Acidosis and Alkalosis

Dr Naim
ACIDOSIS / ALKALOSIS
• Respiratory acidosis / alkalosis results from
changes in blood PCO2

• Metabolic acidosis / alkalosis disorders associated

with changes in blood bicarbonate levels

• As long as the bicarbonate/carbonic acid

ratio is 20:1, the pH will be 7.4
 Acidosis / alkalosis
BASE ACID

• Normal ratio of HCO3- to H2CO3 is 20:1

– H2CO3 is source of H+ ions in the body
• Deviations from this ratio are used to identify Acid-
Base imbalances

+
2 3
-
3
 Disturbance of the Acid-Base Status
• Acidosis : • Alkalosis:

pH < 7.4 • pH > 7.4

HCO3- < 20/1 HCO3- > 20/1

H2CO3- H2CO3-

• ↓ HCO - = metabolic • ↑ HCO3- = metabolic

3

• ↑ H2CO3- = respiratory • ↓ H2CO3- = respiratory

CO2 always related/linked to respiratory system
Bicarbonate always related/linked to renal system
 Acidosis / alkalosis
• Acidosis and alkalosis are not diseases but rather
are the results of a wide variety of disorders
• The presence of
acidosis or
alkalosis provides
an important clue
to physicians that
a serious
metabolic
problem exists
 Acidosis / alkalosis

• Acidosis
– A condition in which the blood has too much
acid (or too little base), frequently resulting in
a decrease in blood pH

• Alkalosis
– A condition in which the blood has too much
base (or too little acid), occasionally resulting
in an increase in blood pH
 Acidosis / alkalosis
• Acidosis and Alkalosis can arise in two
fundamentally different ways:
– 1) Excess or deficit of CO2
(Volatile Acid)
• Volatile Acid can be eliminated by the
respiratory system
– 2) Excess or deficit of Fixed Acid
• Fixed Acids cannot be
eliminated by the
respiratory system
Acidosis / alkalosis
 Acidosis / alkalosis

• Deviations from normal Acid-Base status are

divided into four general categories, depending on
the source and direction of the abnormal change in
H+ concentrations

– Respiratory Acidosis
– Respiratory Alkalosis
– Metabolic Acidosis
– Metabolic Alkalosis
 Acidosis / alkalosis
• Acidosis and Alkalosis are categorized as Metabolic
or Respiratory depending on their primary cause

– Metabolic Acidosis and Metabolic Alkalosis

• caused by an imbalance in the production and
excretion of acids or bases by the kidneys

– Respiratory Acidosis and Respiratory Alkalosis

• caused primarily by lung or breathing disorders
 .

Respiratory Acidosis
Respiratory acidosis
 Respiratory acidosis
• Caused by hyperkapnia due to
hypoventilation
– Characterized by a pH decrease and an
increase in CO2
pH
CO2 CO2
CO2 CO2
CO CO2 CO2
2
CO2CO2 CO2 CO2
pH CO2
CO2
 Hypoventilation

• Hypo = “Under”

Elimination of CO2

H+

pH
 Respiratory acidosis

• Hyperkapnia is defined as an accumulation of

carbon dioxide in extracellular fluids

pH
CO2 CO2
CO2 CO2
CO CO2 CO2
2
CO2CO2 CO2 CO2
pH CO2
CO2
 Respiratory acidosis
• Respiratory acidosis
develops when the lungs
don't expel CO2
adequately
• This can happen in
diseases that severely
affect the lungs, such as
emphysema, chronic
bronchitis, severe
pneumonia, pulmonary
edema, and asthma
 Respiratory acidosis
• Respiratory acidosis can also develop when diseases of
the nerves or muscles of the chest impair the
mechanics of breathing

• In addition, a person can develop respiratory acidosis if

overly sedated from narcotics and strong sleeping
medications that slow respiration
 Respiratory acidosis

• The treatment of respiratory acidosis aims to

improve the function of the lungs
• TREAT the cause
• Drugs to improve breathing may help people who
have lung diseases such as asthma and emphysema
 Respiratory acidosis

• Decreased CO2 removal can be the result of:

1) Obstruction of air passages

2) Decreased respiration (depression of

respiratory centers)

3) Decreased gas exchange between pulmonary

capillaries and air sacs of lungs

4) Collapse of lung
 Respiratory acidosis

• 1) Obstruction of air passages

– Vomit, anaphylaxis, tracheal cancer
 Respiratory acidosis

• 2) Decreased Respiration
– Shallow, slow breathing
– Depression of the respiratory centers in the brain which
control breathing rates
• Drug overdose
 Respiratory acidosis
• 4) Collapse of lung
– Compression injury, open thoracic wound

Left lung
collapsed
24
 Respiratory acidosis - Compensation
• Low pH (<7.35)
• High serum CO2 (>45mmHg)

• Respiratory system cannot compensate

• Body may attempt to compensate through renal

retention of HCO3 (does not happen quickly - hours
to days)

• Although patients with hypoventilation often

require supplemental oxygen, it is important to
remember that oxygen alone will not correct the
problem.
26
 .

