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1 INTRODUCTION:
Blood gas analysis, also called arterial blood gas (ABG) analysis, is a procedure to measure the partial pressure of oxygen (O2) and carbon dioxide (CO2) gases and the pH (hydrogen ion concentration) in arterial blood. Blood gas analyzers are used to measure the pH, partial pressure of oxygen (pO2) & partial pressure of carbon dioxide (pCO2) of the body fluids with special reference to the human blood. Measurements of these parameters are essential for determining the acid-base balance in the body. Sudden change in the pH & pCO2 can lead to ventricular hypotension, cardiac arrhythmias or even death. Hence, this indicates the maintenance of the physiological neutrality of the human blood and consequently the crucial role the Blood gas analyzer plays in determining the pressures.

1.2 PURPOSE:
Blood gas analysis is used to diagnose and evaluate respiratory diseases and conditions that influence how effectively the lungs deliver oxygen to and eliminate carbon dioxide from the blood. The acid-base component of the test is used to diagnose and evaluate metabolic conditions that cause abnormal blood pH. Because high concentrations of inhaled oxygen can be toxic and can damage lungs and eyes, repeated blood gas analysis is especially useful for monitoring patients on oxygen, for example, premature infants with lung disease, so that the lowest possible inhaled oxygen concentration can be used to maintain the blood oxygen pressure at a level that supports the patient. In incubated patients under artificial ventilation, monitoring the levels of arterial carbon dioxide and oxygen allow assessment of respiratory adequacy so that the rate or depth of ventilation, the ventilator dead space, or airway pressure can be changed to preserve the patient's optimal physiologic balance. The measurement of arterial blood pH and carbon dioxide pressure with subsequent calculation of the concentration of bicarbonate (HCO3-), especially in combination with analysis of serum electrolytes, aids in the diagnosis of many diseases. For example, diabetes mellitus is often associated with a condition known as diabetic acidosis. Insulin deficiency often results in the excessive production of ketoacids and lactic acid that lower extracellular fluid and blood pH. 1

Unabated acid-base disorders are life threatening. Acidosis is associated with severe consequences, including shock and cardiac arrest, and alkalosis with mental confusion and coma.

2.1 ACID-BASE BALANCE:

The normal pH of the extracellular fluid lies in the range of 7.35-7.45, indicating that the body fluid is slightly alkaline. When the pH exceeds 7.45, the body is considered to be in a state of alkalosis. A body pH below 7.35 indicates acidosis. Both acidosis and alkalosis are disease conditions widely encountered in clinical medicine. Any tendency of the pH of blood to deviate towards these conditions is dealt with by the following three physiological mechanisms; (i) buffering by chemical means, (ii) respiration, (iii) excretion, into the urine by the kidneys. The blood and tissue fluids contain chemical buffers, which react with added acids and bases and minimize the resultant change in hydrogen ions. They respond to changes in carbon dioxide concentration in seconds. The respiratory system can adjust sudden changes in carbon dioxide tension to normal levels in just a few minutes .Carbon dioxide can be removed effectively by increased breathing, and hence hydrogen concentration can be maintained. The kidney requires many hours to readjust hydrogen ion concentration by excreting highly acidic or alkaline urine to enable body conditions to return towards normal. In order to maintain O2, pCO2 and pH within normal limits, throughout the wide range of body activity, the rate and depth of respiration vary automatically with changes in the metabolism. Control of alveolar ventilation takes place by means of chemical as well as nervous mechanisms. The three important chemical factors regulating alveolar ventilation are the arterial concentrations of CO2, H+ and O2.Carbon dioxide tension in the blood stream and cerebrospinal fluid is the major chemical factor regulating alveolar ventilation. The following table lists out the normal range for pH, pCO2, pO2, total CO2, base excess and bicarbonate(all measurements made at 37C.)

