Acid Base Balance

Acid base balance is determined by hydrogen ion concentration in the body. Normal blood pH range is 7.35-7.45. Blood pH <7.35 = acidosis ; Blood pH >7.45 = alkalosis pH < 6.8 or > 8 is incompatible with life. Compensation will be taking place to maintain the balance of blood pH. Respiration(Lungs) will compensate metabolic problem over hours and metabolic(Kidneys) will compensate respiratory problem to maintain normal blood pH over days.

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Respiratory acidosis is defined as the process of producing acid (H+) because of retention of
CO2 by a decrease in alveolar ventilation.

Clinical Features Hypercapnia Hypoventilation Headache Visual disturbances confusion drowsiness coma depressed tendon reflexes hyperkalemia ventricular fibrillation (secondary to hyperkalemia)

Treatment-Aimed at the underlying disease. -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. -Stop smoking.

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A respiratory alkalosis is defined as the process of reducing arterial blood acid (H+) because of
blowing off CO2 by an increase in alveolar ventilation.

Clinical Features Hypocapnea lightheadedness numb/tingling of digits tetany, convulsions hypokalemia cardiac dysrhythmias (secondary to hypokalemia)

Treatment-Aimed at the underlying disorder. -Respiratory alkalosis itself is rarely life threatening. Therefore, emergent treatment is usually not indicated unless the pH level is greater than 7.5. Because respiratory alkalosis usually occurs in response to some stimulus, treatment is usually unsuccessful unless the stimulus is controlled. -If the PCO2 is corrected rapidly in patients with chronic respiratory alkalosis, metabolic acidosis may develop due to the renal compensatory drop in serum bicarbonate. -The tidal volume and respiratory rate may be decreased in mechanically ventilated patients who have respiratory alkalosis. Inadequate sedation and pain control may be the etiology of respiratory alkalosis in patients breathing over the set ventilator rate. -In hyperventilation syndrome, patients benefit from reassurance, rebreathing into a paper bag during acute episodes, and treatment for underlying psychological stress. Sedatives and/or antidepressants should be reserved for patients who have not responded to conservative treatment. -Beta-adrenergic blockers may help control the manifestations of the hyperadrenergic state that can lead to hyperventilation syndrome in some patients.(2) -In patients presenting with hyperventilation, a stepwise approach should be used to rule out potentially life-threatening, organic causes first.

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Metabolic acidosis is defined as the process of increasing acid (H+) in the blood that can occur
by ingestion, infusion or production of a fixed acid or by eliminating HCO3. Examples are excessive diarrhea when HCO3- is lost, or diabetic ketoacidosis, and lactic acidosis postcardiac arrest when H+ is produced.

Clinical Features Bicarbonate deficit hyperventilation headache mental dullness deep respirations stupor coma hyperkalemia cardiac sysrhthmias (secondary to heperkalemia)

Treatment-Treatment of metabolic acidosis is controversial. -For many years bicarbonate was the mainstay of treatment, but evidence is now accumulating that its effects are mainly cosmetic and may be harmful (Cooper et a I 1990). These include shifting the oxygen dissociation curve thereby inhibiting the release of oxygen, causing hypematraernia and hyperosmolarity, and provoking an intracellular acidosis (Ritter et al 1990). -It would seem that treatment of the cause of the acidosis should be the primary objective.

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Metabolic alkalosis is defined as the process of reducing arterial blood acid (H+) in the blood
that can occur by excessive loss of fixed acids or by ingestion, infusion, or excessive renal absorption of bases eg, HCO3. Examples are overzealous intravenous infusion of sodium

Clinical Features Bicarbonate excess depressed respirations mental confusion dizziness numbness/tinggling of digits muscle twitching, tetany convulsions hypokalemia cardiac dysrhythmia (secondary to hypokalemia)

Treatment:
-Correct cause if possible (eg correct pyloric obstruction, cease diuretics) -Correct the deficiency which is impairing renal bicarbonate excretion (ie give chloride, water and K+). -Expand ECF Volume with N/saline (and KCl if K+ deficiency). -Rarely ancillary measures such as:HCl infusion, Acetazolamide (one or two doses only), Oral lysine hydrochloride. -Supportive measures (eg give O2 in view of hypoventilation; appropriate monitoring and observation). -Avoid hyperventilation as this worsens the alkalaemia.

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References: (1) Donna Frownfelter & ElizabethDean. Cardiovascular and Pulmonary Physical Therapy, 4th Edition. 2006: 233 (2) Effros RM, Wesson JA. Acid-Base Balance. In: Mason RJ, Broaddus VC, Murray JF, Nadel JA, eds. Murray and Nadel's Textbook of Respiratory Medicine. Vol 1. 4th ed. Philadelphia, PA: Elsevier Saunders; 2005:192-93. (3) W. Darlene Reid & Frank Chung. Clinical Management Notes and Case Histories of Cardiopulmonary Physical Therapy. 2004:23-30

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