LeMone, P., Burke, K.M., & Bauldoff, G. (2011). Medical-Surgical Nursing: Critical Thinking in Client Care (5th ed.).

Upper Saddle River, NJ:

Pearson/Prentice Hall.

Bronchoscopy
Bronchoscopy is a procedure to look directly at the airways in the lungs through a thin, lighted tube
(bronchoscope).

Chest Fluoroscopy
Chest fluoroscopy is an imaging test that uses X-rays to look at how well your lungs are working. It can also
look at other parts of your respiratory tract. Your respiratory tract includes your lungs, nose, throat, trachea,
and bronchi.

Chest Ultrasound
Chest ultrasound is a procedure in which sound wave technology is used alone, or along with other types of
diagnostic methods, to examine the organs and structures of the chest.

Chest X-Ray
A chest X-ray is an imaging test that uses X-rays to look at the structures and organs in your chest. It can help
your health care provider see how well your lungs and heart are working. Certain heart problems can cause
changes in your lungs. Certain diseases can cause changes in the structure of the heart or lungs.

CT Scan of the Chest

CT scan is a type of imaging test. It uses X-rays and computer technology to make images or slices of the body.
A CT scan can make detailed pictures of any part of the body, including the bones, muscles, fat, organs, and
blood vessels. They are more detailed than regular X-rays.

Lobectomy
A lobectomy is a surgery to remove one of the lobes of the lungs.

Lung Biopsy
A biopsy is a procedure done to remove a sample of tissue from the body so it can be examined. A lung biopsy
is a procedure to take a small piece of a lung.

Lung Scan
A lung scan is an imaging test to look at your lungs and help diagnose certain lung problems. A lung scan may
also be used to see how well treatment is working.

Lung Transplant
A lung transplant is surgery done to remove a diseased lung and replace it with a healthy lung from another
person.

Mediastinoscopy A mediastinoscopy is a procedure used to examine the mediastinum. This is the space
behind the breastbone (sternum). This area can be examined with a tool called a mediastinoscope. This is a
long, thin, flexible tube that has a light and a tiny camera.

Peak Flow Measurement

Peak flow measurement is a quick test to measure air flowing in and out of the lungs.

Pleural Biopsy
Pleural biopsy is a procedure to remove a tissue sample from the membrane that surrounds the lungs called
the pleura.

Positron Emission Tomography

A positron emission tomography (PET) scan is a type of nuclear medicine imaging test. It is used to examine
various body tissues to identify certain conditions by looking at blood flow, metabolism, and oxygen use. PET
scans may also be used to see how well the treatment of certain diseases is working.

Pulmonary Angiogram
Pulmonary angiogram is an X-ray image of the blood vessels of the lungs.

Pulmonary Function Tests

Pulmonary function tests (PFTs) are non-invasive tests that show how well the lungs are working.

Pulse Oximetry
Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It is an easy,
painless measure of how well oxygen is being sent to parts of your body furthest from your heart, such as the
arms and legs.

Sinus X-ray
A sinus X-ray is an imaging test that uses X-rays to look at your sinuses. The sinuses are air-filled pockets
(cavities) near your nasal passage.

Sleep Study
The stages of sleep range from light to deep. Each stage has characteristics that can be measured. A sleep
study is a number of tests done at the same time during sleep. The tests measure specific sleep characteristics
and help to diagnose sleep disorders. A sleep study may also be called polysomnogram.

Thoracentesis
Thoracentesis is a procedure to remove fluid or air from around the lungs.

Spirometry

Spirometry (figure 1) is the most important function test it measures vital capacity (VC) and forced expiratory volume in 1 second (FEV1). This permits
differentiation between restrictive and obstructive respiratory diseases. If expired volume is measured by electrical integration of airflow (using a
pneumotachograph), maximum flowvolume curves can also be registered. These tests are used to measure the effect of bronchodilating drugs on reversibility of
obstruction as well as to determine responsiveness to bronchial provocation tests. Simple instruments for patient home use include peak flow meters, which
measure the degree of obstruction.

Lung capacity and airway resistance

The total lung capacity can be determined using either gas dilution techniques or body plethysmography. The latter method also allows the measurement of airway
resistance. The forced oscillation technique, which measures the resistance of the total respiratory system, has the advantage that the patient does not need to
perform specific breathing manoeuvres.

Diffusing capacity

The diffusing capacity of the lung for carbon monoxide (also known as transfer factor), which is usually performed as a single-breath test, measures the overall
gas-exchange function of the lung.

Blood gas analysis

Arterial blood gas (ABG) measurement to determine the arterial oxygen tension (PaO2 ) and arterial carbon dioxide tension (PaCO2) is one of the most useful
diagnostic tests: blood can be sampled directly from an artery, or an estimate can be obtained from capillary blood from, for instance, a warmed earlobe. ABG
measurement allows the diagnosis of hypoxaemia (decreased PaO2) with or without hypercapnia (increased PaCO2), a sensitive index of inefficient pulmonary gas
exchange, which is also used for defining respiratory failure. PaO2 measurement after breathing 100% oxygen is sometimes used to estimate the anatomical rightto-left shunt. Arterial oxygen saturation (SaO2) represents the percentage of binding sites on the haemoglobin molecule occupied by oxygen and offers a
noninvasive method of estimating arterial blood oxygenation; it is measured directly by an oximeter with a probe attached to either the finger or the
earlobe.PaCO2 can also be estimated noninvasively, using a transcutaneous electrode but such devices are not yet as widely used as oximeters. ABG
measurement also allows evaluation of acidbase disorders.

Cardiopulmonary exercise testing

Cardiopulmonary exercise testing (CPET), with determination of minute ventilation, cardiac and respiratory frequency, oxygen uptake and carbon dioxide output, is
an objective measure of exercise capacity (spiroergometry). Simpler tests use capillary oxygen partial pressure measurements during exercise on an ergometer or
symptom-limited walking tests, such as the 6-min shuttle walk test, with measurement of SaO2 using an oximeter.

Respiratory muscle function measurement

Respiratory muscle function is commonly assessed by measuring maximal pressures generated at the mouth during maximal inspiratory and expiratory efforts
against an occluded airway.

Control of ventilation

Tests of ventilatory control include the hyperoxic rebreathing method and the hypoxia-withdrawal method. Simpler, but less specific, is the measurement of the
mouth occlusion pressure.

Diagnosis of sleep breathing disorders

The diagnosis of sleep-related respiratory disorders requires special tests. The gold standard is polysomnography, but simpler tests are available for screening
purposes (respiratory polysomnography).

Right heart catheterisation

Right heart catheterisation is used in the differential diagnosis of pulmonary hypertension.

Intensive care monitoring

The management of respiratory failure in the intensive care unit requires, in addition to frequent checking of ABGs, the measurement of several special parameters
(e.g. tidal volume, inspiratory and expiratory pressures); in mechanically ventilated patients, these are often measured automatically by the ventilator.

Arterial Blood Gas (ABG) Test

An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your
lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.
As blood passes through your lungs, oxygen moves into the blood while carbon dioxide moves out of the blood into the lungs. An ABG test uses blood drawn from an artery,
where the oxygen and carbon dioxide levels can be measured before they enter body tissues. An ABG measures:

Partial pressure of oxygen (PaO2): Measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the
blood.

Partial pressure of carbon dioxide (PaCO2): Measures how much carbon dioxide is dissolved in the blood and how well carbon dioxide is able to move out of the body.

pH: The pH measures hydrogen ions (H+) in blood. The pH of blood is usually between 7.35 and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0 is called
basic (alkaline). So blood is slightly basic.