Respiratory Alkalosis
Respiratory alkalosis
 Respiratory alkalosis
• Normal 20:1 ratio is increased
– pH of blood is above 7.4

H2CO3 HCO3-

0.51 : 20
 Respiratory alkalosis

• Cause is Hyperventilation
– Leads to eliminating excessive amounts of
CO2
– Increased loss of CO2 from the lungs at a rate
faster than it is produced
– Decrease in H+

CO2 CO2
CO2 CO2 CO2 CO2 CO2
CO2 CO2 CO2
CO2 CO2
 Hyperventilation

• Hyper = “Over”

Elimination of CO2

H+

pH
 Respiratory alkalosis

• Can be the result of:

– 1) Anxiety, emotional
disturbances
– 2) Respiratory center lesions
– 3) Fever
– 4) Salicylate poisoning
(overdose)
– 5) Assisted respiration
– 6) High altitude (low PO2)
 Respiratory alkalosis

• Anxiety is an emotional
disturbance

• The most common cause of

hyperventilation, and thus
respiratory alkalosis, is
anxiety
 Respiratory alkalosis

• Respiratory center lesions

– Damage to brain centers
responsible for
monitoring breathing
rates
• Tumors
• Strokes
 Respiratory alkalosis

• Fever
– Rapid shallow breathing
blows off too much CO2
 Respiratory alkalosis

• Salicylate poisoning (Aspirin

overdose)
– Ventilation is stimulated
without regard to the status
of O2, CO2 or H+ in the body
fluids
 Respiratory alkalosis
• High Altitude
– Low concentrations of O2 in the arterial blood
reflexly stimulates ventilation in an attempt to
obtain more O2
– Too much CO2 is “blown off” in the process
 Respiratory alkalosis

• Kidneys compensate by:

– Retaining hydrogen ions
– Increasing bicarbonate excretion
HCO3-
HCO3-
H+ H+
HCO3- HCO3-
H+
H+ H+
HCO3-
HCO3- H+
H+HCO3-
HCO3- H+
HCO3-
H+
HCO3- H
+

H+
 Respiratory alkalosis
• Decreased CO2 in the lungs will eventually slow the
rate of breathing
– Will permit a normal amount of CO2 to be
retained in the lung
40
 Respiratory alkalosis - Compensation
• Abnormally low PCO2 (<35mmHg) in systemic
arterial blood

• High pH (>7.45) Carbonic acid deficit

• Kidneys conserve hydrogen ion, Excrete bicarbonate

ion

• One simple treatment to breather into paper bag

for short time
42
 .

Metabolic Acidosis
 Metabolic acidosis
• Occurs when there is a decrease in the normal 20:1
ratio
– Decrease in blood pH and bicarbonate level
• Excessive H+ or decreased HCO3-

H2CO3 HCO3-

1 :: 20
10
 Metabolic acidosis

• Any acid-base imbalance NOT attributable to CO2 is

classified as metabolic
– Metabolic production of Acids
– Or loss of Bases
 Metabolic acidosis

• If an increase in acid overwhelms the body's pH

buffering system, the blood can become acidic

• As the blood pH drops,

breathing becomes
deeper and faster as the
body attempts to rid the
blood of excess acid by
decreasing the amount
of carbon dioxide
 Metabolic acidosis

• Eventually, the kidneys also

try to compensate by
excreting more acid in the
urine

• However, both mechanisms

can be overwhelmed if the
body continues to produce
too much acid, leading to
severe acidosis and
eventually a coma
 Metabolic acidosis
• Metabolic acidosis is always characterized by a
reduction in plasma HCO3- while CO2 remains
normal

Plasma Levels
HCO3-

CO2
 Metabolic acidosis

• Acidosis results from excessive loss of HCO3- rich

fluids from the body or from an accumulation of
acids
– Accumulation of non-carbonic plasma acids uses
HCO3- as a buffer for the additional H+ thus
reducing HCO3- levels
Muscle Cell