Table 1:
Parameter Ph pCO2 pO2 Bicarbonate Total CO2(plasma) Base excess Men Women Resting adult Men Women Men Women Men Women Arterial Blood 7.37 to 7.44 34 to 35 mmHg 31 to 42 mmHg 80 to 90 mmHg 23 to 29 mmol/l 20 to 29 mmol/l 24 to 30 mmol/l 21 to 30 mmol/l -2.4 to +2.3 mmol/l -3.3 to +1.2 mmol/l Capillary Venous Plasma 7.35 to 7.45 36 to 50 mmHg 34 to 50 mmHg 25 to 40 mmHg 25 to 30 mmol/l 23 to 28 mmol/l 26 to 31 mmol/l 24 to 29 mmol/l 0.0 to +5.0 mmol/l -1.0 to +3.5 mmol/l

2.2 BLOOD pH MEASUREMENT:

The acidity or alkalinity of a solution depends on its concentration of hydrogen ions. Increasing the concentration of hydrogen ions makes a solution makes it more acidic, decreasing the concentration of hydrogen ions makes it more alkaline. The amount of hydrogen ions generally encountered in solutions of interest is extremely small and, hence , the figure is usually represented in the more convenient system of pH notation. pH is the measure of hydrogen ion concentration , expressed logarithmically. Specifically, it is the negative exponent log of the hydrogen ion concentration.

pH= -log(H+)

Electrochemical pH determination utilizes the difference in potential occurring between solutions of different pH separated by a special glass membrane. If the pH of one of the solutions is kept 3

constant, so that the potential varies in accordance with the pH of the other solution, then the system can be used to determine the pH. The device used to effect this measurement is the glass electrode. Glass Electrode: The potential (E) of the glass electrode may be written by means of the Nernst Equation;

E=((-2.3RT)/zF)*(log10[Ci/Co])

E = equilibrium potential (mV); z = charge on the ion; (2.3RT)/F = constant (60mV at 37C); Ci = intracellular concentration ; Co = extracellular concentration
The Nernst equation is important because it shows what the equilibrium potential would be for one ion. For instance; The resting membrane potential is normally ~70mV. So during an action potential Na channels open their gates briefly and Na rush inside the cell. Na is ionized and carries a positive charge. So when Na rushes into the cell it makes the inside of the cell more positive. If you were to break off the gate and allow Na to move freely back and forth, the Nernst equation shows us that the equilibrium point for Na is ~+65mV.

2.2.1 pH Measurement:
For making pH measurements, the solution is taken in a beaker. A pair of electrodes: one glass or indicating electrode and the other reference or calomel electrode, are immersed in the solution. The pH meter is usually equipped with controls for calibration and temperature compensation. A measuring silver/silver chloride electrode is encased in a bulb of special pH-sensitive glass and contains a buffer solution that maintains a constant pH (Figure 2). This glass electrode is placed in 4

the blood sample and a potential difference is generated across the glass, which is proportional to the difference in hydrogen ion concentration. The potential is measured between a reference electrode (in contact with the blood via a semi-permeable membrane) and the measuring electrode. Both electrodes must be kept at 37C, clean and calibrated with buffer solutions of known pH.

For very precise work the pH meter should be calibrated before each measurement. For normal use calibration should be performed at the beginning of each day. The reason for this is that the glass electrode does not give a reproducible e.m.f. over longer periods of time. Calibration should be performed with at least two standard buffer solutions that span the range of pH values to be measured. For general purposes buffers at pH 4 and pH 10 are acceptable. The pH meter has one control (calibrate) to set the meter reading equal to the value of the first standard buffer and a second control (slope) which is used to adjust the meter reading to the value of the second buffer. A third control allows the temperature to be set. Standard buffer sachets, which can be obtained 5

from a variety of suppliers, usually state how the buffer value changes with temperature. For more precise measurements, a three buffer solution calibration is preferred. As pH 7 is essentially, a "zero point" calibration (akin to zeroing or tarring a scale or balance), calibrating at pH 7 first, calibrating at the pH closest to the point of interest ( e.g. either 4 or 10) second and checking the third point will provide a more linear accuracy to what is essentially a non-linear problem. Some meters will allow a three point calibration and that is the preferred scheme for the most accurate work. Higher quality meters will have a provision to account for temperature coefficient correction, and high-end pH probes have temperature probes built in. The calibration process correlates the voltage produced by the probe (approximately 0.06 volts per pH unit) with the pH scale. After each single measurement, the probe is rinsed with distilled water or de-ionized water to remove any traces of the solution being measured, blotted with a scientific wipe to absorb any remaining water which could dilute the sample and thus alter the reading, and then quickly immersed in another solution.

