BGA and Clinical Importance

Dicky Soehardiman

Division of Interventional Pulmonology and Respiratory Critical Care

Department of Pulmonology & Respiratory Medicine,
Faculty of Medicine
University of Indonesia Persahabatan Hospital
 Respiratory System

Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott Williams &
Wilkins; 2006.
 Henderson-Hasselbach

Stewart

Vet Clin Pathol 2000;29:115-128.

Stewart Acid Base Disorders

Fencl V. Am J Respir Crit Care Med 2000;162:2246-51

 Acid Base Disorders
Henderson-Hasselbach Stewart
Anion gap SID
Respiratory disorders: pCO2 Respiratory disorders: pCO2
Metabolic disorder: HCO3 Metabolic disorders:
o SID: water (Na+), Cl - , UA,
o nonvolatile weak acid (albumin &
phosphate)
ACIDOSIS ALKALOSIS
ACID BASE DISORDERS
Henderson-Hasselbach

35 < pCO2 < 45

NORMAL

RESPIRATORY

METABOLIC

7,35 7,45

22 < HCO3 < 26

 ACIDOSIS ALKALOSIS

pCO2>45

pCO2<35

RESPIRATORY

METABOLIC 7,35 7, 45

HCO3<22
HCO3>26
RESPIRATORY ACIDOSIS

Respiratory acidosis is caused by disorders in:

1.Respiratory controller:
Automatic controller
Behaviour
pCOcontroller
2 > 45
2. Ventilatory pump problem:
Chest wall muscles
Chest wall skeleton
Chest wall connective tissue
Airways
Pleura
Spinal cord & peripheral nerves
Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott
Williams & Wilkins; 2006.
Ventilatory Pump

Schwartsein RM, Parker MJ. Respiratory physiology: a clinical approach. Philadelphia: Lippincott
Williams & Wilkins; 2006.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB
Sauders; 1995.
 RESPIRATORY ACIDOSIS
ALKALOSIS

Respiratory alkalosis is caused by disorders in gas exchanger:

Ventilation perfusion mismatch: dead space & shunt
Diffusion abnormalities
pCO2 < 45
Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott
Williams & Wilkins; 2006.
 Respiratory System

Schwartsein RM, Parker MJ. Respiratory physiology:a clinical approach. Philadelphia: Lippincott
Williams & Wilkins; 2006.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB
Sauders; 1995.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB
Sauders; 1995.
 METABOLIC ACIDOSIS

HCO3 < 22
Metabolic acidosis is caused by:
1.Loss of base
2.Accumulation of nonvolatile acid
METABOLIC ACIDOSIS

No. Normal Anion Gap (HHARDUP) High Anion Gap (MUDPILES)

1. Hypoaldosteronism Methanol use

2. Hyperosmolar nonketotic coma Uremia (renal failure)

HCO3 < 22
3. Acetazolamide Diabetic ketoacidosis

Poisons (paraldehyde,
4. Renal tubular acidosis
phenformin, propylene glycol)

5. Diarrhea Iron, INH

6. Uterosigmoidectomy, ileostomy Lactic acidosis

7. Pancreatic fistule Ethanol or ethylene glycol use

8. _ Salicylate use, starvation

Spector SA. Critical care companion. 2000

 Treatment
Treat the underlying disease
HCO3 corection
 METABOLIC ACIDOSIS
ALKALOSIS

HCO3 > 26
Metabolic alkalosis is caused by:
1.Loss of nonvolatile acid
2.Accumulation of base
 METABOLIC ALKALOSIS
ACIDOSIS

Chloride responsive Chloride unresponsive

No.
metabolic alkalosis metabolic alkalosis (D.VAGA)

1. Contraction alkalosis Diuretics

HCO3 > 26
2. Diuretics Vomiting

3. Villous adenoma Aldosteronism

Gastric loss from large volume

4. vomiting or continuous gastric Gastric drainage
suction

5. Alkali intake (antacids)

Spector SA. Critical care companion. 2000

 Treatment
Treat the underlying disease
Correct hypovolemia
Correct hypokalemia,
Corect hypochloride (if there is)
Acetazolamide (500 mg every 6 hours)
 ACIDOSIS ALKALOSIS

RESPIRATORY 1.5xHCO3 + (201.5)

METABOLIC
HCO3<22

Compensation
 ACIDOSIS ALKALOSIS

0.7xHCO3 + (82)
RESPIRATORY

METABOLIC

HCO3>26

Compensation
 Prediction

PaCO2 pH HCO3

80 7,2 28
20 60 7,3 26

40 7,4 24

10 30 7,5 22

20 7,6 20

Shapiro BA, Peruzzi WT, Templin R. Clinical application of blood gas. St. Louis: Mosby; 1994.
Pierce LNB. Guide to mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders; 1995.
 ACIDOSIS ALKALOSIS

