Chapter 5

 Oxygenation Assessments

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 Oxygen Transport Review
Oxygen is carried in the blood in two ways:
1. As dissolved oxygen in the blood plasma
2. Bound to the hemoglobin (Hb)
 Most oxygen is carried to the tissue cell bound to
the hemoglobin.

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 Oxygen Dissolved in the Blood
Plasma
 At normal body temperature, about 0.003 mL
of oxygen (O2) will dissolve in each 100 mL of
blood for every 1 mm Hg of PO2.
 Thus when the PaO2 is 100 mm Hg, about
0.3 mL of dissolved O2 exists in every 100 mL
of plasma: 0.003 × 100 mm Hg = 0.3 mL
 Clinically, written as 0.3 volume percent (vol
%)
 0.3 vol% O2

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 Oxygen Bound to Hemoglobin
 Hb value in normal man: 14 to 16 g/100 mL
 Hb value in normal woman: 12 to 15 g/100
mL
 Clinically, the weight measurement of
hemoglobin, in reference to 100 mL of blood,
is known as the grams percent hemoglobin (g
% Hb)

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 Oxygen Bound to Hemoglobin
(Cont’d)
 Each g% Hb can carry 1.34 mL of O2
 Thus if the Hb level is 12 g% and if the Hb is
fully saturated, about 15.72 vol% of O2 will be
bound to the Hb:
O2 bound to Hb = 1.34 mL O2 × 12 g% Hb
= 15.72 vol% O2

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 Oxygen Bound to Hemoglobin
(Cont’d)
 At a normal PaO2 of 100 mm Hg, however,
the Hb saturation (SaO2) is only about 97%
because of these normal physiologic shunts:
 Thebesian venous drainage into the left atrium
 Bronchial venous drainage into the pulmonary
veins

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 Oxygen Bound to Hemoglobin
(Cont’d)
Thus the amount of arterial oxygen in the
calculation must be adjusted to 97%:
15.72 vol% O2
× .97
15.24 vol% O2

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 Total Oxygen Content
 To calculate the total amount of oxygen in
100 mL of blood, the following must be added
together:
 Dissolved oxygen
 Oxygen bound to hemoglobin

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 Case Example
A 44-year-old woman with a long history of
asthma arrives in the emergency room in
severe respiratory distress. Her vital signs
are respiratory rate 36 breaths/min, heart rate
130 bpm, and blood pressure 160/95 mm Hg.
Her hemoglobin concentration is 10 g%, and
her PaO2 is 55 mm Hg (SaO2 85%). Based on
these data, the patient’s total oxygen content is
determined on the next slide:

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1. Dissolved O2
55 PaO2
× 0.003 (dissolved O2 factor)
0.165 vol% O2

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2. Oxygen Bound to Hemoglobin
10 g% Hb
× 1.34 (O2 bound to Hb factor)
13.4 vol% O2 (at SaO2 of 100%)

Above answer is then followed by the SaO2

factor:
13.4 vol% O2
× .85 SaO2
11.39 vol% O2 (at SaO2 of 85%)

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3. Total Oxygen Content.
11.39 vol% O2 (bound to hemoglobin)
+ 0.165 vol% O2 (dissolved O2)
11.555 vol% O2 (total amount of O2/100 mL of blood)

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 Total Oxygen Content (Cont’d)
The total oxygen content can be calculated in
the patient’s:
 Arterial blood (CaO )
2
 Venous blood (CvO )
2
 Pulmonary capillary blood (CcO )
2

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 Total Oxygen Content (Cont’d)
CaO2 = Oxygen content of arterial blood
(Hb × 1.34 × SaO2) + (PaO2 × 0.003)

CvO2 = Oxygen content of mixed venous blood

(Hb × 1.34 × SvO2) + (PvO2 × 0.003)

CcO2 = Oxygen content of pulmonary capillary

blood
(Hb × 1.34) + (PAO2 × 0.003)

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 Oxygenation Indices
 Oxygen tension–based indices
 Oxygen saturation and content indices

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Oxygen Tension–Based Indices
 Arterial oxygen tension (PaO2)
 Alveolar-arterial oxygen tension difference
(P[A-a]O2)

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Arterial Oxygen Tension (PaO2)
 Good indicator of the patient’s oxygenation
status
 The PaO2, however, may be misleading in
these clinical situations:
 Low Hb
 Decreased cardiac output
 Peripheral shunting
 Carbon monoxide and cyanide exposure

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 Alveolar-Arterial Oxygen Tension
Difference (P[A-a]O2)
 The P(A-a)O2 is the oxygen tension difference
between the alveoli and arterial blood.

