Interpretation of ABGs and

Spirometry

DR. SUBODH KUMAR MAHTO

PGI PGIMER,DR.RML HOSPITAL.
NEW Delhi
 Acid base disorders

• Acid–base homeostasis is fundamental for maintaining life

• The hydrogen-ion concentration is tightly regulated because
changes in hydrogen ions alter virtually all protein and
membrane functions.
• The three major methods of quantifying acid–base disorders are
– The physiological approach-isohydric principle
– The base-excess approach
– The physicochemical approach –Stewart method
Normal components of ABG report

Parameters Normal range

pH 7.35 – 7.45
PaCO2 35 – 45
PaO2 80- 100
HCO3 22-26
SaO2 >95%
Check for ERRORS

Have the required parameters been correctly

fed..???
 Patient’s Temperature
 Fi O₂ : specially if patient is in ventilator
 Hemoglobin : some machines may not measure it
 Barometric pressure : some machines may not measure it
 A Stepwise
Approach to
Solving
Acid-Base
Disorders
Step 1:Assessment of validity of test
results

• Assess the internal consistency of the values using the Henderseon-

Hasselbach equation

[H+] in nmol/L = 24 × PaCO₂/HCO₃

• If there is a discripancy between the 2 results, the blood should be

reanalyzed.

• HCO3 should be within 1-3 mEq/L of Total CO2 (electrolyte). A

difference of > 4 mEq/L = technical error

Step 1: Assessment of validity of test results
Relation b/w pH & H+ conc.
pH [H+] in nanomoles/L

7.00 100
7.10 80
7.30 50
7.40 40
7.52 30
7.70 20
8.00 10

pH is inversely related to [H+]; a pH change of

1.00 represents a 10-fold change in [H+]
 STEP -2: Acidemia or alkalemia..???
See the pH (<7.35 or >7.45)

 Acidemia –pH less than 7.35

 Acidosis – A process that would cause acidemia, if not
compensated

 Alkalemia–pH greater than 7.45

 Alkalosis – A process that would cause alkalemia if not
compensated
Four primary acid-base disorders

 Metabolic acidosis

 Metabolic alkalosis

 Respiratory acidosis

 Respiratory alkalosis
 STEP -3 : Identify the primary disorder
See the change in PaCo2 & HCO3-

 If the PaCo2 is deranged in the same direction of pH then the primary

disorder is metabolic

 If the PaCo2 is deranged in the opposite direction of pH then the

primary disorder is respiratory

pH PaCo2 HCO3 Respiratory

7.25 60 26 acidosis
Step 4: COMPENSATION

 It is secondary adaptive response to mitigate the change in

arterial pH – so acid base homeostasis is maintained
 Compensation doesnot return the pH to complete normal and
never over compensate.
 Resp. compensation occurs in hours but Full renal compensation
takes 2-5 days
 If given patient is not compensating as predicted, then second (or
third) acid base disorder must be present
 Prediction of compensation

Metabolic acidosis PaCO2= (1.5 x HCO3-) + 8 ± 2

PaCO2 will↑ 0.75 mmHg per mmol/L ↑ in

Metabolic alkalosis [HCO3-] or
PaCO2= 40 + {0.7(HCO3- - 24)}
[HCO3-] will ↑ 1 mmol/L per 10 mmHg
Acute
in PaCO2
Respiratory
acidosis [HCO3-] will ↑ 4 mmol/L per 10 mmHg
Chronic
in PaCO2

[HCO3-] will ↓ 2 mmol/L per 10 mmHg

Acute
Respiratory ↓ in PaCO2
alkalosis [HCO3-] will ↓ 4 mmol/L per 10 mmHg
Chronic
↓in PaCO2
Example 1

pH Paco2 HCO3
7.50 48 34

• Step 1: Check validity- H+ = 24 (48/34) = 33.8 (7.50 -32)

• Step 2: check pH = alkalemia
• Step 3: check Paco 2 >40 metabolic alkalosis
• Step 4: expected comp. Paco2 = 40 + {0.7(HCO3- -24)}
= 40 + 0.7
(10) = 47
• Appropriate resp. compensation
Example 2

pH Paco2 HCO3
7.12 32 10

• Step 1: Check validity- H+ = 24 (32/10) = 76.8 (7.10 - 79)

