Vet Clin Small Anim 38 (2008) 423–426

VETERINARY CLINICS
SMALL ANIMAL PRACTICE
Hypoxemia: A Quick Reference
Jonathan F. Bach, DVM
Department of Medical Sciences, School of Veterinary Medicine,
University of Wisconsin, Madison, WI 53706, USA

 The partial pressure of oxygen dissolved in arterial blood (PaO2) reflects the
amount of oxygen dissolved in blood. At sea level and when breathing ambi-
ent air, hypoxemia is defined as a PaO2 of less than 80 mm Hg.
 Normally, PaO2 is approximately four- to fivefold the fraction of inspired
oxygen (FIO2).
 At sea level, the FIO2 is 21% and a normal PaO2 is 80 to 100 mm Hg.

ALVEOLAR GAS EQUATION

 The alveolar gas equation uses the partial pressure of arterial carbon dioxide
(PaCO2) to estimate the partial pressure of oxygen within the alveolus (PAO2):
 The PaCO2 is inversely proportional to ventilation, and measuring
it lends direct information about the sufficiency of ventilation. An ele-
vated PaCO2 indicates hypoventilation, whereas PaCO2 is decreased
from hyperventilation.
 PAO2 is estimated taking into account PaCO2, FIO2, barometric pressure (BP),
and vapor pressure of water (PH2O).

PAO2 ¼ FIO2 ðBP  PH2 OÞ  PaCO2 =RQ

 Respiratory quotient (RQ) compensates for an individual’s diet composition.

The RQ most frequently used is 0.8. The expression FIO2 (BP  PH2 O) is the
pressure of inspired oxygen (PIO2). When a blood gas is obtained on am-
bient air (FIO2 ¼ 0:21) at sea level, the BP is often near 760 mm Hg, PH2 O
is approximately 47 mm Hg, and PIO2 is approximately 150 mm Hg. Thus:

PAO2 ¼ 150  PaCO2 =RQ

E-mail address: bachj@svm.vetmed.wisc.edu

0195-5616/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.cvsm.2008.02.001 vetsmall.theclinics.com
424 BACH

ALVEOLAR-ARTERIAL OXYGEN DIFFERENCE

 The alveolar  arterial gas gradient (A  a) is the difference between the
calculated PAO2 (A) and measured PaO2 (a) obtained from the arterial blood
gas. When combined, the equation reads:

A  a ¼ ð150  PaCO2 =RQÞ  PaO2

 Ideal lungs would have an A  a gradient of 0 mm Hg. This is not the case,
however, because there are normal physiologic variations throughout the lung
in which ventilation and perfusion are not ideal.
 Pressure gradients are different between dorsal and ventral lung lobes,
resulting in unequal ventilation between regions.
 The ventral regions have greater blood flow (perfusion) than the dorsal
regions.
 Because of these inequalities, the normal A  a gradient in the dog is gener-
ally less than 15 to 25 mm Hg. Values greater than this indicate that a paren-
chymal pulmonary lesion is present, causing hypoxemia.

ANALYSIS
 Indications: Arterial blood gases should be evaluated in patients suspected of
having respiratory disease to diagnose and estimate the severity of
hypoxemia.
 Typical reference range: PaO2 should be greater than 80 mm Hg in patients
breathing room air at sea level, whereas the A  a gradient should be less
than 25 mm Hg.
 Danger values: Hypoxemia is considered severe when the PaO2 is less than
60 mm Hg.
 Artifacts: Correct sample handling is imperative for accurate PaO2 readings.
Delay in measurement allows continued metabolism by the erythrocytes and
reduces PaO2. Keeping the specimen on ice allows accurate measurement
to be delayed for up to 1 hour. Air bubbles introduce error and cause an
increase in PaO2.

