Acid-Base physiology

Critical Care Nursing

(Clinical)

Presented by
Mohammad Marzouq, MSN./CNS.
Learning Objectives

1. To define acid, base, compensatory mechanism

and acid-base alteration.
2. To explain the normal regulatory mechanism of
acid-base alteration.
3. To discuss the assessment method of acid-base
alteration.
4. To interpret ABGs .
5. To apply Nursing care for patients with acid-base
imbalance.
Introduction

• Man is an acid producing system that continually

forms acid by means of carbohydrate, fat, and glucose
metabolism.
• The hydrogen ion H+ is represented by the symbol
pH.
• The PH of the extracellular fluids must be maintained
within 7.35-7.45.
• The range of the pH that is compatible with life is 6.8-
8.0.
 Definition of Key terms
• Acid : is a molecule or ion that can release a hydrogen
ion into a solution .
• Carbonic acid ionizes in water to form H+ and HCO3.
• Other acids in the body are acetic, uric, and lactic acid.
• pH: is the symbol that represents a concentration of
hydrogen ion.
• Low pH = high hydrogen ion (acidosis)
• High pH = low hydrogen ion (alkalosis)
Definition of Key terms

• Base: is a molecule or ion that can combines with

hydrogen ion.
• Compensatory mechanism : is the regulation of the
hydrogen ion concentration to maintain health. It is
the response of the buffers; the respiratory and the
renal system to alteration in the opposite system.
Definition of Key terms
• The regulatory process is designed to remove acid or
restore base. Respiratory system with high ventilation
decreases the carbonic acid.
• Carbonic dioxide in water forms carbonic acid CO2+
H2O=H2CO3
• The kidney acts by excreting organic and inorganic
acids and retain base.
• Acidosis : Is the state of excess addition of hydrogen
ion into a solution or loss of a basic ions.
• Alkalosis: is the removal of hydrogen or the addition of
basic ions to a solution.
Sources of acid and base in the body

1. The metabolism of fat, and carbohydrate. Some of

carbonic dioxide combines with water to form
carbonic acid.
2. Protein metabolism result in fixed acid like sulfuric,
lactic, aceto acetic. Hydrogen ions produced from
the disassociation of fixed acid.
Sources of acid and base in the body
• Glucose metabolism : produces 2 molecules of pyruvic
acid and 2 molecules of ATP.
• Pyruvic acid is converted into Acetyl coenzyme A,
carbon dioxide and hydrogen atoms.
• Acetyl coenzyme A is converted to carbon dioxide and
hydrogen atoms .
• Hydrogen atoms are changed to hydrogen ions.
• Lactic acid is produced from the muscle activity during
exercise or during severe hypoxia as in M.I.
Assessment of acid –base balance
1. Blood gases : arterial blood sample .
2. Results of arterial blood gas analysis provide
information about alveolar ventilation, oxygenation,
and acid–base balance.
Arterial blood gases (ABG) USES :

1. To evaluate respiratory diseases and conditions that

affect the lungs
2. To determine the effectiveness of oxygen therapy.
3. The acid-base component of the test also gives
information on how well the kidneys are functioning
Blood gases Sample

https://youtu.be/0BSv4iN8T2E?si=UC_sCJht2k5FYa-v
pH

• Concentration of hydrogen ions (H+)

• Normal range 7.35 to 7.45
• pH less than 7.35 = acidosis
• pH greater than 7.45 = alkalosis
 Arterial Blood Gases
• PaO2: partial pressure of oxygen dissolved in
arterial blood
• Normal value 80 to 100 mm Hg.

• SaO2: amount of oxygen bound to hemoglobin

• Normal value 93% to 99%
• Frequently measured via pulse oximetry
PaCO2

• Partial pressure of carbon dioxide in arterial

blood
• Normal value 35 to 45 mm Hg
• PaCO2 greater than 45 mm Hg = acidosis
• PaCO2 less than 35 mm Hg = alkalosis
• Hint: think of CO2 as an acid
PaO2 and SaO2 Relationship

• Oxyhemoglobin dissociation curve

• Critical zone: PaO2 less than 60 mm Hg
• Shifts of oxyhemoglobin dissociation curve
• Acidosis: release of oxygen to tissues
• Alkalosis: hemoglobin holds oxygen
HCO3—Bicarbonate

• Concentration of sodium bicarbonate in the

blood
• Normal value is 22 to 26 mEq/L
• HCO3 less than 22 = acidosis
• HCO3 greater than 26 = alkalosis
• Hint: think of HCO3 as a buffer or base.
Oxygenation

•Hypoxemia—decreased oxygenation of
arterial blood
•Hypoxia—decreased oxygenation at
tissue level
Physiology of Gas Exchange (Respiration)

