HYPOXIA & HYPERCAPNIA

Zulkifli, dr., SpAn.Mkes

Dept of Anesthesiology & Reanimation
Medical Faculty
University of Sriwijaya
 Definition
• Hypoxia :
– A pathological condition in which the body is
deprived of adequate oxygen supply
– Oxygenation is failure

• Hypoxemia :
– The oxygen concentration within the arterial blood
is abnormally low
 Symptoms
Signs of oxygenation failure:
• Tachypnea
• Alkalemia (acidemia if concurrent ventilatory
failure)
• Increased pulsus paradoxus
• Cyanosis
• Agitation  Somnolence
 TYPES OF HYPOXIA

A. HYPOXEMIC HYPOXIA (INADEQUATE ARTERIAL OXYGEN

TENSION)

CAUSES: A. V/Q MISMATCH (EX: COPD)

B. SHUNT (EX: ATELECTASIS, PULM. EDEMA)
C. HYPOVENTILATION (EX: DRUG INDUCED)

B. ANEMIC HYPOXIA (DEFICIENT OXYGEN-CARRYING CAPACITY

OF THE BLOOD)
A. ANEMIA (DECREASED HEMOGLOBIN)
CAUSES: B. CARBON MONOXIDE POISONING
C. SULFHEMOGLOBIN AND METHEMOGLOBIN
 TYPES OF HYPOXIA

C. CIRCULATORY HYPOXIA (DECREASE PERIPHERAL CAPILLARY

BLOOD FLOW)

CAUSES:
A. DECREASED CARDIAC OUTPUT
B. VASCULAR INSUFFICIENCY (SEPSIS)

D. HISTOTOXIC HYPOXIA (DECREASED UTILIZATION OF OXYGEN

AT THE CELL LEVEL)

CAUSES:
A. CYANIDE POISONING
B. ALCOHOL POISONING (RARE)
 Hypoxia - Etiologies
PaO2 = [FIO2 (PI – PH2O)] – (PaCO2 / RQ) – (A-a gradient)

↑ A-a gradient ↓ FIO2

V/Q mismatch Suffocation
COPD
Pulmonary embolus
Pneumonia ↓ PI
Pulmonary edema High altitude
Anatomic shunt
Right to left intracardiac shunts
Pulmonary AVMs
↑ PaCO2
Impaired diffusion
Emphysema As above
Pulmonary fibrosis
Overview of Gas Exchange in the Lungs

Adapted from: Costanzo, LS. Physiology, 1st ed. 1998.

 Mathematical Description of Gas Exchange

PaCO2 – Partial pressure of CO2 in the arterial blood.

PACO2 – Partial pressure of CO2 in the alveolar gas.

PaO2 – Partial pressure of O2 in the arterial blood.

PAO2 – Partial pressure of O2 in the alveolar gas.
 Oxygen Transport
Oxygen is carried in the blood in 2 forms:

• Dissolved O2 (~2% of total O2 content)

• O2 bound to hemoglobin (~98% of total O2

content)
 Oxygen Transport

Total O2 content of blood (CaO2) =

Dissolved O2

O2 bound to hemoglobin
 Oxygen Transport

Total O2 content of blood (CaO2) =

PaO2 x Solubility of O2 in blood

O2 binding x [Hb] x O2 sat

capacity of Hb
 Oxygen Transport
(During Normal Gas Exchange)

Total O2 content of blood (CaO2) =

PaO2 x Solubility of O2 in blood

O2 binding x [Hb] x O2 sat

capacity of Hb
 Oxygen Transport
(During Normal Gas Exchange)

Total O2 content of blood (CaO2) =

100 mmHg x 0.003mL O2___

100mL
blood ∙ mmHg
+

1.34mL O2 x 15g Hb x 0.98

1g Hb 1dL blood
 Oxygen Transport
(During Normal Gas Exchange)

Total O2 content of blood (CaO2) =

0.3mL O2_ (Dissolved O2)

100mL blood

19.7mL O2_ (Hb-bound O2)

100mL blood
 CONTENT VS TENSION (PaO2)
A. CONTENT= TOTAL AMOUNT OF OXYGEN CARRIED IN BLOOD

NORMAL = 20.7 VOL%

CALCULATION: CaO2 = [%sat x l.39 x content] + [PaO2 x 0.003]

EXAMPLES/NORMAL

NORMAL Hb% = 15 GM%, 0.98 02 SAT = PaO2 = 100mmHg

[1.39 X 0.98 x 15] + [100 x 0.003] = 20.7 vol.%

ANEMIA Hb 10g%, %sat = 98%, PaO2 = 100mmHg

[1.39 x 0.98 x 10] + [100 x 0.003] = 14.2 vol.%
HYPOXEMIA Hb% =15 gm%, %Sat=85%, PaO2=50mmHg
» [1.39 x 0.85 x 15] = [50 x 0.003] = 18.0vol%
NORMAL MIXED VENOUS CONTENT = 15%
ARTERIAL VENOUS DIFFERENCE (A-V) = 5VOL%
 CONTENT VS TENSION (PaO2)
B. TENSION (PaO2) = AMOUNT OF OXYGEN DISSOLVED IN BLOOD

NORMAL = 100mmHg [100 x 0.003] = 0.3%

PaO2 = 1.5% OF THE TOTAL O2 CARRIED IN THE BLOOD ONLY

Hg O2 CONTENT CARRIES 19.2 VOL%

VS
PaO2 CONTENT CARRYING 1.5 VOL%

AS YOU CAN SEE PaO2 ISN'T ALWAYS THE MOST

IMPORTANT OXYGENATION INDICATOR
 Pathophysiology
• If oxygen delivery to cells is insufficient for the demand
(hypoxia)
– hydrogen will be shifted to pyruvic acid converting it to lactic acid
• This temporary measure (anaerobic metabolism) allows
small amounts of energy to be produced
• Lactic acid build up in tissues and blood
– is a sign of inadequate mitochondrial oxygenation
– due to hypoxemia, poor blood flow (e.g., shock)
– or a combination of both
• If severe or prolonged it could lead to cell death.
 Hypoxia – Treatment
• Treat the underlying process
• Increase FIO2 with supplemental oxygen
• Reposition the body
• Secretion management
• Bronchodilation
• Diuresis
• Increase mean lung volume
• Reduce O2 requirement
• Consider transfusion if [Hb] < 7.0 g/dL
 Hypercapnia
Respiratory failure manifesting as hypercapnia is
known as ventilatory failure.

Signs of ventilatory failure:

• Tachypnea
• Acidemia
• Increased pulsus paradoxus
• Hyperinflation
• Somnolence / Decreased mental status
 Hypercapnia - Etiologies
PaCO2 = VCO2 x PI
RR (VT – VD)
↑VCO2 (Hypermetabolism) ↓VT
Fever Skeletal muscle weakness
Seizures Impaired neuromuscular transmission
Sepsis ↓ Lung / chest wall compliance
Hyperalimentation Airway obstruction
COPD
Asthma
Obstructive sleep apnea
↓RR (Central hypoventilation)
Drugs
Brainstem lesions ↑VD
Obesity-hypoventilation syndrome Excessive PEEP
 Hypercapnia - Treatment

• Treat the underlying process

• Non-invasive positive pressure ventilation

• Intubation and mechanical ventilation

TERIMA KASIH