Lactic Acid
 Metabolic acidosis

• The causes of metabolic acidosis can be grouped

into five major categories
– 1) Ingesting an acid or a substance that is
metabolized to acid
– 2) Abnormal Metabolism
– 3) Kidney Insufficiencies
– 4) Strenuous Exercise
– 5) Severe Diarrhea
 Metabolic acidosis
• 1) Ingesting An Acid
– Most substances that cause acidosis when
ingested are considered poisonous
– Examples include
wood alcohol
(methanol) and
antifreeze
(ethylene glycol)
– However, even an overdose
of aspirin (acetylsalicylic acid)
can cause metabolic acidosis
 Metabolic acidosis

• 2) Abnormal Metabolism
– The body can produce excess acid as a result
of several diseases
• One of the most significant is Type I
Diabetes Mellitus
 Metabolic acidosis

• Unregulated diabetes
mellitus causes
ketoacidosis

– Body metabolizes fat

rather than glucose

– Accumulations of
metabolic acids (Keto
Acids) cause an increase
in plasma H+
 Metabolic acidosis
• This leads to excessive production of ketones:
– Acetone
– Acetoacetic acid
– B-hydroxybutyric acid
• Contribute excessive numbers of hydrogen ions
to body fluids

Acetone
H+ H+
Acetoacetic acid
H+ H+ H+
Hydroxybutyric acid
H+ H+
 Metabolic acidosis
• 2) Abnormal Metabolism
– The body also produces excess acid in the
advanced stages of shock, when lactic acid is
formed through the metabolism of sugar
 Metabolic acidosis
• 3) Kidney Insufficiencies
– Kidneys may be unable to rid
the plasma of even the
normal amounts of H+
generated from metabolic
acids. (kidneys aren't
functioning normally)

– Kidneys may be also unable to

conserve an adequate
amount of HCO3- to buffer the
normal acid load
 Metabolic acidosis
• 3) Kidney Insufficiencies
– This type of kidney malfunction is called renal
tubular acidosis or uremic acidosis and may
occur in people with kidney failure or with
abnormalities that affect the kidneys' ability to
excrete acid
 Metabolic acidosis
• 4) Strenuous Exercise
– Muscles resort to anaerobic glycolysis during
strenuous exercise
– Anaerobic respiration leads to the production of
large amounts of lactic acid

C6H12O6 Enzymes
2C3H6O3 + ATP (energy)
Lactic Acid
 Metabolic acidosis

• 5) Severe Diarrhea

– Fluids rich in HCO3- are released and reabsorbed

during the digestive process

– During diarrhea this HCO3- is lost from the body

rather than reabsorbed
• 5) Severe Diarrhea
.

– The loss of HCO3- without a corresponding loss of H+

lowers the pH

– Less HCO3- is available for buffering H+

– Prolonged deep vomiting (from duodenum) can

result in the same situation
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 Metabolic Acidosis - Compensation

• Low pH (<7.35)
• Bicarbonate deficit - blood concentrations of
bicarbonate drop below 22mEq/L
• Body may attempt to compensate by increasing
respirations to decrease CO2
• Renal excretion of hydrogen ions if possible
• K+ exchanges with excess H+ in ECF
• ( H+ into cells, K+ out of cells)
63
 .

Metabolic Alkalosis
 Metabolic alkalosis

• Elevation of pH due to an increased 20:1 ratio

– May be caused by:
• An increase of bicarbonate
• A decrease in hydrogen ions
– Imbalance again cannot be due to CO2
– Increase in pH which has a non-respiratory origin
 Metabolic alkalosis
• Can be the result of:
– 1) Ingestion of Alkaline Substances
– 2) Vomiting ( loss of HCl )
 Metabolic alkalosis
• 1) Ingestion of Alkaline Substances
–Influx of NaHCO3
 Metabolic alkalosis
• 2) Vomiting (abnormal loss of HCl)
–Excessive loss of H+
 Metabolic alkalosis
• Reaction of the body to alkalosis is to lower pH
by:
– Retain CO2 by decreasing breathing rate
– Kidneys increase the retention of H+

H+
H+
CO2 H+
CO2 H+
70
 Metabolic alkalosis - Compensation
• Bicarbonate excess - concentration in blood is
greater than 26 mEq/L

• High pH (>7.45)

• Alkalosis most commonly occurs with renal

dysfunction, so can’t count on kidneys

71
 Metabolic alkalosis - Compensation
• Respiratory compensation difficult –
hypoventilation limited by hypoxia
(Body may attempt to compensate by decreasing
respirations to increase CO2).

• Metabolic alkalosis is one of the most difficult

acid-base imbalances to treat.

• It is significant to note that metabolic alkalosis in

hospitalized patients is usually iatrogenic in nature
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