Respiratory acidosis Respiratory acidosis is a medical condition in which decreased ventilation (hypoventilation) causes increased blood carbon dioxide

concentration and decreased pH (a condition generally called acidosis). Carbon dioxide is produced constantly as the body's cells respire, and this CO2 will accumulate rapidly if the lungs do not adequately expel it through alveolar ventilation. Alveolar hypoventilation thus leads to an increased PaCO2 (called hypercapnia). The increase in PaCO2 in turn decreases the PaCO2/HCO3 ratio and decreases pH. Terminology

Acidosis refers to a low pH in tissue. Acidemia refers to a low pH in the blood.

Types of respiratory acidosis Respiratory acidosis can be acute or chronic.

In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (over 6.3 kPa or 47 mm Hg) with an accompanying acidemia (pH <7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal blood pH (7.35 to 7.45) or near-normal pH secondary to renal compensation and an elevated serum bicarbonate (HCO3 >30 mm Hg).

Causes Acute Acute respiratory acidosis occurs when an abrupt failure of ventilation occurs. This failure in ventilation may be caused by depression of the central respiratory center by cerebral disease or drugs, inability to ventilate adequately due to neuromuscular disease (e.g., myasthenia gravis, amyotrophic lateral sclerosis, Guillain-Barr syndrome, muscular dystrophy), or airway obstruction related to asthma or chronic obstructive pulmonary disease (COPD) exacerbation. Chronic Chronic respiratory acidosis may be secondary to many disorders, including COPD. Hypoventilation in COPD involves multiple mechanisms, including decreased responsiveness to hypoxia and hypercapnia, increased ventilation-perfusion mismatch leading to increased dead space ventilation, and decreased diaphragm function secondary to fatigue and hyperinflation. Chronic respiratory acidosis also may be secondary to obesity hypoventilation syndrome (i.e., Pickwickian syndrome), neuromuscular disorders such as amyotrophic lateral sclerosis, and severe restrictive ventilatory defects as observed in interstitial fibrosis and thoracic deformities. Lung diseases that primarily cause abnormality in alveolar gas exchange usually do not cause hypoventilation but tend to cause stimulation of ventilation and hypocapnia secondary to hypoxia. Hypercapnia only occurs if severe disease or respiratory muscle fatigue occurs. Physiological response Mechanism Metabolism rapidly generates a large quantity of volatile acid (H2CO3) and nonvolatile acid. The metabolism of fats and carbohydrates leads to the formation of a large amount of CO2. The CO2 combines with H2O to form carbonic acid (H2CO3). The

lungs normally excrete the volatile fraction through ventilation, and acid accumulation does not occur. A significant alteration in ventilation that affects elimination of CO2 can cause a respiratory acid-base disorder. The PaCO2 is maintained within a range of 39-41 mm Hg in normal states. Alveolar ventilation is under the control of the central respiratory centers, which are located in the pons and the medulla. Ventilation is influenced and regulated by chemoreceptors for PaCO2, PaO2, and pH located in the brainstem,and in the aortic and carotid bodies as well as by neural impulses from lung stretch receptors and impulses from the cerebral cortex. Failure of ventilation quickly increases the PaCO2. In acute respiratory acidosis, compensation occurs in 2 steps.

The initial response is cellular buffering that occurs over minutes to hours. Cellular buffering elevates plasma bicarbonate (HCO3 ) only slightly, approximately 1 mEq/L for each 10-mm Hg increase in PaCO2. The second step is renal compensation that occurs over 3-5 days. With renal compensation, renal excretion of carbonic acid is increased and bicarbonate reabsorption is increased. For instance, PEPCK is upregulated in renal [1] proximal tubule brush border cells, in order to secrete more NH3 and thus to produce more HCO3 .

Estimated changes In renal compensation, plasma bicarbonate rises 3.5 mEq/L for each increase of 10 mm Hg in PaCO2. The expected change in serum bicarbonate concentration in respiratory acidosis can be estimated as follows:

Acute respiratory acidosis: HCO3 increases 1 mEq/L for each 10 mm Hg rise in PaCO2. Chronic respiratory acidosis: HCO3 rises 3.5 mEq/L for each 10 mm Hg rise in PaCO2.

