ABG Interpretation

ABG Interpretation
Dr. Augusto S. Sablan Jr., DPCP, DPCCP

Objectives
• To learn the basic steps in ABG interpretation
• To be able to correlate ABG results with
common clinical problems
Normal Values for ABG
Parameters Normal Range
pH 7.35-7.45
PaCO2 35-45 mmHg
HCO3 22-26 meq/L
PaO2 80-120 mmHg
Base Excess +2.5 to – 2.5 meq/L

Acid-Base Terminology
• Acidemia : blood pH < 7.35
• Acidosis – a primary physiologic process

occurring alone can cause acidemia
• Metabolic Acidosis
• Respiratory Acidosis
• Alkalemia : blood pH > 7.45
• Alkalosis – a primary physiologic process

occurring alone can cause alkalemia
• Metabolic Alkalosis
• Respiratory alkalosis
• Primary acid-base disorder
– One of the four acid-base disturbances that is
manifested by an initial change in HCO3- or PaCO2.
• Compensation
– The change in HCO3- or PaCO2 that results from the
primary event.
Steps in ABG interpretation
• Step 1: Assess internal consistency of values
– Henderson-Hasselbach equation
– [H+] = 24(PaCO2)
[HCO3-]
– pH is inversely related to [H+]; a pH change of 1.00
represents a 10-fold change in [H+]
– If the pH and the [H+] are inconsistent, the ABG is
probably not valid.
• Step 1: Assess internal consistency of values
pH [H+] in nanomoles/L
7.00 100
7.10 80
7.30 50
7.40 40
7.52 30
7.70 20
8.00 10
•
• Step 2: Is there alkalemia or acidemia present?
– pH < 7.35 acidemia
pH > 7.45 alkalemia
• This is usually the primary disorder
• Remember: an acidosis or alkalosis may be
present even if the pH is in the normal range
(7.35 – 7.45)
• You will need to check the PaCO2, HCO3- and
anion gap
• Step 3: Is the disturbance respiratory or
metabolic?
• What is the relationship between the direction
of change in the pH and the direction of change
in the PaCO2?
• In primary respiratory disorders, the pH and
PaCO2 change in opposite directions
• In metabolic disorders the pH and PaCO2 change
in the same direction.
Steps in ABG Interpretation
• Step 3: Is the disturbance respiratory or
metabolic?
Primary disorder pH PaCO2
Respiratory Acidosis
Metabolic Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
• Step 4: Degrees of compensation
• Partially Compensated:
– The body has begun to correct the problem
– pH has not returned to normal
• Fully compensated:
– Compensatory mechanism has corrected the acid-
base balance
– pH is in Normal range
STATUS pH PCO2 HCO3 BE
RESPIRATORY ACIDOSIS
Uncompensated 7.35 45 Normal Normal
Partially compensated 7.35 45 26 +2
Compensated 7.35-7.40 45 26 +2
RESPIRATORY ALKALOSIS
Uncompensated 7.45 35 Normal Normal
Partially compensated 7.45 35 22 -2
Compensated 7.40-7.45 35 22 -2
METABOLIC ACIDOSIS
Uncompensated 7.35 Normal 22 -2
Partially compensated 7.35 35 22 -2
Compensated 7.35-7.40 35 22 -2
METABOLIC ALKALOSIS
Uncompensated 7.45 Normal 26 +2
Partially compensated 7.45 45 26 +2
Compensated 7.40-7.45 45 26 +2
COMBINED RESPIRATORY AND METABOLIC ACIDOSIS 7.35 45 22 -2
COMBINED RESPIRATORY AND METABOLIC ALKALOSIS 7.45 35 26 +2

EXAMPLE NO.1
pH 7.28 acidotic
PaCO2 (torr) 54 acidotic 1. INSPECT THE pH. (Is it acidotic or

alkalotic?)
HCO3 (mmol/L) 29 alkalotic
2. INSPECT THE PaCO2. (Can it explain
BE (mmol/L) +5 alkalotic the pH?)
PaO2 (torr) 90 3. INSPECT THE HCO3. (Can it explain

the pH?)
SaO2 (%) 97 4. CHECK FOR COMPENSATION. (Did
the causative component
Age 22 respond appropriately?)
FiO2 0.4
Interpretation: Partially compensated respiratory acidosis

