ACID-BASE BALANCE

1.1 Introduction
Having a proper balance between acid and base in the body is critical to maintaining homeostasis
and optimal cellular function. Therefore, the uptake and release of hydrogen ions from the body is a
well coordinated process. Understanding acid-base balance is a core concept that can help you think
critically about your patients and recognize how imbalances can impact their overall wellbeing.

Definitions
• An acid is defined as a substance that releases protons or hydrogen ions (H+), e.g. hydrochloric
acid (HCI), carbonic acid (H2CO3).

•A base is a substance that accepts protons or hydrogen ions, e.g. bicarbonate ion (HCO3–), and
HPO4– –,

Proteins in the body also function as bases, because some of the amino acids accept hydrogen ions,
e.g. hemoglobin in red blood cells and plasma protein especially albumin are the most important of
the body’s bases.

Buffer is a solution of weak acid and its corresponding salt which resists a change in pH when a
small amount of acid or base is added to it.

1.2 Blood pH
The normal range for blood pH level is 7.35 to 7.45. If the blood is too acidic then the pH number
will be low; too alkaline and the pH number will be high. In normal conditions, the body manages
to keep the pH in an optimal range through compensatory mechanisms and buffering.

Metabolic process in the body produces two kinds of acids;

i) Volatile acids: which can form gases in solution. Examples of physiologically important volatile
acid is carbonic acid H2CO3, whose total concentration is equivalent to 36L of 1.0 acid. These acids
leave the body through the lungs.

ii) Fixed acids: these are non-gaseous and must therefore leave the body through the kidneys.
Examples include sulfuric and phosphoric acids; organic acids like lactic and pyruvic acids.

1.3 Regulation of blood pH

Three main systems regulate the concentration of hydrogen ions in body fluids. These include:
- Buffer mechanism: this is the first line of defense.
- Respiratory mechanism: second line of defense
- Renal mechanism: third line of defense
Role of Buffer mechanism in acid-base balance
The buffer systems of the blood, tissue fluids and cells; immediately combine with acid or base to
prevent excessive changes in hydrogen ion concentration. These buffers include phosphate buffers,
bicarbonate buffer, protein buffer and haemoglobin buffer.

Buffer systems do not eliminate hydrogen ions from the body or add them to the body, but only
keep them tied up until balance can be re-established.

Respiratory mechanism in acid-base balance

Before looking into the respiratory mechanism of acid-base balance, we will look at some important
factors/definitions to remember.
- Arterial Blood Gases: Arterial blood gases (ABG) are measured by collecting blood from an
artery, rather than a vein, and are most commonly collected via the radial artery. ABGs measure the
pH level of the blood, the partial pressure of arterial oxygen (PaO 2), the partial pressure of arterial
carbon dioxide (PaCO2), the bicarbonate level (HCO3), and the oxygen saturation level (SaO2).
PaCO2 is the partial pressure of arterial carbon dioxide in the blood. The normal PaCO 2 level is 35-
45 mmHg. CO2 forms an acid in the blood that is regulated by the lungs by changing the rate or
depth of respirations.

HCO3 is the bicarbonate level of the blood and the normal range is 22-26. HCO 3 is a base managed
by the kidneys and helps to make the blood more alkaline.

PaO2 is the partial pressure of arterial oxygen in the blood. It more accurately measures by a
patient’s oxygenation status than SaO2 (the measurement of hemoglobin saturation with oxygen).
Therefore, ABG results are also used to manage patients in respiratory distress.

