clinical Mohammad Alhajji
Respiratory Failure and Blood gas analysis
Respiratory system consists of two parts:
Ø Gas exchange organ (lung): responsible for OXYGENATION
Ø Pump (respiratory muscles and respiratory control mechanism): responsible for
VENTILATION
Ø Definition:
o “Failure to maintain oxygenation and carbon dioxide elimination”
Ø Clinical Definition:
o PaO2 <60 mmHg while breathing air Hypoxemic Type I
o PaCO2 >50 mmHg Hypercapnic Type II
Ø Respiratory failure: Inadequate gas exchange function of the lungs PFT
Ø When the lungs fail to adequately oxygenate the arterial blood and/or fail to
prevent undue CO2 retention
Respiratory System Components
Ø CNS (medulla) - Peripheral nervous system (phrenic nerve)
Ø Respiratory muscles - Chest wall - Lung - Upper airway
Ø Bronchial tree - Alveoli - Pulmonary vasculature
Terminology
Ø Anoxia: Absence of oxygen supply. No oxygen.
Ø Asphyxia: Absence of O2 and accumulation of CO2
Ø Hypoxia: Low oxygen in the body, often specified
o e.g. tissue hypoxia, alveolar hypoxia
Ø Hypoxemia: Low oxygen in the blood. [PaO2].
Not every hypoxic patient is hypoxemic, but all hypoxemic patients are hypoxic.
Gas Exchange Unit
Ø Deoxygenated blood comes from the body to the right side of the
heart pulmonary artery pulmonary capillaries (where gas
exchange occurs) pulmonary vein takes oxygenated blood to
the left side of the heart systemic circulation.
Causes of arterial hypoxemia
Ø Reduced PIO2 (High altitude)
Ø Hypoventilation (Central, alveolar)
Ø Ventilation/perfusion mismatch (Asthma, COPD, PE)
Ø Shunt (intrapulmonary, intra-cardiac)
Ø Diffusion abnormality (ILD)
Done by Alanoud Adam
clinical Mohammad Alhajji
Ø The patient can be hypoxemic if the fraction of oxygen (FiO 2) is low (low
pressure like in high altitude).
Ø Ventilation without perfusion pulmonary embolism
Ø Perfusion without ventilation lung collapse or alveoli full of exudates due
to pneumonia (HYPOVENTILATION)
Ø Diffusion abnormality normal ventilation and perfusion BUT no optimal
gas exchange at the level of the alveoli because of alveolar septal thickening.
Range of V/Q mismatch
a. alveolus is not ventilated (exudates due to pneumonia)
V/Q mismatch
b. area of collapse with suboptimal ventilation V/Q
mismatch
c. normal V/Q match
d. + e. partial or complete blockage of vessels
ventilation without perfusion
V/Q ratio in normal lung
Ø Upper areas of the lungs are well ventilated compared to lower areas of the
lungs, which are better perfused V/Q ratio is higher in the upper areas
Shunt
Ø An extreme V/Q mismatch
Ø Blood passes through parts of respiratory system that receives no ventilation
o obstruction OR fluid accumulation
o Not Correctable with 100% O2
Oxyhemoglobin Dissociations Curve
Ø Left shift of the curve is a sign of hemoglobin's increased
affinity for oxygen (e.g. at the lungs)
Ø A rightward shift indicates that the hemoglobin has a
decreased affinity for oxygen. (at the peripheral tissues)
Ø Any changes above 8 kPa will cause minor changes.
However, any decrease below 8kPa will cause significant hypoxemia
Respiratory Quotient (RQ)
Ø CO2 produced : O2 consumed
Ø RQ = CO2 produced/O2 consumed = 0.8
Alveolar gas equation
Ø Alveolar gas equation is important because in cases of
hypoxemia, we calculate the alveolar - arterial gradient
(A-a gradient) helps in differentiating type 1 and
type 2 respiratory failure and predicting the cause of the
respiratory failure.
Done by Alanoud Adam
clinical Mohammad Alhajji
Ø Since the PICO2 in trachea is 0, it is removed from the equation. So, the
tracheal oxygen pressure relies on the barometric pressure (760), water vapor
pressure (-47) and the fraction of O2 in inspired air (FICO2)(0.21).
Ø In the alveolar space, oxygen diffuses into the blood and CO2 diffuses into the
alveolus from the blood. That’s why when we calculate the alveolar pressure of
O2 we have to consider CO2 and so RQ is important.
Ø please watch this 🎬 https://youtu.be/VFDKE2P1Bn8
Oxygenation and Ventilation
Ø hypoxemic patient, either increase the proportion of O2 in
the mixture at the level of the alveolus by oxygenation
(increase paO2) or increase the total pressure at the level of
the alveolus by giving positive pressure ventilation without
changing the proportion of each gas.
Ø We give CPAP (Continuous Positive Airway Pressure) to
hypoxemic patients if oxygen alone is not enough to improve the oxygen
saturation and hypoxemia.
Ø CPAP can help in better gas diffusion and oxygenation.