Bicarbonate (HCO3): Bicarbonate is a chemical (buffer) that keeps the pH of blood from becoming too acidic or too basic.

Oxygen content (O2CT) and oxygen saturation (O2Sat) values: O2 content measures the amount of oxygen in the blood. Oxygen saturation measures how much of the
hemoglobin in the red blood cells is carrying oxygen (O2).Blood for an ABG test is taken from an artery. Most other blood tests are done on a sample of blood taken from a
vein, after the blood has already passed through the body's tissues where the oxygen is used up and carbon dioxide is produced.

Erswhitebook.org,. (2016). Respiratory function tests - ERS. Retrieved 21 January 2016, from
http://www.erswhitebook.org/chapters/principles-of-respiratory-investigation/respiratory-function-tests/
Hopkinsmedicine.org,. (2016). Pulmonary Tests and Procedures | Johns Hopkins Medicine Health Library. Retrieved 21 January 2016, from
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/

What is a Chest X-ray (Chest Radiography)?

The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray produces images of the heart, lungs,
airways, blood vessels and the bones of the spine and chest.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays
involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the
oldest and most frequently used form of medical imaging.
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What are some common uses of the procedure?

The chest x-ray is performed to evaluate the lungs, heart and chest wall.
A chest x-ray is typically the first imaging test used to help diagnose symptoms such as:

shortness of breath.

a bad or persistent cough.

chest pain or injury.

fever.

Physicians use the examination to help diagnose or monitor treatment for conditions such as:

pneumonia.

heart failure and other heart problems.

emphysema.

lung cancer.

line and tube placement.

fluid or air collection around the lungs.

other medical conditions.

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How should I prepare?

A chest x-ray requires no special preparation.
You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry,
removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images.
Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests
are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to
minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.
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What does the equipment look like?

The equipment typically used for chest x-rays consists of a wall-mounted, box-like apparatus containing the x-ray film, or a
special plate that records the image digitally. An x-ray producing tube is positioned about six feet away.
The equipment may also be arranged with the x-ray tube suspended over a table on which the patient lies. A drawer under the table
holds the x-ray film or digital recording plate.
A portable x-ray machine is a compact apparatus that can be taken to the patient in a hospital bed or the emergency room. The x-ray
tube is connected to a flexible arm that is extended over the patient while an x-ray film holder or image recording plate is placed
beneath the patient.
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How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most objects, including the body. Once it is carefully aimed at
the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an
image on photographic film or a special detector.

Different parts of the body absorb the x-rays in varying degrees. Dense bone absorbs much of the radiation while soft tissue, such as
muscle, fat and organs, allow more of the x-rays to pass through them. As a result, bones appear white on the x-ray, soft tissue shows
up in shades of gray and air appears black.
On a chest x-ray, the ribs and spine will absorb much of the radiation and appear white or light gray on the image. Lung tissue absorbs
little radiation and will appear dark on the image.
Until recently, x-ray images were maintained as hard film copy (much like a photographic negative). Today, most images are digital files
that are stored electronically. These stored images are easily accessible and are frequently compared to current x-ray images for
diagnosis and disease management.
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How is the procedure performed?

Typically, two views of the chest are taken, one from the back and the other from the side of the body as the patient stands against the
image recording plate. The technologist, an individual specially trained to perform radiology examinations, will position the patient with
hands on hips and chest pressed against the image plate. For the second view, the patient's side is against the image plate with arms
elevated.
Patients who cannot stand may be positioned lying down on a table for chest x-rays.
You must hold very still and may be asked to keep from breathing for a few seconds while the x-ray picture is taken to reduce the
possibility of a blurred image. The technologist will walk behind a wall or into the next room to activate the x-ray machine.
When the examination is complete, you may be asked to wait until the radiologist determines that all the necessary images have been
obtained.
The entire chest x-ray examination, from positioning to obtaining and verifying the images, is usually completed within 15 minutes.
Additional views may be required within hours, days or months to evaluate any changes in the chest.
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What will I experience during and after the procedure?

A chest x-ray examination itself is a painless procedure.
You may experience discomfort from the cool temperature in the examination room and the coldness of the recording plate. Individuals
with arthritis or injuries to the chest wall, shoulders or arms may have discomfort trying to stay still during the examination. The
technologist will assist you in finding the most comfortable position possible that still ensures diagnostic image quality.
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Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a
signed report to your primary care or referring physician, who will discuss the results with you.
The results of a chest x-ray can be available almost immediately for review by your physician.

Follow-up examinations may be necessary, and your doctor will explain the exact reason why another exam is requested. Sometimes a
follow-up exam is done because a suspicious or questionable finding needs clarification with additional views or a special imaging
technique. A follow-up examination may also be necessary so that any change in a known abnormality can be monitored over time.
Follow-up examinations are sometimes the best way to see if treatment is working or if an abnormality is stable or changed over time.
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What are the benefits vs. risks?

Benefits

No radiation remains in a patient's body after an x-ray examination.

X-rays usually have no side effects in the typical diagnostic range for this exam.

X-ray equipment is relatively inexpensive and widely available in emergency rooms, physician offices, ambulatory care centers,
nursing homes and other locations, making it convenient for both patients and physicians.

Because x-ray imaging is fast and easy, it is particularly useful in emergency diagnosis and treatment.

Risks

There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis
far outweighs the risk.

The effective radiation dose for this procedure varies. See the Safety page for more information about radiation dose.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.See
the Safety page for more information about pregnancy and x-rays.

A Word About Minimizing Radiation Exposure

Special care is taken during x-ray examinations to use the lowest radiation dose possible while producing the best images for evaluation.
National and international radiology protection organizations continually review and update the technique standards used by radiology
professionals.
Modern x-ray systems have very controlled x-ray beams and dose control methods to minimize stray (scatter) radiation. This ensures
that those parts of a patient's body not being imaged receive minimal radiation exposure.
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What are the limitations of Chest Radiography?

The chest x-ray is a very useful examination, but it has limitations. Because some conditions of the chest cannot be detected on a
conventional chest x-ray image, this examination cannot necessarily rule out all problems in the chest. For example, small cancers may
not show up on a chest x-ray. A blood clot in the lungs, a condition called a pulmonary embolism, cannot be seen on chest x-rays.
Further imaging studies may be necessary to clarify the results of a chest x-ray or to look for abnormalities not visible on the chest x-ray.

(ACR),. (2016). Chest X-ray (Radiography). Radiologyinfo.org. Retrieved 21 January 2016, from
http://www.radiologyinfo.org/en/info.cfm?pg=chestrad

Chest X-rays are a common type of exam. A chest X-ray is often among the first procedures you'll undergo if your doctor
suspects you have heart or lung disease. It can also be used to check how you are responding to treatment.

A chest X-ray can reveal many things inside your body, including:

The condition of your lungs. Chest X-rays can detect cancer, infection or air collecting in the space around a
lung (pneumothorax). They can also show chronic lung conditions, such as emphysema or cystic fibrosis, as well as
complications related to these conditions.

Heart-related lung problems. Chest X-rays can show changes or problems in your lungs that stem from heart
problems. For instance, fluid in your lungs (pulmonary edema) can be a result of congestive heart failure.

The size and outline of your heart. Changes in the size and shape of your heart may indicate heart failure, fluid
around the heart (pericardial effusion) or heart valve problems.

Blood vessels. Because the outlines of the large vessels near your heart the aorta and pulmonary arteries
and veins are visible on X-rays, they may reveal aortic aneurysms, other blood vessel problems or congenital heart
disease.

