Blood Gas

and
Acid - Base Disturbances
Jesus N. Egargo, MD, MBAHM, FPCP, FPCCP, FCCP, FAPSR
Learning Objectives:
By the end of this session, you will be able to:
> Understand the purpose of requesting Arterial Blood gas.

> Familiarize with the components of Arterial Blood Gas.

> Differentiate the Four (4) Primary acid-base disturbances.

> Interpret Arterial Blood Gases.

> Apply Arterial Blood Gas results to actual patients.

What is an Arterial Blood Gas?
> group of tests that are performed together to measure
the pH, Carbon Dioxide (CO2) , Bicarbonate and the
amount of Oxygen present in a blood sample, usually
from an artery, in order to evaluate the lung function and
help detect an acid-base imbalance that could indicate a
respiratory, metabolic or kidney disorder.
Why do we request Arterial Blood Gas Analysis:
> It provides a precise measurement of the oxygen and carbon dioxide levels in
your body.

> This can help determine how well your lungs and kidneys are working.

> They are typically ordered if someone is having worsening symptoms of a

respiratory problem such as difficulty of breathing or shortness of breath.

> Can also be used to monitor treatment for lung diseases and to evaluate the
effectiveness of supplemental oxygen therapy.

> May also be ordered when someone is known to have metabolic or kidney
disease and is experiencing respiratory distress.
Components/Parameters of Arterial Blood Gas:
1. pH
2. PaCO2 (Partial pressure of carbon dioxide)
3. HCO3 (Bicarbonate)
4. PaO2 (Partial pressure of Oxygen)
5. SaO2 (Oxygen Saturation)
Normal Values of Arterial Blood Gas:
1. pH
7.35 - 7.45
2. PaCO2 (Partial pressure of carbon dioxide)
35 - 45 mmHg
3. HCO3 (Bicarbonate)
22 - 26 meq/L
4. PaO2 (Partial pressure of Oxygen)
80 - 100 mmHg
5. O2 Sat (Oxygen Saturation)
95 - 100%
Maintaining Acid-Base Balance : Buffer Systems
LUNGS (Respiratory System)

> Regulate Carbon Dioxide (CO2)

KIDNEYS (Renal System)

> Regulate Bicarbonate (HCO3)

Buffer Systems:
Respiratory Buffer:

> Carbon dioxide is carried in the blood to the lungs where it combines with water
to form carbonic acid.

> The more carbonic acid present in the blood , the lower the ph level become
(more acidic) ------ in response, the lungs will increase or decrease the rate and
depth of respiration until balance is restored.

> process occurs within 1-3 mins in healthy individual.

Buffer System:
Renal System:

> acts as a buffer through its ability to excrete or retain bicarbonate (HCO3).

> Bicarbonate is considered alkali and takes longer than the respiratory system to
respond.

> as the blood pH decrease (more acidic). The kidneys will compensate by
retaining HCO3, and likewise as the blood pH increases, the kidneys excrete
HCO3.
Normal Values of Arterial Blood Gas:
pH
7.35 - 7.45
ACIDOSIS < (7.40)> ALKALOSIS

PaCO2
35 - 45 mmHg
ALKALOSIS < (40) > ACIDOSIS

HCO3
22 - 26 meq/L
ACIDOSIS < (24) > ALKALOSIS
Primary Acid-Base Disturbances
1. Metabolic Acidosis

2. Metabolic Alkalosis

3. Respiratory Acidosis

4. Respiratory Alkalosis
Primary Acid - Base Disturbances:

METABOLIC ---------------------------------------- HCO3

RESPIRATORY ------------------------------------ PaCO2

Primary Acid-Base Disturbances

pH ( < 7.4 )

METABOLIC ACIDOSIS:

HCO3 ( < 24 meq/L )

Primary Acid-Base Disturbances

pH ( > 7.4 )

METABOLIC ALKALOSIS :

HCO3 ( > 24 meq/L )

Primary Acid-Base Disturbances

pH ( < 7.4 )

RESPIRATORY ACIDOSIS:

PaCO2 ( > 40 mmHg )

Primary Acid-Base Disturbances

pH ( > 7.4 )

RESPIRATORY ALKALOSIS:

PaCO2 ( < 40 meq/L )

Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis
Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis
EXPECTED

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis
Primary Acid-Base Disturbances

pH HCO3 PaCO2
( < 7.40 ) ( < 24 )

Metabolic Acidosis
EXPECTED

Rule of Thumb: Compensatory Response:

1. For every 1 molecule reduction in HCO3 from 24, PCO2 also will decrease by 1 mmHg.
Example : If HCO3 decreases from 24 to 18 mmol/L, PCO2 also decrease by 6 mmHg, hence
expected PCO2 is 34 mmHg.

