Clinical Interpretation of

Arterial Blood Gas and

Oxygenation

JOHN ARIEL ANTILLON, RT

Faculty College of RT
CPU
Anatomy
 Upper respiratory tract
 Lower respiratory tract
trachea
bronchi
bronchioles
alveoli
Anatomy of Respiratory Tract
(Bronchopulmonary segments)

 Right lung  Left lung

 Upper lobe  Upper
 Apical  Apico-posterior
 Posterior  Anterior
 Anterior
 Superior lingula
 Middle lobe
 Lateral
 Inferior lingula
 Medial  Lower
 Lower lobe  Superior
 Superior  Antero-medial
 Medial  Lateral
 Anterior
 Lateral
 Posterior
 Posterior
 Chest Wall

Ventilatory Organs (Thoracic Pump)

Gas Exchange Organs
Clinical manifestation of respiratory
diseases
 Dyspnea
 Cough
 Chest pain
 hemoptysis
Laboratory tests:
 Sputum analysis
 Culture & sensitivity
 Arterial Blood Gas
(ABG)
 Sputum cytology
Arterial Blood Gas (ABG)

 Specimen:
 Arterial blood
 “arterialized” capillary blood
 Materials:
 cotton balls (wet), rubber stopper
 syringe
 heparin ( 0.5ml of 1000-U/ml per 5ml blood)
 ice for transport
Factors affecting levels of Arterial Blood Gases

 Exposure to ambient atmosphere (or air

bubble)
 Temperature (gas pressures & pH)
 Excess heparin (lower pCO2 by 12-25%)
 Transport on ice
 Stable for 30 minutes
Reference values:
Blood Gases & Electrolytes

 Arterial
 Venous
 Na: 135-148 mEq/liter
 pH: 7.35-7.45 mmHg
 K: 3.5-5.3
 pCO2: 35-45  Cl: 98-106
 pO2: 80-100  Anion gap: 12-18
 O2 sat: 95% of pO2  Serum osmolality:
 HCO3: 22-26 285-310 mOsm/kg H20
Take note:

 Measure ABG at 37C

 For each degree (C) increase in temp.
 pO2 falls by 7%
 pCO2 rise by 3%
SUMMARY ALGORITHM FOR ACID-BASE INTERPRETATION

pH

< 7.35 7.35 – 7.45 > 7.45

ACIDOSIS NORMAL ALKALOSIS

or
COMPENSATED
Uncompensated Uncompensated
35 - 45 PaCO2 PaCO2 35 - 45
Metabolic Acidosis pH Metabolic Alkalosis
< 35 > 45
Partly Compensated < 7.4 > 7.4 Partly Compensated
Metabolic Acidosis Metabolic Alkalosis
> 45 < 35
Normal or Normal or
Compensated Compensated
Respiratory Acidosis Alkalosis Respiratory

Compensated PaCO2
22 - 26 HCO3 Compensated HCO3 22 - 26
Metabolic Respiratory
Acidosis < 35 Alkalosis
> 26 < 22 > 26 < 22
Uncompensated Compensated Compensated Uncompensated
Respiratory Acidosis > 45 Respiratory Alkalosis
Respiratory Metabolic
Acidosis Alkalosis
Partly Compensated Combined 35 - 45 Combined Partly Compensated
Respiratory Acidosis Respiratory and Respiratory and Respiratory Alkalosis
Metabolic Metabolic
Acidosis Normal Acid-Base Alkalosis
HENDERSON-HASSELBACH

Base
pH = pk + log ------------
Acid
 HCO3
(Met. 22-26)
pH = (6.1) + log ----------------
(7.35-7.45) PaCO2
(Resp. 35-45)

