Last edited: 8/31/2021

2. RESPIRATORY ACIDOSIS
Respiratory Acidosis Medical Editor: Jan Camille Santico

OUTLINE III) PATHOPHYSIOLOGY OF RESPIRATORY ACIDOSIS

I) INTERPRETING THE ABG In respiratory acidosis, the carbon dioxide level in the
II) PHYSIOLOGY OF RESPIRATORY ACIDOSIS blood is increased/increasing
III) PATHOPHYSIOLOGY OF RESPIRATORY o Recall: CO2 + H2O ↔ H2CO3 ↔ H+ + HCO2
ACIDOSIS o According to Le Chatelier’s principle, when a
IV) DIFFERENTIALS reactant/substrate is in excess, the reaction will shift
V) EFFECT OF HYPOXIA to the opposite side to maintain equilibrium
VI) TREATMENT o When there is excess CO2, the reaction will shift to
VII) REVIEW QUESTIONS the right, causing an increase in protons (H+), which
VIII) REFRENCES consequently lowers the pH and leads to acidosis
Thus, in respiratory acidosis, there is deficient clearance
of carbon dioxide and deficient oxygen intake/exchange

I) INTERPRETING THE ABG Summary

Table 1. Sample ABG Case The respiratory centers send signals via the phrenic nerve
ABG Result Normal Values and intercostal nerves to stimulate the diaphragm and
pH 7.29 7.35 – 7.45 external intercostals to contract, respectively
The contraction of these muscles will help take in oxygen
pCO2 58 mmHg 35 – 45 during inhalation; during exhalation, healthy lungs will
HCO3 22 mEq/L 22 – 26 collapse and recoil to expel carbon dioxide
pO2 50 mmHg >90 A patient with respiratory acidosis must have a problem with
Note: Please refer to the lecture video on “Acid Base Disorders and ABG
carbon dioxide clearance, oxygen intake, or gas exchange.
Interpretation” to understand this section better.

The pH is acidic, meaning there is acidemia and IV) DIFFERENTIALS

underlying acidosis.
To determine if it is a metabolic or respiratory acidosis, This section gives an overview of the possible
check the HCO3 and pCO2 causes/differentials of respiratory acidosis, arranged
o If the HCO3 is going in the same direction as the pH= anatomically.
Metabolic
(A) RESPIRATORY CENTER
o If the pCO2 is going in the opposite direction as the
pH= Respiratory (1) Lesions in the Respiratory Center
Since the pCO2 is going in the opposite direction, the Possible causes
patient has respiratory acidosis. o Tumor
o In respiratory acidosis, the bicarbonate is expected to o Infection (e.g. encephalitis)
increase to compensate and to make the environment o Traumatic brain injury
more alkalotic; however, in this case, since the
Diagnosis/Work-up
bicarbonate falls within the normal range, this is
o Order cranial imaging (e.g. CT, MRI) to check for lesions
uncompensated respiratory acidosis
o Order a lumbar puncture to check for a CNS infection
The oxygen saturation is low, so there is hypoxia
(2) Drugs
Table 2. Oxygen Saturation Values There are drugs which can depress the medulla and thus
Oxygen Saturation Interpretation the respiratory centers
80 - 100 Normal o Opioids
o Benzodiazepines
60 - 80 Mild Hypoxia
o Barbiturates
40 - 60 Moderate Hypoxia
Diagnosis/Work-up
<40 Severe Hypoxia
o Order a tox screen
o Order a urine drug screen
• For subheading use style “Heading 5”
II) PHYSIOLOGY OF RESPIRATORY ACIDOSIS
(3) Decreased metabolic activity
In the medulla, there is a ventral and dorsal respiratory
group, which function as respiratory centers that There are certain conditions which decrease the
regulate our rate and depth of breathing. metabolic activity of neurons
When the neurons of these respiratory centers fire, they o Hypothyroidism
send signals to the lower motor neurons in the spinal  Pathophysiology: decreased production of T3 and T4 
cord decreased basal metabolic rate  decreased firing of
The action potentials then travel through the peripheral neurons in the respiratory center
nerves that innervate the muscles for breathing  Diagnosis: Check TSH and T3/T4 levels
o Diaphragm • In hypothyroidism, expect high TSH and low
o External intercostals T3/T4 levels
o Hypothermia
When these muscles contract, they help pull oxygen in  Pathophysiology: increased body temperature
the lungs and blow carbon dioxide out  Diagnosis: Check core temperature

