Respiratory part 2

Chronic respiratory acidosis:

• Emphysema • Obstructive
• SOB • COPD
• Pink puffer • Blue boater
• • Confused
Pursed lips
• Hypoinflated
• Hyperinflated
• Wheeze
• Wheeze
• Warm full veins
• Peripheral oedema
 Chronic respiratory acidosis:
• Pink puffer • Blue bloater
• Respiratory drive high • Respiratory drive low
• Hypo oxygen • Hypo oxygen
• Hypo CO2 • Hyper CO2.
• Desaturates on exercise. • Right side heart
failure (Oedema)
• Type 1 respiratory failure • Type 2 respiratory
failure.
 Chronic pulmonary disease
• Type 1 – could be from pulmonary
oedema, pulmonary fibrosis, lobar
pneumonia, “shunting”.
• Type 2 – could be from
bronchopneumonia, chronic bronchitis.
 Typical chronic respiratory
acidosis:
• Life long heavy smoker.
• (Alpha 1 anti trypsin deficiency)
• Male
• Urban dweller.
• Low social class.
• Air pollution.
Pursed lips breathing
 Bronchiectasis – dilation of the
bronchi
• Congenital or genetic – cystic fibrosis.
• Childhood infection – whooping cough.
• Bronchial obstruction – inhaled
• Allergic disease aspergillosis
• Autoimmune disease – primary biliary
cirrhosis.
Bronchiectasis
 Respiratory alkalosis
• Hysteria
• Mechanical over ventilation
• Raised intracranial pressure,
• Hypoxia.

• Acute condition – no renal compensation

possible.
 How to interpret blood gas
results
• Look at pH, is it acidosis, normal or alkalosis?
• If pH is low, look at pCO2, if increased then
respiratory, look at bicarbonate, if decreased
then metabolic disease.
• If pH is high, look at pCO2, if decreased then
respiratory, look at bicarbonate, if increased then
metabolic disease.
• Look for compensation, is it partial or full?
25 year-old woman with history
of mental illness, suicide tries
Rapid breathing
• Blood pH 7.58 (7.35-7.45)
• pCO2 26 mm Hg (35-45)
• Bicarbonate 18 mmol/L (22-30)
• pO2 115 mm Hg (80-100)
• Acid base diagnosis? What next?
 Mixed acid base disorders
• Patient may have more than one acid
base disease.
• Both could give acidosis or alkalosis – a
potentially lethal mix.
• They could offset each other.
 Mixed acid base diseases
examples:
• COPD with thiazide induced K depletion
• Over ventilation with prolonged nasogastric
suction
• Salicylate poisoning after a hour or so.

Limits to compensation:
• pCO2 12-55 mm Hg- takes seconds to happen
• Bicarbonate 5-50 mmol/L – takes days.
 70 year old man collapsed,
cyanosed.
Blood pH 6.9 (7.35-7.45)
pCO2 60 mm Hg (35-45)
pO2 50 mm Hg (80-100)
Bicarbonate 15 mmol/L (22-30)

Comment on his acid base status.

 80 year old man, DM II, chest
pain, breathless, cyanosed
Blood pH 7.6 (7.35-7.45)
pCO2 15 mm Hg (35-45)
pO2 50 mm Hg (80-100)
bicarbonate 40 mmol/L (22-30) {infused}

Comment on his acid base status.

 Oxygen transport diseases.
• Blood O2 2% dissolved, 98% on haemoglobin
Hb
• Oxygen saturation: % Hb as oxyhaemoglobin.
Pulse oximetry
Affinity of O2 for Hb depends on pH and DPG
(diphosphoglycerate)
Delivery depends on pO2, Hb, Hb function, cardiac
output and peripheral perfusion (vasodilation
contraction).
• Plasma lactate for perfusion efficiency.
 Stimulation to ventilation
• Increased pCO2
• Fall in pH (rise in H+)
• Decreased pO2 ( below 60 mm Hg).
 Respiratory failure:
• Type 1: low pO2 and normal pCO2.
Pulmonary edema, pulmonary fibrosis, lobar
pneumonia, “shunting”.
• Type 2: low pO2 and raised pCO2.
Bronchial pneumonia, chronic bronchitis.
 Some pulmonary diseases of
laboratory interest:
• Asthma
• Interstitial lung diseases
• Pleural diseases
• Pulmonary embolus/infarct
• Lung cancer.
 Asthma:
• Narrowing of bronchi.
• Children 5%, adults 2%.
• Possible occupational.
• Possible exercise in cold triggers it
(Lillehammer Olympics, Joyner-Kersey)
• Infections.
• Drugs: aspirin, beta blockers.
 Asthma symptoms:
• Short of breath
• Wheeze
• Worst in early morning
• Sometimes seasonal
• Cough.
• May be acute or chronic.
 Asthma laboratory work:
• Air flow obstruction > 15%.
• Arterial blood gases
• Oesinophilia if caused by extrinsic factors.
• Skin tests positive and raised IgE in
extrinsic.
• Aminophylline drug used in treatment.
Caffeine in infants. May be measured to
prevent toxicity.
Asthma