Calcium deposits. Chest X-rays can detect the presence of calcium in your heart or blood vessels. Its presence
may indicate damage to your heart valves, coronary arteries, heart muscle or the protective sac that surrounds the
heart. Calcium deposits in your lungs are most often from an old, resolved infection.
Fractures. Rib or spine fractures or other problems with bone may be seen on a chest X-ray.

Postoperative changes. Chest X-rays are useful for monitoring your recovery after you've had surgery in your
chest, such as on your heart, lungs or esophagus. Your doctor can look at any lines or tubes that were placed during
surgery to check for air leaks and areas of fluid or air buildup.

A pacemaker, defibrillator or catheter. Pacemakers and defibrillators have wires (leads) attached to your heart
to make sure your heart rate and rhythm are normal. Catheters are small tubes used to deliver medications or for
dialysis. A chest X-ray usually is taken after placement of such medical devices to make sure everything is positioned
correctly.

Normal Chest X-ray Test

As mentioned earlier, the image on chest X-ray film is in shades of black and white, similar to a negative of a regular
photograph. The shadows on a chest X-ray test depend on the degree of absorbed radiation by the particular organ based
on its composition. Bony structures absorb the most radiation and appear white on the film. Hollow structures containing
mostly air, such the lungs, normally appear dark. In a normal chest X-ray, the chest cavity is outlined on each side by the
white bony structures that represent the ribs of the chest wall. On the top portion of the chest is the neck and the collar
bones (clavicles). On the bottom, the chest cavity is bordered by the diaphragm under which is theabdominal cavity. On
either side of the chest wall, the bones of the shoulders and arms are easily recognizable.
Inside the chest cavity, the vertebral column can be seen down the middle of the chest, splitting it nearly in equal halves.
On each side of the midline, the dark appearing lung fields are seen. The white shadow of the heart is in the middle of the
field, atop the diaphragm and more to the left side. The trachea (wind pipe), aorta (main blood vessel exiting the heart),
and the esophagus descend down the middle, overlapping the vertebral column.
Abnormal Chest X-ray Test

Many abnormalities can be detected on a chest X-ray test. Common abnormalities seen on a chest X-ray test include:

pneumonia (abnormally white or hazy shadow on the lung fields that would normally look dark);

abscess in the lung (lung abscess);

fluid collection between the lung and the chest wall appearing whiter than the lungs and making the sharp lung borders on the film more hazy
(pleural effusion);

pulmonary edema (fluid build-up in the lung or its blood vessels) seen as diffuse haziness on the lung fields (for example, from congestive
heart failure);

enlarged heart size (or cardiomegaly);

broken ribs or arm bones (irregularity in the structure and shape of any of the ribs or the humerus bone of the arm);

broken vertebrae or vertebral fractures;

dislocated shoulders;

lung cancer or other lung masses (irregular and abnormal shadow on the lung fields);

cavities in the lungs or cavitary lung lesions (tuberculosis, sarcoidosis, etc.);

abnormal presence of air between the chest wall and the lung creating a distinct black shadow (darker than the lung fields) between the
border of the lung tissue and the inside border of the chest wall (pneumothorax);

hiatal hernia (protrusion of the upper portion of the stomach into the chest cavity); and

aortic aneurysm (dilated aorta - a widening of the midline of the chest overlying the vertebral column).

These are some of the common abnormal findings that can be seen on chest X-ray test. There are many other less
common abnormalities that can be detected on chest X-ray tests.

Bacteriologic examination of sputum material raised from the lungs and bronchi during deep coughing is an
important aid in managing lung disease. The usual method of specimen collection is expectoration. Other
methods include tracheal suctioning and bronchoscopy. A gram stain of expectorated sputum must be
examined to ensure that its representative of secretions from the lower respiratory tract rather than
contaminated by oral flora. Careful examination of an acid-fast sputum smear may provide presumptive
evidence of a mycobacterial infection, such as tuberculosis.
Sputum may be cultured to identify respiratory pathogens. Expectoration, the usual sputum collection method,
may require ultrasonic nebulization, hydration, or chest percussion and postural drainage. Less common
method include tracheal suctioning where in it provides a more reliable diagnostic specimen but generally isnt
used, unless expectoration fails to provide sample.

Purpose

To isolate and identify causes of pulmonary infections.

To aid diagnosis of respiratory diseases, such as bronchitis, tuberculosis, lung abscess,

and pneumonia.
Procedure
Preparation
1.
Inform the patient that his test requires a sputum specimen.
2.
Explain that the specimens may be collected on at least three consecutive mornings if
the suspected organism is Myobacterium Tuberculosis.
3.
Inform the patient that result for TB cultures take up to 2 months.
Implementation
Expectoration
1.
Put on gloves and a mask.
2.
Instruct the patient to cough deeply and expectorate into the container.
3.
If the cough in nonproductive, use chest physiotherapy or nebulization to induce
sputum, as ordered.

4.

Using aseptic technique, close the container securely and place it in a leak proof bag
before sending it to the laboratory.
Tracheal Suctioning
1.
Give oxygen to the patient before and after the procedure as necessary.
2.
Attach the sputum trap to suction catheter.
3.
Lubricate the catheter with normal saline solution and pass the catheter through the
nostril without suction.
4.
Advance the catheter into the trachea; apply suction while withdrawing the catheter,
not during catheter insertion.
5.
Suction only for 5 to 10 seconds at a time.
6.
Stop suction and remove the catheter.
7.
Discard the catheter in the proper receptacle.
8.
Detach the in-line sputum trap from the suction apparatus and cap the opening.
9.
During the passage through the throat and oropharynx, sputum specimens are
commonly contaminated with indigenous bacterial flora.
10. Label the container with the patients name, the nature and origin of the specimen,
the date and time of collection, the initial diagnosis, and any current antimicrobial
therapy.
11. Send the specimen to the laboratory immediately after collection.
Nursing Interventions
1.
Provide mouth care to the patient.
2.
Monitor his vital signs and respiratory status.
3.
Monitor oxygen saturation with a pulse oximeter.
4.
If the patient becomes hypoxic or cyanotic during suctioning, remove the catheter
immediately and give oxygen while suctioning pulse oximetry.
Interpretation
Normal Results
1.
Common flora includes alpha-hemolytic streptococci. Neisseria, and diptheroid.
2.
Presence of common flora doesnt rule out infection.
Abnormal Results
1.
Because sputum is invariably contaminated with normal oropharyngeal flora, a culture
isolate must be interpreted in light of the patients overall clinical condition.
2.
Isolation of Myobacterium Tuberculosis suggests tuberculosis.
3.
Isolation of pathogenic organisms most often includes Streptococcus pneumonia,
Myobacterium Tuberculosis, Klebsiella pneumoniae (and other Enterobacteriaceae),
Haemophilus influenzae, Staphyloccocus aureus, and Pseudomonas aeruginosa.
Complications

Hypoxemia

Cardiac arrhythmias

Laryngospasm

Bronchospasm

Pneumothorax

Perforation of the trachea or bronchus

Trauma to repiratory structures

Bleeding
Interfering Factors

Contaminated or inadequate sample.

What are pulmonary function tests?
Pulmonary function tests (PFTs) are non-invasive tests that show how well the lungs are working. The tests measure lung volume, capacity, rates of flow,
and gas exchange. This information can help your healthcare provider diagnose and decide the treatment of certain lung disorders.
There are 2 types of disorders that cause problems with air moving in and out of the lungs:

Obstructive. This is when air has trouble flowing out of the lungs due to resistance. This causes a decreased flow of air.
Restrictive. This is when the chest muscles cant expand enough. This creates problems with air flow.