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 Alveolar-Arterial Oxygen Tension
Difference (P[A-a]O2) (Cont’d)
PAO2 = FIO2 (PB − PH2O) − PaCO2 (1.25)

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 Case Study Example
If a patient is receiving an FIO2 of 0.30 on a day
when the barometric pressure is 750 mm Hg,
and if the patient’s PaCO2 is 70 mm Hg and
PaO2 is 60 mm Hg, the P(A-a)O2 can be
calculated as shown on the next slide:

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Case Study Example (Cont’d)
PAO2 = FIO2 (PB − PH2O) − PaCO2 (1.25)
= 0.30 (750 − 47) − 70 (1.25)
= (703) 0.30 − 87.5
= (210.9) − 87.5
= 123.4 mm Hg

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Case Study Example (Cont’d)
Using the PaO2 obtained from the ABG:
123.4 (PAO2)
− 60.0 (PaO2)
63.4 mm Hg [P(A-a)O2]

The normal P(A-a)O2 ranges from 7 to 15 mm Hg and

should not exceed 30 mm Hg.

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 P(A-a)O2 Increases
 Oxygen diffusion disorders
 Decreased V/Q ratios
 Right-to-left cardiac shunting
 Age

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 Note: The P(A-a)O2
Loses sensitivity in patients breathing high FIO2

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Oxygen Saturation– and
Content–Based Indices

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Oxygen Saturation– and Content–Based
Indices
 CaO2 = (Hb × 1.34 × SaO2) + (PaO2 × 0.003)

 CvO2 = (Hb × 1.34 × SvO2) + (PvO2 × 0.003)

 CcO2 = (Hb × 1.34) + (PAO2 × 0.003)

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Most Common Oxygen Saturation–and
Content–Based Indices
 Total oxygen delivery
 Arterial-venous oxygen content difference
 Oxygen consumption
 Oxygen extraction ratio
 Mixed venous oxygen saturation
 Pulmonary shunting

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 Total Oxygen Delivery
DO2 = QT × (CaO2 × 10)
The total oxygen delivery is the amount of
oxygen delivered to the peripheral tissue cells.

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 Total Oxygen Delivery
DO2 = QT × (CaO2 × 10) (Cont’d)
For example, if a patient has a cardiac output of
4 L/min and a CaO2 of 15 vol%, the DO2 is 600
mL of oxygen per minute—as calculated on the
next slide:

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Total Oxygen Delivery
DO2 = QT × (CaO2 × 10)
= 4 L/min × (15 vol% × 10)
= 600 mL O2 per minute

Normally, about 1000 mL/min

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Total Oxygen Delivery (Cont’d)
Decreases:
 Low PaO
2
 Low SaO
2
 Low Hb
 Low cardiac output

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Total Oxygen Delivery (Cont’d)
Increases:
 Increased PaO
2
 Increased SaO
2
 Increased Hb
 Increased cardiac output

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 Arterial-Venous Oxygen Content
Difference
C(a-v)O2 = CaO2 − CvO2
The arterial-venous oxygen content difference
(C[a-v]O2) is the difference between the CaO2
and the CvO2—that is, CaO2 − CvO2.

