Acid Base imbalances .

There are three main ways that acid/base imbalances can be compensated.
A. Blood Buffers. Buffers are chemical systems that can accept or donate H+ as
required to maintain a normal [H+].
There are two main blood buffers. Protein buffers such as haemoglobin and
other blood proteins and the bicarb-carbonic acid buffer. The bicarb carbonic
acid buffer can be shown in the following equations

CO2 + H2O  H2CO3  H+ + HCO3-

This equation can go in either direction. In acidosis it will shift to the left to
decrease [H+] and in alkalosis it will shift to the right to increase [H+]. The
buffers are the fastest compensation to act but are limited in their capacity.
B. Respiratory Buffers. You can increase or decrease the rate and depth of
breathing to change the [CO2] and thus change the [H2CO3]. For example in
acidosis you would want to compensate by increasing the rate of breathing to
lower the [CO2} and thus decrease the [H2CO3]. These are the next fastest
compensations but you can only increase or decrease your breathing so much
without causing other problems.
C. Renal compensations. These are the slowest to kick in but ultimately the most
effective. The kidneys can do two different things. They can ;
- increase or decrease the rate of H+ secretion in the distal tubules
- increase or decrease the rate of HCO3- reabsorption in the proximal tubules
For acidosis the kidneys will increase H+ secretion and increase the HCO3-
reabsorption.
For alkalosis the kidneys will decrease H+ secretion and decrease HCO3-
reabsorption.

Things to remember

In order to maintain a pH or 7.35-7.45 you must maintain a blood

Bicarbonate : Carbonic acid ratio of
20 : 1
In acidosis the ratio will be < 20:1 and in alkalosis the ratio will be >20:1. The
absolute values of bicarb and carbonic are less important – it is the ratio that
matters.

If an acid /base imbalance is compensated then the pH remains in the normal range
(7.35-7.45 ) and the ratio will be 20:1.
If the imbalance is uncompensated or decompensated then the pH and ratio will be
outside of the normal range.
 For example if you have uncompensated respiratory acidosis then you will have a pH
less than 7.35 and a less than 20:1 ratio.
If you have uncompensated metabolic alkalosis the your pH will be > 7.45 and the
ratio will be > 20:1

Note that if the cause of an imbalance is respiratory then the compensations will
include the action of buffers plus the mechanisms of renal compensation.
If the causes is metabolic then the compensations will be respiratory and buffers of
course.

There are really four categories of acid/base imbalance based on cause;

1. Respiratory Acidosis. This will involve an increase in PCO2 and therefore a

rise
in [H2CO3]. Causes can include ;
a. impaired ventilation and gas exchange d/t direct changes in the airway
system. This might be d/t
- asthma narrowing bronchi
- bronchitis ( mainly d/t smoking)
- emphysema ( also mainly d/t smoking
- pneumonia ( viral and bacterial but esp. bacterial)
- pulmonary edema
b. impaired neuromuscular function causing a decrease in the ability of
intercostal and diaphragm muscles to change the chest volume This
includes;
- clostridium neurotoxin effects
- Lou gehrigs disease (amyotrophic lateral sclerosis)
- chest injury causing restriction d/t severe pain
- postural problems such as kyphosis, scoliosis
c. impaired respiratory control by the resp. control centre in the medulla
- drug effects . eg. Opioids, barbituates
- compression or trauma to the medulla
The effects of resp. acidosis will include all the effects of acidosis such as
depressed neural function ( lethargy, disorientation, stupor etc.) ,severe headache
d/t cerebral vasodilation and s/s of attempted compensation such as tachycardia
and lower pH of the urine as the renal compensations kick in.

2. Respiratory Alkalosis. This will involve a decrease in PCO2 an decreased

[H2CO3]. Causes can include;
- anxiety induced hyperventilation
- hypoxemia – so you attempt compensation by increased ventilation
- drug effects on the R.C.Centre ( eg. Salicylates)
- excess mechanical ventilation
- alcohol withdrawal
 The effects of resp. alkalosis will be hyperexcitability of the nervous system
leading to tingling sensations, numbness, high levels of excitability as well as a more
alkaline urine as the kidneys try to compensate.

3. Metabolic Acidosis. This will involve a decrease in [HCO3-] This can be d/t
one of two main factors;
a. excess gain of acids. Examples include;
- ketoacidosis in response to fasting or diabetes or alcoholism. Fats are
broken down to provide energy if CHO’s are not available and fat
breakdown produces ketones which are acidic
- lactic acidosis. This occurs when tissues ( esp. muscles) are working
without adequate oxygen supply. They do anaerobic respiration
which produces a lot less energy and also produces lactic acid.
- Excessive acid intake. This might include salicylates, ethylene glycol
( antifreeze) etc.
- Kidney disease that causes the kidneys to be unable to secrete
enough H+ or reabsorb enough HCO3-.
- Hyperkalemia or hypoaldosteronism so that H+ is not secreted
normally
b. excess loss of bases. Examples include;
- diarrhea . You lose the bicarb secreted by the pancreas because you
don’t have time to reabsorb it.
- Long term vomiting – because you lose that same bicarb from the
intestines but up the other way.
- Loss of kidney ability to reabsorb bicarb.
The effects will be typical effects of acidosis but also the s/s of attempted
respiratory compensations such as rapid, deep breathing ( Kussmauls breathing)

4. Metabolic Alkalosis. This will involve an increase in [HCO3-]. This can be d/t ;
a. excess gain of bases. Examples are;
- excess intake of bicarbonate. When people eat tums and other
antacids like candy. Excess citrate, lactate or acetate ingestion.
b. excess loss of acids. Examples are;
- short term vomiting leading to the loss of HCl from the stomach
- gastric suction
- hyperaldosteronism or hypokalemia
There will be typical alkalosis effects on tissues plus the s/s of attempted
respiratory compensations such as a greatly decreased rate and depth of
breathing so that PCO2 will rise leading to increased [HCO3-]