PFT can be done with 2 methods:

Spirometry. A spirometer is a device with a mouthpiece hooked up to a small electronic machine.

Plethysmography. You sit or stand inside an air-tight box that looks like a short, square telephone booth to do the tests.

PFT measures:

Tidal volume (VT). This is the amount of air inhaled or exhaled during normal breathing.
Minute volume (MV). This is the total amount of air exhaled per minute.
Vital capacity (VC). This is the total volume of air that can be exhaled after inhaling as much as you can.
Functional residual capacity (FRC). This is the amount of air left in lungs after exhaling normally.
Residual volume. This is the amount of air left in the lungs after exhaling as much as you can.
Total lung capacity. This is the total volume of the lungs when filled with as much air as possible.
Forced vital capacity (FVC). This is the amount of air exhaled forcefully and quickly after inhaling as much as you can.
Forced expiratory volume (FEV). This is the amount of air expired during the first, second, and third seconds of the FVC test.
Forced expiratory flow (FEF). This is the average rate of flow during the middle half of the FVC test.
Peak expiratory flow rate (PEFR). This is the fastest rate that you can force air out of your lungs.

Normal values for PFTs vary from person to person. The amount of air inhaled and exhaled in your test results are compared to the average for someone
of the same age, height, sex, and race. Results are also compared to any of your previous test results. If you have abnormal PFT measurements or if your
results have changes, you may need other tests.

Why might I need pulmonary function tests?

There are many different reasons why pulmonary function tests (PFTs) may be done. They are sometimes done in healthy people as part of a routine
physical. Or you may have PFTs if your healthcare provider needs help to diagnose you with a health problem such as:

Allergies
Respiratory infections
Trouble breathing from injury to the chest or a recent surgery
Chronic lung conditions, such as asthma, bronchiectasis, emphysema, or chronic bronchitis
Asbestosis, a lung disease caused by inhaling asbestos fibers
Restrictive airway problems from scoliosis, tumors, or inflammation or scarring of the chest wall
Sarcoidosis, a disease that causes lumps of inflammatory cells around organs such as the liver, lungs, and spleen
Scleroderma, a disease that causes thickening and hardening of connective tissue

PFTs may be used to check lung function before surgery or other procedures in patients who have lung or heart problems, who are smokers, or who have
other health conditions. Another use of PFTs is to assess treatment for asthma, emphysema, and other chronic lung problems. Your healthcare provider
may also have other reasons to advise PFTs.

What are the risks of pulmonary function tests?

Because pulmonary function testing is not an invasive procedure, it is safe and quick for most people. But the person must be able to follow clear, simple
directions.
All procedures have some risks. The risks of this procedure may include:

Dizziness during the tests

Feeling short of breath
Coughing
Asthma attack brought on by deep inhalation

In some cases, a person shouldnt have PFTs. Reasons for this can include:

Recent eye surgery, because of increased pressure inside the eyes during the procedure
Recent belly (abdominal) or chest surgery
Chest pain, recent heart attack, or an unstable heart condition
A bulging blood vessel (aneurysm) in the chest, belly, or brain
Active tuberculosis (TB) or respiratory infection, such as a cold or the flu

Your risks may vary depending on your general health and other factors. Ask your healthcare provider which risks apply most to you. Talk with him or her
about any concerns you have.
Certain things can make PFTs less accurate. These include:

Use of medicines that open the airways (bronchodilators)

Use of pain medicines
Pregnancy
Stomach bloat that affects the ability to take deep breaths
Extreme tiredness or other conditions that affect a persons ability to do the tests

How do I get ready for pulmonary function tests?

Your healthcare provider will explain the procedure to you. Ask him or her any questions you have. You may be asked to sign a consent form that gives
permission to do the procedure. Read the form carefully. Ask questions if anything is not clear.
Tell your healthcare provider if you take any medicines. This includes prescriptions, over-the-counter medicines, vitamins, and herbal supplements.
Make sure to:

Stop taking certain medicines before the procedure, if instructed by your healthcare provider
Stop smoking before the test, if instructed by your healthcare provider
Not eat a heavy meal before the test, if instructed by your healthcare provider
Follow any other instructions your healthcare provider gives you

Your height and weight will be recorded before the test. This is done so that your results can be accurately calculated.

What happens during pulmonary function tests?

You may have your procedure as an outpatient. This means you go home the same day. Or it may be done as part of a longer stay in the hospital. The
way the procedure is done may vary. It depends on your condition and your healthcare provider's methods. In most cases, the procedure will follow this
process:

Youll be asked to loosen tight clothing, jewelry, or other things that may cause a problem with the procedure.
If you wear dentures, you will need to wear them during the procedure.
Youll need to empty your bladder before the procedure.
Youll sit in a chair. A soft clip will be put on your nose. This is so all of your breathing is done through your mouth, not your nose.
Youll be given a sterile mouthpiece that is attached to a spirometer.
Youll form a tight seal over the mouthpiece with your mouth. Youll be instructed to inhale and exhale in different ways.
You will be watched carefully during the procedure for dizziness, trouble breathing, or other problems.
You may be given a bronchodilator after certain tests. The tests will then be repeated several minutes later, after the bronchodilator has taken
effect.

What happens after pulmonary function tests?

If you have a history of lung or breathing problems, you may be tired after the tests. You will be given a chance to rest afterwards. Your healthcare
provider will talk with you about your test results.

Next steps
Before you agree to the test or the procedure make sure you know:

The name of the test or procedure

The reason you are having the test or procedure
The risks and benefits of the test or procedure
When and where you are to have the test or procedure and who will do it
When and how will you get the results
How much will you have to pay for the test or procedure

What is pulse oximetry?

Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It is an easy, painless measure of how well oxygen is being
sent to parts of your body furthest from your heart, such as the arms and legs.
A clip-like device called a probe is placed on a body part, such as a finger or ear lobe. The probe uses light to measure how much oxygen is in the blood.
This information helps the health care provider decide if a person needs extra oxygen.

Why might I need pulse oximetry?

Pulse oximetry may be used to see if there is enough oxygen in the blood. This information is needed in many kinds of situations. It may be used:

During or after surgery or procedures that use sedation

To
To
To
To

see how well lung medicines are working

check a persons ability to handle increased activity levels
see if a ventilator is needed to help with breathing, or to see how well its working
check a person has moments when breathing stops during sleep (sleep apnea)

Pulse oximetry is also used to check the health of a person with any condition that affects blood oxygen levels, such as:

Heart attack
Heart failure
Chronic obstructive pulmonary disease (COPD)
Anemia
Lung cancer
Asthma
Pneumonia

Your healthcare provider may have other reasons to advise pulse oximetry.

What are the risks of pulse oximetry?

All procedures have some risks. The risks of this procedure may include:

Incorrect reading if the probe falls off the earlobe, toe, or finger
Skin irritation from adhesive on the probe

Your risks may vary depending on your general health and other factors. Ask your healthcare provider which risks apply most to you. Talk with him or her
about any concerns you have.

How do I get ready for pulse oximetry?

Your healthcare provider will explain the procedure to you. Make sure to ask any questions you have about the procedure. If a finger probe is to be used,
you may be asked to remove fingernail polish.
Your healthcare provider may have other instructions for getting ready.

What happens during pulse oximetry?