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 Arterial-Venous Oxygen Content
Difference
C(a-v)O2 = CaO2 − CvO2 (Cont’d)
For example, if a patient’s CaO2 is 15 vol% and
the CvO2 is 8 vol%, the C(a-v)O2 is 7 vol%—as
calculated on the next slide:

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 Arterial-Venous Oxygen
Content Difference
C(a-v)O2 = CaO2 − CvO2
= 15 vol% − 8 vol%
= 7 vol%

Normally, 5 vol%

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 Arterial-Venous Oxygen
Content Difference (Cont’d)
Increases:
 Decreased cardiac output
 Exercise
 Seizures
 Hyperthermia

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 Arterial-Venous Oxygen
Content Difference (Cont’d)
Decreases:
 Increased cardiac output
 Skeletal relaxation
 Peripheral shunting
 Cyanide
 Hypothermia

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 Oxygen Consumption
VO2 = QT [C(a-v)O2] × 10
Oxygen (VO2) consumption is the amount of
oxygen consumed by the peripheral tissue cells
during a 1-minute period.

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 Oxygen Consumption
VO2 = QT [C(a-v)O2] × 10 (Cont’d)
For example, if a patient has a cardiac output of
4 L/min and a C(a-v)O2 of 6 vol%, the total
amount of oxygen consumed by the tissue cells
in 1 minute would be 240 mL—as calculated on
the next slide:

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Oxygen Consumption
VO2 = QT [C(a-v)O2] × 10
= 4 L/min × 6 vol% × 10
= 240 mL O2/min

Normal is 250 mL O2/min

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Oxygen Consumption (Cont’d)
Increases:
 Seizures
 Exercise
 Hyperthermia
 Body size

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Oxygen Consumption (Cont’d)
Decreases:
 Skeletal muscle relaxation
 Peripheral shunting
 Certain poisons (e.g., cyanide)
 Hypothermia

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 Oxygen Extraction Ratio
O2ER = CaO2 − CvO2
CaO2
The O2ER is the amount of oxygen consumed
by the tissue cells divided by the total amount of
oxygen delivered.

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 Oxygen Extraction Ratio
O2ER = CaO2 − CvO2
CaO2 (Cont’d)
For example, if a patient’s CaO2 is 15 vol% and
the CvO2 is 10 vol%, the O2ER would be 33%—
as calculated on the next slide:

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Oxygen Extraction Ratio
O2ER = CaO2 − CvO2
CaO2
= 15 vol% − 10 vol%
15 vol%
= 5 vol%
15 vol%
= 0.33
Normal is 0.25%

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Oxygen Extraction Ratio (Cont’d)
Increases:
 Decreased cardiac output

 Periods of increased O consumption

2
 Exercise, seizures, hyperthermia
 Anemia
 Decreased arterial oxygenation
 ↓ Hb, ↓ PaO2

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Oxygen Extraction Ratio (Cont’d)
Decreases:
 Increased cardiac output

 Skeletal muscle relaxation

 Peripheral shunting
 Certain poisons (e.g., cyanide)
 Hypothermia
 Increased arterial oxygenation

 ↑ Hb, ↑ PaO2

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Mixed Venous Oxygen Saturation
SvO2
Signals changes in the:
 C(a-v)O
2
 VO
2
 O ER
2

Normally about 75%

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Mixed Venous Oxygen Saturation
SvO2 (Cont’d)
Decreases:
 Decreased cardiac output
 Exercise
 Seizures
 Hyperthermia

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Mixed Venous Oxygen Saturation
SvO2 (Cont’d)
Increases:
 Increased cardiac output
 Skeletal muscle relaxation
 Peripheral shunting
 Certain poisons (e.g., cyanide)
 Hypothermia

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Pulmonary Shunt Faction
Qs = CcO2 − CaO2
QT CcO2 − CvO2

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 Alveolus

Ventilated
Alveolus
Oxygenated
Pulmonary capillary
blood

Nonoxygenated
blood

Normal alveolar-capillary unit.

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 Alveolus

Ventilated
Alveolus
Oxygenated
Pulmonary capillary
blood

Nonoxygenated
blood Anatomic
shunt

Anatomic shunt.
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 Alveolus

Collapsed Alveolus
or
Consolidated or
Nonoxygenated
Pulmonary capillary Fluid-Filled blood
Alveolus

Nonoxygenated
blood

Types of capillary shunts.