• Step 2: check pH = acedemia
• Step 3: check Paco 2 <40 metabolic acidosis
• Step 4: expected comp. PaCO2= (1.5 x HCO3-) + 8 ± 2
= (1.5 x 10)
+8 ± 2 = 23 ± 2
• Inappropriate resp. compensation ( 32 ≠ 23)
• PaCO2 is higher than predicted so 2° disorder is resp acidosis
STEP -5 : Calculate anion gap

 Calculation of the anion gap is useful in the initial evaluation of

metabolic acidosis.
 An elevated anion gap usually indicates the production of pathologic
acid (unmesured anion).
 Total Serum Cations = Total Serum Anions

 Unmeasured anions- unmeasured cations= Na+] – {[Cl-]+[HCO3-]}

 Anion gap = [Na+] - [Cl-]-[HCO3-]

 Up to 12 is normal anion gap

• Albumin is the major unmeasured anion

• The anion gap should be corrected if there are gross changes in

serum albumin levels.

AG (CORRECTED) = AG + { (4 – [ALBUMIN]) × 2.5}

 Causes of High AG Met Acidosis

• A useful
Cowen – Woodsmnemonic for theofmost
classification lacticcommon
acidosis causes is GOLD
TypeMARRK
AK- hypoxic Type B — nonhypoxic
KETOACIDOSIS
 UG
(septic - Ethylene
shock, Glycol
mesenteric B1 – 2nd to
UREMIA
 LO -hypoxemia,
ischemia, Hepatic
5-oxoproline [pyroglutamic failure
LACTICacid]
ACIDOSIS
hypovolemic
 TL -Lactic shock, carbon – metformin
Acidosis Renal failure
monoxide TOXINS?
malignancy
 D –cyanide)
poisoning, d lactate – bacterial overgrowth syndrome
B2:
 M – Methanol Thiamine def, seizure
 A- Aspirin Toxins - salicylate, ethylene
 R- Renal Failure glycol, propylene glycol,
methanol, paraldehyde
 R- Rhabdomyolsis Drugs - metformin, propofol,
 K - Ketoacidosis: niacin, isoniazid, iron or NNRTI
B3 – inherited syndromes
 CAUSES OF NORMAL ANION GAP
METABOLIC ACIDOSIS
Primary issue GI tract Renal
1. HCO3 loss: 2. Impaired renal acid
Gain of H+ Hyperalimentation Distal (type 1) RTA
 GIT excretion:
Hyperkalemia (type4)
 Diarrhoea  Distal (type RTA 1) RTA
 Pancreatic or biliary Hypoaldosteronism
drainage  Hyperkalemia (type 4)
Early uremic acidosis
 Urinary diversions RTA
Loss of HCO3  Diarrhoea
(ureterosigmoidostomy) Renal Proximal (type
 Renal Proximal (type 2) RTA
 Hypoaldosteronism
 Pancreatic or biliary 2) RTA
drainage
 Ketoacidosis (during diversions Early uremic acidosis
therapy)
 Urinary
(ureterosigmoidostomy)
 Post-chronic hypocapnia
Cholestyramine
3. Misc:
 Acid Administration
Infusion of normal saline (NH4Cl)
 Hyperalimentation
NORMAL ANION GAP METABOLIC ACIDOSIS

• It occurs when the decrease in HCO3- corresponds with an

increase in Cl- to retain electroneutrality - hyperchloremic
metabolic acidosis.

• Leads to increased renal excretion of NH4.

• Measurement of urinary NH4 can be used to differentiate

between renal and extrarenal causes.
• Urinary anion gap and urinary osmolal gap are often used as
surrogate measures of urinary ammonium.
 NORMAL ANION GAP METABOLIC ACIDOSIS

• UAG

= [Na+ + K+]u – [Cl–]u

• Hence a -ve UAG seen in GI causes while +ve value seen in renal causes
• The urinary osmolal gap
= (2 × [Na+] + 2 × [K+]) + (urine urea nitrogen ÷ 2.8) + (urine glucose ÷ 18)
• Osmolal gap below 40 mmol/L indicates renal cause
• Urine pH
– If urine pH > 5.5 : Type 1 RTA
– If urine pH < 5.5 : Type 2 or Type 4 RTA
 Approach to normal anion gap metabolic acidosis