Respiratory Acidosis RENAL PATHOLOGY: NOTE #2. . 1 of 4

 (B) SPINAL CORD AND PERIPHERAL NERVES (D) LUNGS
(1) Anterior Grey Horn (1) Airway Obstruction
A lesion in the anterior grey horn of the spinal cord might Airway obstruction can interfere with proper oxygen
interfere with the transmission of action potentials from intake and carbon dioxide clearance
the respiratory centers to the muscles for breathing Possible causes of obstruction include:
Possible lesions include: o Mucus plugging
o Amyotrophic Lateral Sclerosis (ALS) o Collapsing of airway due to loss of elasticity
 Diagnosis: signs of upper motor neuron (UMN) o Foreign body aspiration
and lower motor neuron (LMN) lesions Obstruction may occur in the lower or upper airways
o Poliomyelitis
 Diagnosis: No polio vaccine, muscle weakness (i) Lower Airway
o Transverse myelitis
• Common cause: Chronic Obstructive
 Diagnosis: History of fever, muscle pain
Pulmonary Disease (COPD)
 Work-up: Order a lumbar puncture
• History: smoking
(2) Myelin Sheath • Diagnosis/Work-up
Demyelination of peripheral nerves can interfere with the o Abnormal pulmonary function test
transmission of action potentials and thus affect the o Hyperinflated lungs in chest X-ray
muscles for breathing o Barrel-chested appearance
Guillain-Barré Syndrome (GBS) o Cough with mucus
o Pathophysiology: presence of autoantibodies (ii) Upper Airway
attacking the myelin sheath
o Diagnosis: history of previous gastrointestinal (GI) or • Possible causes:
upper respiratory tract (URT) infections o Foreign body aspiration
o Classic sign: symmetric ascending paralysis  Young children who choke on small
o Work-up: Order a lumbar puncture; look for albumin- objects
cytological dissociation  Diagnosis: Laryngoscopy,
bronchoscopy
(3) Neuromuscular Junction (NMJ) o Laryngeal edema
Recall: Acetylcholine (Ach) is released by the peripheral  Causes:
nerves (in the NMJ, and this neurotransmitter binds to • generalized angioedema due to
nicotinic receptors on the muscle cells medication
Myasthenia Gravis • mechanical ventilation
o Pathophysiology: autoantibodies attack the nicotinic
(2) Fluid in the Airway
receptors, interfering with muscle contraction
o Diagnosis The presence of fluid/pus/secretions in the airway
 History/presence of thymoma interferes with proper gas exchange, leading to hypoxia
 Bulbar weakness Possible causes:
• Double vision o Pneumonia
• Eyelid drooping o Acute Respiratory Distress Syndrome (ARDS)
• Facial weakness o Pulmonary edema
 Muscle weakness that is worse as the day passes  Fluid/secretions between the lung space (alveoli)
o Work-up: Check Ach receptor antibodies and capillaries
o Pulmonary embolism
(C) MUSCLES  A blood clot enters and obstructs a pulmonary
Muscle exhaustion/fatigue is one of the most common vessel, causing failure of gas exchange
causes of respiratory acidosis
o Due to increased work of breathing from underlying
respiratory problems
Polymyositis and dermatomyositis are less likely causes
o Diagnosis: muscle biopsy

2 of 4 RENAL PATHOLOGY: NOTE #2. Respiratory Acidosis

 Figure 1. Differentials for Respiratory Acidosis

V) EFFECT OF HYPOXIA IV immunoglobulin

GBS Plasma exchange
When there is less oxygen in the bloodstream, there is (PLEX)
hypoxia NERVES
Chemoreceptors detect the increased carbon dioxide in Myasthenia IV immunoglobulin
the body, sending signals to the respiratory centers gravis PLEX
The respiratory centers will then direct your body to Steroids
increase respiratory rate and depth Non-invasive positive
o Breathing faster and deeper pressure ventilation
Respiratory (NPPV)
The increased breathing rate will expel more carbon MUSCLES
muscle fatigue Mechanical ventilation
dioxide, which initially leads to respiratory alkalosis
(e.g. endotracheal
However, if the increased respiratory rate is sustained
tube)
over a long time, the respiratory muscles will eventually
fatigue, leading to decreased respiratory rate and depth Inhaled
The decreased respiratory rate and depth leads to the corticosteroids
reduced clearance of carbon dioxide and acidic pH COPD Duoneb
Oral/IV steroids (in
acute exacerbations)
NPPV
LUNGS
Laryngeal Steroids
edema Benadryl
VI) TREATMENT (antihistamines)
The approach to treating respiratory acidosis is to treat Foreign body Remove foreign body
the underlying cause aspiration
Pneumonia Antibiotics
Support respiratory
Table 3. Treatments for Respiratory Acidosis
ARDS system via positive
Organ Differential Treatment pressure ventilation
Resect the tumor Pulmonary Diuretics to decrease
Tumor Steroids to decrease edema (due to fluid
vasogenic edema heart failure)
Infection Antibiotics or antivirals Heparin drip
Dependent on nature of Pulmonary Tissue plasminogen
Trauma activator
trauma embolism
Opioid Naloxone Embolectomy to
MEDULLA remove the clot
overdose
Benzodiazepine Flumazenil While treating the underlying cause, it is also important to
overdose support the airway of the patient. The empirical
Barbiturate Sodium bicarbonate approaches for this are:
overdose o NIPPV
 High flow nasal cannula
Hypothyroidism Levothyroxine
 Bilevel Positive Airway Pressure (BiPAP)
Hypothermia Warm the patient o Mechanical Ventilation (invasive)

Respiratory Acidosis RENAL PATHOLOGY: NOTE #2. . 3 of 4

 VII) REVIEW QUESTIONS

Given the following ABG results, determine if the

acidosis is respiratory or metabolic.

ABG Result
pH 7.31
pCO2 35 mmHg
HCO3 14 mEq/L
pO2 75 mmHg

a. Respiratory
b. Metabolic

Given the following ABG results, determine if the

acidosis is respiratory or metabolic.
ABG Result
pH 7.31
pCO2 50 mmHg
HCO3 28 mEq/L
pO2 75 mmHg

a. Respiratory
b. Metabolic

In a patient with opioid overdose, which is the most

likely culprit for respiratory acidosis?
a. Lesion in the medulla
b. Depressed respiratory center
c. Demyelination of peripheral nerves
d. Generation of autoantibodies

Which of the following pathophysiologic

mechanisms lead to respiratory acidosis?
a. Impaired clearance of carbon dioxide
b. Impaired gas exchange
c. Both A and B
d. None of the above

Which of the following is supportive treatment for

patients with respiratory acidosis?
a. Ice packs
b. Antihistamines
c. BiPAP
d. None of the above

CHECK YOUR ANSWERS

VIII) REFRENCES

4 of 4 RENAL PATHOLOGY: NOTE #2. Respiratory Acidosis