You may have your procedure as an outpatient. This means you go home the same day. Or it may be done as part of a longer stay in the hospital. The
way the procedure is done may vary. It depends on your condition and your healthcare provider's methods. In most cases, pulse oximetry will follow this
process:

A clip-like device called a probe will be placed on your finger or earlobe. Or, a probe with sticky adhesive may be placed on your forehead or
finger.
The probe may be left on for ongoing monitoring.
Or it may be used to take a single reading. The probe will be removed after the test.

What happens after pulse oximetry?

You can go home after the test, unless you are in the hospital for another reason. You may go back to your normal diet and activities as instructed by
your healthcare provider. Your health care provider may give you other instructions after the procedure.

Next steps
Before you agree to the test or the procedure make sure you know:

The name of the test or procedure

The reason you are having the test or procedure
The risks and benefits of the test or procedure
When and where you are to have the test or procedure and who will do it
When and how will you get the results
How much will you have to pay for the test or procedure

Hopkinsmedicine.org,. (2016). Pulse Oximetry | Johns Hopkins Medicine Health Library. Retrieved 21 January 2016, from
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/oximetry_92,P07754/

Used to noninvasively monitor arterial oxygen saturation.

A photo detector slipped over the finger measures transmitted light as it passes
through the vascular bed, detects the relative amount of color absorbed by arterial

blood, and calculates exact mixed venous oxygen saturation without interference from
surrounding venous blood, skin, connective tissue, or bone.
Equipment

Oximeter

Sensor probe

Alcohol pads

Nail polish remover, if necessary

Preparation of Equipment

Review the manufacturers instruction for assembly.

Procedure

Reinforce the explanation of the procedure to the patient.

Using a finger probe

Select a finger (usually index finger) on the patients nondominant hand, if possible for
placement of the probe.

Remove fake fingernail and nail polish from the test finger.

Place the transducer (photoprotector) probe over the patients finger so the light
beams and sensor oppose each other.

Trim long fingernails or position the probe perpendicular to the finger.

Position the patients hand at heart level.

Turn on the power switch. If the device is working properly, a beep will sound, a display
will light momentarily, and the pulse search light will flash.

After four to six heartbeats the pulse amplitude indicator will begin tracking the pulse.

Rotate the sensor site according to the manufacturers instructions.

Clean the probe per facility policy between patients or, if disposable, discard.
Nursing Interventions
1.
Some machines have a pleth wave. A steady, level, even wave form ensures that the
numerical reading is accurate.
2.
The pulse rate on the oximeter should correspond to the patients actual pulse. If it
doesnt, monitor the patient, check the oximeter, and reposition the probe.
3.
Factors that interfere with accuracy include:
o
Elevated carboxyhemoglobin or methemoglobin levels
o
Lipid emulsions and dyes
o
Excessive light
o
Excessive patient movement
o
Hypothermia
o
Hypotension
o
Vasoconstriction
o
Medications such as dapsone, vasopressors.

Use the bridge of the nose if the patient has compromised circulation in his
extremities.

If an automatic blood pressure cuff is used on the same extremity as the

saturation probe is placed, the cuff will interfere with oxygen saturation readings during
inflation.

If the light is a problem, cover the probes.

If patient movement is the problem, move the probe or select a different probe.

Notify the physician of any significant change in the patients condition.

Pulse oximetryin context

PAT CARROLL, RN, BC, CEN, RRT, MS

PAT CARROLL, a member of the RN editorial board, is an independent nurse consultant and healthcare coordinator at Shelter NOW, a facility
for the homeless in Meriden, Conn.

KEY WORDS: pulse oximetry, arterial oxygen saturation (SpO or SaO ), arterial blood gas (ABG) analysis, partial oxygen
2

pressure (PaO ), partial carbon dioxide pressure (PaCO ), capnography, oxyhemoglobin dissociation curve
2

Pulse oximetry is a useful tool for assessing oxygen saturation, but it doesn't provide a complete picture of your
patient's respiratory status. Understanding what pulse oximetry can and can't do will help you to use this
technology wisely.
Jump to:

Pulse oximetry is a noninvasive method of monitoring a patient's pulse rate and arterial oxygen saturation. A pulse
oximeter uses a light-emitting diode (LED) and a photodetector to estimate the percentage of total hemoglobin that's
saturated (filled) with oxygen molecules, based on the amounts of red and infrared light that pass through the vascular
bed. Arterial oxygen saturation is represented by the symbol SpO when measured by pulse oximetry or SaO when
2

measured by arterial blood gas (ABG) analysis. For a healthy patient, an SpO of 97% 99% is generally considered
2

normal.

Pulse oximetry is now a part of routine perioperative monitoring, and is widely used to monitor patients in many different
settings, including the ED, OR, ICU, PACU, and med/surg units. However, because it doesn't provide any information
2

about a patient's ventilation, relying on pulse oximetry alone could compromise patient safety, particularly in patients who
are receiving supplemental oxygen or who are at risk of respiratory depression.

Yet, a recent study found that only 35% of nurses (and 39% of physicians) in a major medical center knew that pulse
oximetry monitored oxygen saturation only and did not reflect changes in ventilation. The study also found that an
3

educational program significantly improved clinicians' knowledge of pulse oximetry.

Pulse oximetry is a valuable tool, but it's only one part of a complete assessment of a patient's respiratory status. To be
most effective, it must be used properly, and in conjunction with other methods of respiratory monitoring. By understanding
the uses and limitations of pulse oximetry, you'll be able to better assess and care for your patients.

What pulse oximetry can and can't tell you

A complete respiratory assessment of at-risk patients must include assessment of bothoxygenation and ventilation.
Oxygenationhow well oxygen is moving across the alveolar-capillary membrane and into the blood to be carried to
tissuecan be determined by analyzing a patient's partial oxygen pressure (PaO ) and SpO (or SaO ). Ventilation (how
2

well a patient can exhale carbon dioxide produced by metabolic activities) can be determined by analyzing a patient's
partial carbon dioxide pressure (PaCO ), and the partial pressure of carbon dioxide in exhaled gasthe end-tidal
2

CO (EtCO ).
2

Pulse oximetry can tell you about saturation only; to assess other measures of oxygenation and ventilation, you need to
consider ABG analysis and capnography (which will be discussed below). In some cases, acceptable pulse oximetry
readings ("good sats") have falsely reassured clinicians despite serious deterioration in a patient's respiratory status as
shown by dangerously high levels of PaCO .
2

Taking a more comprehensive approach to respiratory monitoring is especially important for patients at increased risk of
respiratory depression, which can be precipitated by:
altered level of consciousness due to sedation, medications such as opioids, or other conditions;
decreased blood flow to the brain's respiratory centers as the result of increased intracranial pressure, shock, or other
factors;
fatigue associated with the increased work of breathing; or
cardiac or pulmonary diseases that affect oxygenation.
At-risk patients may need not only pulse oximetry but also ABG analysis or capnography. ABG analysis provides a more
complete picture of a patient's respiratory status, including PaO , PaCO , arterial pH, and acid-base balance, but it requires
2

a sample of arterial blood and takes time to receive the results.

A quicker, noninvasive way to monitor a patient's respiratory status is to use pulse oximetry to evaluate oxygen saturation
together with capnography to measure exhaled carbon dioxide that can provide information about ventilation.
Capnography provides a graphic representation (a capnogram) of the level of exhaled carbon dioxide (CO ). The
2

capnogram gives you breath-to-breath information about the CO that's being exhaled from the lungs. Apnea monitors are
2

an alternative to capnography, but false alarms occur more often with apnea monitors than with
capnography. Capnography devices are now easy to use and available for patients without artificial airways; exhaled
5

CO is collected from a nasal cannula-like device. Monitors are available for bedside use in med/surg, as part of portable
2

monitor-defibrillators for transport, and as cartridges that can be added to the wall-mounted component of central
monitoring systems in critical care areas.