In patients receiving saline

infusion, stop & switch to RL

Did acidosis resolve Excess NaCl

yes
Is GFR < 40 Renal failure

no
Asses serum K, UAG & U.pH
yes
 Diarrhea
 Pancreatic drainage Distal RTA Hyperkalemia
 Neg UAG
Urinary diversions high UAG pH>5.5 (type4)
K very highRTA
STEP -6 : Calculate the delta gap/ delta ratio

 To diagnose a high anion-gap acidosis with concomitant metabolic

alkalosis or normal anion-gap acidosis

 Delta gap =(measuredAG- normAG) – (norm.HCO3 – measuredHCO3)

±6 = (
 AG
±6
Delta
+24=+=AG)
gap=
HCO -3 24
((
( AG)
AG) = +18
AG) -HCO
- (
(24 –)
-3033HCO -
)
3
measuredHCO3)

 Usual range: -6 to +6 mmol/L ; should be 0

 > 6 mmol/l - concomitant metabolic alkalosis,.
 < −6 mmol/l - concomitant normal anion-gap metabolic acidosis
Easier alternative

Result Metabolic disorder

( AG + HCO3)

< 18 High anion gap + normal anion gap

metabolic acidosis

18- 30 High anion gap acidosis only

>30 High anion gap acidosis + metabolic

alkalosis
Delta ratio

• It is calculation that compares the increase in anion gap to the

decrease in HCO3
Delta ratio = ( AG) / ( HCO3- )
• Delta ratio depends on cause of elevated anion gap
Pathologic process Expected delta ratio
Lactic acidosis 1-2
ketoacidosis 0.8 - 1.2
Delta ratio

Delta ratio Metabolic disorder

Less than expected range High anion gap + normal anion gap
metabolic acidosis

Within expected range High anion gap acidosis only

Higher than expected High anion gap acidosis +

range metabolic alkalosis
 PLASMA OSMOLAR GAP

 Calculated Plasma Osmolarity = 2[Na+] + [Gluc]/18 + [BUN]/2.8

Normal Measured Plasma Osmolarity > Calculated Plasma Osmolarity
(upto 10 mOsm/L)
 Measured Plasma Osmolarity - Calculated Plasma Osmolarity > 10
mOsm/kg indicates presence of abnormal osmotically active substance
Ethanol
Methanol
Ethylene glycol
 METABOLIC
ALKALOSIS
 CAUSES OF METABOLIC ALKALOSIS

Primary issue GI tract Renal

1. HCO3 loss: 2. Impaired renal acid
Loss of H+ Vomitting Diuretics
 GIT excretion:
Gitelman
Gastric aspiration
 Diarrhoea  Distal
Congenital chloridorrhea (type 1) RTA
Bartter
 Pancreatic orVillous
biliary adenoma Mineralocorticoid
drainage  Hyperkalemia excess (type 4)
 Urinary diversions RTA
of HCO3 Milk alkali syndrome
Gain (ureterosigmoidostomy) Contraction alkalosis
Ingestion of NaHCO3
 Renal Proximal (type 2) RTA
 Hypoaldosteronism
 Ketoacidosis (during therapy)  Early uremic acidosis
 Post-chronic hypocapnia

3. Misc:
 Acid Administration
(NH4Cl)
 Hyperalimentation
 METABOLIC ALKALOSIS

Assess volume status

Low
normal Contraction alkalosis
Vomitting
Asses BP and S. NG suction
potassium Diuretics
Gitelman, Bartter ,
Normal BP n K
High BP

Mineralocorticoid hypokalemia Exogenous alkali

excess milk alkali syndrome
 Algorithm for assessing acid base status

 STEP -1 :check for validity

 STEP -2 : Acidosis or alkalosis..???

