Pathophysiology of

Acid-Base Disturbances
Acid-Base/pH Balanc
Interpreting ABG’ s: Step 1
1. Look at the pH & determine if it is 
(acidosis)  (alkalosis), or normal.
Consider 7.0 Neutral
*If < 7.40, label “acidosis”; if > 7.40 –
label “alkalosis”
Examples:
7.26
7.49
7.38
Interpreting ABG’ s: STEP 1
Look at the pH & determine if it is 
(acidosis)  (alkalosis), or normal.

*If < 7.40, label “acidosis” or “A”

*If > 7.40 – label “alkalosis” or “B”

for base

Examples:
7.26  A “acidosis”
7.49  B “alkalosis”
7.38 normal but more_ A “ACIDOSIS”
Interpreting ABG’ s: STEP 2

2. Look at the pCO² -

Is it  (A/acid),  ( B/alkaline), or normal?

(If abnormal here…CO2 → RESPIRATORY problem –

inverse relationship {})

ROME = Respiratory Opposite

Examples:
pH  - pCO² 
pH  - pCO² 
3. Look at the
HCO³ - Is it 
(B/alkaline)
OR  (A/acid), or normal?

(If abnormal here…HCO3, METABOLIC problem –

direct relationship { or })

ROME = Metabolic Equivalent

Examples:
pH  - HCO³ 
pH  - HCO³ 
 Example:

□ pH 7.52 ( B/alkaline)
□ pCO² 37(normal)
□ HCO³ 28(B/alkaline)

□ Label this imbalance: metabolic alkalosis

Example

□ pH 7.29 (A/acid)
□ pCO² 55 ( A/acid)
□ HCO³ 23(normal)

□ Label this imbalance: respiratory acidosis

Compensation: 4 Levels
□ Uncompensated
■ pH abnormal; acid OR base component
abnormal
□ Partially compensated
■ pH abnormal; acid AND base component
abnormal
□ Compensated
■ pH WNL; acid or base imbalance is neutralized,
but not corrected; acid or base components
are abnormal, but balanced
□ Corrected
■ pH WNL; all acid or base parameters are
returned to WNL after state of imbalance
Interpreting ABG’ s: STEP
44. Check for compensation
Is the body trying to restore normal pH by
altering the buffer system which is NOT
involved in the imbalance?

If compensation has occurred, this value

will move in SAME direction as the
other component
Apply All 4 Steps…Let’ s Try
One
pH 7.30  A/acid
pCO² 52 A/acid
HCO³ 29  B/alkaline

Interpretation: respiratory acidosis, partial compensation

Hint: PH points the way....which value “matches” the PH? Here it is the
PCO2 the respiratory indicator, (both are “acid) so the problem is
respiratory acidosis.

The kidneys are compensating by retaining bicarbonate (note the

compensating mechanism is moving in the SAME direction as the causative
component, in this case “increasing”)
Interpreting ABGs….. Another one
□ PH 7.52
□ PCO2 48
□ HCO3 39
 Another one…
pH 7.52  B/alkaline
pCO² 48 A/acid
HCO³ 39  B/alkaline

Interpretation: metabolic alkalosis, partial compensation

Hint: PH points the way to metabolic problem. BOTH the PH and the bicarb
component are on the alkaline side (the HCO3 means more base), metaboic
alkalosis.

The compensatory component is the lungs and the value is moving in the same
direction (increasing).
 And Another:
Mrs. Neace, a 72 year old female with COPD
in hospital with URI

pH 7.39
pCO² 60
HCO³ 37
And Another:
72 year old female with COPD in hospital with
URI pH 7.39 A/more acid
pCO² 60  A/acid
HCO³ 37 
B/alkaline

Interpretation: compensated respiratory acidosis

Hint: PH is normal, but on the acidic side. The pCO2 is high also indicating
acidity (more hydrogen ions).

Remember pCO2 combines with H2O to form carbonic acid H2CO3,

respiratory acidosis.

We know full compensation occurred because the PH is NORMAL.

Another Example:

Ally, a seven year old semi-comatose

diabetic with Kussmaul breathing

pH 7.05
pCO² 12
HCO³ 5
17 year old semi-comatose diabetic with Kussmaul breathing

pH 7.05  A/acid
pCO² 12  B/alkaline
HCO³ 5  A/acid

Interpretation: metabolic acidosis, partial compensation

Hint: PH points toward acidiosis. Low bicarb (HCO3) indicates low levels
of base, so acidotic. PH and HCO3 match so problem is metabolic in
nature, metabolic acidosis.

Lungs are attempting to compensate by decreasing CO2 (lower hydrogen).

