HYPOXIA & HYPOXEMIA by Nick Mark MD ONE

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DEFINITIONS: 100% 20 13
Hypoxia – insufficient oxygen delivered to tissues to meet demands OXYGEN DELIVERY:

HB SATURATION SaO2
Tissue hypoxia occurs when DELIVERY OF OXYGEN (DO2) is inadequate to meet

O2 CONTENT CaO2
80% 16 11
Hypoxemia – low oxygen in the blood (most common type of hypoxia) P O2
metabolic demands. DO2 depends on CARDIAC OUTPUT (CO) & the
I

=140
60% 12 8
PIO2 – atmospheric oxygen (how much O2 is inspired) MIXED OXYGEN CONTENT OF BLOOD (CaO2)
PAO2 – alveolar oxygen (how much O2 reaches the alveoli) VENOUS ARTERIAL 8 5
40%
BLOOD
PaO2 – oxygen dissolved in arterial blood (measured on ABG) BLOOD PA O2 20% 4 3
𝐃𝑶𝟐 = 𝑯𝑹 × 𝑺𝑽 × 𝟏. 𝟑𝟒 × 𝑯𝒃 × 𝑺𝒂𝑶𝟐 + (𝑷𝒂𝑶𝟐 × 𝟎. 𝟎𝟎𝟑)
SaO2 – percent saturation of hemoglobin in arterial blood SvO2 = 70%
=100
SaO2 = 98%

@Hb = 10
@Hb = 15
20 40 60 80 100
CaO2 – oxygen content of art. blood (dissolved & Hb bound) CvO2 = 15 CaO2 = 20
DISSOLVED O2 PaO2 O2 bound to hemoglobin O2 dissolved in blood
PaO2 = 95 CO

HYPOXEMIC HYPOXIA ISCHEMIC HYPOXIA ANEMIC HYPOXIA CYTOPATHIC HYPOXIA

v1.0 (2020-12-06)
Insufficient oxygen in the blood Insufficient blood flow to tissues, Insufficient O2 carrying capacity Cells cannot use oxygen

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(the most common type of hypoxia) also called stagnant hypoxia (e.g. severe blood loss) or abnormal (e.g. cyanide toxicity, maybe sepsis)
(e.g low cardiac output) hemoglobin (e.g. COHb, MetHb)
Low PaO2 Low SvO2 ! Low PaO2 Low CaO2 ! Low SvO2 ! Low PaO2 High PaO2, High SvO2

LOW INSPIRED OXYGEN (PIO2) ALVEOLAR HYPOVENTILATION V/Q MISMATCH SHUNT DIFFUSION LIMITATION

Fewer oxygen molecules enter the Fewer O2 molecules reach the alveoli Imbalance between regional lung Blood passes from the right side of Impaired O2 diffusion from alveoli to
lungs with respiration (low PAO2) due to decreased ventilation (low ventilation and perfusion (low V/Q). the heart to the left side without RBC, causing hypoxemia particularly
PAO2). Most common cause of hypoxemia. being oxygenated. in with increased cardiac outpu.
· Normal Aa difference · Normal Aa difference · Increased Aa difference · Increased Aa difference · Increased Aa difference
· PaO2 normalizes with supplemental · PaO2 normalizes with supplm. O2 · PaO2 normalizes with suppl. O2 · PaO2 does NOT normalize with · PaO2 normalizes with supplm. O2
oxygen · Increased PaCO2 supplemental oxygen

· Causes: low atmospheric pressure · Causes: decreased respiratory drive · Causes: obstructive lung diseases · Causes: anatomical (ASD, VSD, · Causes: pulmonary fibrosis, edema,
(e.g. high altitude), or low partial (opioids, brainstem stroke, OHVS), (COPD), pulmonary vascular disease pulm AVMs) & physiological shunts & inflammation that impair gas
pressure of oxygen (FiO2 < 0.21 e.g. neuromuscular weakness (GBS, ALS), (PE), alveolar filling processes (atelectasis, pneumonia, ARDS) exchange in the alveoli
confined space, low O2 gas mixtures) chest wall problems (kyphoscoliosis, (pneumonia, pulmonary edema), where blood bypasses alveoli
Borderline With increased blood
flail chest) or airflow obstruction interstitial disease & atelectasis without effective gas exchange
normoxemia at flow frank hypoxemia
(COPD, asthma) rest ensues
Low PAO2 due to Low PAO2 due to ↓ No O2 exchange
globally reduced ventilation relative to occurs and blood is
LOW MIXED VENOUS O2 (SVO2) ventilation perfusion in one area not oxygenated
(PAO2 & PaO2 will NL PA O2 ↓PA O2
(PAO2 & PaO2 will
↓↓PAO2
=0 (PaO2 will not fully
↓PA O2 ↓PA O2
Venous blood returning to the lungs normalize with normalize with normalize with SvO2 = 70% SaO2 = 95% SvO2 = 70% SaO2 = 85%

(SvO2) has very low O2 due to supplemental O2) supplemental O2) supplemental O2) CvO2 = 15 CaO2 = 19 CvO2 = 15 CaO2 = 17

increased extraction. Aa DIFFERENCE (aka Aa GRADIENT): 𝑨𝒈𝒆 𝒚𝒓𝒔 + 𝟏𝟎

𝑵𝒐𝒓𝒎𝒂𝒍 𝑨𝒂 𝒅𝒊𝒇𝒇𝒆𝒓𝒆𝒏𝒄𝒆 =
· Normal Aa difference The Aa DIFFERENCE is the ALVEOLAR OXYGEN TENSION 𝟒 Alveolar CO2 tension
· PaO2 normalizes with (PAO2) minus the ARTERIAL OXYGEN TENSION (PaO2), (assumed to be equal to
SvO2 = 50% SaO2 = 85% 𝑨𝒂 𝒅𝒊𝒇𝒇𝒆𝒓𝒆𝒏𝒄𝒆 = 𝑷𝑨 𝑶𝟐 − 𝑷𝒂 𝑶𝟐
arterial CO2)
supplemental oxygen CvO2 = 10 CaO2 = 17
reflecting the efficiency of oxygen exchange. It is
used to identify the etiology of hypoxemic hypoxia: 𝑷 𝑶 = 𝑭𝒊𝑶 × 𝑷 𝑷𝒂𝑪𝑶 𝟐
unable to fully 𝑨 𝟐 𝟐 𝒂𝒕𝒎 − 𝑷𝑯𝟐𝑶 −
Causes: severe anemia (low CaO2 oxygenate the pulmonary causes have ↑ Aa difference whereas 𝑸
rarely a problem unless Hb <5), low Respiratory
extremely extra-pulmonary etiologies (↓ PiO2, ↓SvO2, & Atmospheric pressure H2O vapor pressure
cardiac output, & extremely high deoxygenated (760 mmHg @ sea level, 630 mmHg @ Quotient
oxygen consumption venous blood
alveolar hypoventilation) have nl Aa difference. (47 mmHg in the lungs) (normally ~0.8)
1500m, 530 mmHg @ 3000m)