2.2.2 Electrodes for Blood pH Measurement:

Several types of electrodes can be utilized for the measurement of blood pH. Most common type of electrode is the syringe electrode, which is preferred for the convenience of taking small samples of blood anaerobically. Micro capillary glass electrodes are preferred when it is required to monitor pH continuously. For example; during surgery. These types of electrodes are especially useful when a very small volume of the sample is to be analyzed. A micro-electrode for clinical applications requires only 20-25uL of capillary blood for the determination of pH. Glass electrode assemblies as normally supplied by manufacturers require that the glass electrode, as a small bulb, together with either the standard calomel electrode or a potassium chloride-agar bridge, shall dip into the liquid under examination. Under these conditions a reduction in the volume of liquid below 5-10 ml. means that the containing vessel becomes so small that the risk of scratching the thin glass bulb becomes considerable. Rather smaller volumes can safely be used in the Morton (1930) electrode since only the glass electrode dips into the liquid; contact with the calomel electrode being through a stop cock at the base of the electrode vessel.

The pH electrode consists of 2 half cells: the glass electrode and a reference electrode (e.g; calomel electrode). This unit develops an electrical potential across the glass which is dependent on the difference in a H+ across the glass membrane. This effectively allows measurement of the pH of the test solution because the pH in the solution on the other side of the membrane is constant. Other potentials develop in the pH electrode (e.g; liquid junction potential, asymmetry potential & diffusion potentials) and these are usually not quantified in a particular electrode. The problem is overcome by standardization and calibration. Standardization refers to the process of requiring that these potentials are the same when measuring the sample solution and when measuring the calibrating solutions. In particular, the liquid junction potential must remain unchanged. The calibrating solutions are chemical standard buffer solutions with a known pH. Many of the components of the electrode (eg the calomel reference cell) are very temperature sensitive. The temperature of the measurement must be precisely controlled: usually at 37C.

2.3 MEASUREMENT OF BLOOD pCO2 :

The carbon dioxide partial pressure (pCO2 ) is an indicator of CO 2 production and elimination: for a constant metabolic rate, the pCO2 is determined entirely by its elimination through ventilation. A high pCO2 (respiratory acidosis, alternatively hypercapnia) indicates under ventilation (or, more rarely, a hypermetabolic disorder), a low pCO2 (respiratory alkalosis, alternatively hypocapnia) hyper- (or) over ventilation. The pCO2 , along with the pH, can be used to distinguish among metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Hypoventilation exists when the ratio of carbon dioxide production to alveolar ventilation increases above normal values. Hyperventilation exists when the same ratio decreases. The following table indicates the various areas of variation of pCO2 within the human body;

Table 2: pCO2 (Torr) 7

Location

Outside air - dry air at sea level

0.3

Alveolar air

35

Arteriole blood

40

Venous blood

50

Cells

50

The blood pCO2 is the partial pressure of carbon dioxide of blood taken anaerobically. It is expressed in mmHg and is related to the percentage CO2 as follows:

pCO2 = Barometric Pressure Water vapor Pressure*(%CO2)/100

At 37C, the water vapor pressure is 47mmHg, so at 750 mm barometric pressure, 5.7% CO2 corresponds to a pCO2 of 40mm. pCO2 is measured by direct potentiometer. In the calculation of results for pCO2, concentration is related to potential through the Nernst equation. Results are measured at 37C when using cartridges that require thermal control and corrected to 37C when using cartridges that do not require thermal control.

2.3.1 Clinical Significance:

pCO2 along with pH is used to assess acid-base balance. pCO2 (partial pressure of carbon dioxide), the respiratory component of acid-base balance, is a measure of the tension or pressure of carbon dioxide dissolved in the blood. PCO2 represents the balance between cellular production of CO2 and ventilator removal of CO2 and a change in pCO2 indicates an alteration in this balance. 8

Causes of primary respiratory acidosis (increase in pCO2) are airway obstruction, sedatives and anesthetics, respiratory distress syndrome, and chronic obstructive pulmonary disease. Causes of primary respiratory alkalosis (decreased pCO2) are hypoxia (resulting in hyperventilation) due to chronic heart failure, edema and neurologic disorders, and mechanical hyperventilation. The Severinghaus (or) carbon dioxide electrode is a modified pH electrode in contact with sodium bicarbonate solution and separated from the blood specimen by a rubber or Teflon semi-permeable membrane. Carbon dioxide, but not hydrogen ions, diffuses from the blood sample across the membrane into the sodium bicarbonate solution, producing hydrogen ions and a change in pH.

Hydrogen ions are produced in proportion to the pCO2 and are measured by the pH-sensitive glass electrode. As with the pH electrode, the Severinghaus electrode must be maintained at 37C, be calibrated with gases of known pCO2 and the integrity of the membrane is essential. Because diffusion of the CO2 into the electrolyte solution is required the response time is slow at 23 minutes. Method comparisons will vary from site to site due to differences in sample handling, comparative method calibration and other site specific variables.