• Step 5: Prediction of underlying secondary
problem
Respiratory acidosis:
Expected HCO3 = [ (actual PaCO2 – 40) X 0.4 ] + 24 ± 2
Respiratory alkalosis:
Expected HCO3 = 24 – [(40 – actual PaCO2) X 0.5 ] ± 2
• Step 5: Prediction of underlying secondary
problem
Metabolic acidosis:
Expected PaCO2 = (1.5 X HCO3) + 8 ± 2
Metabolic alkalosis:
Expected PaCO2 = [ ( actual HCO3 – 24 ) X 0.6 ] + 40 ± 2
EXAMPLE NO.1 Respiratory acidosis:
pH 7.28 Expected HCO3 = [ (actual PaCO2 – 40) X 0.4 ] + 24 ± 2

PaCO2 (torr) 54
Expected HCO3 = [ (54 – 40) X 0.4 ] + 24 ± 2
HCO3 (mmol/L) 29
BE (mmol/L) +5 Expected HCO3 = 29.6 ± 2
PaO2 (torr) 90
Expected HCO3 = 27.6 – 31.6 meq/L
SaO2 (%) 97
There is no underlying metabolic alkalosis. The
Age 22 problem is purely respiratory acidosis.
FiO2 0.40
Interpretation: Partially compensated respiratory acidosis with

corrected hypoxemia (or oxygenation)
• Step 6: Assessment of Oxygenation
• Patient at Room Air , under 60 year old
State of Oxygenation PaO2 (mmHg)
More than adequate oxygenation >120
Adequate oxygenation 80-120
Mild hypoxemia 70-79
Moderate hypoxemia 60-69
Severe hypoxemia < 60
• Step 6: Assessment of Oxygenation
– Uncorrected hypoxemia: PaO2 < 80 mmHg
– Corrected hypoxemia/oxygenation: PaO2 80-100

mmHg
– Overcorrected hypoxemia/oxygenation: PaO2 >100

mmHg
EXAMPLE NO.2
pH 7.47 alkalotic
PaCO2 (torr) 28.6 alkalotic
HCO3 (mmol/L) 20.5 acidotic
BE (mmol/L) -1.5
acidotic
PaO2 (torr) 95.2
SaO2 (%) 97.7
Age 72
Oxygen Room
air
Interpretation: Partially compensated respiratory alkalosis with

adequate oxygenation
EXAMPLE NO.3
pH 7.461 alkalotic
PaCO2 (torr) 58.1 acidotic
HCO3 (mmol/L) 40.9 alkalotic
BE (mmol/L) +14.1 alkalotic
PaO2 (torr) 57.5
SaO2 (%) 90.4
Age 78
Oxygen 4L
Interpretation: Partially compensated Metabolic alkalosis with

uncorrected hypoxemia
EXAMPLE NO.4
pH 7.499 alkalotic
PaCO2 (torr) 35.8 normal
HCO3 (mmol/L) 27.7 alkalotic
BE (mmol/L) +4.8 alkalotic
PaO2 (torr) 87.6
SaO2 (%) 97.2
Age 54
FiO2 3L
Interpretation: Uncompensated Metabolic alkalosis with

corrected hypoxemia
EXAMPLE NO.5
pH 7.445 normal
PaCO2 (torr) 28 alkalotic
HCO3 (mmol/L) 18.9 acidotic
BE (mmol/L) -3.3 alkalotic
PaO2 (torr) 68.0

Expected HCO3: 16-20 mmol/L
SaO2 (%) 94.1
Age 79
Oxygen Room
air
Interpretation: Fully compensated respiratory alkalosis with

moderate hypoxemia
Respiratory Acid-base Disorders:
Some Clinical Causes
RESPIRATORY ACIDOSIS ↑PaCO2 & ↓ pH
Central nervous system depression (e.g., drug overdose)
Chest bellows dysfunction (e.g., Guillain-Barré syndrome, myasthenia
gravis)
Disease of lungs and/or upper airway (e.g., chronic obstructive lung
disease, severe asthma attack, severe pulmonary edema)
RESPIRATORY ALKALOSIS ↓PaCO2 & ↑ pH