Respiration is the process by which O2 is transferred

from the air to tissues and CO2 is excreted in the
expired air
3-Step Process
1.Ventilation
2.Diffusion
3.Transport
 Altered breathing pattern

Used with permission. Ahrens TS. Pulmonary Data Acquisition. In: Kinney MR, Packa DR, Dunbar SB, eds. AACN’s Clinical Reference for Critical-Care Nursing. St. Louis, Mo: 1993:690
 Fundamental alterations in Acid -
base
• Alteration in acid-base equilibrium are classified by
changes in pH, PCO2, and HCO3-
• The four primary acid-base disorders are :
a. Primary increase in PCO2: respiratory acidosis
b. Primary decrease in PCO2: respiratory alkalosis
c. Primary decrease in [HCO3-]: metabolic acidosis
d. Primary increase in [HCO3-]: metabolic alkalosis
 Respiratory acidosis
• Is clinical disorder characterized by alveolar hypo-
ventilation resulting in hypercapnia PaCO2 > 45mmHg
• Causes:
1. Resp. disease as COPD, ARDS, asthma, pulm.
embolism, and lung injury.
2. Resp. muscle weakness as multiple sclerosis, spinal
cord injury , neuromuscular blockades.
3. Low resp. drive as drug narcotics, sedation, and high
O2 administration in COPD.
4. Airway obstruction as in foreign body or spasm.
I) Respiratory acidosis

• TREATMENT:
1. Treat the underlying cause.
2. O2 administration to treat hypoxemia.
3. Ventilator

• Lab test : pH < 7.35 , PaCO2 > 45 mmHg.

 Oxygen delivery method
DISADVANTAGE ADVANTAGE OXYGEN METHOD
CONCENTRATION

DRYNESS OF ALLOWS PT TO L/MINUTE 6 - 4 NASAL

MUCOSA EAT AND TALK CANNULA

POOR --------------- % 60 – 30 SIMPLE FACE

TOLERANCE L/MINUTE 5-8 MASK

DRYNESS OF ------------ L/M 10 - 6 PARTIAL

THE SKIN % 90 - 60 REBREATHING
MASK
-------------- ---------------- 10-15L/M NONREBREATH
% 100- 95 MASK
---------------- PROVIDES % 50 - % 24 VENTURI MASK
CALIBRATED L/ M 10- 4
OXYGEN
Oxygen Administration

• O2 Toxicity
• Methods of Delivery
• Nasal cannula
• Simple mask
• PRB
• NRB
• Venturi
Method of oxygen delivery

Nasal cannula
Humidifier

Respirator
Oxygen mask
II) Respiratory alkalosis
• Occurs due to hyperventilation due to either
psychogenic or CNS stimulation
• Causes : anxiety, pain, head injury, hypoxemia
(COPD, hypotension, pulm. edema and
hyperthermia.
• S&S : Dizziness, numbness, sweating, muscle
cramp, tetany, dry mouth , and blurred vision.
• ABG: pH > 7.45. pCO2 <35 mmHg.
Management of resp. alkalosis
1. Treat the cause.
2. Correct hypoxia.
3. Increase pressure of CO2 by using rebreathing
O2 mask.
Metabolic acidosis
• Results from either retention of acid or loss of
base.
• Abnormal protein and fat metabolism as in DM,
starvation, and diuretics, fever, infection,
anerobic metabolism as in M.I, shock, exercise.
• Retention of acid as in renal failure.
• Loss of alkaline as in diarrhea, and bowel fistula
Metabolic acidosis
• S & S : headache, confusion, kussmaul’s
breathing , weakness, stupor, arrhythmias, warm
flushed skin.
• ABG: pH < 7.35, HCO3 <22 mEq/L,
PCO2 < 35 mmHg or normal.
• Management:
• * Treat the cause.
• * Support ventilation oxygen therapy.
• * Give bicarbonate
 Metabolic alkalosis

• Results from accumulation of excess base or loss of

hydrogen ions from the body.
• Causes:
1. Loss of hydrogen ions as vomiting, nasogastric
suctioning, diuretics, loss of potassium.
2. Addition of base: excess use of bicarbonate,
lactate, intake of milk.
Metabolic alkalosis

• ABG : pH > 7.45 , HCO3 > 26 mEq/L, PaCO2

normal or high.
• Management:
1. Treat the cause.
2. Restore fluid volume and electrolyte balance
3. Use acidifying agent as carbonic anhydrase
inhibitors (Diamox)
Compensation
Compensatory mechanism

• Compensatory (secondary) processes restore pH

toward normal in response to one or more primary
acid-base abnormalities:
• The kidneys compensate for primary respiratory
disorders.
• The lungs compensate for primary metabolic
disorders.
Buffer System

