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The sampling of arterial blood gases is a common practice in 
   
acute care medicine. Patients with respiratory disease are at 
risk for inadequate lung ventilation and inadequate tissue
oxygenation. Patients with metabolic diseases and selected c   

drug overdoses are at risk for acid-base abnormalities.
Arterial blood gas sampling is a simple procedure that can be º ABG syringe and needle. Various types are available.
performed at the bedside and can provide important Most modern ones are self-filling, i.e. do not need the
information about lung ventilation, tissue oxygenation and operator to draw back the plunger. They also come with
acid-base status. anti-coagulant in the syringe (either as a heparin liquid or
 as a small pledget containing heparin):
 
  º Some self-filling syringes must have the plunger
An arterial blood gas (ABG) test measures the acidity (pH) fully pushed down to expel heparin, e.g. Pulsator®
and the levels of oxygen and carbon dioxide in the blood (as shown in photograph). On reaching the artery,
from an artery. This test is used to check how well your lungs the blood pressure is sufficient to push the plunger
are able to move oxygen into the blood and remove carbon back and fill the syringe.
dioxide from the blood. º For other self-filling syringes, you pull back the
It is a blood test that is performed using blood from an artery. plunger to the appropriate volume required. On
It involves puncturing an artery with a thin needle and syringe hitting the artery, the syringe allows air to be
and drawing a small volume of blood. The most common expelled and replaced with blood.
puncture site is the radial artery at the wrist, but sometimes º If no specialised equipment is available, use a
the femoral in the groin or other sites are used. The blood standard syringe and needle. Draw up a small
can also be drawn from an arterial catheter. amount of heparin and expel it. This is fiddlier as
 you need to fix the position of the needle and


  syringe with one hand and aspirate with the other.
As blood passes through your lungs, oxygen moves into the º Alcohol wipe
blood while carbon dioxide moves out of the blood into the º Cotton gauze or dental roll
lungs. An ABG test uses blood drawn from an artery, where º Tape to secure gauze
the oxygen and carbon dioxide levels can be measured
before they enter body tissues. An ABG measures:

i
 




 i This measure the  

  
 
pressure of oxygen dissolved in the blood and how well
oxygen is able to move from the airspace of the lungs into
Explain to the patient that this test is used to
the blood. evaluate how well the lungs are delivering oxygen to

i
 






i  This blood and eliminating carbon dioxide.
measures how much carbon dioxide is dissolved in the blood
Tell him that the test requires a blood sample.
and how well carbon dioxide is able to move out of the body. Explain who will perform the arterial puncture and

 The pH measures hydrogen ions (H+) in blood. when and which site - radial, brachial, or femoral

?

  Bicarbonate is a chemical (buffer) that artery - has been selected for the puncture.
keeps the pH of blood from becoming too acidic or too basic.
Inform him that he needn't restrict food or fluids.

 
 
  

 
Instruct the patient to breathe normally during the
   O2 content measures the amount of oxygen in the test, and warn him that he may experience a brief
blood. Oxygen saturation measures how much of cramping or throbbing pain at the puncture site.
the hemoglobin in the red blood cells is carrying oxygen (O2).
 0     


 

 
An arterial blood gas (ABG) test is done to:

Check for severe breathing problems and lung diseases,

Perform an arterial puncture.
such as asthma, cystic fibrosis, or chronic obstructive
After applying pressure to the puncture site for 3 to
pulmonary disease (COPD). 5 minutes, tape a gauze pad firmly over it. (If the

See how well treatment for lung diseases is working. puncture site is on the arm, don't tape the entire
circumference; this may restrict circulation.)

Find out if you need extra oxygen or help with breathing

(mechanical ventilation).
If the patient is receiving anticoagulants or has a
coagulopathy, hold the puncture site longer than 5

Find out if you are receiving the right amount of oxygen when
minutes if necessary.
you are using oxygen in the hospital.

Monitor vital signs, and observe for signs of

Measure the acid-base level in the blood of people who have

circulatory impairment, such as swelling,
heart failure, kidney failure, uncontrolled diabetes, sleep
discoloration, pain, numbness, and tingling in the
disorders, severe infections, or after a drug overdose.
bandaged arm or leg.