Mechanism;
• The respiratory centre regulates the removal or retention of CO 2 and thereby H2CO3 from the
extracellular fluid by the lungs. Thus, lungs function by maintaining one component (H 2CO3) of the
bicarbonate buffer as follows:
– An increase in (H+) or (H 2CO3) stimulates the respiratory center to increase the rate of respiratory
ventilation. When the ventilation rate increases, more CO 2 is released from the blood and pH
increases.
– Similarly, an increase in (OH–) or (HCO3–) depresses respiratory ventilation. A decrease in
ventilation rate will cause a decrease in release of CO 2 from the blood. The increased blood CO2
will result in the formation of more H2CO3. Thus, there will be decrease in pH.
• Thus, when the rate of ventilation is increased, excess acid (H 2CO3) in the form of CO2 is quickly
removed. Similarly, when the rate of ventilation is decreased, acid (H 2CO3) in the form of CO2 is
added to neutralize excess alkali (HCO3–).
Renal Mechanism in Acid-base Balance
Renal mechanism is the third line of defense in acid-base balance. Long-term acid-base control is
exerted by renal mechanisms. Kidney participates in the regulation of acid base balance primarily
by conservation of HCO3– (alkali reserve) and excretion of acid as the case may be.
• The pH of the initial glomerular filtrate is approximately 7.4 same as that of plasma,
whereas the average urinary pH is approximately 6.0 due to the renal excretion of non-
volatile acids produced by metabolic processes.
• The pH of the urine may vary from 4.5 to 8.0 corresponding to the case of acidosis or
alkalosis. In acidosis, excretion of acids is increased and base is conserved, in alkalosis, the
opposite occurs. This ability to excrete variable amounts of acid or base makes the kidney the
final defense mechanism against change in body pH.
• Renal conservation of bicarbonate (HCO3–) and excretion of acid occur through four key
mechanisms:
1. Exchange of H+ for Na+ of tubular fluid.
2. Reabsorption (reclamation) of bicarbonate from tubular fluid.
3. Formation of ammonia and excretion of ammonium ion (NH4+) in the urine.
4. Excretion of H+ as H2PO4– in urine.

Assignment: Read on the four mechanisms listed above.

1.4 ACIDOSIS AND ALKALOSIS

Acid-base balance depends on the ratio of HCO 3–/H2CO3 (bicarbonate/carbonic acid) which is
constant at 20:1 at physiological pH. Any alteration produced in the ratio between bicarbonate and
carbonic acid results in an acid-base imbalance and leads to acidosis or alkalosis.

- Acidosis may be defined as an abnormal condition caused by the accumulation of excess acid in
the body or by the loss of alkali from the body.
- Alkalosis is an abnormal condition caused by the accumulation of excess alkali in the body or by
the loss of acid from the body.

Acidosis and alkalosis are classified, in terms of their immediate cause as follows:
a) Respiratory acidosis: Increase in Carbonic acid (H2CO3) concentration.
b) Metabolic acidosis: Decrease in bicarbonate (HCO3–) concentration.
c) Respiratory alkalosis: Decrease in H2CO3 concentration.
d) Metabolic alakalosis: Increase in HCO3– concentration.

a) Respiratory acidosis
Respiratory acidosis develops when carbon dioxide (CO 2) builds up in the body (referred to as
hypercapnia), causing the blood to become increasingly acidic, due to increased levels of dissolved
carbon dioxide in the form of H2CO3.

Respiratory acidosis is identified when reviewing ABGs and the pH level is below 7.35 and the
PaCO2 level is above 45, indicating the cause of the acidosis is respiratory. Note that in respiratory
acidosis, as the PaCO2 level increases, the pH level decreases.
Causes of Respiratory acidosis
i) Obstruction of respiration: typically caused by a medical condition that decreases the exchange
of oxygen and carbon dioxide at the alveolar level, such as an acute asthma exacerbation, chronic
obstructive pulmonary disease (COPD), or an acute heart failure exacerbation causing pulmonary
edema.
ii) Depression of respiration: caused by decreased ventilation from anaesthesia, alcohol, or
administration of medications such as opioids and sedatives

Signs of symptoms of hypercapnia vary depending upon the level and rate of CO 2 accumulation in
arterial blood:
•Patients with mild to moderate hypercapnia may be anxious, experience daytime sluggishness,
headaches, or hypersomnolence.
•Patients with higher levels of CO2 or rapidly developing hypercapnia develop, paranoia,
depression, and confusion that can progress to seizures and coma as levels continue to rise.

Treatment for respiratory acidosis typically involves improving ventilation and respiration by
removing airway restrictions and reversing over-sedation.

b) Metabolic acidosis
This is primarily caused by a decrease in the bicarbonate (HCO 3–) concentration, leading to a
decrease in the blood pH.
Under normal conditions, the kidneys work to excrete acids through urine and neutralize excess
acids by increasing bicarbonate (HCO3–) reabsorption from the urine to maintain a normal pH.
When the kidneys are not able to perform this buffering function to the level required to excrete and
neutralize the excess acid, metabolic acidosis results. Another cause of metabolic acidosis is
diabetic ketoacidosis, where acids called ketones build up in the blood when blood sugar is
extremely elevated.
Metabolic acidosis is characterized by a pH level below 7.35 and an HCO3– level below 22 when
reviewing ABGs. It is important to notice that both the pH and HCO3– decrease with metabolic
acidosis (i.e., the pH and HCO3– move in the same downward direction).