See the pH (<7.35 or >7.45)

 STEP -3 : Identify the primary disorder

See the change in PCo2 & pH

 STEP -4 : Calculate the compensatory response

Is adequately compensated???
 STEP -5 : Calculate anion gap

 STEP -6 : Calculate the delta gap (unmask hidden mixed

disorders)

 STEP -7 : Acquire additional relevant diagnostic data for each

identified disorder and generate differential diagnosis.
Case 1

• A 75 yr old woman presents with profuse diarrhea and fever her HR –

130 n BP is 60/40 pH 7.29 Na 128
• Step 1: Check validity- H+ = 24 (30/14) =51 PCO₂ 30 K 3.2
(7.30 -50)
HCO₃ 14 Cl 94
• Step 2: check pH = acidemia
• Step 3: check Paco 2 <40 metabolic acidosis
• Step 4: expected comp. Paco2 = (1.5 x HCO3-) + 8 ± 2 = 29 ± 2
appropriate resp. comp
• Step 5: calculate anion gap = Na – HCO3 – Cl- = 128-94-14= 20
high anion gap met. Acidosis
High anion gap metabolic acidosis + normal
• Step 6: delta ratio = ( AG) / ( HCO3- ) =(20-12)/10 = 0.8.
anion gap metabolic acidosis
 pH 6.96 Na 132
PCO₂ 60 K 3.4
Case 2 Measured Osm= 310 HCO₃ 12 Cl 95
BUN 24 Glu 74
Alb 1.9

• A 32 yr old woman with schizophrenia found unconscious and her HR

– 130 n BP is 104/70, SaO2 - 88% on RA
Lactate 0.8mmol/l
• Step 1: Check validity- H = 24 (60/13) = 110 (6.95 -112)
+
ketones negative
• Step 2: check pH = acidemia
s.creat 1.1
• Step 3: check Paco 2 >40 respiratory acidosis
• Step 4: expected comp. HCO3 = ↑ 1 mmol/L per 10 mmHg in PaCO2
no. Comp. Metabolic alkalosis.
• Step 5: calculate anion gap = Na – HCO3 – Cl-= 132-95-12= 25
Presumed
adjusted anioningestion
gap =25 + of toxic alcohol
2.5(4-alb)=30 high leading
anion gap met. Acidosis
• to
Stephigh anion
6: delta ratiogap
= ( metabolic acidosis
AG) / ( HCO and resp
3 ) =(30-12)/12 = 1.5
-

acidosis. Cannot rule out ingestion of

• additional respOsmolarity
Calculate Plasma depressant= 2(132) +24/2.8+74/18= 277
Case 3

• A 14 yr old girl with bulimia was brought to ER after bieng found

unconscious at her home with empty drug bottlepHnearby.7.39 Na 139
• Step 1: PCO₂ 22 K 3.1
• Step 2: check pH = normal
HCO₃ 13 Cl 88
• Step 3: check Paco 2 <22 resp.alkalosis
• Step 4: calculate comp. 2nd – met.acidosis
• Step 5: calculate anion gap = Na – HCO3 – Cl- = 139-88-13= 38
high anion gap met. Acidosis
• Step 6: delta ratio = ( AG) / ( HCO3- ) =(38-12)/(24-13) = 2.2

High anion gap metabolic acidosis +

metabolic alkalosis + resp. alkalosis
Analyse the adequacy of oxygenation..
• Causes of hypoxia
– Hypoxemia
– Anemia
– Dyshemoglobenemia
– Histotoxic hypoxia
 A-a gradient

A-a gradient = PAO 2 – PaO2

PAO2 is always calculated based on FIO2, PaCO2, and barometric

pressure. - alveolar gas equation.

 Alveolar Gas Equation
• Where PAO2 is the average alveolar PO2, and FIO2 is the partial pressure of
inspired oxygen in the trachea

PAO2=150
PAO2=(Patm-47)xFIO2
– 1.25(PaCO2)
PAO2=(760-47)x0.21 - PaCO2/RQ
- PaCO2/0.8

• Normal A- a gradient increase with age

Normal A- a gradient = (age/4) +4

A-a gradient in hypoxic patient

• If A- a gradient is normal

– Hypoventilation

– Low PI (extreme hight)

• If A- a gradient is elevated

– Shunt

– V/Q mismatch

– Imapaired diffusion
PaO2 / FIO2 Ratio

• Measure of severity of hypoxemia in ARDS

– Mild 200 – 300
– Moderate 100- 200
– Severe < 100
Saturation gap

• Saturation gap = [ SpO2 - Sa O2]