Watch for bleeding from the puncture site.



 c 
 Low PaO2, O2CT, and SaO2 levels and a high PacO2 may
result from conditions that impair respiratory function, such
Is a test to determine if there is sufficient collateral blood as respiratory muscle weakness or paralysis, respiratory
supply to the hand on occluding the radial or ulnar arteries. It center inhibition (from head injury, brain tumor, or drug
is traditionally used prior to radial artery puncture to ensure abuse, for example), and airway obstruction (possibly from
that in the event of damage to the radial artery that the ulnar mucus plugs or a tumor). Similarly, low readings may result
artery will continue to provide sufficient blood. from bronchiole obstruction caused by asthma or
Whether it is sufficiently sensitive or specific to prevent emphysema, from an abnormal ventilation-perfusion ratio
complications is less clear. In one series of 1699 patients, due to partially blocked alveoli or pulmonary capillaries, or
only 16 had abnormal Allen's test, but none of the 16 from alveoli that are damaged or filled with fluid because of
suffered complications of radial cannulation. disease, hemorrhage, or near-drowning.
p When inspired air contains insufficient oxygen, PaO2, O2CT,

pFeeling of brief cramping or throbbing at the puncture and SaO2 decrease, but PacO2 may be normal. Such
site findings are common in pneumothorax, impaired diffusion
between alveoli and blood (due to interstitial fibrosis, for
 
  example), or an arteriovenous shunt that permits blood to by
pass the lungs.
Low O2CT - with normal PaO2, Sa02 and, possibly,

Wait at least 15 minutes before drawing arterial PacO2 values may result from severe anemia, de creased
blood when starting, changing, or discontinuing blood volume, and reduced hemoglobin oxygen-carrying
oxygen therapy. capacity.

Before sending the sample to the laboratory, note  
on the laboratory slip whether the patient was Lower numbers mean more acidity; higher number mean
breathing room air or receiving oxygen therapy more alkalinity.
when the sample was collected. pH is Elevated (more alkaline, higher pH) with:

If the patient was receiving oxygen therapy, note the
Hyperventilation
flow rate. If he is on a ventilator, note the fraction of
Anxiety, pain
inspired oxygen and tidal volume.
Anemia

Note the patient's rectal temperature and respiratory
Shock
rate.

Some degrees of Pulmonary disease
ü
c 
Some degrees of Congestive heart failure
   !
Myocardial infarction
Normal Adult Arterial Values*
Hypokalemia (decreased potassium)
pH 7.35-7.45
Gastric suctioning or vomiting

Antacid administration
pCO2 35-45

Aspirin intoxication
torr
pH is Decreased (more acid, lower pH) with:
pO2 >79 torr
Strenuous physical exercise
CO2 23-30
Obesity
mmol/L
Starvation
Base ±3
Diarrhea
Excess/Deficit mEq/L
Ventilatory failure
SO2 >94%
More severe degrees of Pulmonary Disease

More severe degrees of Congestive Heart Failure

Pulmonary edema

Cardiac arrest
Normal Adult Venous Values*
pH 7.31-7.41

Renal failure
Note: mEq/L = milliequivalents
Lactic acidosis
pCO2 41-51 per liter; mmHg = millimeters
Ketoacidosis in diabetes
torr of mercury  0
#
  0 " $ %
pO2 30-40 At altitudes of 3,000 feet and Indirectly, the pCO2 reflects the exchange of this gas
torr above, the oxygen values are through the lungs to the outside air. Two factors each have a
lower. significant impact on the pCO2. The first is how rapidly and
CO2 23-30
Normal value ranges may vary deeply the individual is breathing:
mmol/L
slightly among different
Someone who is hyperventilating will "blow off"
Base ±3 laboratories. more CO2, leading to lower pCO2 levels
Excess/Deficit mEq/L
Someone who is holding their breath will retain
SO2 75% CO2, leading to increased pCO2 levels
c"    ! The second is the lungs capacity for freely exchanging CO2
across the alveolar membrane:
Abnormal results may be due to lung, kidney, or metabolic
With pulmonary edema, there is an extra layer of
diseases. Head or neck injuries or other injuries that affect fluid in the alveoli that interferes with the lungs'
breathing can also lead to abnormal results. ability to get rid of CO2. This leads to a rise in
pCO2.