Hypoxemia (includes altitude)
Anxiety
Sepsis
Any acute pulmonary insult (e.g., pneumonia, mild asthma attack, early
pulmonary edema, pulmonary embolism)
Metabolic Acid-base Disorders:
Some Clinical Causes
METABOLIC ACIDOSIS ↓HCO3- & ↓ pH
- Increased anion gap
• lactic acidosis; ketoacidosis; drug poisonings (e.g., aspirin,
ethylene glycol, methanol)
- Normal anion gap
• diarrhea; some kidney problems (e.g., renal tubular acidosis,
interstitial nephritis)
METABOLIC ALKALOSIS ↑ HCO3- & ↑ pH

• Chloride responsive (responds to NaCl or KCl therapy): contraction
alkalosis, diuretics, corticosteroids, gastric suctioning, vomiting
• Chloride resistant: any hyperaldosterone state (e.g., Cushing’s syndrome,
Bartter’s syndrome, severe K+ depletion)
Summary
• Examine pH, PaCO2, and HCO3- for the obvious primary acid-base
disorder and for deviations that indicate mixed acid-base disorders
• Use a full clinical assessment (history, physical exam, other lab data
including previous arterial blood gases and serum electrolytes) to
explain each acid-base disorder.
• Remember that co-existing clinical conditions may lead to opposing
acid-base disorders.
• Treat the underlying clinical condition(s) and not the values
• Clinical judgment should always apply

Thank you

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ABG Interpretation

Dr. Augusto S. Sablan Jr., DPCP, DPCCP

PaCO2 35-45 mmHg

HCO3 22-26 meq/L

PaO2 80-120 mmHg

Base Excess +2.5 to – 2.5 meq/L

• Acidosis – a primary physiologic process

• Alkalosis – a primary physiologic process

COMBINED RESPIRATORY AND METABOLIC ACIDOSIS 7.35 45 22 -2

COMBINED RESPIRATORY AND METABOLIC ALKALOSIS 7.45 35 26 +2

PaCO2 (torr) 54 acidotic 1. INSPECT THE pH. (Is it acidotic or

PaO2 (torr) 90 3. INSPECT THE HCO3. (Can it explain

Interpretation: Partially compensated respiratory acidosis

pH 7.28 Expected HCO3 = [ (actual PaCO2 – 40) X 0.4 ] + 24 ± 2

BE (mmol/L) +5 Expected HCO3 = 29.6 ± 2

Interpretation: Partially compensated respiratory acidosis with

– Corrected hypoxemia/oxygenation: PaO2 80-100

– Overcorrected hypoxemia/oxygenation: PaO2 >100

PaCO2 (torr) 28.6 alkalotic

HCO3 (mmol/L) 20.5 acidotic

SaO2 (%) 97.7

Interpretation: Partially compensated respiratory alkalosis with

PaCO2 (torr) 58.1 acidotic

HCO3 (mmol/L) 40.9 alkalotic

BE (mmol/L) +14.1 alkalotic

PaO2 (torr) 57.5

SaO2 (%) 90.4

Interpretation: Partially compensated Metabolic alkalosis with

PaCO2 (torr) 35.8 normal

HCO3 (mmol/L) 27.7 alkalotic

BE (mmol/L) +4.8 alkalotic

PaO2 (torr) 87.6

SaO2 (%) 97.2

Interpretation: Uncompensated Metabolic alkalosis with

PaCO2 (torr) 28 alkalotic

HCO3 (mmol/L) 18.9 acidotic

BE (mmol/L) -3.3 alkalotic

PaO2 (torr) 68.0

Interpretation: Fully compensated respiratory alkalosis with

RESPIRATORY ALKALOSIS ↓PaCO2 & ↑ pH

METABOLIC ALKALOSIS ↑ HCO3- & ↑ pH

• Clinical judgment should always apply

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