Arterial Blood Gas Workshop

Dr. Lanzona

Hypoxemia
* Central hypoventilation
* Decreased inspired oxygen tension
* Diffusion limitation
* V/Q of zero (shunt)
* Low V/Q

12.06.07

Hypercapnia
* Increased CO2 production
* Decreased ventilatory drive
* Malfunction of the respiratory pump
* Inefficiency of gas exchange
Respiratory Equation
#1. Henderson-Hasselbach
pH = 6.1 + log HCO3- / PaCO2 x 0.03
Arterial Blood Gas
Information:
* Ventilation Status
* Acid-Base Balance
* Oxygenation Status
Normal Values:
7.35 7.45
* pH
35 45 mm Hg
* PaCO2
* PaO2
80 100 mm Hg
22 26 mEq/L
* HCO3
95%
* O2 SAT

Acid-Base Balance
Abnormality
Respiratory
Acidosis
Alkalosis
Metabolic
Acidosis
Alkalosis

Compensation

CO2
CO2

HCO3
HCO3

HCO3
HCO3

CO2
CO2

#2. Alveolar Ventilation

VA = KVCO2 / PaCO2
VE = VT x RR (min)
VA = VE VD VE total minute ventilation
VD dead space ventilation

Ideal Lung Unit

#3. Alveolar Gas

PAO2 = FiO2 (PB - PH2O) PACO2/R
B

FiO2 = fractional content of inspired O2

PB = barometric pressure (760 torr at sea level)
PH2O = vapor pressure of water in the alveoli at (full saturation at
37C) is 47 torr
PACO2 = alveolar CO2 tension identical to PaCO2
R = respiratory quotient (CO2 production divided by O2 consumption
0.8)

Hypoxia: refers to
reduced oxygen in the
alveolus
Hypoxemia: refers to
reduced oxygen in the
blood

Alveolar Gas at Room Air

PAO2 = 0.21 (760 - 47) PACO2/0.8
PAO2 = 150 1.25 x PACO2

Lala 3C-Med-09

#4. Alveolar-arterial oxygen difference AaDO2

PAO2 = FiO2 (PB - PH2O) PACO2/R
PaO2 = arterial O2 result
PAO2 - PaO2 = 10 20 torr
B

PAO2 - PaO2 < 15 torr

Why does a gradient exist?
1. small amount of cardiac output behaves as a shunt
2. ventilation-perfusion gradients from the top to the
bottom of the lungs

O2 Hemoglobin Curve

Causes of Increased AaDO2

Shunt
* Low V/Q
* High V/Q
* Diffusion block

** Refer to module handout for algorithm on respiratory/metabolic

alkalosis and acidosis (uncompensated, compensated, partly
compensated)

V/Q Relationship
Important Equations to Remember
1. Henderson-Hasselbach
pH = 6.1 + log HCO3- / PaCO2 x 0.03
2.

Alveolar Ventilation
VA = VCO2 / PaCO2 x K
VE = VD + VA

3.

Alveolar Air Equation

PAO2 = FiO2 (PB - PH2O) PACO2/R
PAO2 = FiO2 (713) PACO2 / 0.8
B

4.

Alveolar-arterial O2 difference (AaDO2)

AaDO2 = PAO2 PaO2
PAO2 is derived from the alveolar air equation (eq #3)
PaO2 is derived from the ABG result
Lala 3C-Med-09

Normal AaDO2 is 10 20 torr (this value may increase to 30

torr in the elderly)
5.

aAO2 ratio
aAO2 ratio = PaO2 / PAO2
PAO2 is derived from the alveolar air equation (eq #3)
PaO2 is derived from the ABG result
Normal aAO2 ratio is 0.75

6.

P/F ratio (PaO2/FiO2)

PaO2 is derived from the ABG result
FiO2 is fraction of inspired oxygen (equation #7)
Normal P/F ratio is 400 - 500

7.

FiO2 in patients on supplemental oxygen (1 to 6 liters/min) by

nasal cannula
FiO2 = liters/minute given x 4 + 20
Example: patient given 5 liters minute (lpm) of oxygen by
nasal cannula
FiO2 = 5 x 4 + 20
FiO2 = 40
If substituted in the alveolar air equation (equation #3)
FiO2 is 0.40

8.

