analysis refers to the measurement of Ph and the partial pressure of oxygen (O2) and carbon diaoxide (CO2) in arterial

blood.
 To assess the effectiveness of gas exchange by

providing measurements of the partial pressures of O2 and CO2 in arterial blood.  Po2 = partial pressure of O2 Pao2 = partial pressure of O2 in arterial blood -- PaCO2 is controlled by ventilation and the level of ventilation is
adjusted to maintain PaCO2 within tight limits.

Note : P02 does not actually tell us how much O2 is in blood.

Amount of O2 in blood depends on:

 Hb concentration  Saturation of Hb with O2 (So2) carrying capacity is being used
how much of the

Po2 is not the amount of O2 in blood but is the driving force for saturating Hb with O2.

When Hb approaches maximal O2 saturation, futher increases in Po2 do not significantly increase blood O2 content.

There are 3 majors factors that dictate the PaO2:

 Alveolar ventilation  Matching of ventilation with perfussion (V/Q)  Concentration of O2 in inspired air (FiO2)

Both oxygenation and CO2 elimination depend on alveolar ventilation : impaired ventilation causes PaO2 to fall and PaCO2 to rise.

FiO2 = percentage of O2 in the air we breathe in. FiO2 in room air = 21% (can be increased)
The exact FiO2 requirement varies depending on how severely oxigenation is impaired and will help to determine the choice of delivery device

Oxigen delivery devices

 Nasal prongs : FiO2 < 40% (1-6L/min)  Standard Face Mask : FiO2 30-50%, 6-10L/min  Fixed performance (high flow) mask : FiO2 24-60%  Face mask with reservoir FiO2 60-80%  Endotracheal intubation : FiO2 21-100%

HYPOXIA (cells not getting enough O2)

Hypoxaemia (not enough O2 in blood)

Ischaemia (not enough blood)

Haemoglobin unable to carry O2

Low Haemoglobin

Low Pao2 (impaired oxygenation)

All tissues or specific tissues

low PaO2 with normal or low PaCO2. Assessing severity :

MILD PaO2 (kPa) PaO2 (mmHg) SaO2 (%) 8-10.6 60-79 MODERATE 5.3-7.9 40-59 SEVERE <5.3 <40

90-74

75-89

<75

High PaCO2 (hypercapnia) and due to inadequate alveolar ventilation The ABG in different patterns
PaCO2 ACUTE CHRONIC HCO3 pH

ACUTE ON CHRONIC

PaO2 TYPE 1

PaCO2 /

HCO3

ACUTE TYPE 1

CHRONIC TYPE 2*

HYPERVENTILATION * Acute on chronic distinguished from chronic by presence of H+

Respiratory mechanisms --- PaCO2--Renal (metabolic) mechanisms ---- HCO3 --*If our system is overwhelmed, leading to a change in
blood pH, the other usually adjusts, automatically, to limit the disturbance (e.g. if kidneys fail to excrete metabolic acids, ventilation is increased to exhale more O2)

PaCO2 raised = Respiratory acidosis PaCO2 low = Respiratory alkalosis HCO3 raised = Metabolic alkalosis HCO3 low = metabolic acidosis

When face with such an ABG, how can we tell which is the primary disturbance and which is the compensatory process?
 Overcompensation does not occur.

The mid-point of acid-base scales : pH 7.4 (< acidaemia) (alkalaemia)

 Patient is more important than ABG

HCO3 ( and negative base excess)

 HCO3 < 15mmol/L (or BE < 10) indicates severe

acidotic process pH < 7.25  hyperventilation (Kussmaul s respiration)

 Anion gap = (Na + K)

(Cl + HCO3)  Normal = 10- 18 mmol/L

HCO3
 Vomitting, potassium depletion, Cushing s

syndrome  Respiratory compensation ( PaCO2) occurs to limit the resulting alkalaemia but is limited by the need to avoid hypoxaemia

PaCO2 (

Ph)

 Reduced alveolar ventilation

Respiratory alkalosis


PaCO2 alveolar hyperventilation

H + ( 35-45nmol/L) pH : 7.35-7.45 Po2 : > 10.6 kPa

> 80mmHg

Na : 135 145 mmol/L K : 3.5-5 mmol/L Cl : 95-105 mmol/L iCa : 1.0-1.25 mmol/L Glucose : 3.5-5.5 mmol/L

