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This patient is acidotic, without any question. So we have an acidotic patient. So it’s either respiratory acidosis or metabolic acidosis. Let’s just say for though purposes we are going to try to make this patient respiratory acidosis. If that’s true, the patient is hypoventilating, right? The patient is hypoventilating the PCO2 goes up. In this case, the PCO2 is down, not up. So even if you get taken down the wrong road, if you go in order you are immediately blocked. You can’t get there. So we thought maybe this was respiratory acidosis, and then we say, “No, it can’t be that. So it must be metabolic acidosis.” So what happens with metabolic acidosis, if you remember, is you lose hydrogen ion and then everything else you hyperventilate and everything else goes away to try to buffer up that extra hydrogen ion so the PCO2 is down, the bicarbonate is down and the patient obviously does not have a respiratory problem. PO2 is normal, saturation is normal for a patient who is on room air. So this patient is metabolic acidosis. It’s a 46-year-old lady who came in comatose with an unknown history. I think this one was a drug overdose if I remember correctly. I’m not positive about that.
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This patient, the pH is normal. So now if the pH is normal, either the gases are normal or the system is compensated completely. One or the other. Either it’s normal or compensated completely. We have those two choices. PCO2 is normal. Base excess normal. The arterial oxygen is a little bit up from what you want, doing room air, but it’s okay. But you wonder why does a person have all these? Have a saturation of 80%. So there’s a question when you look at those things. Is there something wrong? Was the saturation wrong? Or is there something wrong? So, 25-year-old person brought into the emergency room, narcotic overdose and possible aspiration. Repeat, at the end of a little while in the emergency room. So now we repeat them. The patient is still on room air so they haven’t done anything with the patient. The saturation is still 80%, so there’s still something going on here. The pH is now acidotic. So it’s either metabolic acidoses or respiratory acidosis. So now you maybe or maybe not, you don’t know if it’s narcotic overdose because this patient is in the ER, so I don’t remember when they found that out. Let’s say you don’t know it. Let’s say it’s respiratory acidosis then. If it’s respiratory acidosis, people quit breathing, PCO2 goes up. This is quite a bit up. 64. So this is compatible with respiratory acidosis. The base excess hasn’t changed very much so that’s a tip that this is acute rather than chronic. We’ll have some patients like that later on. So this is respiratory acidosis and there is a respiratory problem evolving. The patient is on room air, the PO2 is falling, the saturation is staying down. Something needs to be done. Those people, you either ventilate them or you don’t, depending on how serious they are and eventually that all goes away and you are left with only a suicide or a chronic drug problem. A nice little problem.
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Okay, here’s another case. Now we are going to step up the pace a little bit. We are going to ask you from now on to give us all what you know about it. Not just the acidosis, alkalosis but give us every bit of information that you learned just from these very simple tests. This is a patient, again breathing room air, but immediately you can see there’s a problem breathing room air. The PO2 is at 60 mmHg. So the patient has some kind of respiratory problem and you haven’t even gotten very far. And it’s severely acidotic. Again, very easy. Is it metabolic or is it respiratory? If you know this patient for instance and it’s one of your diabetics. So you’ve decided to go in and your mind is poisoned because you know the patient. So you decide it’s a metabolic acidosis and you remember metabolic acidosis is too my hydrogen ion and breathing too fast. Immediately you are blocked there because this PCO2 is way up. So this patient is having trouble breathing, not moving PCO2 and not moving O2 so it can’t be diabetic ketoacidosis. It could be a diabetic all right, but not ketoacidosis. So it’s respiratory acidosis. Here’s then the question. You know that it hasn’t been going on for very long because the bicarbonate isn’t up and the base excess is still normal – plus or minus 5 is what most people use – so you know this is an acute respiratory acidosis because the bicarb and the base excess have not moved. That is going to be important if you are dealing with any COPD patients in your practice.
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So here’s a 43-year-old man in an automobile accident with severe head trauma and he’s probably got a central hypoventilation and probably put him on a ventilator, and if the head trauma goes away there’s no reason that that can’t go away.