SpO needs to be interpreted in context

2

To determine whether a patient has an adequate amount of oxygen in his blood, you need to first interpret his SpO value
2

in the context of his total hemoglobin. Not all patients with the same SpO have the same amount of oxygen in their blood.
6

For example, pulse oximetry may show that two patients, Mr. Thomas and Mr. Martin, both have what appears to be an
acceptable SpO of 97%. However, a complete blood count reveals that Mr. Thomas' total hemoglobin level is normal at 15
2

gm/dL, while Mr. Martin's is low at 11 gm/dL.

Recall that the standard formula used to determine overall oxygen content is the product of total hemoglobin level 3
saturation 3 1.34 ml (the amount of oxygen each gram of hemoglobin carries). Saturation values can be taken from an
ABG or from pulse oximetry, if oximetry results are found to be reliable. (See below for situations in which pulse oximetry
results should not be used.)
In our scenario, Mr. Thomas' overall oxygen content bound to hemoglobin is 19.50 ml/dL, which falls within the normal
range of 19 20 ml/dL. But Mr. Martin's content is far below normal at 14.30 ml/dL. Even though both patients' sats were
the same, each has a very different clinical picture.
In addition, SpO value can't be accurately interpreted without knowing about other factors that affect how oxygen binds to
2

hemoglobin, such as the patient's temperature, pH, and PaCO . The impact of each of these factors is demonstrated in the
2

oxyhemoglobin dissociation curve in the "The oxyhemoglobin dissociation curve" box. While PaO values shouldn't be
2

ignored, remember: Only 2% to 3% of all oxygen carried in the blood is dissolved in plasma and reflected in the
PaO value. The rest is bound to hemoglobin, which makes saturation all the more importantas long as it's interpreted in
2

context with other patient variables.

The technical side of accurate pulse ox data

To use a pulse oximeter correctly, you have to know what technical variables can affect the accuracy of a pulse oximetry
reading. One common cause of inaccurate SpO readings is patient movement, or, technically speaking, a "motion
2

artifact." Any motion, but particularly rhythmic movements such as tremors, shivering, or seizures, can affect the accuracy
7

of the pulse oximeter.

To avoid this, ask the patient to keep the extremity still, or try placing the sensor on a different part of the body, such as the
ear, that is less likely to be affected by motion. Don't apply the pulse oximeter on the hand distal to an automatic blood
pressure cuff, because when the cuff inflates, it will cut off blood flow to the sensor and cause the pulse oximeter to sound
an alarm.
Another factor affecting accuracy is the positioning of the pulse oximeter's LED and the photodetector when you attach the
sensor to the patient. The two components need to be directly opposite each other.
Since a pulse oximeter measures light, any bright light shining on the sensor applied to the patient (such as from warming
lights, sunlight, or a light used during a procedure) can be picked up by the sensor, which can result in inaccurate
readings. To determine if ambient light is affecting your readings, cup your hand around the sensor; if the reading
changes, it's likely that external light is the problem. If that's the case, cover the sensor with a washcloth or sheet, or move
it away from the light source.

The human side of accurate pulse ox data

Low perfusion due to decreased cardiac output or local vasoconstriction can also affect the accuracy of the reading. This
is because pulse oximeters rely in part on arterial pulsatile flow beneath the sensor that creates an intermittent signal to
measure oxygen saturation. (See "How pulse oximetry works".) Weak or nonexistent peripheral pulses can make it
impossible to obtain a reading or may produce an unreliable measurement. In particular, pulse oximetry shouldn't be used
on patients experiencing cardiac arrest, due to extreme limitations of blood flow.

How can you check to see if low perfusion is affecting your readings? One option is to compare the pulse rate displayed
on the pulse oximeter with a palpated pulse or apical heart rate. If they don't match, the oximeter isn't picking up each
arterial pulsation and your readings are probably not reliable. Moving the sensor to the patient's ear lobe, which is least
affected by poor blood flow, or to another digit, may allow you to obtain a more accurate reading.

You should also regularly monitor the pulse oximeter's signal strength indicator. Some monitors provide a waveform,
others a bar of light, and still others provide indicators such as a green light when signal strength is best, yellow when it's
borderline, and red when it's too low for an accurate reading.
Venous pulsationswhich may occur as a result of a rare cardiac defect like tricuspid regurgitationwill cause the
oximeter to record venous oxygen saturation instead of arterial saturation. Often, however, it's not a patient's physical
condition that causes venous pulsations. Taping a clip-on sensor to a toe or finger, for example, can impede venous return
and cause pulsation. To solve this problem, don't use tape, and transfer the sensor to a different extremity on a regular
basis.

Abnormal hemoglobins, such as carboxyhemoglobin or methemoglobin, can also affect how you interpret readings. The
pulse oximeter will accurately measure the percentage of filled binding sites on hemoglobin, but it cannot differentiate
between hemoglobin molecules filled with oxygen and those filled with carbon monoxide (or any other molecule). For
example, hemoglobin binds 200 250 times more readily to carbon monoxide than to oxygen, but because the pulse
oximeter cannot distinguish between the two, the device will give a high SpO reading even if half of the hemoglobin
2

molecules are filled with carbon monoxide and not oxygen. For this reason, pulse oximetry should never be used on
patients suspected of having carbon monoxide exposure; instead use ABG.

Similarly, anemia or polycythemia will not affect the accuracy of the SpO values, but as described above, these factors will
2

affect your interpretation of those values. In this case, you must know the patient's hemoglobin content. An anemic patient
may have a 99% saturation, but because there are fewer hemoglobin molecules, it's easier to fill them up and the total
oxygen content can be significantly decreased despite the "good sats." The jury is still out regarding whether pulse
oximetry readings are reliable in patients with sickle cell disease, in which the hemoglobin is shaped abnormally. Any
abnormalities of hemoglobin have the potential to make SpO readings unreliable.
2

In addition, any discoloration of the nail bed can affect pulse oximetry readings by altering the transmission of light through
the finger. Dark nail polish or bruising under the nail could result in a reading that's artificially low. You can try turning the
1

clip 90 degrees and then placing it on the finger so the light will pass through the finger side-to-side rather than through
the nail bed. Otherwise, move the sensor to the earlobe.

Know the limits of this technology

Even though a pulse oximeter's display can read from 0% 100%, most manufacturers will claim that their devices are
accurate for readings from 70% 100%. Therefore, if you observe a reading of 55% and have checked the signal strength
and verified that every arterial pulsation is being detected, make sure that you get an ABG right away. If the pulse oximeter
reading is below 70%, you really won't know what the true saturation is without an ABG.
Recent advances in pulse oximetry technology, such as signal extraction technology (SET) pulse oximetry, can
significantly reduce inaccuracies resulting from motion artifact or low perfusion. However, even the most accurate pulse
oximeter available does not provide information about a patient's ventilation. While pulse oximetry is an easy and effective
way to assess a patient's oxygen saturation, it's only part of a thorough respiratory assessment. By realizing the
indications and limitations of this widely used assessment tool, you will be able to use it most effectively.
An arterial blood gas (ABG) is a blood test that measures the acidity (pH) and the levels of oxygen and
carbon dioxide in the blood. Blood for an ABG test is taken from an artery whereas most other blood tests
are done on a sample of blood taken from a vein. This test is done to monitor several conditions that can
cause serious health complications especially to critically ill individuals.
Every day, a lot of nursing and medical students assigned in acute areas encounter ABG results, which
they may not necessarily be able to interpret with its knotty aspect. They struggle over the interpretation
of its measurements, but they are not especially complicated nor difficult if you understand the basic
physiology and have a step by step process to analyze and interpret them.
There may be various tips and strategies to guide you, from mnemonics, to charts, to lectures, to practice,
but this article will tell you how to interpret ABGs in the easiest possible way. And once you have finished
reading this, youll be doing actual ABG analysis in the NCLEX with fun and excitement! Here are the steps:

1. Know the normal values

Know the normal and abnormal ABG values when you review the lab reports. Theyre fairly easy to
remember: for pH, the normal value is 7.35 to 7.45; 35-45 for paCO 2; and 22-26 for HCO3. Remember also
this diagram and note that paCO2 is really inverted for the purpose of this method.

