Adjusting Mechanical

Ventilation based on Blood Gas

Analysis

Annual Neonatal Update

Workshop Mechanical Ventilator
UKK Neonatologi Ikatan Dokter Anak Indonesia
 Objective
• Anatomy of the Blood Gas
• How to get the blood test for BG?
• Interpretation of BG
• Targeted BG based on Diseases
• Parameter Ventilation
• Adjusting ventilation based on BG
Anatomy of the Blood Gas
 ABG – Procedure and Precautions

SITE Ensure No Air Bubbles.

 Umbilical Artery Syringe must be sealed
 Radial Artery immediately after
 Brachial Artery withdrawing sample.
 Femoral Artery

ABG Syringe must be

transported at the earliest to
the laboratory for EARLY
analysis via COLD CHAIN
 ABG – Procedure and Precautions
Ideally - Pre-heparinised ABG syringes
- Syringe should be FLUSHED with 0.5ml
of 1:1000 Heparin solution and emptied.
•DO NOT LEAVE EXCESSIVE HEPARIN IN
THE SYRINGE

HEPARIN DILUTIONAL HCO3

EFFECT PCO2
 Only small 0.5ml Heparin for flushing and discard it
 Syringes must have > 50% blood. Use only 3ml or less
syringe.
 Timing the ABG
Healthy lungs Lung disease

• There is slow mixing of

alveolar gas 
There is rapid mixing of inhomogenity of
inhaled air, between the ventilation between
different regions of the diseased and healthy
lung. alveolar units.

Blood gases drawn after 5–

7 min of any change in • Blood gases should ideally
FIO2 are acceptable. be drawn after 20–25 min of
any change in FIO2 to enable
equilibration
 Factors Modifying the Accuracy
of ABG Results

• The Effects of Metabolizing Blood Cells

• Air Bubble in the Syringe
• Over-Heparinization of the Syringe
• Pyrexia (Hyperthermia)
 Normal Values
ANALYTE Normal Value Units

pH 7.35 - 7.45

PCO2 35 - 45 mm Hg

PO2 72 – 104 mm Hg`

[HCO3] 22 – 30 meq/L

SaO2 95-100 %

Anion Gap 12 + 4 meq/L

∆HCO3 +2 to -2 meq/L
Arterial, Capillary and Venous BG
How about if the arterial blood
can’t be taken?
Vein and Capillary Blood
 Responses to Blood Gas Result on
the FiO2

• If PaO2 < 45  Increased oxygenation ( see the component of

oxygenation), immediate fall of PaO2 evaluate the DOPE
• If PaO2 40-80  No need to change
• If PaO2 >80 FiO2 decreased by 5%
• If PaO2 > 120 FiO2 decreased by 10%
Response to SpO2

Pembacaan Oksimeter Tindakan

Naikkan FiO2 hingga SaO2 mencapai 85– 95%

dalam 1–2 menit. Jika SaO2 menurun dengan
SaO2<85%
cepat, evaluasi terdapat pneumotoraks atau
masalah mekanik lain seperti dislokasi pipa ET.
SaO2 85–95% Tidak perlu dilakukan tindakan cepat. Namun,
perlu dilakukan analisis gas darah secara
berkala untuk menilai PaO2, PaCO2, dan pH
(bila AGD mungkin dilakukan).
SaO2>95% Turunkan FiO2 bertahap tiap 5% per menit
hingga SaO2 mencapai 95%. Lalu periksalah
AGD (bila mungkin) untuk menilai PaO2 darah
arteri.
What is Normal BGA for
preterm?
Is it the same for all newborn?
 Normal ABG
• In Preterm babies the acid base balance is a bit different
• We use usually the term “acceptable blood gas ‘ instead of normal
blood gas
• This is to avoid more aggressive interventions to normalize their
blood gas, which may lead to harm
 Target Blood Gas in Neonates*

< 28 28-40 Term

Infant
weeks' weeks' with
with BPD
GA GA PPHN

pH » 7.25 » 7.25 7.30-7.50 7.35-7.45

PaCO 2 45-55 45-55 30-40

Pa0y 45-65 50-70 80-120 50-80

' Goldsmith and Korofkin, Assisted Ventilation of the Ne'onote, 4'h edition, Saunders
 Interpretation of Blood Gas Analysis

• 1. Determined if pH is acidotic or alkalotic

• 2. Determined the cause of the anomaly :
• Respiratoric
• Metabolic
• Mixed
•  Anion Gap
• 3. Check oxygenation
 Acidemia or Alkalemia

Look at pH
<7.35 - acidemia
>7.45 – alkalemia

RULE – An acid base abnormality is present even if either

the pH or PCO2 are Normal.
 Anion Gap
IN METABOLIC ACIDOSIS WHAT IS THE ANION GAP?
ANION GAP(AG) = Na – (HCO3 + Cl)
Normal Value = 12 + 4 ( 7- 16 Meq/l)

Adjusted Anion Gap = Observed AG +2.5(4.5- S.Albumin)

50% in S. Albumin 75% in Anion Gap !!!