Increased pCO2 is caused by:

Pulmonary edema Obstructive lung disease

Decreased pCO2 is caused by:

Hyperventilation Hypoxia Anxiety 9

Pregnancy Pulmonary Embolism (In cases of massive pulmonary embolism, the infracted or nonfunctioning areas of the lung assume greater significance and the pCO2 may increase.)

2.4 MEASUREMENT OF BLOOD pO2:

The partial pressure of oxygen in the blood or plasma indicates the extent of oxygen exchange between the lungs and the blood, and normally, the ability of the blood to adequately perfuse the body tissue with oxygen. The partial pressure of oxygen is usually measured with a Polarographic electrode. There is a characteristic polarizing voltage at which any element in solution is predominantly reduced and in the case of oxygen, it is 0.6 to 0.9 V. In this voltage range, it is observed that the current flowing in the electrochemical cell is proportional to the oxygen concentration in the solution. pO2 (Partial Pressure of Oxygen) reflects the amount of oxygen gas dissolved in the blood. It primarily measures the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere. Most of the Blood gas analyzers utilize an oxygen electrode for measuring oxygen partial pressure. This type of electrode consists of a platinum cathode, a silver/silver chloride anode in an electrolyte filling solution and a polypropylene membrane.

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The Polarographic (Clark) oxygen electrode measures the oxygen partial pressure in a blood or gas sample. A platinum cathode and a silver/silver chloride anode are placed in a sodium chloride electrolyte solution, and a voltage of 700 mv is applied (Figure 1). The following reactions occur.

At the cathode:

O2 + 2H2O + 4e = 4OH

In the electrolyte:

NaCl + OH = NaOH + Cl.

At the anode:

Ag + Cl = AgCl + e.

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Electrons are taken up at the cathode and the current generated is proportional to oxygen tension. A membrane separates the electrode from blood, preventing deposition of protein but allowing the oxygen tension in the blood to equilibrate with the electrolyte solution. The electrode is kept at a constant temperature of 37C and regular checks of the membrane are required to ensure it is not perforated or coated in proteins. Sampling two gas mixtures of known oxygen tension allows calibration. The measurement at the current developed at the oxygen electrode due to the partial pressure of oxygen presents special problems. The difficulty arises because of the extremely small size of the electrical signal. The sensitivity is typically of the order of 20pA per Torr for most instruments. Measurement of oxygen electrode current is made by using high input impedance, low noise, and, low current amplifiers. Field effect transistors usually form the input stage of the pre-amplifiers. Elevated pO2 levels are associated with:

Increased oxygen levels in the inhaled air Polycythemia

Decreased pO2 levels are associated with:

Decreased oxygen levels in the inhaled air Anemia Heart decompensation Chronic obstructive pulmonary disease Restrictive pulmonary disease Hypoventilation

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3.1 COMPLETE BLOOD GAS ANALYZER:

Blood gas analyzers quantify and analyze the amount of various gases within blood. They operate in a similar way to blood glucose monitors. A chemical reagent is mixed with a sample of blood, which is examined using either photo-optical sensors or electrochemical sensors. The readings of the blood sample are compared against a calibration reagent to determine the result.

Block Diagram of Blood Gas Analyzer:

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3.1.1 Signal Path:

Blood gas analyzers have multiple sensors that are driven through an amplifier and a multiplexer to an analog-to-digital converter (ADC). The data is processed in the microcontroller, which is connected to a PC or other instruments through RS-232, USB, or Ethernet. A digital-toanalog converter (DAC) is often used to calibrate the sensor amplifiers to maximize the sensitivity of the electrodes.

3.1.2 Applications:
Blood gas analyzers are often used for simple blood tests, as well as for sophisticated suites of tests that allow physicians to monitor patient health in various settings. In addition to clinical diagnostics, blood gas analyzers are finding use in respiratory therapy and point-of-care diagnostics. These markets require device miniaturization and sophistication. Small, sometimes handheld, form factors are needed that integrate multiple testing capabilities, such as blood glucose and electrolyte analysis. This testing versatility increases the cost effectiveness of the device. Blood gas analyzers are used in most pathology and biochemistry laboratories in hospitals to analyze blood samples for CO2 and Oxygen levels in order to detect respiratory and metabolic issues. The routine calibration of the Analyzer using a calibration gas mixture is essential to ensure its continued accuracy.

