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Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee
pCO2 and pH
A change in pCO2 up or down 10 mm Hg is associated with an increase or decrease in pH of 0.08 units. As the pCO2 decreases, the pH increases; as the pCO2 increases, the pH decreases.
In certain cases, however, particularly in seriously ill patients, two or more different primary disorders may occur simultaneously, resulting in a mixed acid-base disorder.
The net effect of mixed disorders may be additive (eg, metabolic acidosis and respiratory acidosis) and result in extreme alteration of pH; or they may be opposite (eg, metabolic acidosis and respiratory alkalosis) and nullify each others effects on the pH.
If both components act in the same direction (eg, both respiratory [pCO2 > 44 mm Hg] and metabolic [HCO3 - <22 mmol/L] acidosis are present), then this is a mixed acid-base problem. The primary disturbance will be the one that varies from normal the greatest, that is, with a [HCO3 -] = 6 mmol/L and pCO2 = 50 mm Hg, the primary disturbance would be a metabolic acidosis, the [HCO3 -] is about one-quarter normal, whereas the increase in pCO2 is only 25%.
Step 4:
Calculate the anion gap. Anion gap = Na+ - (Cl- + HCO3 -). Normal anion gap is 8-12 mmol.
Metabolic acidosis represents an increase in acid in body fluids . Reflected by a decrease in [HCO3 -] and a compensatory decrease in pCO2.
METABOLIC ALKALOSIS:
Metabolic alkalosis represents an increase in [HCO3 -] with a compensatory rise in pCO2.
Differential Diagnosis
In two basic categories of diseases the kidneys retain [HCO3 -] They can be differentiated in terms of response to treatment with sodium chloride and also by the level of urinary [Cl-] as determined by ordering a Spot,or random urinalysis for chloride (UCl).
Differential Diagnosis
1. Neuromuscular Abnormalities with Ventilatory Failure 2. Central Nervous System Drugs, Sedative,,Central sleep apnea 3. Airway Obstruction a. Chronic (COPD) b. Acute (asthma) c. Upper airway obstruction d. Obstructive sleep apnea 4. Thoracic/Pulmonary Disorders a. Bony thoracic cage: Flail chest, kyphoscoliosis b. Parenchymal lesions: Pneumothorax, pulmonary edema, c. Large pleural effusions d. Scleroderma e. Marked obesity (Pickwickian syndrome)
RESPIRATORY ALKALOSIS:
Respiratory alkalosis is a primary fall in pCO2 with a compensatory decrease in plasma [HCO3 -]. Respiratory alkalosis occurs with increased alveolar ventilation.
Differential Diagnosis
1. Central stimulation a. Anxiety, hyperventilation syndrome, pain b. Head trauma or CVA with central neurogenic hyperventilation c. Tumors d. Salicylate overdose e. Fever, early sepsis 2. Peripheral stimulation a. PE b. CHF (mild) c. Interstitial lung disease d. Pneumonia e. Altitude f. Hypoxemia: 3. Miscellaneous a. Hepatic insufficiency b. Pregnancy c. Progesterone d. Hyperthyroidism e. Iatrogenic mechanical overventilation