HCO3
pH = -----
PaCO2
 HCO3 HCO3
pH = ------ pH = ------
PaCO2 PaCO2

Metabolic Acidosis Respiratory Acidosis

HCO3 HCO3
pH = ------ pH = ------
PaCO2 PaCO2

Metabolic Alkalosis Respiratory Alkalosis

 HCO3 HCO3
pH = ------ pH = ------
PaCO2 PaCO2

Uncompensated Partly Compensated

Respiratory Acidosis Respiratory acidosis

HCO3
N pH = ------
PaCO2

Compensated
Respiratory Acidosis
 HCO3 Combined
pH = ------ Respiratory & Metabolic
PaCO2 Alkalosis

HCO3 Combined
pH = ------ Respiratory & Metabolic
PaCO2 Acidosis
ACID-BASE BALANCE
ABNORMALITY COMPENSATION

RESPIRATORY
ACIDOSIS ↑CO2 ↑HCO3
ALKALOSIS ↓CO2 ↓HCO3

METABOLIC
ACIDOSIS ↓HCO3 ↓CO2
ALKALOSIS ↑HCO3 ↑CO2
 26 year old female, complaining of
dyspnea and chest pain, RR– 30/min

 pH 7.49
 pCO2 30
 pO2 98
 HCO3 24
 Sat 99%
Uncompensated Respiratory Alkalosis
OXYGENATION

AT ROOM AIR
 Patients < 60 y/o

Expected pO2 = 80 –100 mm Hg

 Patients > 60

Expected pO2 = 80 – ( yrs above 60)

Ex. 70 year-old male
Expected pO2 = 80 – 10 = 70
OXYGENATION STATUS

 Patients < 60 y/o

pO2 < 80 = Hypoxemic
80 –100 = Normal
> 100 = more than adequate
 Patients > 60
pO2 < Expected = hypoxemic
pO2 = expected = Normal
pO2 > 100 = more than adequate
Interpretation:
OXYGENATION STATUS (ABG TAKEN
AT ROOM AIR)
 Normal
 Hypoxemia
 Mild- 60-79
 Moderate- 40-59
 Severe- <40
Interpretation:
Oxygenation status (ABG taken, patient
receiving oxygen supplementation)
 Adequate oxygenation
 Inadequate oxygenation
 More than adequate oxygenation
 66 year old COPD patient, 5 days
progressive dyspnea, in respiratory
distress, RR 35. ABG at RA.

 pH 7.32
 pCO2 77
 pO2 55
 HCO3 32
 Sat 88%
Partly Compensated Respiratory Acidosis
with Moderate Hypoxemia.
 50 year old diabetic female, 3 days
progressive alteration in sensorium, T- 39,
RR 24, rapid, deep. ABG at 6 LPM.

 pH 7.2
 pCO2 32
 pO2 78
 HCO3 14
 Sat 90%
Partly Compensated Metabolic Acidosis
with inadequate oxygenation.
Degree of compensation: Detection of
underlying acid-base abnormality
 Metabolic Acidosis
 Determine anion gap
 Anion gap: Na- (Cl+HCO3)
 Expected pCO2: 1.5 X actual HCO3 + 8 (+/-2)
 Example: pH=7.2 HCO3=19.3
 Expected pCO2= 1.5 X 19.3 + 8
= 36.5 (+/-2) (range=34.5 -
38.5)
Degree of compensation: Detection of
underlying acid-base abnormality

 Metabolic Alkalosis
 Expected pCO2= 0.75 X actual HCO3 + 20 (+/-5)
 Example: pH= 7.47 HCO3=38
 Expected pCO2= 0.75 X 38 + 20
= 48 (range 43.5-53.5)
Degree of compensation: Detection of
underlying acid-base abnormality

 Respiratory Acidosis
 Expected compensation
 Acute: HCO3 rises 1mEq/L for each 10mmHg rise in
pCO2
 Chronic: HCO3 rises 3.5 mEq/L for each 10mmHg rise
in pCO2
Degree of compensation: Detection of
underlying acid-base abnormality

 Respiratory Alkalosis
 Expected compensation
 Acute: HCO3 falls 2mEq/L for each 10mmHg fall in
pCO2
 Chronic: HCO3 falls 5mEq/L for each 10mmHg fall in
pCO2
 Acid-base
Compensation Limit
disturbance