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3.1.3 Display:
Modern blood gas analyzers increasingly employ a touch screen in combination with a graphical user interface (GUI) to make the programming process more intuitive. Visible, audible, and haptic responses to user inputs help designers improve the user experience. Advanced touchscreen controllers from Maxim offer haptic feedback, touch processing to reduce bus traffic, and autonomous modes for precision gesture recognition.

3.1.4 Precautions:
The syringe used to collect the sample for a blood gas analysis must contain a small amount of heparin to prevent clotting of the blood. It is very important that air be excluded from the syringe both before and after the sample is collected. The syringe must be filled completely and never exposed to air. For transportation, the syringe should be capped with a blind hub, placed on ice, and immediately sent to the laboratory for analysis to guarantee the accuracy of the results. 15

A blood gas analysis requires a sample of arterial blood in order to evaluate gas exchange by the lungs. Arterial puncture is associated with a greater risk of bleeding than vein puncture. The test may be contraindicated in persons with a bleeding disorder such as hemophilia or low platelet count. During the arterial puncture, the patient may feel a brief throbbing or cramping at the puncture site. In cases where the primary concern is ascertaining that the blood is adequately oxygenated, a pulse oximeter may be used in lieu of arterial blood gas analysis. Medical personnel must follow standard precautions for prevention of exposure to blood borne pathogens when performing arterial blood collection.

3.2 PROCESS OF TESTING THE SAMPLE:

The sample of choice for blood gas analysis is arterial blood. This is usually collected from the radial artery in the wrist, but in cases where no radial pulse is obtained, the femoral or brachial artery may be used. The sample may also be collected from an arterial line after flushing the line to remove excess anti-coagulant and fluid. In neonates and in adults when arterial puncture is contraindicated or unsuccessful, a capillary blood sample may be used. The sample is inserted into an analytical instrument that uses electrodes to measure the concentration of hydrogen ions (H+), which is reported as pH, and the partial pressures of oxygen [PO2] and carbon dioxide PO2gases. The pH-measuring electrode consists of a special glass membrane that is selectively permeable to hydrogen ions. An electical potential develops across the inner and outer surfaces of this membrane that is related to the log of hydrogen ion activity in the sample. A Severinghaus electrode is used to measure PCO2 . The measuring principle is the same as for hydrogen ions, except that the electrode tip is covered with a gas permeable membrane, so that the pH change is proportional to carbon dioxide diffusing from the sample to the electrode surface. The PO2 is measured using a polarographic (Clark) electrode. Oxygen diffuses from the sample to the cathode, where it is reduced to peroxide ions. The electrons come from a silver anode that is oxidized, generating current in proportion to oxygen concentration at the cathode. Electrode signals are dependent upon temperature as well as concentration, and all measurements are performed at 37C. Since the in-vivo pH and levels of oxygen and carbon dioxide are temperature dependent, results may need to be adjusted for the patient's actual temperature. Portable blood gas analyzers are available that can be used at the bedside. 16

Blood gas analyzers calculate blood bicarbonate concentration using the formula: pH = 6.1 + Log bicarbonate/.0306 x PCO2 . They also calculate oxygen content, total carbon dioxide, base excess, and percent oxygen saturation of hemoglobin. These values are used by physicians to assess the extent of hypoxia and acid-base imbalance.

3.2.1 Aftercare:
After the blood sample has been taken, the health care practitioner or patient applies pressure to the puncture site for about 10 minutes or until bleeding has stopped, after which a dressing is applied. The patient should rest quietly while applying pressure to the puncture site and be observed for signs of bleeding or impaired circulation at the puncture site.

3.2.2 Complications:
Complications posed by the arterial puncture are minimal when the procedure is performed correctly, but may include bleeding or delayed bleeding or bruising at the puncture site, or, rarely, impaired circulation around the puncture site.

3.3 TEST RESULTS:

3.3.1 Normal Results:
The following normal results are for arterial blood at sea level (at altitudes of 3,000 feet and above, the values for oxygen are lower) for an assumed fluid sample of a patient; Partial pressure of oxygen (pO2 7500 mm Hg). Note that PO2values normally decline with age. Partial pressure of carbon dioxide pCO2 355 mm Hg. pH: 7.35 - 7.45 Oxygen content (O2CT): 153 volume%. Oxygen saturation (SaO2): 94%00%. Concentration of bicarbonate (HCO3/sup>): 226 millimols per liter (mEq/liter).