Respiratory Controller + Ventilatory Pump

Gas Exchanger

RESPIRATORY

METABOLIC 7,35 7, 45

Metabolic alkalosis is caused by:

Metabolic acidosis is caused by:
1.Loss of nonvolatile acid
1.Loss of base
2.Accumulation of base
2.Accumulation of nonvolatile acid
 ACIDOSIS ALKALOSIS

1. Treat the underlying disease

2. Oxygen therapy

RESPIRATORY

METABOLIC 7,35 7, 45

1. Treat the underlying disease 1. Treat the underlying disease

2. Bicnat correction 2. Electrolyte correction
3. Azetazolamide correction
 Summary
Role of lung and kidneys is to maintain acid
base balance
Respiratory acidosis is caused by disorder of
respiratory controller and ventilatory pump
problems.
Respiratory alkalosis is caused by gas
exchanger problems.
 Summary
Metabolic acidosis is caused by loss of base or
accumulation of nonvolatile acid.
Metabolic alkalosis is caused by loss of
nonvolatile acid or accumulation of base.
 Formula
1. PAO2 = (713xFiO2) (PaCO2 x 1.25)
2. PaO2 = PaO2 target
PAO2 PAO2 new
PAO2 new = (PAO2 x PaO2 target)
PaO2
3. PAO2 new = (713xFiO2) (PaCO2 x 1.25)
FiO2 = PAO2 new + (PaCO2 x 1.25)
713
 Example
BGA: no oxygen
pH: 7.1
pCO2: 70 mmHg
PO2: 60 mmHg
HCO3: 30 mmHg
BE: - 5.0
Sat O2: 80 %
 Formula
1. PAO2 = (713xFiO2) (PaCO2 x 1.25)
= (713 x 0.21) (70 x 1.25)
= 149.73 87.5 = 62.23 (=62)
2. PAO2 new = (PAO2 x PaO2 target)
PaO2
= (62 x 90) = 93
60
3. FiO2 = PAO2 new + (PaCO2 x 1.25)
713
3. FiO2 = PAO2 new + (PaCO2 x 1.25)
713

= 93 + (70 x 1.25) = 93+87.5 = 0.25

713
4. AaDO2= 62-60=2
 Pemilihan jenis alat berdasarkan FiO2
No. Jenis alat Aliran (L/m) FiO2
1. Kanul hidung 1 0,24
2 0,28
3 0,32
4 0,36
5 0,40
6 0,44
2. Simple Mask 5-6 0,4
6-7 0,5
7-8 0,6
3. Rebreathing Mask 7 0,65
8-15 0,7-0,8
4. Nonrebreathing Mask Atur reservoir jgn 0,85-1,0
kempes

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
 AaDO2
AaDO2 = PAO2 PaO2

AaDO2 Kelainan

< 20 Normal

20-40 V/Q mismatch

40-60 Shunt

>60 Gangguan difusi

 Example
BGA: nasal cannula 6 Lpm
pH: 7.1
pCO2: 70 mmHg
PO2: 60 mmHg
HCO3: 30 mmHg
BE: - 5.0
Sat O2: 80 %
 Formula
1. PAO2 = (713xFiO2) (PaCO2 x 1.25)
= (713 x 0.44) (70 x 1.25)
= 313.72 87.5 = 226.22(=226)
2. PAO2 new = (PAO2 x PaO2 target)
PaO2
= (226 x 90) = 339
60
3. FiO2 = PAO2 new + (PaCO2 x 1.25)
713
3. FiO2 = PAO2 new + (PaCO2 x 1.25)
713

= 339 + (70 x 1.25) = 339+87.5 = 0.598

713 713
4. AaDO2=226-60=166
 Pemilihan jenis alat berdasarkan FiO2
No. Jenis alat Aliran (L/m) FiO2
1. Kanul hidung 1 0,24
2 0,28
3 0,32
4 0,36
5 0,40
6 0,44
2. Simple Mask 5-6 0,4
6-7 0,5
7-8 0,6
3. Rebreathing Mask 7 0,65
8-15 0,7-0,8
4. Nonrebreathing Mask Atur reservoir jgn 0,85-1,0
kempes

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
 AaDO2
AaDO2 = PAO2 PaO2

AaDO2 Kelainan

< 20 Normal

20-40 V/Q mismatch

40-60 Shunt

>60 Gangguan difusi