CLINICAL APPROACH
 The causes of hypoxia include hypoventilation, low FIO2, diffusion impair-
ment, ventilation-perfusion (V/Q) mismatch, and right-to-left shunt. Fig. 1 illus-
trates how the arterial blood gas results and calculation of the A  a gradient
can direct the clinician to the underlying cause of a patient’s hypoxemia.
Supplying 28% FIO2 can be achieved using a single nasal cannula and an
oxygen flow rate of 50 mL/kg/min.
 Hypoventilation: When a patient has hypoventilation, the PaO2 and PAO2
decrease to a similar degree that the PaCO2 and alveolar carbon dioxide
(CO2) increase. Because of these opposite and nearly equal changes, the
A  a gradient does not increase. If a deviation is present in a patient with hy-
poventilation, concurrent diffusion impairment, V/Q mismatch, or right-to-left
shunting is present. Causes of hypoventilation include centrally acting
HYPOXEMIA: A QUICK REFERENCE 425

Fig. 1. Algorithm depicts the clinical approach to a patient with hypoxemia. (Adapted from
DiBartola SP, de Morais HSA. Respiratory acid-base disorders. In: DiBartola SP, editor. Fluid
therapy in small animal practice. Philadelphia: WB Saunders; 1992. p. 242; with permission.)

respiratory depressants, neuromuscular diseases inhibiting the muscles of res-

piration, chest wall injuries, pleural space lesions, and upper airway
obstruction.
 Decreased FIO2: The most common cause of decreased FIO2 is decreased BP
associated with high altitude or anesthetic error, such as a low oxygen (O2)
supply source or administration of nitrogen oxide (N2O) without O2. As a re-
sult of the low alveolar O2, the PaO2 decreases, which stimulates ventilation.
The hyperventilation decreases PaCO2. The A  a gradient remains normal;
however, the PaCO2 and PaO2 are low.
 Diffusion impairment: When there is inadequate equilibration of O2 tension
across the alveoli and capillaries, diffusion impairment is present. In normal
individuals, O2 rapidly diffuses from alveoli into the capillaries. Diffusion im-
pairment may occur earlier in the course of pulmonary disease than V/Q mis-
match. The clinical signs are mild, and by the time an owner detects clinical
signs and seeks veterinary attention, his or her pet may have diffusion impair-
ment and V/Q mismatch. Diffusion impairment is caused by thickening of the
alveolar interstitial space or the capillary wall. Disease processes include in-
terstitial edema, fibrosis, vasculitis, or emphysema.
 V/Q mismatch: V/Q mismatch is common in patients that have pulmonary
disease. It occurs when regions of the lung lack ventilation or perfusion, im-
pairing efficient gas exchange. The A  a gradient increases by abnormally
low or abnormally high V/Q ratios. V/Q mismatch may occur from diseases
affecting air flow (eg, asthma, bronchitis), decreased compliance (eg, pulmo-
nary fibrosis), increased compliance (eg, emphysema), or vascular obstruc-
tion (eg, pulmonary embolism). Patients with V/Q mismatch often have
426 BACH

hypoxemia (low PaO2) and hypocapnia (low PaCO2). When they are placed
on 100% O2, their hypoxemia improves, and the PaO2 should improve by at
least 50 mm Hg.
 Right-to-left shunt: In patients with right-to-left shunt, deoxygenated venous
blood passes from the right heart back to the systemic circulation without
exposure to ventilated lung. Normal animals have a small amount of physio-
logic right-to-left shunting. Causes of pathologic right-to-left shunt include alve-
olar collapse (eg, atelectasis), flooding of alveoli with fluid (eg, cardiogenic
and noncardiogenic pulmonary edema, acute respiratory distress syndrome),
alveolar consolidation (eg, pneumonia), and congenital cardiac or vascular
anomalies. Patient with right-to-left shunt have low PaO2 and usually low
PaCO2, although the PaCO2 can be elevated. Because mixed venous blood
is being added to the systemic circulation, the PaO2 fails to increase following
administration of 100% O2.
Further Readings
Dunphy ED, Mann FA, Dodam JR, et al. Comparison of unilateral versus bilateral nasal catheters
for oxygen administration in dogs. J Vet Emerg Crit Care 2002;12(4):245–51.
Johnson RA, de Morais HA. Respiratory acid-base disorders. In: DiBartola SP, editor. Fluid,
electrolyte, and acid-base disorders. 3rd edition. St. Louis (MO): Elsevier; 2006. p. 283–96.