2. From the pH, value drop the number 7, the last 2 numbers will be expected PCO2.
Example : If the ph is 7.40, the expected PCO2 is 40 mmHg. If the pH is 7.32, the expected
PCO2 is 32 mmHg.
Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis
EXPECTED

Rule of Thumb:

3. Expected PCO2 = (HCO3 X 1.5) + 8 2 (WINTER’S FORMULA)

Expected PCO2 = ( 24 X 1.5) + 8 2 = 44 2

4. Add 15 to HCO3 value to get the expected PCO2

Example : If HCO3 is 20, expected PaCO2 is 35 mmHg
Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis

Metabolic Alkalosis
EXPECTED

Respiratory Acidosis

Respiratory Alkalosis
Primary Acid-Base Disturbances

pH HCO3 PaCO2
( > 7.4 ) ( > 24 )

Metabolic Alkalosis
EXPECTED

1. PaCO2 increases by 0.7 - 0.75 mmHg for every 1meq/L increase in HCO3.

2. Expected PaCO2 between the concentrations of HCO3 from 10-40 mmmol/L can be
calculated using the simple formula:
PaCO2 = HCO3 + 15
Example : If HCO3 is 40, the expected PaCO2 = 55
Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis
Primary Acid-Base Disturbances
pH HCO3 PaCO2
( < 7.4 ) ( > 40 )

Respiratory Acidosis
EXPECTED

Expected Changes:
1. Rise in HCO3 :
Acute Respiratory Acidosis ----------- 1 meq/L for each 10 mmHg rise in PaCO2..
Chronic Respiratory Acidosis -------- 3.5 - 4 meq/L for each 10 mmHg rise in PaCO2.

2. Fall in pH
Acute Respiratory Acidosis ----------- 0.008 X ( PaCO2 - 40 )
Chronic Respiratory Acidosis -------- 0.003 X ( PaCO2 - 40 )
Primary Acid-Base Disturbances
Acute Respiratory Acidosis
(1meq/L increase in HCO3 for every 10 mmHg increase in PaCO2

HCO3 HCO3 HCO3

same as expected more then expected less than expected

Simple Coexisting Coexisting

Respiratory Acidosis Metabolic Alkalosis Metabolic Acidosis
Primary Acid-Base Disturbances
Chronic Respiratory Acidosis
(3.5 - 4 meq/L increase in HCO3 for every 10 mmHg increase in PaCO2

HCO3 HCO3 HCO3

same as expected more than expected less than expected

Simple Coexisting Coexisting

Respiratory Acidosis Metabolic Alkalosis Metabolic Acidosis
Primary Acid-Base Disturbances
pH HCO3 PaCO2

Metabolic Acidosis

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis
Primary Acid-Base Disturbances
pH HCO3 PaCO2
( > 7.4 ) ( < 40 )

Respiratory Alkalosis
EXPECTED

Expected Changes:
1. Fall in HCO3
Acute Respiratory Alkalosis -------------- 2 mmol/L for each 10 mmHg fall in PaCO2
Chronic Respiratory Alkalosis ------------ 4 mmol/L for each 10 mmHg fall in PaCO2

2. Rise in pH
Acute Respiratory Alkalosis ------------- 0.008 X ( 40 - PaCO2 )
Chronic Respiratory Alkalosis ----------- 0.017 X ( 40 - PaCO2)
Primary Acid-Base Disturbances
Acute Respiratory Alkalosis
(2 meq/L reduction in HCO3 for every 10 mmHg decrease in PaCO2

HCO3 HCO3 HCO3

same as expected more than expected less than expected

Simple Coexisting Coexisting

Respiratory Alkalosis Metabolic Alkalosis Metabolic Acidosis
Primary Acid-Base Disturbances
Chronic Respiratory Alkalosis
(4 meq/L reduction in HCO3 for every 10 mmHg decrease in PaCO2

HCO3 HCO3 HCO3

same as expected more than expected less than expected

Simple Coexisting Coexisting

Respiratory Alkalosis Metabolic Alkalosis Metabolic Acidosis
Normal Values of Arterial Blood Gas:
1. pH
7.35 - 7.45
2. PaCO2 (Partial pressure of carbon dioxide)
35 - 45 mmHg
3. HCO3 (Bicarbonate)
22 - 26 meq/L
4. PaO2 (Partial pressure of Oxygen)
80 - 100 mmHg
5. O2 Sat (Oxygen Saturation)
95 - 100%
Oxygenation (PaO2) :