With an acute asthmatic attack, even though the A "Base Deficit" of 10 means that 10 mEqu/L of buffer has
alveoli are functioning normally, there may be been used up to neutralize metabolic acids (like lactic acid).
enough upper and middle airway obstruction to Another way to say the same thing would be the "Base
block alveolar ventilation, leading to CO2 retention. Excess is minus 10."
Increased pCO2 is caused by: More Negative Values of Base Excess may Indicate:

Pulmonary edema
Lactic Acidosis

Obstructive lung disease
Ketoacidosis
Decreased pCO2 is caused by:
Ingestion of acids

Hyperventilation
Cardiopulmonary collapse

Hypoxia
Shock

Anxiety More Positive Values of Base Excess may Indicate:

Pregnancy
Loss of buffer base

Pulmonary Embolism (This leads to
Hemorrhage
hyperventilation, a more important consideration
Diarrhea
than the embolized/infarcted areas of the lung that
Ingestion of alkali
do not function properly. In cases of massive  $! '
 
 #'
%
pulmonary embolism, the infarcted or non- While this measurement can be obtained from an arterial or
functioning areas of the lung assume greater venous blood sample, it's major attractive feature is that it
significance and the pCO2 may increase.) can be obtained non-invasively and continuously through the
 
#
   $! % use of a "pulseoximeter."
Elevated pO2 levels are associated with: Normally, oxygen saturation on room air is in excess of 95%.

Increased oxygen levels in the inhaled air With deep or rapid breathing, this can be increased to 98-

Polycythemia 99%. While breathing oxygen-enriched air (40% - 100%), the
Decreased PO2 levels are associated with: oxygen saturation can be pushed to 100%.

Decreased oxygen levels in the inhaled air $! '
 
 (

Anemia
Inspired oxygen levels are diminished, such as at
increased altitudes.

Heart decompensation

Upper or middle airway obstruction exists (such as

Chronic obstructive pulmonary disease
during an acute asthmatic attack)

Restrictive pulmonary disease

Significant alveolar lung disease exists, interfering

Hypoventilation with the free flow of oxygen across the alveolar
 0
 membrane.
Most of this is in the form of bicarbonate (HCO3), controlled $! '
 
  (
by the kidney. A small amount (5%) of the CO2 is dissolved
in the blood, and in the form of soluble carbonic acid

Deep or rapid breathing occurs
(H2CO3).
Inspired oxygen levels are increased, such as
For this reason, changes in CO2 content generally reflect breathing from a 100% oxygen source
such metabolic issues as renal function and unusual losses
(diarrhea). Respiratory disease can ultimately effect CO2 
   !
 
content, but only slightly and only if prolonged.
Elevated CO2 levels are seen in:

Failure to heparinize syringe, place Rumple in an

Severe vomiting iced bag, or send the sample to the laboratory

Use of mercurial diuretics immediately (possible altered PaO2 and

COPD PacO2 because metabolic processes continue after

Aldosteronism sample is drawn)
Decreased CO2 levels are seen in:
Exposing the sample to air (increase or decrease in

Renal failure or dysfunction PaO2 and PacO2)

Severe diarrhea
Venous blood in the sample (possible decrease in

Starvation Pa02 and increase in PII(02)

Diabetic Acidosis
Bicarbonate, ethacrynic acid hydrocortisone,

Chlorthiazide diuretic use metolazone, prednisone, and Ihlllzides (possible
 &$ 
increase in PacO2) . Acetazolamide, methicillin,
Whenever there is an accumulation of metabolically- nitrofurantoin, and tetracycline (possible decrease in
produced acids, the body attempts to neutralize those acids PacO2)
to maintain a constant acid-base balance.
Fever (possible false-high PaO2 and PacO2).
This neutralizing is achieved by using up various "buffering"
compounds in the blood stream, to bind the acids,
disallowing them from contributing to more acidity. 0
 
