↓ ventilation (expel or retain CO2)
3. Renal Regulation (hrs  days)
– H+ & HCO3 – which are retained or lost

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Objective #3

INTERPRET ARTERIAL BLOOD GASES,

IDENTIFY PRIMARY ACID-BASE
DISTURBANCES AND IF PARTIAL OR
COMPLETE COMPENSATION IS
OCCURRING

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 ABG Normative Values

• Normal Ranges:
– pH: 7.35 – 7.45
– PaO2: 80 – 100 mmHg
– PaCO2: 35 – 45 mmHg
– HCO3: 22 – 26 mmol/L
– SaO2: 95 – 100%

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 ABG Interpretation

1. Assess pH
– Acidemia or Alkalemia
2. Determine Primary Disorder
– Respiratory or Metabolic
3. Determine State of Compensation
– Compensated or uncompensated
– Degree to which pH is returning to normal

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 Summary

Primary Acid Base Disorders

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 Summary
Methods of Compensation
pH  Kidneys (slow)
Lungs (fast)

1. Buffer Systems (immediate)

2. Respiratory Regulation (minutes)

3. Renal Regulation (hrs  days)

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 ABG Example #1

PO2 = 43 mm Hg
PCO2 = 31 mm Hg
pH = 7.48
HCO3 = 23 mEq/l

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 ABG Example #1

• Uncompensated Respiratory Alkalosis

Possible clinical causes?

• alveolar hyperventilation
– anxiety, hypoxia

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 ABG Example #2
PO2 = 65 mm Hg
PCO2 = 42 mm Hg
pH = 7.30
HCO3 = 20 mEq/l

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 ABG Example #2

• Uncompensated Metabolic Acidosis

Possible clinical causes?

• Low perfusion lactic acidosis

– Anaerobic metabolism
• Diabetic ketosis

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 ABG Example #3

PO2 = 67 mm Hg
PCO2 = 85 mm Hg
pH = 7.36
HCO3 = 47 mEq/l

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 ABG Example #3

• Compensated Respiratory Acidosis

Possible clinical causes?

• alveolar hypoventilation
– Chronic lung disease

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 Acute vs Chronic
Respiratory Disorder
• Acute Respiratory Acidosis
– 1 to 10 rule: For every 10mmHg increase in PaCO2
there is a 1 mEq/L increase in HCO3-
– Intracellular buffering

• Chronic Respiratory Acidosis

– 3.5 to 10 rule: For every 10 mmHg increase in PaCO2
there is a 3.5 mEq/L increase in HCO3-
– Renal retention of bicarbonate

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 Acute vs Chronic
Respiratory Acidosis
• MR F has COPD.
– What is the state of Mr F’s acid-base balance?
– Is Mr F a chronic CO2 retainer?

ABGs: on 4L O2 on nasal prongs

pH 7.33, PaCO2 65, PaO2 75, HCO3 33

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 Chronic Respiratory Acidosis
with Compensation

PO2 = 75 mm Hg
PCO2 = 65 mm Hg
pH = 7.33
HCO3 = 33 mEq/l

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Objective #4
DESCRIBE MECHANISMS OF HYPOXEMIA
AS THEY RELATE TO ARTERIAL BLOOD
GAS INTERPRETATION.

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 Mechanisms of Hypoxemia

1. Alveolar Hypoventilation

2. Diffusion Impairment

3. Shunt

4. Ventilation/Perfusion (V/Q) Mismatch

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 Alveolar Ventilation (VA)

• Ventilation is matched to CO2 produced in the

body

• Need blood bases to determine hyper or hypo

ventilation
Hyperventilation = ↓ PaCO2
Hypoventilation = ↑ PaCO2

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 Is hypoventilation (↓ VA)
the major cause for hypoxemia?

• If hypoventilation is the major cause for

hypoxemia, the PaO2 should only decrease 1
mmHg for every 1mmHg increase in PaCO2
– If there is a greater decrease in PaO2, there must be
other causes for hypoxemia (shunt, diffusion
impairment, V/Q mismatch)

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 Is hypoventilation (↓ VA)
the major cause for hypoxemia?
• Hypoventilation → ↑PaCO2
– Inadequate ventilation to cope with CO2 production

• Possible Clinical causes

– Chronic lung disease
– Depressed central nervous system
– Post-operative, pain and splinting

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 References
• Hillegass E. Essentials of Cardiopulmonary Physical
Therapy. 3rd ed. Philadelphia, PA: Saunders; 2010.
• Reid WD, Chung F, Hill K. Cardiopulmonary Physical
Therapy Management and Case Studies. 2nd ed.
Thorofare, NJ: SLACK Incorporated; 2014.
• Paz JC, West MP. Acute Care Handbook for
Physical Therapists. 2nd ed. Woburn, MA:
Butterworth-Heinemann; 2002.

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