Okay, next case. This person is on room air, and saturation is normal and PO2 is pretty normal. So we don’t have any evidence at this point that there is any respiratory problem. But the pH is up, so the patient is alkalotic. So is it respiratory or is it metabolic? If the patient was hyperventilating the PCO2 would be down. In this case it is up. So it’s not respiratory alkalosis. It’s got to be metabolic alkalosis and again, it’s been going on for awhile because that bicarbonate is high. So this is metabolic alkalosis, chronic. Probably the most common thing that we see in clinical practice that produces this is what? Diuretics. You got it. That’s right. It’s very common. The problem is we don’t do gasses on these people unless we have another reason, so you don’t see it. But it’s very very common.
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This is a 32-year-old patient. Intestinal obstruction with a nasogastric tube in and so forth. And it has been on for too long.

Okay, last case. Here’s a patient on breathing room air and having trouble. The saturation is 52% and the PO2 is 39, so we’ve got a patient with a respiratory problem so there’s an acidotic and it’s pretty easy to say, well that’s a respiratory patient with an acidosis. It ought to be respiratory acidosis. If people who have a respiratory problem are hypoventilating, their PCO2 goes up. This is way up. The bicarb has not moved very much so this would then be an acute respiratory acidosis. This patient had a history of chronic bronchitis but you’d have to say from this standpoint the numbers look more acute than they do chronic. As you know, chronic bronchitis patients don’t necessarily have interval problems. They may, but they may not.

Take the reverse now, last hyperventilation: teenager, anxiety, the ventilator is going to fast, brain tumor, stroke, doesn’t matter. The person is hyperventilating. If you are hyperventilating into room air, there’s no problem that I know of on the oxygen side. So if you are hyperventilating you can forget about the oxygen. It will still stay mostly within limits. But then the hyperventilation, off goes the CO2 and drives everything from your right to your left: bicarbonates down, hydrogen ion is down, PCO2 is down and pH is obviously is then up. So now if the problem is respiratory the result is alkalosis. In the first case, the problem is acidosis and you have a bunch of results. In this case the problem is respiratory and then you have alkalosis or you have acidosis.
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I put a few of these things on the charts here. I don’t think we have any of them in there because I don’t think they are at all necessary. People have invented little schemes to help you do your work. I believe that if you understand what you are doing, you can survive any one of these charts. The reason I don’t like them is very simple, and that is; the lab is not that precise and if these little schemes are supposed to be different diagnostic categories – which they are – you see if your crosses are right there you get one answer, and if they are right there you get another answer. And that’s a very little lab error that does that. Here’s another one. It’s not so good to go in and tell the patient, “You know I think you have a J but you may have an E. The damn lab isn’t reliable so I can’t tell whether you’ve got a J or an E” and now they’ve got a new doctor after you tell them that. This one I’ve had now for about 15 years and I’ve never been able to figure out how anybody actually uses it. That makes it the best one of all. Then here’s the last one. But the point is, if you think about those points and you think about reasonable lab error, it’s very easy to go from one zone to another zone. Whereas if you are just thinking about them in abstract, it won’t take your diagnosis out of the place it should be. So, for those of you who look in the stratosphere or wherever, the Washington Post now predicts the next planet that is found again, so all of you from Nebraska rejoice.
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What I am going to do is I want you all to just take a quick – I’ve got some cases here – and we will take some quick goes through the cases and they are in order to kind of demonstrate how to do it. Now what I generally do, and I think most of you have your habits already, but the easiest thing to do is to go to the pH. It’s the most reliable. And if it is abnormal, it reduces your choices. So what I do is go to the pH and see whether you can reduce the choices from 4 or 6 down to 2 or 3, and then fill in the blanks. So here’s case two. I’ll give you a couple of minutes to think it over. This is the fraction of inspired oxygen and .21 is 21%. That means the patient here is on room air. If the patient is not on room air, there will be some other thing right there. These are all arterial values and this is the saturation of oxygen, and again, normal is going to be 95% or so.

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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