• > 5% is significant.
• Causes: methemoglobinemia

carboxyhemoglobinemia
Example 1

• 83 yr old woman with dementia was sent ER after she was found
tachypnic and hypoxic. She is in resp distress. Her ABG reads
pH – 7.53, PCO2- 26, PaO2- 41.
• check A-a gradient PAO2=(Patm-47)xFIO2 - PaCO2/RQ
PAO2=150 - 26/0.8 = 118
A-a gradient = PAO2 - PaO2
= 118 – 41 = 77
• Estimate normal A-a gradient = (age/4) +4 =83/4 +4 =25
Example 2

• A 22 yr old young male who works in printing press

presented to RML emergency with one day history of
confusional state, headache and slurring of speech. On
examination he appeared cyanosed, SpO2 -87% and ABG
revealed -
pH PaO2 SaO2
7.48 140 99
Spirometry
Learning objectives

 Introduction
 Types of spirometry
 Understand the meaning of spirometric indices and flow
volume loop
 How to use these values for diagnostic evaluations
 Severity of disease based on FEV1
Spirometry

• Method of assessing lung function by measuring the volume of

air that the patient is able to expel from the lungs after a maximal
inspiration.
• It is a reliable method of differentiating between obstructive
airways disorders and restrictive diseases.
• Spirometry is the most effective way of determining the severity
of COPD.
Indications

• Diagnosis of symptomatic disease

– Obstructive
– Restrictive
– Mixed
• Screening for early asymptomatic disease
• Prognostication
• Monitor response to treatment
Technologies used in spirometers

• Volumetric Spirometers
– Water bell
– Bellows wedge
• Flow measuring Spirometers
Types of spirometer

 Pneumotachometer
 Fully electronic spirometer
 Incentive spirometer
 Tilt-compensated spirometer
 Windmill-type spirometer
Spirograms

• Most spirometers display the following graphs

 a volume-time curve, showing volume (liters) along the Y-axis
and time (seconds) along the X-axis
 a flow-volume loop, which graphically depicts the rate of airflow
on the Y-axis and the total volume inspired or expired on the X-
axis
Volume-time curve

flow =  volume /  time

Maximum slope of curve = peak expiratory flow rate
Spirometry indices

• FVC – the total volume of air that the patient can forcibly exhale
in one breath after maximal inspiration.
• FEV1 – the volume of air that the patient is able to exhale in the
first second of forced expiration.
• FEV1 /FVC – the ratio of FEV1 to FVC expressed as a fraction
(previously this was expressed as a percentage).
• MEF25-75 This is the mid expiratory flow rate between 25-75%
of an expired air .
Flow volume loop

PEFR

FVC
 Values measured by spirometry

Major Minor
• FEV1 • PEFR
• FVC • PEF 25-75%
• FEV1/FVC ratio • Response to Bronchodilators
• Flow- volume loop
INTERPRETATION
 Patterns of Spirometric Curves

Interpretation FVC FEV1 FEV1/FVC%

(Tiffeneau index)
Healthy person Normal Normal (>80%) Normal
(>80%) (>0.7)
Airway Low/normal Low Low
obstruction
Restrictive Low Low/ normal Normal/
increased(>0.7)
Mixed Low Low Low
 Interpretation

Asses FEV- 1/ FVC ratio

low normal
Asses FVC
Asses FVC

Low normal low normal

Possible
restriction
Obstruction/
mixed
Normal lung
mechanics
Obstruction
Variable extrathoracic Variable intrathoracic Fixed
Airway obstruction Airway obstruction Airway obstruction
Staging of COPD based on FEV1

GOLD staging FEV1 compared to

predicted
Stage 1 > 80%
Stage 2 50% < FEV1 <80%
Stage 3 30% < FEV1 <50%
Stage 4 <30%
Bronchodilator Reversibility

• Administer salbutamol in four separate doses of 100 µg through a

spacer
• FEV1/FVC should be measured before and 15-20 minutes after
bronchodilator
• An increase in FEV1 and/or FVC >12% of control and >200 mL
constitutes a positive bronchodilator response.
• It is important to determine whether fixed airway narrowing is
present. In patients with COPD, post-bronchodilator FEV1/FVC
remains < 0.7.
Limitations of test