Level of PaO2

> 100 mmHg More than adequate Oxygenation

80m - 100 mmHg NORMAL

70 - 79 mmHg Mild Hypoxemia

60 - 69 mmHg Moderate Hypoxemia

< 60 mmHg Severe Hypoxemia

Basic Steps in ABG Analysis
Basic Steps in ABG Analysis:
1. Analyze the pH.
2. Analyze the PaCO2.
3. Analyze the HCO3.
4. Match either the PaCO2 or the HCO3 with the pH.
5. Determine for Compensation.
6. Analyze the PaO2 and SaO2.
Basic Steps in ABG Analysis:
1. Analyze the pH
If the pH is less than 7.4 ----- The patient is ACIDOTIC

If the pH is more than 7.4 ----- The patient is ALKALOTIC

Basic Steps in ABG Analysis:
2. Analyze the PaCO2
If the PaCO2 is less than 40 ----- The patient is ALKALOTIC

If the PaCO2 is more than 40 ---- The patient is ACIDOTIC

Basic Steps in ABG Analysis:
3. Analyze the HCO3
If the HCO3 is less than 24 ----- The patient is ACIDOTIC

If the HCOE is more than 24 --- The patient is ALKALOTIC

Basic Steps in ABG Analysis:

pH HCO3 PaCO2

ACIDOTIC

ALKALOTIC
Basic Steps in ABG Analysis:

4. Match either the PaCO2 or the HCO3 with the pH:

pH HCO3 PaCO2

ACIDOTIC

ALKALOTIC
Basic Steps in ABG Analysis:
5. Determine for Compensation
> Compensation is the ability of of one system to attempt to balance the pH
when the other system is causing an imbalance.

> For example, when the respiratory system (PaCO2) becomes acidotic, the
metabolic system (HCO3) will become alkalotic to attempt to bring the pH
back to normal.

> Categories of Compensation:

> UNCOMPENSATED
> PARTIALLY COMPENSATED
> FULLY COMPENSATED
 Basic Steps in ABG Analysis : COMPENSATION
METABOLIC ACIDOSIS
pH HCO3 PaCO2

Uncompensated NORMAL
Partially
Compensated
Fully
Compensated Normal
 Basic Steps in ABG Analysis : COMPENSATION
METABOLIC ALKALOSIS
pH HCO3 PaCO2

Uncompensated NORMAL
Partially
Compensated
Fully
Compensated Normal
 Basic Steps in ABG Analysis : COMPENSATION
RESPIRATORY ACIDOSIS
pH HCO3 PaCO2

Uncompensated
Normal
Partially
Compensated
Fully
Compensated Normal
 Basic Steps in ABG Analysis : COMPENSATION
RESPIRATORY ALKALOSIS
pH HCO3 PaCO2

Uncompensated
Normal
Partially
Compensated
Fully
Compensated Normal
Basic Steps in ABG Analysis : Oxygenation
6. Analyze the PaO@ and SaO2 for Hypoxemia
Level of PaO2

> 100 mmHg More than adequate Oxygenation

80m - 100 mmHg NORMAL

70 - 79 mmHg Mild Hypoxemia

60 - 69 mmHg Moderate Hypoxemia

< 60 mmHg Severe Hypoxemia

Primary Acid-Base Disturbances
EXAMPLES

1. pH 7.28

PaCO2 56 mmHg

HCO3 25 meq/L

pO2 70 mmHg

SaO2 91%
Primary Acid-Base Disturbances
EXAMPLES

1. pH 7.28

PaCO2 56 mmHg

HCO3 25 meq/L

pO2 70 mmHg

SaO2 91%

UNCOMPENSATED RESPIRATORY ACIDOSIS WITH MILD HYPOXEMIA

Primary Acid-Base Disturbances
EXAMPLES

2. pH 7. 5

PaCO2 36 mmHg

HCO3 27 meq/L

pO2 92 mmHg

SaO2 97%
Primary Acid-Base Disturbances
EXAMPLES

2. pH 7. 5

PaCO2 36 mmHg

HCO3 27 meq/L

pO2 92 mmHg

SaO2 97%

UNCOMPENSATED METABOLIC ALKALOSIS WITH NORMAL OXYGENATION

Primary Acid-Base Disturbances
EXAMPLES

3. pH 7.37

PaCO2 66 mmHg

HCO3 37 meq/L

pO2 65 mmHg

SaO2 91%
Primary Acid-Base Disturbances
EXAMPLES

3. pH 7.37

PaCO2 66 mmHg

HCO3 37 meq/L

pO2 65 mmHg

SaO2 91%

FULLY COMPENSATED RESPIRATORY ACIDOSIS WITH MODERATE

HYPOXEMIA
THANK YOU