The expected change in pH with respiratory acidosis can be estimated with the following equations:

Acute respiratory acidosis: Change in pH = 0.008 X (40 PaCO2) Chronic respiratory acidosis: Change in pH = 0.003 X (40 PaCO2)

Respiratory acidosis does not have a great effect on electrolyte levels. Some small effects occur on calcium and potassium levels. Acidosis decreases binding of calcium to albumin and tends to increase serum ionized calcium levels. In addition, acidemia causes an extracellular shift of potassium, but respiratory acidosis rarely causes clinically significant hyperkalemia.

Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces. This causes body fluids, especially the blood, to become too acidic. Causes Causes of respiratory acidosis include:

Pulmonary function test

Treatment Treatment is aimed at the underlying disease, and may include:

Diseases of the airways (such as asthma and chronic obstructive lung disease) Diseases of the chest (such as sarcoidosis) Diseases affecting the nerves and muscles that "signal" the lungs to inflate or deflate Drugs that suppress breathing (including powerful pain medicines, such as narcotics, and "downers," such as benzodiazepines), especially when combined with alcohol Severe obesity, which restricts how much the lungs can expand

Bronchodilator drugs to reverse some types of airway obstruction Noninvasive positive-pressure ventilation (sometimes called CPAP or BiPAP) or a breathing machine, if needed Oxygen if the blood oxygen level is low Treatment to stop smoking

Outlook (Prognosis) How well you do depends on the disease causing the respiratory acidosis. Possible Complications

Chronic respiratory acidosis occurs over a long period of time. This leads to a stable situation, because the kidneys increase body chemicals, such as bicarbonate, that help restore the body's acid-base balance. Acute respiratory acidosis is a condition in which carbon dioxide builds up very quickly and before the kidneys can return the body to a state of balance. Symptoms Symptoms may include:

Poor organ function Respiratory failure Shock

When to Contact a Medical Professional Severe respiratory acidosis is a medical emergency. Seek immediate medical help if you have symptoms of this condition. Call your health care provider if you have symptoms of lung disease. Prevention Do not smoke. Smoking leads to the development of many severe lung diseases that can cause respiratory acidosis. Losing weight may help prevent respiratory acidosis due to obesity (obesity-hypoventilation syndrome). Be careful about taking sedating medicines, and never combine these medicines with alcohol. Alternative Names Ventilatory failure; Respiratory failure; Acidosis respiratory

Confusion Easy fatigue Lethargy Shortness of breath Sleepiness

Exams and Tests The health care provider will perform a physical exam. Tests that may be done include:

Arterial blood gas, which measures oxygen and carbon dioxide levels in the blood Basic metabolic panel Chest x-ray

Respiratory alkalosis Respiratory alkalosis is a condition marked by low levels of carbon dioxide in the blood due to breathing excessively. Causes Common causes include:

When to Contact a Medical Professional Call your health care provider if you have any symptoms of lung disease, such as chronic cough or shortness of breath. Alternative Names Alkalosis - respiratory Metabolic acidosis Metabolic acidosis is a condition in which there is too much acid in the body fluids. Causes Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. There are several types of metabolic acidosis:

Anxiety Fever Hyperventilation

Any lung disease that leads to shortness of breath can also cause respiratory alkalosis. Symptoms The symptoms may include:

Dizziness Lightheadedness Numbness of the hands and feet

Exams and Tests The health care provider will perform a physical exam. Tests that may be done include:

Arterial blood gas, which measures oxygen and carbon dioxide levels in the blood Chest x-ray Pulmonary function test

Treatment Treatment is aimed at the condition that causes respiratory alkalosis. Breathing into a paper bag -- or using a mask that causes you to re-breathe carbon dioxide -sometimes helps reduce symptoms. Outlook (Prognosis)

Diabetic acidosis (also called diabetic ketoacidosis and DKA) develops when substances known as ketone bodies, which are acidic, build up during uncontrolled type 1 diabetes Hyperchloremic acidosis results from excessive loss of sodium bicarbonate from the body, as can happen with severe diarrhea Lactic acidosis is a buildup of lactic acid. It can be caused by: o Alcohol o Cancer o Exercising for a very long time o Liver failure o Low blood sugar (hypoglycemia) o Medications such as salicylates o Prolonged lack of oxygen from shock, heart failure, or severe anemia o Seizures

Other causes of metabolic acidosis include:

What will happen depends on the condition that is causing the respiratory alkalosis. Possible Complications Seizures may occur if the alkalosis is extremely severe. This is very rare.

