Arterial Blood Gas

Interpretation
DR ZACHARY LEONG
Normal values
What information does an ABG provide?

1. Oxygenation status
2. Acid base balance
Oxygenation status
• PaO2 = partial pressure of oxygen in arterial blood
• Dependent on 3 factors
1. Age
• PaO2 = 109 – 0.4(Age)
• As Age increases, expected PaO2 decreases

2. Fraction of inspired O2
• As FiO2 increases, the expected PaO2 increases along

3. Patm (atmospheric pressure)

PaO2/FiO2 ratio ( P/F Ratio)
• PaO2 value alone is not helpful when patient is receiving
supplemental oxygen
• P/F ratio helps us to understand the patients oxygenation with
respect to the oxygen that is delivered
When P/F ratio should not be used?
• Acute on chronic respiratory failure ( patients with raised baseline
PaCO2)
• Patients with chronic respiratory failure ie. Chronic COPD already have a P/F
ratio of <300 at their baseline stable state.
• Compare with previous baseline ABGs

• Presence of intrapulmonary shunt

Acid Base Assessment
6-Steps Approach in ABG interpretation
Step 1 - Acidemia or Alkalemia
Step 2 - Is the primary disorder Metabolic or Respiratory
Step 3 - If respiratory – Acute or Chronic?
Step 4 - Is compensation adequate?
Step 5 - If metabolic – Anion Gap?
Step 6 - if HAGMA , Delta Ratio?
Step 1 – Acidemia or Alkalemia

• pH
< 7.35 – acidemia
>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 2 – Respiratory or Metabolic
• Is the primary disturbance respiratory or metabolic?
• Look at PCO2, then HCO3
Step 3 – Respiratory – Acute/ Chronic
If respiratory disorder, is it Acute or Chronic?
• Need to compare between measured pH and expected pH
Step 4 – is Compensation Adequate?
Usually, compensation does not return the pH to normal (7.35 – 7.45).

If the observed
compensation is not
the expected
compensation, it is
likely that more than
one acid-base disorder
is present.
Step 5 – If metabolic acidosis – Calculate
Anion Gap
 Step 6 – If HAGMA present, any coexistent
metabolic disorder?

DELTA RATIO

Assess the ratio of the change in the anion gap (∆AG ) to the change in [HCO3-] (∆[HCO3-]):
∆AG/∆[HCO3-]

This ratio should be between 1.0 and 2.0 if an uncomplicated anion gap metabolic acidosis is present.

If this ratio falls outside of this range, then another metabolic disorder is present:
•If ∆AG/∆[HCO3-] < 1.0, then a concurrent non-anion gap metabolic acidosis is likely to be present.
•If ∆AG/∆[HCO3-] > 2.0, then a concurrent metabolic alkalosis is likely to be present.
Case example 1
Mr T, 74 y/o man
u/l DM, dyslipidemia, IHD

p/w lethargy, shortness of breath anosmia, ageusia x 4

ABG under NP 3L :
days
pH 7.481
O/e : alert, mildly tachypnoiec pO2 85.9
SpO2 92% under RA, started on NP3L pCO2 30
HCO3 24.8
lungs – right LZ creps SpO2 95%

CRP 44, ALC 0.9

CXR : b/l LZ mild-mod GGO
Covid-19 PCR +ve

Diagnosis : COVID- 19 Cat 4a , DOI 4

 Interpretation
ABG under NP 3L : Oxygenation status
FiO2 Np3L = 32%
pH 7.481 PF ratio : pO2/FiO2 = 85.9/0.32 = 268 (mildly hypoxic)
pO2 85.9
pCO2 30
HCO3 24.8 Acid base status
SpO2 95% Step 1 : pH 7.481 = alkalemia
Step 2 : pH↑ , pCO2↓ = primary respiratory disorder , respiratory
alkalosis
Step 3 :
Expected pH in acute respiratory alkalosis
7.4 + 0.008 (40-30) = 7.48
Expected pH in chronic respiratory alkalosis
7.4 + 0.003 (40-30) = 7.43
Measured pH = 7.481 ≈ acute respiratory alkalosis

Impression : Acute respiratory alkalosis

Continuation
• Started on IV dexamethasone 8mg OD
• Next day, noted worsening tachypnoea RR 35, vomited x 2
• Reassessed SpO2:
• Np3L 86%
• FM5L 88%
• FM10L 92%
• HFM15L 98%

• Repeat ABG on HFM15L

pH 7.517
pO2 73.8
pCO2 32.9
HCO3 28
SpO2 96%
 Interpretation
Oxygenation status
FiO2 HFM15L = 95%
PF ratio : pO2/FiO2 = 73.8/0.95 = 77.6 (severe hypoxia)

Acid base status

pH 7.517 Step 1 : pH 7.517 = alkalemia
pO2 73.8 Step 2 : pH↑ , pCO2↓ = respiratory alkalosis
Step 3 :
pCO2 32.9 Expected pH in acute respiratory alkalosis
HCO3 28 7.4 + 0.008 (40-32.9) = 7.456
Expected pH in chronic respiratory alkalosis
SpO2 96% 7.4 + 0.003 (40-32.9) = 7.421
Measured pH = 7.517

Step 4 :
measured pH falls outside of estimated range ( 7.421 – 7.456)
HCO3 is slightly raised/higher range of normal
Suggestive of mixed acid base disorder : concurrent metabolic
alkalosis likely from vomiting

Impression: Mixed respiratory alkalosis + metabolic alkalosis

Case example 2
Miss D , 22 year old lady
u/l T1DM
p/w polyuria, increased thirst
Non compliant to insulin therapy
OE : afebrile, dehydrated, HR 110
Lungs clear

Na 137 K 4.8 Cl 101

 Interpretation
Oxygenation status
pO2 128 under room RA

Acid base status

Step 1 : pH 7.26 = acidemia

Step 2 : pH ↓, pCO2↑ , HCO3 ↓ = metabolic acidosis

ABG :
pH 7.26 Step 4 :
Expected pCO2 = (1.5 x HCO3) +8 ± 2
pCO2 17
= (1.5 x 7.1) + 8 ± 2
pO2 128 = 16.65 – 20.65
HCO3 7.1 Measured pCO2 falls within expected range. Thus metabolic acidosis is compensated
and there is no mixed acid base disorder.

Step 5 :
Anion gap = 137 – (101+7.1) = 28.9 ( high anion gap metabolic acidosis)

Step 6 :
Delta gap = (28.9 -12)/ (24-7.1) = 16.9/16.9 = 1
Pure high anion gap metabolic acidosis

Impression : compensated high anion gap metabolic acidosis

RP normal, Serum lactate 2.0 , serum ketone :5.3, DKA
References
• ATS : Interpretation of Arterial Blood Gases (ABGs);David A. Kaufman, MD
Thank you for your attention