Metabolic acidosis pC02= 1.5 X HCO3 + 8 (+/-2) 10 mmHg

Metabolic Each meq ↑ in HCO3 0.5-1.0 mmHg ↑ in

55 mmHg
alkalosis pCO2

Respiratory
acidosis:
Acute 30 meq/L
Chronic HCO3 ↑ by 3-4 meq/L 40 meq/L
HCO3 ↑ by 0.4 meq/L

Respiratory
alkalosis:
Acute 18 meq/L
Chronic HCO3 ↓ by 2-4 meq/L 12-15 meq/L
HCO3 ↓ by 0.5 meq/L
GAS EXCHANGE PARAMETERS
 PaO2
 P/F RATIO
 A-aDO2
 AaO2 ratio
OXYGENATION

WITH SUPPLEMENTAL OXYGEN

P/F RATIO = PaO2/ FiO2

where FiO2 = LPM X 4 + 20

Ex: 6 LPM x 4 + 20 = 44%

OXYGENATION
EXPECTED P/F RATIO
 PATIENT < 60 years old = 400

 PATIENT > 60 years old

400 – ( age above 60 x 5)
Ex. 75 yrs old
400 – ( 15 x 5) = 325
DESIRED FiO2

d PaO2 PaCO2
-------- + -------

aAO2 0.8 DESIRED FiO2 =

-----------------------
713
ALVEOLAR-ARTERIAL O2
DIFFERENCE (A-aDO2)

ALVEOLAR PO2 = 713(FiO2) – PaCO2/0.8

A-aDo2 = ALVEOLAR PO2 – arterial PO2

NORMAL = < 15 @ 30 y/o and add 3
for every decade above 30
 Arterial PO2 (ABG)
Aao2 ratio = ------------------------
Alveolar PO2
( 713 x FiO2 – Pa CO2/0.8)

NORMAL = 0.75
CAUSES OF HYPOXEMIA

 HYPOVENTILATION
 DECREASED FiO2
 V/Q MISMATCH
 SHUNT
 DIFFUSION ABNORMALITIES
ABG INTERPRETATION

 Check pH : Normal or Abnormal?

 If abnormal, is it acidemia or alkalemia?
 Check for PaCO2, is it respiratory or metabolic?
 Check for compensation (same direction)
 Check for combined acid-base abnormality (opposite
direction)
 Check for oxygenation (room air; supplementation))
Difficult to interpret ABG

 please take note:

 pH, PaO2 & pCO2 are directly measured.
 HCO3- derived or computed parameter.
Difficult to interpret ABG

 Example:
 pH- 7.43 pH- 7.41
 pCO2- 40 pCO2- 34
 paO2- 80 paO2- 90
 HCO3- 29 HCO3- 23
Answers:

1. Normal Acid Base balance with normal

oxygenation (NORMAL ABG)

2. Compensated Respiratory Alkalosis with

normal oxygenation
Acid-Base Disturbances
 Metabolic Alkalosis
 Exogenous steroids
 GI loss (vomitting, etc.)
 Renal loss (Conn syndrome, Cushing)
 Decreased chloride intake
 Diuretics
 Bicarbonate administration
 Contraction alkalosis
Acid-Base Disturbances
 Respiratory Alkalosis
 Hyperventilation of any cause
 Anemia
 Pulmonary embolism
 Sarcoid
 Anxiety
 Pain
Acid-Base Disturbances
 Metabolic Acidosis
 Anion gap=(Na+K)-(HCO3+Cl)
 NV= 8-14
 Nonanion gap
 Diarrhea
 Renal tubular acidosis (RTA)
 Increased Anion gap
 Lactate (sepsis, ischemia)
 Aspirin,Methanol
 Uremia, DKA
 INH
Acid-Base Disturbances
 Respiratory Acidosis
 Hypoventilation
 COPD
 Pickwickian syndrome
 Obesity
 Suffocation
 Opiate overdose
 Sleep apnea