Desired FiO2
A. Compute for PAO2
B. Compute for aAO2 ratio (equation #5)
C. Compute for desired FiO2

Case 1. A 24 year old student is brought to the ER cyanotic and

profoundly weak. His roommate who brought him told you that an
empty medicine bottle was found at the patients bedside. His ABG
results:
pH = 7.0
PaCO2 = 80
PaO2 = 37
HCO3- = 26
1. Is the patient acidemic or alkalemic?
pH = 7.0 (N: 7.35 - 7.45) , therefore patient is acidemic.
2. Is the patient hypoxemic?
Yes
No
3. Does that patient have a pneumonia to account for his extreme
hypoxemia?
Compute PaO2
PAO2 = FiO2 (PB - PH2O) PACO2/R
PAO2 = .21 (713) 80 / 0.8
PAO2 = 50
Compute for AaDO2
AaDO2 = PAO2 PaO2
AaDO2 = 50 37
AaDO2 = 13 Normal
In hypoventilation, AaDO2 is normal.
In V/Q mismatch and shunt, AaDO2 is increased.
Since AaDO2 is normal, then the patient does not have
pneumonia.
4. What is the mechanism of hypoxemia?
Hypoventilation
V/Q mismatch
Shunt
Diffusion defect
B

Oxygen was given at 6 lpm per nasal cannula. Repeat ABG results
showed
pH = 7.2
PaCO2 = 65
PaO2 = 70
HCO3 - = 26
5. Compute for the percentage of oxygen given?
FiO2 = liters/minute given x 4 + 20
FiO2 = 6 x 4 + 20
FiO2 = 44
21
40
44
60
6. Compute for P/F ratio
PaO2 / FiO2 = 70 / .44 = 159
N: 400 500
130
140
150
160
7. What is the oxygenation status?
More than adequate oxygenation
Adequate oxygenation with supplemental oxygen
Inadequate oxygenation with supplemental oxygen
Hypoxemia
8. Compute for desired FiO2 if your aim is to increase the PaO2 is
80mm Hg?
PAO2 = FiO2 (PB - PH2O) PACO2/R
PAO2 = 0.44 (713) 65/ 0.8
PAO2 = 232.47 232

* desired PaO2 is usually computed at 80 100 (normal PaO2

values)
Steps in Acid-Base Analysis
Step 1: Acidemic or Alkalemic?
Step 2: Is the primary disturbance respiratory or metabolic?
Step 3: Is there compensation (acute or chronic)?
Step 4: For a metabolic acidosis, is there an increased anion gap?
Step 5: Are there other metabolic processes present in a patient
with an increased anion gap metabolic acidosis?
Step 6: Is the respiratory system compensating adequately for a
metabolic disturbance?
Oxygenation
At room air
* Patients < 60 years old the expected PaO2 is 80 100
mmHg
* Patients > 60 years old
Expected PaO2 is 80 (years above 60)
Example: 70-years-old male
Expected PaO2 = 80 10 = 70
Oxygenation Status
* Patients < 60
PaO2 < 80 = hypoxemic
PaO2 80 100 = adequate oxygenation
PaO2 > 100 = more than adequate oxygenation
* Patients > 60
PaO2 < expected = hypoxemic
PaO2 = expected and < 100 = adequate
PaO2 > 100 = more than adequate oxygenation
* With supplemental O2 therapy
PaO2 < 80 = inadequate oxygenation
PaO2 80 100 = adequate oxygenation
PaO2 > 100 = more than adequate oxygenation

aAO2 ratio = PaO2 / PAO2

aAO2 ratio = 70 / 232 = 0.30

Lala 3C-Med-09

= 0.50

50%

50%
55%
60%
65%
Case #2. A 71 year old male, retired teacher, is admitted to the
ICU with a history of increasing dypsnea, cough, and sputum
production. He has a 120 pack year smoking history, and quit 5
years previously. On exam he is moving minimal air despite using
his accessory muscles of respiration. He has acral cyanosis. He
was given 2 liters per minute of oxygen by inhalation.
His ABG results: pH = 7.29
PaCO2 = 60
HCO3 = 29
PaO2 = 60
1.

2.

What is the etiology of this mans hypoxemia?

Neuromuscular disease
Pneumonia
Airways disease due to COPD
Pulmonary embolism
Name the acid-base disturbance(s) present. (Refer to page 6
of module handout)
Partly compensated respiratory acidosis
Uncompensated respiratory acidosis
Combined respiratory and metabolic acidosis
Compensated metabolic acidosis

Lala 3C-Med-09