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Now these charts are all in your handout, but I have developed over the years a way of looking at what is going on that relates to the interface between the alveolus and the capillary. I think it’s the best way to think about it because you only have to have one picture in your mind and it’s almost impossible to forget how this picture looks. Because, I don’t care how you draw the alveolus. You can draw it any way you want, and I don’t care how you draw the capillary, you can draw it any way you want. But I think everybody knows that the air has got nitrogen coming in and out. The air has got oxygen coming in and out, and everybody knows that the oxygen goes in the blood and the CO2 comes out of the blood. So now you’ve got most of the thing drawn. Then, if you just know that the main buffer system in the plasma is the bicarbonate buffer system, which everybody pretty much knows that, then you just write it down. CO2 is in equilibrium with un-associated carbonic acid, which is in equilibrium with hydrogen ion and bicarbonate. This bicarbonate is what you measure for the bicarbonate level, this is what you measure for the pH level and over here, the physically dissolved stuff, this is what you measure for the PCO2. So you are metabolizing out here, producing hydrogen ion. You are breathing over here, getting off the CO2, back and forth, back and forth. So that’s what we are rolling off of, is this diagram. Then of course we can go quickly through this because I don’t think there’s a problem here, but if you have too much hydrogen ion, then by definition, that’s acidosis. If you just have this thing in mind then there’s no other way it can be. If you are pushing in hydrogen ion at this point and there’s nothing else wrong – if that’s all you are doing, is firing more hydrogen on in – diabetic acidosis, renal failure, doesn’t matter, then the bicarbonate is going to grab onto it. You are going to get more PCO2. The people are going to breathe faster and everything is going to go outside. In theory, nothing happens to the oxygen so it just keeps on breathing, and the result is the problem is too much hydrogen ion. Everything else is low. The problem is too much hydrogen ion and everything else is low because you just breathe it off.
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Now, let’s just reverse the charges. You’ve got a patient with a nasogastric tube in, or chronic vomiting, or you are taking some nonabsorbable antacids, or there’s too little hydrogen ion. Again, for our purposes it doesn’t matter what the cause. It does for the patient because we are going to have to eventually figure that out. But for our purposes it doesn’t matter. If our problem is loss of hydrogen ion, then everything stops. The PCO2 goes up, the carbonic acid goes up and bicarbonate goes up. Hydrogen ion is down because you just continue to lose it and it just keeps going toward your right. Therefore, your problem is alkalosis. Everything else is up. Now the body has a problem. You can’t stop breathing completely. So there is a limit to the hypoventilation you can do – that’s about 50, 55 mmHg but that’s irrelevant. You can look at the patient and tell whether they are breathing or not. That’s fairly easy in most cases. So the patient can only hypoventilate so much, in which to try to compensate for what’s going on, and then otherwise it just continues to produce alkalosis. So if you have alkalosis, everything is up.
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Now we’ll quickly go through the other two. Okay, now we have some trouble breathing. The patient has got a piece of steak in here or there’s pneumonia or there’s the hyaline membrane or there’s pulmonary edema, or the ventilator is going too slow. Again, it doesn’t matter if there is some reduction in respiration. Now you’ve got oxygen in play, because if you’ve got reduction in respiration, you’ve got the oxygen in play. The oxygen is down so therefor the PO2 is down, so therefor the oxyhemoglobin will be down. That’s over on the other side of the equation. But in this case, metabolism keeps going on but the CO2 backs up, backs up, backs up, backs up. So now you have hypoventilation which means it’s respiratory so the pH is down. But that’s the problem. That’s not the cause. The cause is respiratory. The problem now is acidosis down, everything else is up. Again, same diagram.
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