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 Alveolus

Alveolus with
Decreased Ventilation
or
Nonoxygenated
Pulmonary capillary Alveolus with a blood
Diffusion Defect

Nonoxygenated
blood

Types of relative or shuntlike effects.

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 Pulmonary Shunting
Need following information:
 Barometric pressure

 PaO
2
 PaCO
2
 PvO
2
 Hb concentration

 PAO (partial pressure of alveolar oxygen)

2
 FIO
2

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 Case Example:
Automobile Accident Victim
A 22-year-old man is on a volume-cycled
mechanical ventilator on a day when the
barometric pressure is 755 mm Hg. The patient
is receiving an FIO2 of 0.60. The following
clinical data are obtained:
 Hb: 15 g/dL

 PaO : 65 mm Hg (SaO = 90%)

2 2
 PaCO : 56 mm Hg
2
 PvO : 35 mm Hg (SvO = 65%)
2 2

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 Case Example:
Automobile Accident Victim (Cont’d)
With this information the following
can now be calculated:
 PAO
2
 CcO
2
 CaO
2
 CvO
2

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 Case Example:
Automobile Accident Victim (Cont’d)
PAO2 = (PB − PH2O) FIO2 − PaCO2 (1.25)
= (755 − 47) 0.60 − 56 (1.25)
= (708) 0.60 − 70
= 424.8 − 70
= 354.8

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 Case Example:
Automobile Accident Victim (Cont’d)
CcO2 = (Hb × 1.34) + (PAO2 × 0.003)
= (15 × 1.34) + (354.8 × 0.003)
= 20.1 + 1.064
= 21.164 (vol% O2)

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 Case Example:
Automobile Accident Victim (Cont’d)
CaO2 = (Hb × 1.34 × SaO2) + (PaO2 × 0.003)
= (15 × 1.34 × 0.90) + (65 × 0.003)
= 18.09 + 0.195
= 18.285 (vol% O2)

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 Case Example:
Automobile Accident Victim (Cont’d)
CvO2 = (Hb × 1.34 × SvO2) + (PvO2 × 0.003)
= (15 × 1.34 × 0.65) + (35 × 0.003)
= 13.065 + 0.105
= 13.17 (vol% O2)

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 Case Example:
Automobile Accident Victim (Cont’d)
QS = CcO2 − CaO
QT CcO2 − CvO2
= 21.164 − 18.285
21.164 − 13.17
= 2.879
7.994
= 0.36

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Table 5-2. Clinical Significance of Pulmonary Shunting

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Table 5-3. Oxygenation Index Changes Commonly Seen in Respiratory Diseases

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 Hypoxemia
 Hypoxemia refers to an abnormally low
arterial oxygen tension (PaO2) and is
frequently associated with hypoxia.
 Although hypoxemia may suggest tissue
hypoxia, it does not necessary mean the
absolute existence of tissue hypoxia.
 For example, a low arterial oxygen level may be
offset by an increased cardiac output.

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 Table 5-4. Hypoxemia Classifications*

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 Hypoxia
 Hypoxia refers to low or inadequate oxygen
for aerobic cellular metabolism.

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 Table 5-5. Types of Hypoxia

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 Cor Pulmonale
 The term used to denote:
 Pulmonary arterial hypertension
 Right hypertrophy
 Increased right ventricular work
 Right ventricular failure

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 Cor Pulmonale (Cont’d)
 Three major causes:
 Increased viscosity of blood (polycythemia)
 Increased vascular resistance
• Caused by hypoxic vasoconstriction
 Obliteration of the pulmonary capillary bed

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 Polycythemia
 Increased red blood cell level

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 Hypoxic Vasoconstriction
of the Lungs
 Caused by decreased PAO2
 Generalized pulmonary vasoconstriction
combined with polycythemia leads to:
 Cor pulmonale
 Distended neck veins
 Peripheral edema and pitting edema

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Pitting edema. (From Bloom A, Ireland J: Color atlas of diabetes, ed 2,
London, 1992, Mosby-Wolfe.)

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 Distended
Neck Veins

Distended neck veins (arrows).

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