Alveolar gas equation and A-a O2 gradient
Ø why we use
o PaCO2 PAO2 = (PIO2) – (PaCO2/R)
Ø In a normal individual breathing room air:
o PAO2 = 150 – 40/0.8 = 100 mmHg
Ø A-a O2 gradient
o is the difference between alveolar and arterial PO2
Ø This number is a result of imperfect diffusion, low V/Q areas at the lung bases,
and physiological shunts
Ø Normal A-a gradient < 10-15 mmHg
Ø please watch this 🎬 https://youtu.be/rTXTc8MNQ60
A-a gradient = 10-15 (healthy adults)
Ø Decreased A-a gradient
o Alveolar hypoventilation (elevated PACO2)
o Low PiO2 (FiO2 < 0.21 or barometric pressure < 760 mmHg)
Ø Increased A-a gradient
o V/Q mismatch
o Diffusion defect
o Right-to-Left shunt (intrapulmonary or cardiac)
o Increased O2 extraction (CaO2-CvO2)
Done by Alanoud Adam
clinical Mohammad Alhajji
Hypoxemic Respiratory Failure (Type I)1 gas abnormality
Ø PaO2 <60mmHg
Ø Normal or low PaCO2
Ø Most common form of respiratory failure
Ø Interferes with pulmonary O2 exchange, but overall
ventilation is maintained
Ø Physiologic causes: Ventilation/Perfusion (V/Q) mismatch
and shunt
Hypercapnic Respiratory Failure (Type II) 2 gas abnormality
Ø PaCO2 >50 mmHg
Ø Hypoxemia is usually present
Ø PH depends on level of HCO3
Ø HCO3 level depends on duration of hypercapnia
Ø A-a gradient normal if pure type II respiratory failure
Ø it can be:
o Acute – Chronic - Acute on chronic
Causes of Hypercapnic Respiratory Failure
Ø Respiratory center (medulla) dysfunction
o Drug over dose, CVA, tumor, hypothyroidism, central hypoventilation
Ø Neuromuscular disease
o Guillain-Barre, Myasthenia Gravis, polio, spinal injuries
Ø Chest wall/Pleural diseases
o kyphoscoliosis, pneumothorax, massive pleural effusion
Ø Upper airways obstruction
o tumor, foreign body, laryngeal edema
Ø Peripheral airway disorder
o COPD
Clinical Signs of Severe Hypercapnia
Ø Cyanosis
Ø Confusion, somnolence and coma
Ø Convulsions
Ø Bounding pulse
Ø Papilledema
Ø Flapping tremor
o due to metabolic encephalopathy, it can be seen in patients with liver failure
Blood Gas Analysis
Ø pH 7.35 - 7.45
Ø PaCO2 35 - 45 mm Hg
Ø HCO3¯ 22 - 26 mEq/L
Ø PaO2 70 - 100 mm Hg
Ø SaO2 93 - 98%
Done by Alanoud Adam
clinical Mohammad Alhajji
ABG Interpretation
Ø Step 1 Look at pH Normal 7.35-7.45
o Acidotic < 7.35
o Alkalotic >7.45
o If normal 7.35-7.45
- High normal? 7.4-7.45 normal/alkalotic
- Low normal? 7.35-7.40 normal/acidic
Ø Step 2 Look at PaCO2 Normal 35 - 45 mm Hg
o Is it altered (i.e. increased or decreased)?
o If altered, consider the direction of the alteration:
o Normal pCO2 35-45mmHg
- Below 35 - alkalotic
- Above 45 - acidotic
Ø Step 3 Look at HCO3- Normal 22-26 mEq/L
o Is it altered (i.e. increased or decreased)?
o If altered, consider the direction of the alteration
o Normal HCO3 22-26 mEq/L
- HCO3 < 22 - acidotic
- HCO3 > 26 - alkalotic
Ø Step 4 Decide if the abnormal pH is caused by the pCO2 (respiratory causes) or
the HCO3 (metabolic causes).
o pH acidotic and PCO2 acidotic (same direction) = Resp Acidosis
o pH alkalotic and PCO2 alkalotic (same direction) = Resp Alkalosis
o pH alkalotic and HCO3 alkalotic (same direction) = Met Alkalosis
o pH acidotic and HCO3 acidotic (same direction) = Met Acidosis
Ø Step 5 Determine if compensation is present
o Does the CO2 or HCO3 go the opposite direction of the pH?
- (Acidotic vs Alkalotic)
o If yes, compensation is present.
o If no, compensation is not present.
- For example, pH is acidotic, CO2 is acidotic, and HCO3 is alkalotic, then
compensation is present
Expected changes in pH and HCO3- for a 10 mm Hg change in PaCO2 resulting
from either respiratory acidosis or respiratory alkalosis
ACUTE CHRONIC
Ø Step 6 Assess oxygenation
o Look at PaO2 and SaO2 Resp Acidosis Resp Acidosis
o Normal? pH ↓ by 0.08 pH ↓ by 0.03
HCO ↑ by 1
- HCO ↑ by 3.5 -
o Hypoxemic 3 3
o Check A-a gradient Resp Alkalosis Resp Acidosis
pH ↑ by 0.08 pH ↑ by 0.03
HCO3- ↓ by 2 HCO3- ↓ by 5
Done by Alanoud Adam
clinical Mohammad Alhajji
Test Your Knowledge 💡
https://nurseslabs.com/arterial-blood-gas-abgs-nclex-quiz/
Done by Alanoud Adam
