A-a gradient

OVERVIEW

calculated as PAO2 – PaO2

PAO2 is the ‘ideal’ compartment alveolar PO2 determined from the alveolar gas equation
PAO2 = PiO2 – PaCO2/0.8
A normal A–a gradient for a young adult non-smoker breathing air, is between 5–10 mmHg.
However, the A–a gradient increases with age (see limitations)

CLASSIFICATION OF HYPOXIA BASED ON A-a GRADIENT

Normal A-a gradient

“ 1. Alveolar hypoventilation (elevated PACO2)

2. Low PiO2 (FiO2 < 0.21 or barometric pressure < 760mmHg)

Raised A-a gradient

“ 1. Diffusion defect (rare) severe pneumonia (inflammatory infiltrates block alveolar capillary membrane)
2. V/Q mismatch
3. Right-to-Left shunt (intrapulmonary or cardiac)
4. Increased O2 extraction (CaO2-CvO2)

LIMITATIONS

Gradient varies with age and FiO2:

“ FiO2 0.21 – 7 mmHg in young, 14 mmHg in elderly

FiO2 1.0 – 31 mmHg in young, 56 mmHg in elderly
 For every decade a person has lived, their A–a gradient is expected to increase by 1 mmHg – a
conservative estimate of normal A–a gradient is < [age in years/4] + 4.
an exaggerated FiO2 dependence in intrapulmonary shunt (PAO2 vs PAO2/PaO2 difference
diagram with regard to increasing percentage of shunt) and even more so in V/Q mismatch.

About Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case
of knowledge dipsosis. Key areas of interest include: the ED-ICU interface,
toxicology, simulation and the free open-access meducation (FOAM)
revolution. @Twitter | + Chris Nickson | RAGE | INTENSIVE| SMACC

Comments
 East Surrey Anaesthesia Teaching Group says
July 7, 2017 at 9:36 pm

After discussing this in our anaesthetic teaching, although you state the Aa gradient is increased
with increased O2 extraction, in spontaneously breathing patients with increased O2 extraction,
due to increased metabolic rate there is increased CO2 so alveolar conc drops and Aa gradient
drops

One explanation we came up with for a raised Aa gradient is that decreased transit time in
hyperdynamic patient might reduce the PaO2 and therefore the reduced Aa gradient. Is this the
cause?

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