The compensating component is moving in the SAME direction.
Megan, a 26 year old visibly anxious and
hyperventilating

pH 7.50
pCO² 25
HCO³ 25
26 year old visibly anxious and hyperventilating

pH 7.50  B/alkaline
pCO² 25  B/alkaline
HCO³ 25  Normal

Interpretation: respiratory alkalosis, uncompensated

Hint: PH pointing toward alkalosis

Matching component is pCO2 (low levels so also alkalotic). Therefore, we have

respiratoy alkalosis.

Bicarb (HCO3 is normal, so no compensation.

 Levels Of Compensation:
Respiratory Acidosis
Uncompensate Partially Compensated Correcte
d compensate d
d

pH    

pCO²    

HCO³
   
With acidosis With acidosis we
we need MORE need MORE base to
compensate
base to
Levels Of Compensation:
compensate
 Respiratory Alkalosis
Uncompensate Partially Compensated Correcte
d compensate d
d

pH    

pCO    
²

HCO³ 
  
with alkalosis with
we need LESS alkalosis we
base to need LESS
compensate base to
compensate
 Metabolic Acidosis
Uncompensate Partially Compensated Correcte
d compensate d
d

pH    

pCO²    
With acidosis With acidosis
we need less we need less
acid (hydrogen) acid
to compensate (hydrogen) to
compensate

HCO 
³
  
 Metabolic Alkalosis
Uncompensate Partially Compensate Correcte
d compensate d d
d

pH    

pCO    
² With alkalosis With alkalosis we
we need MORE need MORE acid
acid (hydrogen) (hydrogen) to
to compensate compensate

HCO   
³

Primary Acid-Base Disorders

□ Respiratory Acidosis
Mr. Abner

□ Respiratory Alkalosis
Mrs. Beasley

□ Metabolic Acidosis
Mr. Couch

□ Metabolic Alkalosis
Ms. Dunn
Night Shift In The ER…
Primary Acid-Base Disturbance

□ Causes
■ WHAT IS THE PRIMARY EVENT?
■ WHAT IS THE PRIMARY DISORDER?

□ Clinical manifestations
■ WHAT DOES THIS PATIENT LOOK LIKE?

□ Interpret ABG’s
■ WHAT ARE HIS/HER ABG’S? IS THERE
ANY COMPENSATION TAKING PLACE YET?

□ Treatment
■ HOW DO YOU TREAT THIS PATIENT?
Mr. Abner: Respiratory Acidosis
□ PH 7.25 A ↓
□ PCO2 67 A ↑
□ HCO3 24 N ↔

□ Causes: 58 y/o painter who smokes 1 ppd.

□ H/O COPD with home oxygen at HS. Became increasingly SOA over
the last couple of days. DX: acute exacerbation COPD
□ Clinical Manifestations: SOA, productive cough of
thick green sputum, T 101; RR 26/min; Pulse Ox 89% on RA
□ Interpretation: Resp Acidosis, uncompensated
□ Treatment: IV abx, O2 per venturi mask, elevate HOB,
Solu Medrol IV
Mrs. Beasley: Respiratory
Alkalosis
□ PH 7.57  B
□ CO2 30 
□ HCO3 18 

□ Causes: 27 y/o female with acute anxiety attack after

hearing her friend was injured in Boston Marathon
□ Clinical Manifestations: c/o chest pain and
numbness in hands. RR 36/min SOA
□ Interpretation: Resp alkalosis , partial compensation
□ Treatment: Xanax po, reassurance, O2, breathe into
paper bag to increase CO2 levels
Mr. Couch: Metabolic Acidosis
□ PH 7.36 Normal but more A ↔
□ PCO2 30 B 
□ HCO3 19 A 
□ Causes: 23 y/o college student with Type I DM. Patient
developed diarrhea after eating sushi in the Blue Deli
yesterday.
□ Clinical Manifestations: Liquid stools 10 -15 in the
last 24 hours. 5 lb weight loss. Weak . R32/min. Fruity smell to
breath. FSBS 412
□ Interpretation: Metabolic Acidosis, full compensation
□ Treatment: NPO, IVF, IV Regular insulin
Ms. Dunn: Metabolic Alkalosis
□ PH 7.52 B 
□ PCO2 38 ↔

□ HCO3 50 B 
□ Causes: 20 y/o female who began vomiting after
drinking at at Keenland on Sat. Roommate found her
listless and barely responsive this morning.
□ Clinical Manifestations: lethargic, poor skin
turgor, FC with concentrated urine.
□ Interpretation: Metabolic Alkalosis, uncompensated
□ Treatment: IVF, NPO, Phenergan supp