High Anion Gap Metabolic Acidosis

Metabolic Acidosis
Normal Anion Gap Acidosis
 Interpretation of ABG

OXYGENATION ACID BASE

PO2/ FiO2 ratio ( P:F Ratio )
Gives understanding that the patients OXYGENATION
with respect to OXYGEN delivered is more important
than simply the PO2 value.
Example,

Patient 1 Patient 2
On Room Air On MV

PO2 60 90

FiO2 21% (0.21) 50% (0.50)

P:F Ratio 285 180

 Acid Base Regulation
H+ ion concentration in the body is precisely regulated
The body understands the importance of H+ and hence devised
DEFENCES against any change in its concentration-

• Three mechanism to maintain pH

1. Respiratory (CO2) within minutes
2. Buffer (in the blood:
carbonic acid/bicarbonate, phosphate buffers, Hb)
3. Renal (HCO3-)
Is there any non invasive methode of measuring
Blood gas or blood gas component?
 ACc urac y of Transcutaneous CO2 Values Compared With A8erial and
Capillary Blood Gases
Laura L Lambert RRT RRT-NPS, Melissa B Baldwin RRT RRT-NPS,
Cruz Velasco Gonzalez PhD, Gary R Lowe MEd RRT RRT-NPS RPFT, and
I Randy Willis MBA RRT RRT-NPS AE-C

Estimated Difference SD Lower Limit of Agreement* Upper Limit of Agreement•

ABGfB 7.62 8.45
Capillary blood gasfP,pjy t3.66

50

40

30

20

10

q 0
-10

@ -20

50 70 80 90 100 110

Average ABG and P

CONCLUSIONS: Based on these data, capillary blood gas comparisons showed less variation and a
slightly lower correlation with PtcCO2 than did ABG comparisons. After accounting for serial
measurements perpatient, due to the wide limits of agreement and poor repeatability, the utility
of relying on PtcCO2 readings for this purpose is questionable.
 End Tidal CO2 and PtcCO2
• Under normal physiologic conditions, the difference
between arterial PCO2 (from ABG) and alveolar PCO2
(ETCO2 from capnograph) is 2-5 mmHg. This difference is
termed the PaCO2
• With diseased lungs, there is an increased arterial to end-
tidal CO2 gradient due to ventilation-perfusion mismatch
• PtcCO2 is the preferred technology in patients with lung
disease, significant mouth breathing , or those who are
using supplemental oxygen or mask ventilation
 Ventilator Parameter that will change the
Blood Gas Results
1. PEEP (positive end expiratory pressure)
• Component that will increase oxygenation
• Recommended level 5-7 cmH2O
• PEEP > 6-7  overdistensi
• PEEP <3 cmH2O  atelectase
•  MAP (Mean Airway Pressure)
•  O2
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2. PIP (peak inspiratory pressure)
• Increase PIP :
•  MAP
•  PaO2
•  PaCO2
•  Tidal volume (TV)

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•  PIP, when overventilasi:
• PaCO2 < 45 mmHg
• Tidal Volume (TV) > 5 ml/kg
• CXR (posterior ribs > 8)
• Expiratory curve doesnt
reach 0

• High PIP (> 30) 

Barotrauma and ⭽ Stroke
volume  HFO ?
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 …parameter ventilasi

3. Tidal Volume
• Increasing tidal volume  CO2 vise versa
• N: 3,5-6 ml/kg
• Initial setting: 4 ml/kg, very preterm 5
• TV  or  by 0,5 ml/kg upon PaCO2
4. Time Inspiration (TI)
• increase TI:
• Lung recruitment/ alveoli
•  MAP   O2
• Normal 0,3 – 0,5 (<0,2 dan > 0,7 berbahaya) PEEP
> 6-7  hati-hati overdistensi
•  rate:
•  PaCO2
•  Minute volume

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5. O2 Fraction (FiO2)
• Based on level O2 arterial blood gas (PaO2 ) & Pulse
(SpO2 )
• Normal Level PaO2 50-80 mmHg
• SpO2 88-92%
• FiO2 > 40%  Toxic

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• Increase oxygenation by :
 FiO2 dan  MAP
•  MAP :
•  PEEP
•  ET
•  IT
•  PIP
•  Flow
 Adjutment Ventilation
based on Blood Gas Result

• Always remember DOPE before any

intervention
• Displaced tube Clinical ev, Pulmonary graph
• Obstructed tube  Clinical ev,Pulmonary
graph
• Pneumothorax  Clinical ev, transillumination.
• Equipment failure
 Kesimpulan
• Analisis Gas Darah adalah hal salah satu hal yang menjadi pertimbangan
penting dalam keberhasilan penanganan pasien dalam ventilasi mekanik
• Pertimbangan perlu diperhatikan pada komponen respiratorik, metabolic,
anion gap dan buffer dalam darah untuk mempertahankan pH yang normal
• Target pH dan komponen pada bayi premature dan beberapa penyakit
respiratorik berbeda
• Perubahan setting ventilasi mekanik akan mempengaruhi perubahan pH
• Terdapat alternatif monitoring pH yang non invasive namun tetap perlu
digunakan secara bijak dengan memperhatikan beberapa keterbatasannya