2. Determine if pH is under acidosis or alkalosis

Next thing to do is to determine the acidity or alkalinity of the blood through the value of pH. The pH level
of a healthy human should be between 7.35 to 7.45. The human body is constantly striving to keep pH in
balance.
pH level below 7.35 is acidosis
pH level above 7.45 is alkalosis

3. Determine if acid-base is respiratory or metabolic

Next thing you need to determine is whether the acid base is Respiratory or Metabolic.
paCO2 = Respiratory
HCO3 = Metabolic

4. Remember ROME
Still, it all boils down to mnemonics. The mnemonic RO-ME.
Respiratory Opposite
When pH is up, PaCO2 is down = Alkalosis
When pH is down, PaCO2 is up = Acidosis
Metabolic Equal
When pH is up, HCO3 is up = Alkalosis
When pH is down, HCO3 is down = Acidosis

5. Tic-Tac-Toe
And yes, ABG problems can be solved work using the tic-tac-toe method. All you have to do is make a
blank chart similar to this:

6. Mark the Chart

Using the lab result values, mark them on your tic-tac-toe. Lets begin with this sample problem:

pH: 7.26, paCO2: 32, HCO3: 18

Using the normal values reference chart in the first step, determine where the values should be under in
the tic-tac-toe. In the given example, the solution is as follows:
pH of 7.26 is LOW = ACID so place pH under Acid
paCO2 of 32 is LOW = BASE so place paCO2 under Base
HCO3 of 18 is LOW = ACID so place HCO3 under Acid
Your chart should look like this:

7. Match it up
In this step, determine at which column matches up with the pH. In the given example, HCO 3goes with pH.
HCO3 is considered Metabolic (shown in step 3), and both are under Acid, so this example implies Metabolic
Acidosis.

8. Determine compensation
The last step is to determine if the ABG is Compensated, Partially Compensated, or Uncompensated. Heres
the trick:
If pH is NORMAL, PaCO2 and HCO3 are both ABNORMAL = Compensated
If pH is ABNORMAL, PaCO2 and HCO3 are both ABNORMAL = Partially Compensated
If pH is ABNORMAL, PaCO2 or HCO3 is ABNORMAL = Uncompensated
Therefore this ABG is METABOLIC ACIDOSIS, PARTIALLY COMPENSATED .
By applying the steps above, interpret the following ABGs:
pH:7.44, PaCO2: 30, HCO3: 21
pH is NORMAL = NORMAL so place pH under Normal
PaCO2 is LOW = BASE so place PaCO2 under Base
HCO3 is LOW = ACID so place HCO3 under Acid
*Since the acidity of the blood is determined by the value of the pH, determine whether the normal pH is
SLIGHTLY ACIDIC or SLIGHTLY BASIC. In this example, pH is NORMAL but SLIGHTLY BASIC therefore it is
ALKALOSIS.
In this case PaCO2 goes with pH. PaCO2 is considered Respiratory (shown in step 3), and both are under
Basic, so this example implies Respiratory Alkalosis. The HCO3 is also abnormal. When pH is NORMAL and
PaCO2 and HCO3 are both ABNORMAL, it indicates FULL COMPENSATION.
Therefore this ABG is RESPIRATORY ALKALOSIS, FULLY COMPENSATED.
Try this problem next:

pH 7.1, PaCO2 40, HCO3 18

pH is LOW = ACID so place pH under Acid
PaCO2 is NORMAL = NORMAL so place PaCO2 under Normal
HCO3 is LOW = ACID so place HCO3 under Acid
In this case HCO3 goes with pH. HCO3 is considered Metabolic (shown in step 3), and both are under Acidic,
so this example implies Metabolic Acidosis. The PaCO2 is normal. When pH is ABNORMAL, and when either
one of PaCO2 or HCO3 is ABNORMAL, it indicates UNCOMPENSATION.
Therefore this ABG is METABOLIC ACIDOSIS, UNCOMPENSATED.
Wayne, G. (2015). 8-Step Guide to ABG Analysis: Tic-Tac-Toe Method - Nurseslabs. Nurseslabs. Retrieved 21 January 2016, from
http://nurseslabs.com/8-step-guide-abg-analysis-tic-tac-toe-method/

Interpreting an arterial blood gas (ABG) is a crucial skill for physicians, nurses, respiratory therapists, and other health care personnel.
ABG interpretation is especially important in critically ill patients.
The following six-step process helps ensure a complete interpretation of every ABG. In addition, you will find tables that list commonly
encountered acid-base disorders.
Many methods exist to guide the interpretation of the ABG. This discussion does not include some methods, such as analysis of base
excess or Stewarts strong ion difference. A summary of these techniques can be found in some of the suggested articles. It is unclear
whether these alternate methods offer clinically important advantages over the presented approach, which is based on the anion gap.
6-step approach:
Step 1: Assess the internal consistency of the values using the Henderseon-Hasselbach equation:
[H+] = 24(PaCO2)
[HCO3-]
If the pH and the [H+] are inconsistent, the ABG is probably not valid.

pH

Approximate [H+]
(mmol/L)

7.00

100

7.05

89

7.10

79

7.15

71

7.20

63

7.25

56

7.30

50

7.35

45

7.40

40

7.45

35

7.50

32

7.55

28

7.60

25

7.65

22

Step 2: Is there alkalemia or acidemia present?

pH < 7.35 acidemia
pH > 7.45 alkalemia

This is usually the primary disorder

Remember: an acidosis or alkalosis may be present even if the pH is in the normal range (7.35 7.45)

You will need to check the PaCO2, HCO3- and anion gap

Step 3: Is the disturbance respiratory or metabolic? What is the relationship between the direction of change in the pH and the
direction of change in the PaCO2? In primary respiratory disorders, the pH and PaCO2 change in oppositedirections; in metabolic
disorders the pH and PaCO2 change in the same direction.

Acidosis

Respiratory

pH

PaCO

Acidosis

Metabolic&

pH

PaCO

Alkalosis

Respiratory

pH

PaCO

Alkalosis

Metabolic

pH

PaCO

Step 4: Is there appropriate compensation for the primary disturbance? Usually, compensation does not return the pH to normal (7.35
7.45).

Disorder

Expected compensation

Correction factor

Metabolic acidosis

PaCO = (1.5 x [HCO -]) +8

Acute respiratory acidosis

Increase in [HCO -]= PaCO /10

Chronic respiratory acidosis (3-5 days)

Increase in [HCO -]= 3.5( PaCO /10)

Metabolic alkalosis

Increase in PaCO = 40 + 0.6(HCO -)

Acute respiratory alkalosis

Decrease in [HCO -]= 2( PaCO /10)

Chronic respiratory alkalosis

Decrease in [HCO -] = 5( PaCO /10) to 7( PaCO /10)

If the observed compensation is not the expected compensation, it is likely that more than one acid-base disorder is present.
Step 5: Calculate the anion gap (if a metabolic acidosis exists): AG= [Na+]-( [Cl-] + [HCO3-] )-12 2

A normal anion gap is approximately 12 meq/L.

