C

Arterial Blood Gases:

Guidelines for
Interpretation and
Sample Problems
The following guidelines are meant to expand on the material presented in Chapter 3
and to simplify the interpretation of arterial blood gas values. Because memorizing a
cookbook approach can sometimes be counterproductive if the reason why the
approach is being used is not clear, these guidelines are meant to supplement a basic
understanding of the underlying physiologic principles.
Numerous formulas are used to assess the appropriateness of compensation for a
primary acid-base disorder. These formulas are particularly useful for suggesting
whether a mixed acid-base disorder is present. Table C-1 lists commonly used formulas
that predict the expected degree of respiratory compensation for a primary metabolic
problem and metabolic compensation for a primary respiratory problem. These formulas relate arterial Pco2 and measured HCO3. However, measured values from
arterial blood gases include arterial Pco2 and pH, not serum HCO3. Therefore, to use
the formulas in the table, one must either measure serum HCO3 (as part of serum
electrolyte values) or use a value calculated from Pco2 and pH according to the
Henderson-Hasselbalch equation.
Alternatively, one can use other guidelines relating Pco2 and pH values. Because
these latter guidelines are based on direct measurements obtained with arterial blood
gasesand because they are relatively easy to rememberthey are used in the method
outlined here. It is worth noting that formulas relating Pco2 and pH become less
accurate at the extremes of Pco2 and pH values and provide only rough guidelines.
The human body does not respond to physiologic disturbances with mathematical
precision.

ANALYSIS OF ACID-BASE STATUS

1. Look at the pH value to determine the net disturbance in acid-base
balance. An alkalotic pH (>7.44) indicates the presence of a primary
respiratory alkalosis, a metabolic alkalosis, or both. An acidotic pH
(<7.36) indicates the presence of a primary respiratory acidosis, a
metabolic acidosis, or both. A normal pH (approximately 7.36-7.44)
indicates normal acid-base status or a mixed disturbance (of two
balancing problems).
2. Look at Pco2. A high Pco2 (>44) indicates that a respiratory acidosis
is present. A low Pco2 (<36) indicates that a respiratory alkalosis is

384 n Principles of Pulmonary Medicine

Table C-1
EXPECTED COMPENSATION FOR PRIMARY ACID-BASE DISORDERS
Primary Disorder

Compensatory
Response

Metabolic acidosis
Metabolic alkalosis

PCO2
PCO2

Respiratory acidosis

HCO3

Respiratory alkalosis

HCO3

Expected Magnitude of Response

PCO2 = 1.5 (HCO3) + 8 2
PCO2 increases 6mmHg for each 10mEq/L
increase in HCO3
Acute: HCO3 increases 1mEq/L for each
10mmHg increase in PCO2
Chronic: HCO3 increases 3.5mEq/L for each
10mmHg increase in PCO2
Acute: HCO3 falls 2mEq/L for each 10mmHg
decrease in PCO2
Chronic: HCO3 falls 5mEq/L for each
10mmHg decrease in PCO2

Adapted from Narins RG, Emmett M: Medicine 59:161186, 1980. by Williams & Wilkins, 1980.

present. If the pH value moves in the appropriate direction for the

Pco2 change (i.e., pH with Pco2; pH with Pco2), the
respiratory disorder is the primary disturbance. If the pH value
does not move in the appropriate direction for the Pco2 change,
a metabolic disorder is the primary disorder.
3. When a primary respiratory disorder is present, the pH value
should change approximately 0.08 units for each 10mmHg change
in Pco2 if the process is acute. If the process is chronic, the kidneys
compensate (by retaining or losing HCO3) and blunt the pH
change in response to any change in Pco2. The resulting change in
pH when the respiratory disorder is chronic is slightly different for
acidosis versus alkalosis. With a chronic respiratory acidosis, the
expected pH decrease is approximately 0.03 for each 10mmHg
increase in Pco2. With a chronic respiratory alkalosis, the expected
pH increase is approximately 0.02 for each 10mmHg decrease
in Pco2.
4. If a pH change cannot be explained by an alteration in Pco2,
a primary metabolic disturbance is present. A low pH value with a
low Pco2 indicates a primary metabolic acidosis with respiratory
compensation. A high pH value with a high Pco2 can indicate
a primary metabolic alkalosis with secondary suppression of
respiratory drive. However, in many patients the latter pattern
of a high pH value with a high Pco2 often represents a complex
acid-base disturbance, such as a chronic compensated respiratory
acidosis with a superimposed primary metabolic alkalosis (e.g., as a
result of diuretics, vomiting, or nasogastric suction).
5. To determine whether there has been appropriate respiratory
compensation for a primary metabolic disorder, a rough guideline
is that Pco2 should approximate the last two digits of the pH value.
For example, a Pco2 of 25mmHg accompanying a pH value of
7.25 indicates appropriate respiratory compensation for a primary
metabolic acidosis. However, the degree of compensatory
hyperventilation (i.e., lowering of Pco2) for a metabolic acidosis
tends to be more predictable than the degree of compensatory
hypoventilation (i.e., CO2 retention) accompanying a metabolic
alkalosis.