 
About half of these buffering compounds come from HCO3,
and the other half from plasma and red blood cell proteins
Contraindications are relative and should be
and phosphates.
considered in terms of the risks to the patient under
The words "base deficit" and "base excess" are equivalent
the circumstances and the importance of obtaining
and are generally used interchangeably. The only difference
the sample. Areas of skin infection should be
is that base deficit is expressed as a positive number and
avoided because of the risks of inoculating the
base excess is expressed as a negative number.
 blood with bacteria. Patients on anticoagulants and
Nebulization does what your nose and mouth use to
those with coagulopathies are at risk for severe do
bruising and hematoma formation so blood gases
Nebulization humidifies
should only be done when absolutely necessary and
the operator should take extra care to apply    (
pressure to the area to reduce bruising. Anytime an
arterial puncture is made there is a risk of causing
an obstructing thrombus in the artery. Patients with 1. Place the air compressor on a sturdy surface that will
poor collateral flow to an area, for example a support its weight. Plug the cord from the compressor into a
positive Allen test (discussed later) at the wrist, properly grounded electrical outlet.
should not have an arterial puncture to that site. 2. Wash your hands with soap and warm water, and dry
Finally, if it seems likely that a patient will require completely with a clean towel.
frequent arterial blood gas samples, consideration 3. Carefully measure the medicine exactly as you have been
should be given to starting an indwelling arterial line. instructed. Use a separate, clean measuring device
Arterial lines are beyond the scope of this module (eyedropper or syringe) for each medicine.
and will not be discussed further. 4. Remove the top part of the nebulizer cup.
5. Place your medicine in the bottom of the nebulizer cup.
6. Attach the top portion of the nebulizer cup and connect the
0
  mouthpiece or face mask to the cup.
7. Connect the tubing to both the aerosol compressor and
The most common complication from an arterial nebulizer cup.
puncture is hematoma at the site. Less common but 8. Turn on the compressor with the on/off switch. Once you
important complications are thrombus in the artery turn on the compressor, you should see a light mist coming
and infection at the site. from the back of the tube opposite the mouthpiece as.
9.Sit up straight on a comfortable chair.
ü) 10. If you are using a mask, position it comfortably and
There is very little risk when the procedure is done correctly. securely on your face.
Veins and arteries vary in size from one patient to another 11. If you are using a mouth piece, place it between your
and from one side of the body to the other. Taking blood from teeth and seal your lips around it.
some people may be more difficult than from others. 12. Take slow, deep breaths through your mouth. If possible,
Other risks associated with this test may include: hold each breath for two to three seconds before breathing
out. This allows the medication to settle into the airways.
13. Continue the treatment until the medication is gone

Bleeding at the puncture site (about seven to 10 minutes).

Blood flow problems at puncture site (rare) 14. If you become dizzy or feel "jittery," stop the treatment

Bruising at the puncture site and rest for about five minutes. Then continue the treatment,

Delayed bleeding at the puncture site but try to breathe more slowly. If these symptoms continue
with future treatments, inform your health care provider.

Fainting or feeling light-headed
15. Turn the compressor off.

Hematoma (blood accumulating under the skin) 16. Take several deep breaths and cough. Continue

Infection (a slight risk any time the skin is broken) coughing and try to clear any secretions you might have in
 your lungs. Cough the secretions into a tissue and dispose of
"*
  it properly.
17. Wash your hands with warm water and soap, and dry
Nebulization is a process of adding fine drops of moisture or them with a clean towel.
fine particles of medication to inspired air. The water or
medication is usually broken up by gas under pressure or by  0c (
high-frequency vibrations (ultrasonic nebulization). Patient who has an asthma
Nebulization improves the clearance of pulmonary secretions Patient who has a severe cough that blockens
by altering the tracheo-bronchial mucosa.A nebulizer the airways.
changes liquid medicine into fine droplets (in aerosol or mist Patients who has a respiratory distress
form) that are inhaled through a mouthpiece or mask.
Nebulizers can be used to deliver bronchodilator (airway-
opening) medicines such as albuterol (Ventolin®, Proventil®  0c '# %
or Airet®) or ipratropium bromide (Atrovent®).
 Nebulizers may be used to provide aerosol therapy
  "* to patients too ill or too young to use hand-held devices, and

Nebulization thins secretions & mucus making it in situations where large drug doses are necessary. These
easier to expel pulmonary secretions devices also are required for some medications available
only in liquid form, including pentamidine, ribavirin,

Nebulization makes coughing easier while lessening rhDNAase, and tobramycin.
the need to cough
The potential benefits of nebulizers need to be

Nebulization keeps your windpipe & trachea lining balanced with the disadvantages associated with the use of
and stoma moist & healthy these devices. These include higher costs, longer setup and

Nebulization moistens the air that goes into your delivery time, decreased portability, variable nebulizer
lungs performance, and (with jet nebulizers) the need for a source

Nebulization hydrates & moisturizes your nasal of compressed air or oxygen.
passages, mouth and throat
c +
! "*
 
Nebulizers mix medicine with compressed air to create a fine
mist that the patient
breathes in through a facemask or mouthpiece.1 Nebulizers
offer the advantage of
delivering the drug directly into the lungs, and are often
easier to coordinate for
young children.
For children, nebulization is one of the easiest and most
effective ways to
administer asthma medicine.2 Using appropriately sized
masks that fit infants, or
mouthpieces for older children and adults, patients simply
breathe normally until all
the medicine has been inhaled. Another advantage of
nebulization, particularly for
young children, is that it requires no special technique to get
the medicine into the
lungs. By contrast, MDIs require proper technique that may
be hard for young
children to master, and in many cases a significant portion of
the medicine does not
reach the child's lungs.

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Hypersensitivity