In patients with hypoalbuminemia, the normal anion gap is lower than 12 meq/L; the normal anion gap in patients with
hypoalbuminemia is about 2.5 meq/L lower for each 1 gm/dL decrease in the plasma albumin concentration (for example, a
patient with a plasma albumin of 2.0 gm/dL would be approximately 7 meq/L.)

If the anion gap is elevated, consider calculating the osmolal gap in compatible clinical situations.
o

Elevation in AG is not explained by an obvious case (DKA, lactic acidosis, renal failure

Toxic ingestion is suspected

OSM gap = measured OSM (2[Na+] - glucose/18 BUN/2.8

o

The OSM gap should be < 10

Step 6: If an increased anion gap is present, assess the relationship between the increase in the anion gap and the decrease in [HCO3-].
Assess the ratio of the change in the anion gap (AG ) to the change in [HCO3-] ([HCO3-]): AG/[HCO3-]
This ratio should be between 1.0 and 2.0 if an uncomplicated anion gap metabolic acidosis is present.
If this ratio falls outside of this range, then another metabolic disorder is present:

If AG/[HCO3-] < 1.0, then a concurrent non-anion gap metabolic acidosis is likely to be present.

If AG/[HCO3-] > 2.0, then a concurrent metabolic alkalosis is likely to be present.

It is important to remember what the expected normal anion gap for your patient should be, by adjusting for hypoalbuminemia
(see Step 5, above.)
Table 1: Characteristics of acid-base disturbances

Disorder

pH

Primary problem

Compensation

Metabolic acidosis

in HCO -

in PaCO

Metabolic alkalosis

in HCO -

in PaCO

Respiratory acidosis

in PaCO

in [HCO -]

Respiratory alkalosis

in PaCO

in [HCO -]

Table 2: Selected etiologies of respiratory acidosis

o

Airway obstruction
- Upper
- Lower

COPD

asthma

other obstructive lung disease

CNS depression

Sleep disordered breathing (OSA or OHS)

Neuromuscular impairment

Ventilatory restriction

Increased CO2 production: shivering, rigors, seizures, malignant hyperthermia, hypermetabolism, increased intake of
carbohydrates

Incorrect mechanical ventilation settings

Table 3: Selected etiologies of respiratory alkalosis

o

CNS stimulation: fever, pain, fear, anxiety, CVA, cerebral edema, brain trauma, brain tumor, CNS infection

Hypoxemia or hypoxia: lung disease, profound anemia, low FiO2

Stimulation of chest receptors: pulmonary edema, pleural effusion, pneumonia, pneumothorax, pulmonary embolus

Drugs, hormones: salicylates, catecholamines, medroxyprogesterone, progestins

Pregnancy, liver disease, sepsis, hyperthyroidism

Incorrect mechanical ventilation settings

Table 4: Selected causes of metabolic alkalosis

o

Hypovolemia with Cl- depletion

o

GI loss of H+

Renal loss H+

Vomiting, gastric suction, villous adenoma, diarrhea with chloride-rich fluid

Loop and thiazide diuretics, post-hypercapnia (especially after institution of mechanical ventilation)

Hypervolemia, Cl- expansion

o

Renal loss of H+: edematous states (heart failure, cirrhosis, nephrotic syndrome), hyperaldosteronism,
hypercortisolism, excess ACTH, exogenous steroids, hyperreninemia, severe hypokalemia, renal artery stenosis,
bicarbonate administration

Table 5: Selected etiologies of metabolic acidosis

o

Elevated anion gap:

o

Methanol intoxication

Uremia

Diabetic ketoacidosisa, alcoholic ketoacidosis, starvation ketoacidosis

Paraldehyde toxicity

Isoniazid

Lactic acidosisa

Type A: tissue ischemia

Type B: Altered cellular metabolism

a
b

Ethanolb or ethylene glycolb intoxication

Salicylate intoxication

Most common causes of metabolic acidosis with an elevated anion gap

Frequently associated with an osmolal gap
o

Normal anion gap: will have increase in [Cl-]

o

GI loss of HCO3

Diarrhea, ileostomy, proximal colostomy, ureteral diversion

Renal loss of HCO3

proximal RTA

carbonic anhydrase inhibitor (acetazolamide)

Renal tubular disease

ATN

Chronic renal disease

Distal RTA

Aldosterone inhibitors or absence

NaCl infusion, TPN, NH4+ administration

Table 6: Selected mixed and complex acid-base disturbances

Disorder
Respiratory acidosis with metabolic
acidosis

Respiratory alkalosis with metabolic

alkalosis

Characteristics
in pH
in HCO
in PaCO
3

Selected situations

Cardiac arrest

Intoxications

Multi-organ failure

Cirrhosis with diuretics

Pregnancy with vomiting

Over ventilation of COPD

COPD with diuretics, vomiting, NG suction

in pH
in HCO in PaCO
3

Respiratory acidosis with metabolic

alkalosis

pH in normal range
in PaCO ,
in HCO 2

Respiratory alkalosis with metabolic

acidosis

pH in normal range
in PaCO
in HCO
2

Severe hypokalemia

Sepsis

Salicylate toxicity

Renal failure with CHF or pneumonia

Advanced liver disease

Uremia or ketoacidosis with vomiting, NG suction, diur

etc.

Metabolic acidosis with metabolic

alkalosis

pH in normal range
HCO - normal
3

Arterial Blood Gases

An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from
an artery. This test is used to check how well your lungs are able to move oxygen into the blood and remove carbon
dioxide from the blood.
As blood passes through your lungs, oxygen moves into the blood while carbon dioxide moves out of the blood into the
lungs. An ABG test uses blood drawn from an artery, where the oxygen and carbon dioxide levels can be measured before
they enter body tissues. An ABG measures:

Partial pressure of oxygen (PaO2). This measures the pressure of oxygen dissolved in the blood and how well oxygen is
able to move from the airspace of the lungs into the blood.
Partial pressure of carbon dioxide (PaCO2). This measures the pressure of carbon dioxide dissolved in the blood and how
well carbon dioxide is able to move out of the body.
pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually between 7.35 and 7.45. A pH of less than 7.0 is
called acid and a pH greater than 7.0 is called basic (alkaline). So blood is slightly basic.
Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood from becoming too acidic or too basic.
Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content measures the amount of oxygen in the blood.
Oxygen saturation measures how much of the hemoglobin in the red blood cells is carrying oxygen (O2).

Blood for an ABG test is taken from an artery. Most other blood tests are done on a sample of blood taken from a vein,
after the blood has already passed through the body's tissues where the oxygen is used up and carbon dioxide is
produced.

Why It Is Done
An arterial blood gas (ABG) test is done to:

Check for severe breathing problems and lung diseases, such asasthma, cystic fibrosis, or chronic obstructive pulmonary
disease (COPD).
See how well treatment for lung diseases is working.
Find out if you need extra oxygen or help with breathing (mechanical ventilation).
Find out if you are receiving the right amount of oxygen when you are using oxygen in the hospital.
Measure the acid-base level in the blood of people who have heart failure, kidney failure, uncontrolled diabetes, sleep
disorders, severe infections, or after a drug overdose.