Arterial Blood Gases: Guidelines for Interpretation and Sample Problems n 385

ANALYSIS OF OXYGENATION
1. When analyzing arterial Po2, first calculate alveolar Po2 according to
the following equation:
PAO2 = (713 FIO2 )

PCO2
0 .8

For room air, the equation can be simplified as follows: Pao2 = 150
(1.25 Pco2). Then calculate the alveolar-arterial O2 gradient
(AaDo2), which is the difference between the calculated Pao2 and
the measured Pao2: AaDo2 = Pao2 Pao2.
2. If the patient is hypoxemic, Pco2 is elevated, and AaDo2 is normal
(<15mmHg on room air in a young person, although it increases
with age), hypoventilation is the cause of the hypoxemia.
3. If the patient is hypoxemic, Pco2 is normal or low, and AaDo2 is
 
increased, either V /Q mismatch or shunting is present. With V/Q
mismatch, the patients Pao2 has a good response to administration
of supplemental O2. With a true shunt, Pao2 does not rise much
with supplemental O2 (even 100% O2).
4. If the patient is hypoxemic, Pco2 is high, and AaDo2 is increased,
  mismatch or
the patient has both hypoventilation and either V/Q
shunt as the cause of the low Pao2.

SAMPLE PROBLEMS
All blood gases are drawn with the patient breathing room air (Fio2 = 0.21), except as
otherwise noted.
1. Room air
(100% O2)
2. Room air
(100% O2)
3.
4.
5.
6.
7.
8.

PO2 = 45mmHg
PO2 = 65mmHg
PO2 = 45mmHg
PO2 = 560mmHg
PO2 = 88mmHg
PO2 = 65mmHg
PO2 = 30mmHg
PO2 = 110mmHg
PO2 = 55mmHg
PO2 = 90mmHg

PCO2 = 30mmHg
PCO2 = 32mmHg
PCO2 = 30mmHg
PCO2 = 32mmHg
PCO2 = 20mmHg
PCO2 = 60mmHg
PCO2 = 60mmHg
PCO2 = 20mmHg
PCO2 = 48mmHg
PCO2 = 60mmHg

ANSWERS
1. Acute respiratory alkalosis. On room air, the patients AaDo2 =
67.5mmHg, which is elevated. The minimal elevation in Po2 with
100% O2 indicates that a shunt is the major cause of the hypoxemia.
2. Identical to Problem 1, except that the dramatic increase in Po2
with 100% O2 indicates that ventilation-perfusion mismatch is the
major cause of the hypoxemia.
3. Acute respiratory alkalosis. Even though Po2 appears normal, AaDo2
is elevated to 37mmHg, indicating the presence of a disorder
impairing normal oxygenation of blood.

pH = 7.47
pH = 7.46
pH = 7.47
pH = 7.46
pH = 7.55
pH = 7.35
pH = 7.35
pH = 7.30
pH = 7.49
pH = 7.20

386 n Principles of Pulmonary Medicine

4. Chronic respiratory acidosis. AaDo2 = 10mmHg, indicating that

hypoxemia is due to hypoventilation.
5. Chronic respiratory acidosis, as in Problem 4. However, unlike
Problem 4, AaDo2 is elevated (to 45mmHg), indicating that both
hypoventilation and either ventilation-perfusion mismatch or
shunting (most likely the former) are responsible for the
hypoxemia.
6. Mixed acid-base disorder with a primary metabolic acidosis
complicated by a primary respiratory alkalosis. Pco2 is too low to
represent just compensation for the metabolic acidosis, indicating
the presence of a respiratory alkalosis as well. AaDo2 = 15mmHg,
the upper limit of normal for a young adult.
7. The simplest explanation of the acid-base status is a compensated
metabolic alkalosis. However, this pattern is probably seen more
commonly with a mixed acid-base disorder consisting of a
compensated respiratory acidosis complicated by a superimposed
primary metabolic alkalosis. AaDo2 = 35mmHg. Therefore,
hypoxemia is due partly to hypoventilation but mostly to
ventilation-perfusion mismatch or shunt, probably the former.
8. Something is wrong because AaDo2 is negative (15mmHg).
Several possible explanations are: (a) the patient was receiving
supplemental O2, (b) a laboratory error was made, or (c) the blood
was not collected or transported properly under anaerobic
conditions.