Niki Paphitou, MD, FRCPC, FCCP Critical Care-Infectious Diseases, NGH ICU
PaCO2 equation: PaCO2 reflects ratio of metabolic CO2 production to alveolar ventilation
VCO2 x 0.863
VCO2 = CO2 production VA = VE VD VE = minute (total) ventilation VD = dead space ventilation 0.863 converts units to mm Hg
PaCO2
= ----------------VA
Hypercapnia
VCO2 x 0.863 PaCO2 =
------------------
VA The only physiologic reason for elevated PaCO2 is inadequate alveolar ventilation (VA) for the amount of the bodys CO2 production (VCO2). Since alveolar ventilation (VA) equals minute ventilation (VE) minus dead space ventilation (VD), hypercapnia can arise from insufficient VE, increased VD, or a combination.
Hypercapnia
VCO2 x 0.863 PaCO2 =
------------------
VA
VA = VE VD
Examples of inadequate VE leading to decreased VA and increased PaCO2: sedative drug overdose; respiratory muscle paralysis; central hypoventilation Examples of increased VD leading to decreased VA and increased PaCO2: chronic obstructive pulmonary disease; severe pulmonary embolism, pulmonary edema.
P(A-a)O2
P(A-a)O2 is the alveolar-arterial difference in partial pressure of oxygen. It is commonly called the A-a gradient. It results from gravity-related blood flow changes within the lungs (normal ventilation-perfusion imbalance). Normal P(A-a)O2 ranges from 5 to 25 mm Hg breathing room air (it increases with age). A higher than normal P(A-a)O2 means the lungs are not transferring oxygen properly from alveoli into the pulmonary capillaries. Except for right to left cardiac shunts, an elevated P(A-a)O2 signifies some sort of problem within the lungs.
Ventilation-Perfusion imbalance
A normal amount of ventilation-perfusion (V-Q) imbalance accounts for the normal P(A-a)O2. By far the most common cause of low PaO2 is an abnormal degree of ventilation-perfusion imbalance within the hundreds of millions of alveolar-capillary units. Virtually all lung disease lowers PaO2 via V-Q imbalance, e.g., asthma, pneumonia, atelectasis, pulmonary edema, COPD. Diffusion barrier is seldom a major cause of low PaO2 (it can lead to a low PaO2 during exercise).
Hb = hemoglobin in gm%; 1.34 = ml O2 that can be bound to each gm of Hb; SaO2 is percent saturation of hemoglobin with oxygen; .003 is solubility coefficient of oxygen in plasma: .003 ml dissolved O2/mm Hg PO2.
CO poisoning was missed on the first set of blood gases because SaO2 was not measured!
Causes of Hypoxia
1. Hypoxemia (=low PaO2 and/or low CaO2) a. reduced PaO2 usually from lung disease (most common physiologic mechanism: V-Q imbalance) b. reduced SaO2 -- most commonly from reduced PaO2; other causes include carbon monoxide poisoning, methemoglobinemia, or rightward shift of the O2-dissociation curve c. reduced hemoglobin content -- anemia 2. Reduced oxygen delivery to the tissues a. reduced cardiac output -- shock, congestive heart failure b. left to right systemic shunt (as may be seen in septic shock) 3. Decreased tissue oxygen uptake a. mitochondrial poisoning (e.g., cyanide poisoning) b. left-shifted hemoglobin dissociation curve (e.g., from acute alkalosis, excess CO, or abnormal hemoglobin structure)
Terminology
Acidemia: blood pH < 7.35 Alkalemia: blood pH > 7.45 Acidosis: a physiologic process that tends to cause acidemia Alkalosis: a physiologic process that tends to cause alkalemia
100 80 50 40 30 20 10
Does any change in the PaCO2 account for the direction of the change in PH?
Respiratory acidosisEtiology
Upper airway obstruction Lower airway obstruction Cardiogenic or non-cardiogenic pulmonary edema Pneumonia Pulmonary emboli Fat emboli Central nervous system depression Neuromascular impairment Ventilatory restriction
Respiratory alkalosisEtiology
Central nervous system stimulation: Fever, pain, fear, cerebrovascular accident, CNS infection, trauma, tumor. Hypoxia: High altitude, profound anemia, pulmonary disease. Stimulation of chest receptors: Pulmonary edema, pulmonary emboli, pneumonia, pneumothorax, pleural effusion. Drugs or hormones : Salicylates, medroxyprogesterone, catecholamines. Miscellaneous: Sepsis, pregnancy, liver disease, hyperthyroidism.
Metabolic Acidosis
Elevated AG acidosis
Ketoacidosis: Diabetic, starvation, alcoholic. Lactic acidosis. Uremia (phosphates, sulfates, organic anions). Toxins: Ethylene glycol, methanol, salicylate.
Metabolic Acidosis
Normal AG acidosis
The fall in bicarbonate is matched by a proportional rise in serum chloride (hyperchloremic metabolic acidosis). Most common causes are gastrointestinal and renal loses of bicarbonate. More rarely, it is caused by rapid dilution of the plasma bicarbonate by saline.
Renal losses
Renal insufficiency Proximal RTA Distal RTA Type 4 RTA Acetazolamide
Metabolic alkalosis
Most common cause is volume depletion, urine Clis low and the alkalosis resolves after volume replacement (vompiting, NG suction). Can also occur with bicarbonate administration, mineralcorticoid excess, acetates in TPN, diuretics. Urine Cl- is 40 mEq/l.
Case study 1
A 25 y old asthmatic presents acutely short of breath to the ER with a PH of 7.56, pa CO2 20, HCO3 24 and 02 Sat. 96%.
Case study 2
A 30 y old woman with a history of eating disorder comes to the ER with a change in mental status and vomiting. An empty bottle of aspirin is found in her bedroom. Na 134, K 4.3, Cl 90, HCO3 10, BUN 20, creatinine 0.7, PH 7.52, PaCO2 28, Pa O2 73, Sat. 93%.
Case study 3
A 19 y old girl with type I DM and depression with alcoholism, has severe nausea and vomiting for several days. Lethargic, RR 34/min, HR 120/min, BP orthostatic. Na 135, Cl 70, K 3.6, HCO3 19, BUN 21, Glucose 580, sOsm. 315, PH 7.58, PaCO2 21, PaO2 104.
Case study 4
A 50 y old man with a history of renal transplant and baseline creatinine 2.0, is brought to the ICU with tachypnea and lethargic after surgery for VP shunt placement for NPH. His RR is 35, he moans to paiful stimuli BP 120/70, HR 120. He underwent cataracts surgery 10 days ago. Creatinine is 3.O, urea 40, HCO3 8, PH 7.10, Paco2 25, PaO2 9o on room air, Na 134, CL96.
MEDICALPPTX.COM