Symptoms of metabolic acidosis include rapid breathing that occurs as the lungs try to remove
excess CO2 in an attempt to resolve the acidosis. Other symptoms of metabolic acidosis include
confusion, decreased level of consciousness, hypotension, and electrolyte disturbances that can
progress to circulatory collapse and death if not treated promptly.

c) Respiratory alkalosis
Respiratory alkalosis develops when the body removes too much carbon dioxide or (H2CO3)
through respiration, resulting in increased pH and an alkalotic state.
When reviewing ABGs, respiratory alkalosis is identified when pH levels are above 7.45 and the
PaCO2 level is below 35. With respiratory alkalosis, notice that as the PaCO2 level decreases, the pH
level increases.
Respiratory alkalosis is caused by hyperventilation that can occur due to anxiety, panic attacks,
pain, fear, fever, working at high temperatures, etc.
Respiratory alkalosis can be compensated by increased excretion of bicarbonate (HCO3).

Patients experiencing respiratory alkalosis often report feelings of shortness of breath, dizziness or
light-headedness, chest pain or tightness, and palpitations as a result of decreased carbon dioxide
levels. Treatment of respiratory alkalosis involves treating the underlying cause of the
hyperventilation

d) Metabolic alkalosis
A rise in blood pH (above 7.45) due to rise in the bicarbonate (HCO 3–) levels of plasma is called
metabolic alkalosis. Note that both pH and HCO3– are elevated in metabolic alkalosis. This is seen
in the following conditions:
● Loss of gastric juice along with H+ ions in prolonged and severe vomiting.
● Therapeutic administration of large dose of alkali (as in peptic ulcer) or chronic intake of
excess antacids.
● Excessive urinary loss (due to diuretics) can cause metabolic alkalosis due to loss of
hydrogen ions in the urine

Symptoms of metabolic acidosis include decreased respiratory rate (as the lungs try to retain
additional CO2 to increase the acidity of the blood and resolve the alkalosis). The patient may also
be confused due to the altered pH level.
The body compensates for this condition by increased excretion of bicarbonate (HCO 3–) by the
kidney.

Treatment is prescribed based on the suspected cause of imbalance. For example, treat the cause of
the vomiting, stop the gastrointestinal suctioning, or stop the administration of diuretics.

1.5 Mixed Acid-Base Disturbances

Mixed acid-base disturbances refers to when respiratory and metabolic disorders occurs
simultaneously.
For example, some patients with chronic renal failure (which causes a primary metabolic acidosis)
may also have chronic obstructive airways disease, which causes a primary respiratory acidosis.
Plasma (H+) will be increased in these patients, but the results for plasma CO2 and concentration of
(HCO3–) cannot be predicted.

1.6 Compensatory responses in acid-base disturbances

Compensatory responses: Involves responses by the respiratory tract and kidney to primary
metabolic and respiratory acid-base disturbances, respectively.

Respiratory compensation for a primary metabolic disturbance: Alterations in alveolar ventilation

occurs in response to primary metabolic acid-base disturbances because the body senses changes in
pH with peripheral chemoreceptors. This begins within minutes to hours of an acute primary
metabolic disturbance. Note that complete compensation via this mechanism takes up to 24 hours.

Renal compensation for a primary respiratory disturbance: Here, the kidney alters excretion of acid
(excrete an acid, gain a base; retain an acid, excrete a base) in response to primary respiratory
disturbances. This begins within hours of an acute respiratory disturbance, but take several days (3-
5 days) to take full effect.
Compensation can either be partial or full. If the pH is close to normal ranges, then partial
compensation exists. If the pH is back within normal ranges, then a full compensation has occurred.
A non compensated or uncompensated abnormality usually presents an acute change occurring in
the body.

Example:
Patient case: John Doe is rushed to the hospital with bouts of severe prolonged vomiting. Analysis
of his ABGs showed increased bicarbonate (HCO 3) and blood pH (7.5) levels. Further, an increased
pCO2 was recorded. These laboratory results indicate which type of acid-base disorder? Is the
disorder compensated or uncompensated?