Kidney disease (distal tubular acidosis and proximal renal tubular acidosis) Poisoning by aspirin, ethylene glycol (found in antifreeze), or methanol Severe dehydration

Symptoms Most symptoms are caused by the underlying disease or condition that is causing the metabolic acidosis. Metabolic

acidosis itself usually causes rapid breathing. Confusion or lethargy may also occur. Severe metabolic acidosis can lead to shock or death. In some situations, metabolic acidosis can be a mild, chronic (ongoing) condition. Exams and Tests

Alkalosis Alkalosis is a condition in which the body fluids have excess base (alkali). This is the opposite of excess acid (acidosis). Causes

Arterial blood gas Serum electrolytes Urine pH

Arterial blood gas analysis or a serum electrolytes test (such as a basic metabolic panel) will confirm acidosis is present and determine whether it is respiratory acidosis or metabolic acidosis. Other test may be needed to determine the cause of the acidosis. Treatment Treatment is aimed at the underlying condition. In certain circumstances, sodium bicarbonate (baking soda) may be given to improve the acidity of the blood. Outlook (Prognosis) What can be expected will depend on the underlying disease causing the metabolic acidosis. Possible Complications When very severe, metabolic acidosis can lead to shock or death. When to Contact a Medical Professional Seek medical treatment if you develop symptoms of any disease that can cause metabolic acidosis. Prevention Keeping type 1 diabetes under control may help prevent diabetic ketoacidosis, one type of metabolic acidosis. Alternative Names Acidosis - metabolic

The kidneys and lungs maintain the proper balance of chemicals, called acids and bases, in the body. Decreased carbon dioxide (an acid) or increased bicarbonate (a base) levels make the body too alkaline, a condition called alkalosis. Respiratory alkalosis is caused by low carbon dioxide levels in the blood. This can be due to:

Fever Being at a high altitude Lack of oxygen Liver disease Lung disease, which causes you to breathe faster (hyperventilate) Salicylate poisoning

Metabolic alkalosis is caused by too much bicarbonate in the blood. Hypochloremic alkalosis is caused by an extreme lack or loss of chloride, which can occur with prolonged vomiting. Hypokalemic alkalosis is caused by the kidneys' response to an extreme lack or loss of potassium, which can occur when people take certain diuretic medications. Compensated alkalosis occurs when the body returns the acid - base balance to normal in cases of alkalosis, but bicarbonate and carbon dioxide levels remain abnormal. Symptoms

Confusion (can progress to stupor or coma) Hand tremor Light-headedness Muscle twitching Nausea, vomiting Numbness or tingling in the face, hands, or feet Prolonged muscle spasms (tetany)

Exams and Tests An arterial blood gas analysis and basic metabolic panel will confirm alkalosis and determine if it is respiratory alkalosis or metabolic alkalosis. Other tests may be needed to determine the cause of the alkalosis. These may include:

Prevention Prevention depends on the cause of the alkalosis. Normally, people with healthy kidneys and lungs do not have significant alkalosis.

Urinalysis Urine pH

Treatment To treat alkalosis, your health care provider needs to find the cause. For alkalosis caused by hyperventilation, breathing into a paper bag allows you to keep more carbon dioxide in your body, which improves the alkalosis. If your oxygen level is low, you may receive oxygen. Some people need medications to correct chemical loss (such as chloride and potassium). Your health care provider will monitor your vital signs (temperature, pulse, rate of breathing, blood pressure). Outlook (Prognosis) Most cases of alkalosis respond well to treatment. Possible Complications

Arrhythmias Coma Electrolyte imbalance (such as hypokalemia)

When to Contact a Medical Professional Call your health care provider if you become confused, unable to concentrate, or unable to "catch your breath." A visit to the emergency room or call to the local emergency number (such as 911) is warranted for:

Loss of consciousness Rapidly worsening symptoms of alkalosis Seizures Severe breathing difficulties