Pco2 : 4.7-6.0 kPa

>35-45mmHg

SaO2 : > 96 in room air HCO3 act : 22-28 mmol/L BE : -2 to 2+ Lactate : 0.4-1.5 mmol/L Hb : 13-18g/dl men , 11.5-16g/dl women

NORMAL

NORMAL LOW

NORMAL

NORMAL HIGH

H/x: 25/M/gentleman
 KNMI  + Fever, + productive cough, + worsening

breathlessness x2/7  o/e : T= 39.3 C PR: 104  BP: 118/70 RR:30  Sao2 RA : 89%

NORMAL RANGE Ph Pco2 Po2 Bicarb BE SPo2 Lactate : K : Na : CI : iCa+ : Hb : Glocose : 7.50 3.74 kPa 28.1 mmHg 7.68 kPa 57.8 mmHg 23.9 0.5 mmol/L 88.7% 1.2 (0.4 1.5) 3.7 mmol/L (3.5 5) 138 mmol/L (135 145) 99 mmol/L (95 105) 1.2 mmol/L (1 1.25) 15 g/dL (13 18) 5.4 mmol/L (3.5 5.5) (7.35 7.45) (4.7 6.0) (35 45) (> 10.6) (> 80) (22 28) ( 2 +2) (> 98%)

H/x: 34/M/women
 Morbidly obese female with a body mass index of

49 has an ABG sample taken as part of her preoperative assessment for weight reduction surgery  Otherwise well and has no respirotary symptom.  Apart from morbid obesity and type 2 diabetis.  Otherwise well and has no respirotary symptom.

NORMAL RANGE Ph Pco2 Po2 Bicarb BE SPo2 Lactate : K : Na : CI : iCa+ : Hb : Glocose : 7.35 7.3 kPa 54.8 mmHg 9.6 kPa 72.2 mmHg 29 mmol/L +3.8 mmol/L 96% 1 (0.4 1.5) 4.7 mmol/L (3.5 5) 134 mmol/L (135 145) 102 mmol/L (95 105) 1.2 mmol/L (1 1.25) 13 g/dL (13 18) 9 mmol/L (3.5 5.5) (7.35 7.45) (4.7 6.0) (35 45) (> 10.6) (> 80) (22 28) ( 2 +2) (> 98%)

H/x: 24/M/women
 Nursing student - sudden-onset breathlessness.  May have a pulmonary embolism.  No pleuritic pain, haemopathysis or leg swelling,

no past history of lung disease and non smoker.  PR: 104  BP: 124/76  Sao2 RA : 95%

NORMAL RANGE Ph Pco2 Po2 Bicarb BE SPo2 Lactate : K : Na : CI : iCa+ : Hb : Glocose : 7.51 3.90 kPa 29.3 mmHg 10.3 kPa 77.0 mmHg 25.0 mmol/L +0.7 mmol/L 93.7% 1.0 (0.4 1.5) 4.3 mmol/L (3.5 5) 141 mmol/L (135 145) 101 mmol/L (95 105) 1.2 mmol/L (1 1.25) 13 g/dL (13 18) 4.6 mmol/L (3.5 5.5) (7.35 7.45) (4.7 6.0) (35 45) (> 10.6) (> 80) (22 28) ( 2 +2) (> 98%)

H/x: 75/M/gentleman
 Brought into the emergency department by his

family.  He has a long history of chronic obstructive pulmonary disease.  Over the last 3 days his breathing has worsened considerably and he has expectorated increase volume of sputum.  Struggling for breath and appears extremely distressed.

NORMAL RANGE Ph Pco2 Po2 Bicarb BE SPo2 Lactate : K : Na : CI : iCa+ : Hb : Glocose : 7.40 4.9 kPa 36 mmHg 5.8 kPa 44 mmHg 23 mmol/L 1.2 mmol/L 80% 1.0 (0.4 1.5) 4.1 mmol/L (3.5 5) 137 mmol/L (135 145) 99 mmol/L (95 105) 1.1 mmol/L (1 1.25) 16.5 g/dL (13 18) 3.8 mmol/L (3.5 5.5) (7.35 7.45) (4.7 6.0) (35 45) (> 10.6) (> 80) (22 28) ( 2 +2) (> 98%)