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Total CO2 is often reported with blood gas analysis results and is defined as the sum of carbonic acid and bicarbonate concentrations. Normally, the ratio of bicarbonate to carbonic acid at physiological pH is about 20:1, thus, the total CO2 is normally about 5% higher than the bicarbonate value.

3.3.2 Abnormal results:

Values that differ from the normal values may indicate the presence of respiratory, metabolic, or renal diseases. For most clinical decisions, the bicarbonate value, PCO2 , and pH are used to evaluate acid-base status. The pH value defines the magnitude of the disturbance and the bicarbonate and PCO2 determine the cause. The bicarbonate level is under the control of the kidneys, which may increase or decrease bicarbonate blood levels in response to pH changes. Bicarbonate is also the principal blood buffer anion, and it functions as the conjugate base to increase pH. PCO2 is the respiratory component because it is regulated by the lungs. It is determined by the concentration of dissolved carbon dioxide (anhydrous carbonic acid) and is the principal acid component of the blood. Abnormal results are classified on the basis of pH and whether the abnormal pH is caused by the metabolic or respiratory component. pH <7.35 indicates acidosis, either metabolic (nonrespiratory) or respiratory, and pH >7.45 indicates alkalosis. Metabolic or non-respiratory acidosis is characterized by pH <7.35 (i.e. increased [H+]) and decreased [HCO3-]. In most cases, the decrease in pH stimulates the respiratory center causing hyperventilation. The loss of carbon dioxide that results serves to decrease the severity of the acidosis and is referred to as compensation. Metabolic acidosis is caused by bicarbonate deficit which may result from increased H+formation or ingestion, from decreased H+ excretion, or failure to produce or retain bicarbonate. Common causes of metabolic acidosis are diabetes mellitus, alcoholism, lactic acidosis (associated with hypoxia), acid poisoning, renal failure, renal tubular acidosis (an inherited defect of the renal tubules), and diarrhea. Respiratory acidosis is caused by deficient ventilation that results in retention of carbon dioxide. The pH is <7.35, and PCO2 is increased. If time has permitted renal compensation, the [HCO3-] is somewhat increased. Respiratory acidosis is associated with airway obstruction such as occurs with asthmatic bronchial spasm, bronchitis, and emphysema; pulmonary diseases such as 18

severe pneumonia and pulmonary fibrosis; thoracic conditions such as multiple broken ribs. Respiratory acidosis is also caused by neuromuscular disease, and by depression of the respiratory center in the brain due to drugs, head trauma, or cranial tumor. The blood gas analysis results may deviate only slightly from normal values, and pH may even fall within the normal range (compensated respiratory acidosis) in cases of chronic compared to acute acidosis. Metabolic alkalosis is caused by excess blood bicarbonate and usually involves a renal factor. Metabolic alkalosis is characterized by pH >7.45 and elevated [HCO3-]. The PCO2 is usually elevated due to respiratory compensation. Metabolic alkalosis can be caused by mineralcorticoid excess (e.g. Cushing's or Conn's syndromes), which promotes increased acid excretion and bicarbonate retention by the kidney. Other causes are diuretic therapy, vomiting, severe dehydration, hypokalemia (low blood potassium), and hypo parathyroidism. Respiratory alkalosis is caused by hyperventilation. The pH is >7.45 and the PCO2 is low. If the kidneys are functioning normally and given sufficient time, the HCO3- will be decreased in compensation. Respiratory alkalosis may be caused by hyperventilation psychologically induced (anxiety), by drugs that stimulate the respiratory center, excessive ventilation therapy, and mild hypoxia. A decrease in PO2 is a sensitive measure of respiratory function and hypoxia. In addition to ventilation defects that also result in increased PCO2, PO2 will be low in persons with poor ratios of ventilation to perfusion; mild emphysema and other gas diffusion defects; pulmonary arterialvenous shunts; and those breathing air with a low oxygen content. Elevated PO2 is caused by excessive administration of oxygen which can lead to optic nerve damage and acidosis by displacing hydrogen ions from hemoglobin. It is important to note that in cases of carbon monoxide poisoning the PO2: will be normal, but life-threatening hypoxia may be present. Blood gas analyzers calculate the oxygen saturation of hemoglobin from PO2, temperature, and pH. In cases of CO poisoning, the calculation will be falsely elevated. Accurate assessment of hypoxia in CO poisoning requires direct measurements of carboxy hemoglobin and oxygen saturation of hemoglobin by oximetry or colorimetry methods.

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