• Maintain body’s pH
• Three buffer systems
• Blood
• Respiratory
• Renal
Blood Buffer System

• Activated as the H+ ion concentration changes

• Increased H+ ions combined with HCO3 to form
carbonic acid (H2CO3)
• Carbonic acid breaks down into H2O and CO2 in the
lung
Renal Buffer System

• Excretes excess H+ ions and retains HCO3

• Slow activation (up to 2-3 days)
Blood and bone buffers

• Plasma proteins, as albumin and hemoglobin,

can buffer large amounts of H+.
• Preventing significant changes in the pH.
• Bone contains a large reservoir of bicarbonate
and phosphate and can buffer a significant
acute acid load
Respiratory Buffer System

•In response to low pH , the resp. hyper

ventilate; and hypoventilate in response
to high pH.
•It returns the pH toward normal over a
period of 4 to 12 hours, but do not fully
normalize it.
Respiratory regulation of acid-base balance
• Goals of respiration are to maintain normal
level of oxygen, carbon dioxide and hydrogen
ions

• So, excess carbon dioxide and hydrogen ion

stimulate resp. to wash carbon dioxide and
the carbonic acid from the plasma .
Renal regulation of acid- base balance
• It acts by increasing or decreasing the bicarbonate
concentration of the body fluid and secreting fixed
acid.
• It takes 1-3 days for the kidney to restore the acid-
base balance.
• Renal regulation by:
1. Sodium bicarbonate : hydrogen ion is attached to
a protein that is a carrier protein that combines
with sodium and excreted.
Renal regulation of acid- base balance
2. Ammonia combines with hydrogen ion to form
ammonium ion (NH4+), at the same time a
bicarbonate is reabsorbed.
Compensation :
• When there is a disturbance in the acid –base
system the unaffected system will compensate to
correct it
Overall, the kidneys must
excrete H+ and prevent the
loss of HCO3-.
Filtered bicarbonate must
react with secreted H+ in
order to be reabsorbed as
H2CO3
Compensatory duration

• For a primary respiratory acidosis, buffers provide

acute compensation in the initial minutes to hours.
Chronic compensation requires a gradual increase in
renal acid excretion, a process that takes 3 to 5 days
Compensation

• *None
• *Partial
• Mechanisms occurring
• pH still abnormal
• *Complete
• Mechanisms occurring
• pH within normal range
Consequence of acidemia
• Cardiovascular
• Decreased myocardial contractility.
• Arrhythmia
• Vasoconstriction
• Pulmonary: Hyperventilation, Dyspnea, Central
nervous system confusionn,and Coma.
• Metabolic: Hyperkalemia, Insulin resistance , and
Protein catabolism
Consequence of alkalemia

• Increased mortality
• Cardiovascular: Arrhythmia, Decreased coronary
and cerebral blood flow
• Pulmonary: Hypoventilation, Decreased peripheral
oxygen delivery
• Neurologic: Neuromuscular irritability, and Tetany.
• Metabolic : Hypokalemia, and Hypocalcaemia
Systematic method to assessing acid-base
balance:
1. History : if the client has
• Respiratory disease as : pneumonia , COPD,
anxiety or renal disease.
• Renal disease as renal failure, DM, or
dehydration.
2. S&S of acid – base imbalance .
3. Lab findings : ABG .
Interpretation of ABGs

• Step 1: Evaluate oxygenation

• Step 2: Evaluate the acid-base status
• Evaluate pH
• Evaluate PaCO2
• Evaluate HCO3
• Step 3: Determine primary acid-base
imbalance
• Step 4: Determine compensation
 Steps for interpretation

1. Look at the PH is it on the acid or base side

2. Look at the PaCO2 if it fits into respiratory
acidosis or alkalosis.
3. Look at HCO3 if it is acidosis or alkalosis or
normal.
Analysis of simple acid base disorders and how they are compensated
for by the body.
Examples:

pH 7.25 7.25 7.47

PaCO2 50 mmHg 40 mmHg 35 mmHg

HCO3 22mEq/L 17mEq/L 30 mEq/L

Example: Respiratory Arrest

pH 7.15
PO2 55 mm Hg
PCO2 85 mm Hg
HCO3 24 mEq/L

What does this ABG show?

REFERENCES:
* Hinkle, J. L., Cheever, K. H. (2020). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing (15th edition). Wolters
Kluwer: Lippincott Williams & Wilkins.

* Smith SF, Duell DJ, Martin BC, Gonzalez L, Aebersold ML,

eds. Clinical Nursing Skills: Basic to Advanced Skills. 9th ed.
New York, NY: Pearson; 2017.
ANY QUESTIONS??