• Highly dependent on patient cooperation and effort, - FVC may

be underestimated
• Not suitable for unconscious, heavily sedated, or have limitations
that would interfere with vigorous respiratory efforts.
• Many intermittent or mild asthmatics have normal spirometry
between acute exacerbation
• Normal results in pulmonary vascular disorders
goldcopd.com
case 1
65 year-old man No pulmonary complaints PFT as part of a routine
health screening test Lifelong non-smoker Prior history of asbestose
exposure
Pre-Bronchodilator (BD) Post- BD
Test Actual Predicted % Predicted % Change
FVC (L) 4.39 4.32 102 -1
FEV1 (L) 3.20 3.37 95 7
FEV1/FVC (%) 73 78
FRC (L) 3.17 3.25 98
ERV (L) 0.63 0.93 68
RV (L) 2.54 2.32 109
TLC (L) 6.86 6.09 113
DLCO uncorr 25.69 31.28 82
DLCO corr 26.14 31.28 84
His flow volume loops is as follows:
:
Case 2

34 year – old woman With dyspnea &cough Non-smoker,with no occupational

exposures.
 PFT report

Pre-Bronchodilator (BD) Post- BD

Test Actual Predicted % Actual %

Predicted Change

FVC (L) 3.19 4.22 76 4.00 25

FEV1 (L) 2.18 3.39 64 2.83 30

FEV1/FVC 68 80 78 4
(%)
 Case 2 interpretation

Flow volume loop: decreased PEFR and coving of 2nd phase of

exp loop

Decreased FEV1 ,FVC & FEV1/FVC moderate airflow

obstruction

BD response

Dx: obstructive disease

 Case 3

32 year-old animal trainer presents With progressive

dyspnea and dry cough over last 2 months.

RR – 28, sa02 – 88% on RA,

RS - fine B/l basal crepts.

 PFT report

Pre-Bronchodilator (BD) Post- BD

Test Actual Predicted % Actual %
Predicted Change
FVC (L) 1.7 4.4 39 1.7
FEV1 (L) 1.6 3.7 43 1.6
FEV1/FVC 94 84 94
(%)
RV (L) 0.7 1.4 50
TLC (L) 2.5 5.7 44
RV/TLC 76 37
(%)
DLCO corr 20.73 33.43 62
 Case 4

25 year-old man With dyspnea and wheezing Non smoker History of mtor
vehicle accident , hospitalization and tracheostomy 2 years ago

His flow volume loops is as follows:

 PFT report

Pre-Bronchodilator (BD)

Test Actual Predicted % Predicted

FVC (L) 4.73 4.35 109

FEV1 (L) 2.56 3.69 69

FEV1/FVC (%) 54 85
 Case 4 interpretation

Flow volume loop: Flattened inspiratory &expiratory

limb
Decreased FEV1 , FEV1/FVC moderate
obstruction
Dx: Fixed UAWO
Take home messages…
• ABG and spirometry are very useful diagnostic tools for our day
to day practice.

• Approach to interpret should be step wise & in a systematic

manner.

• Any abnormal result should be analyzed cautiously in light of

clinical context.

• Appropriate use of these tools using clinical judgment is of

paramount importance
Bibliography

• HARRISON’S principles of internal medicine, 18th edition.

• Disorders of Fluids and Electrolytes, Julie R. Ingelfinger, M.D.,
NEJM, 0ct-9, 2014.
• Spirometry for health care providers, GOLD, 2010.
• ‘‘ATS/ERS TASK FORCE: STANDARDISATION OF LUNG
FUNCTION TESTING’’ V. Brusasco, R. Crapo and G. Viegi,
Eur Respir J 2005; 26: 948–968
• Vijayan ; Spirometry in South Indian children Indian J Chest Dis
Allied Sci 2000; 42: 147–156
Case

• A 56 yr old woman with copd presents with shortness of breath since

3hr. Her HR – 130 n BP is 110/70, SaO2-90% pH 7.50 Na 138
• Step 1: Check validity- H+ = 24 (48/36) =32 PCO₂ 48 K 3.2
(7.50 -30)
HCO₃ 36 Cl 92
• Step 2: check pH = alkalemia
• Step 3: check Paco 2 <40 metabolic alkalemia
• Step 4: expected comp. Paco2 = 40+{0.7(36-24)=48
• appropriate resp. comp
• Step 5: calculate anion gap = Na – HCO3 – Cl- = 138-92-36= 10
Post hypocapnic metabolic alkalosis