เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

496 lrtdrrinrlnqmfil5ru

ttlfr 2 uf,nt hemoglobin oxygen dissocietion

cu*" Taufr

SaO" 95Vo nlnfrJ tuOr^O tJtuJran,

ntniSaO2 909o PaO2 60 xtu.rlTan,

SaO,88o/o n1$iu PaO,55 t$l. 7on,

SaO" 75Vo nln u PaOr 40 atr.tJrBn.

sao2 50ok nx'rilJ Pao2 27 Nu.tlfin

fr1Ni'tdx

ilia ARDS dfiarnr:uria.:odrnrxflti, trfiattfin1:5nur.l"rrur;l:Judrfinrr dr:ro,r Pao,/Fio, fi

lffluudn:tirr rrnrc:hiwirriu nsirrdo firilosfrfi u16fln1 1n rdu AFDS ri't PaolFio, atdl

fiififio,rid rio. g.rn'irdrnunhu'xulfi dxulo6flildoflfivlur6anrltrsosro:rouo,reionrrinurlid
a1 paolFio, lvfirirg.rn6alnfiriurrir:Jnfi rirlfifiadd rio" rfrnirdrnuniurruld n-'lriunr:

fi nnu ril'r::i,: {r-huotir.rri o rdo.'rit riufl.rfi fi nmrdrd'ry

PaCO

2

rir Paco, riuir#rjrfi'l'jrilonldiunr::vlruarn'1f, (ventilation) rfiulnouio'lri nilJnd

35110.I paco, o{:;r'ho 35-45 rlrJ.:Jror {d't Fbco, drioun'jr .rh0yt uont'irfirJruo{lunr, :

hyperventilation uia hypocapnia uardr Paco, dmnn'jr 45 tJ. :or rrcc,r'jr{ilruaqj'tunm:

hypoventilation fi?o hypercapnia

odr.rl:fisrril tt1ndl Fbco, fiejruldqouul:nrioun'jr 35 rl.t.:J:or drn'rlfidrurflu nyper-

ventitation tunouu:n udnr;drunrrsfin:Jnfitalqantoeirofintav respiratory acidosis i.)s|firu
'lfir:Jdtrunr:eitrc'rn hyperventilation lunoulr:nlflu hypoventilation

tunrrm:rn'u{u nrnrdr eacq ddruldsrouu:nlrnn'jr 45 u.r.rl:ovr d.rrirtridrurflu
hypoventilation 'lunou$:n usinrtdrunrrrfiorrJnfi1lotqnn:9rrir,rfin1,]c respiratory alkalosis dlll

dru lfirriduunr':Ei1r91n hypoventilation luooutt:nriu hyperventialtion

cir paco, cv 'rnviofiourflu}Jrrtrarnr:d z ri',rd

aunttfr 7 PaCO, 0 CO, roduction

I alveolar veniilation

Arterial Blood Ga.s Analysis and Clioical Applicarion nnfuni nfrftftg 497

Alveolar ventilation = Minute ventilation - Dead space ventilation

PaCO, MxRR)-(V"xRR)

xk CO, production

(V, x RR) - (Vdx RR)

= k *_,e-o3!'"1q,*

RRM-V.)

tn flYr K 0.863

lidal volume
dead space volume
HR respiratory rate

fu rfiu16'jrrir paco, cr lnnSoriouduo{rilfle{r 4 :J:;nr: 6o

1) Carbondioxide production on:rnr:oiroffrsn.riloulnoanbdlrnduvlll6'1u{rhffi
'ld:"lar:orvr:nrfl:isrnrn rnrfiu.l loufirir respiratory quotient (Re = CO, productior/ Oxygen
consumption) d,:o:fiaralrnlu{rJrufifi respiratory acidosis odudl niu {r-l.lu COpD uanlrnd

rirvrrlu{ilrudfi urnrlafifilnl fn riu (shivering)

2) Tidal votume rrursfil:Jilror:arnrfldfiru'lardr'luusin;ail fir iidat votume fl{ ri.t

PaCO, ?ifl"') rlnitil tidal volume sir n'r paCO. tvn,:

3) Respiratory rate dt respiratory rate fl{ d1 paco, eyuh rrflrfl't respiratory rate ffi.t

n1 PaCO, eyfl,r

4) Dead space votume yrrtfi.r:JirJ1nrfl0{o1n.lfifi1rj'ld'uonrildtufirr d'1 dead space
volume d'J d't Paco, e:d.r tto:d't dead space volume n'1 Fi.t paco, olgir d.:eir dead space

volume r:rrn'tufthufrfi auto-pEEp d.rrrrufiuirwru'llaanaotirfin dr.rogju0: flow 1Jo{o1n1cr
hjrflunutifiwruld'lufirJrtrfifiraanal arnin (bronchospasml'luI:n copD xio asthma uanoln
dftuil61udltrud'ldvioti':uvruloiiamrfiu}J rirlfifidrula{ornrfidlilldunnr!duulrndu drhl
dead space volume lrnduhifiru

nr: ufi-lt rd orrnriloulooonbdn'r drulnqj orlr:n ufi'h'ldlornrr:Jfulfi mi nure venti ta-
tion rfirdulfi n"rnrnr:fi e n-td

gannfi I (PaCO" x MV), = (PaCO, x MV),

lo0ii trrtv rrrad.,.r minute ventilation rrirrTr v, x Rn

498 rrrirrininqnirSru

Flow

Flow

strtlii uand tn*- me curve'lu n. vcv mode ua.- s. rcv mode rfiu7fri'ttod'uoonaunttlloaan lend

of expintion) flow nounla'IcaBnqabiuaii1ui uaa,titfi flow Mdflfr:,rrtsoulhntllultaanqo
d,tuaa,tnnaantar auto-PEEP fuSntwduth:f,&affiflv dn'lunlnnfrfrnstulenn:ncldlaantt

f,iduisxnta?cllrhtntu'looanqn @nd of expiration) d,slnu nflu#1esfra,i*ifr6u,taunta'lq
Iudxnta'le aanqa uanetniplzuifr auto-PEEp qfin;lrtnhatiatilannnlu'lcludz,tnlt
Guntn1alc6latnni1 n6

idrorirod 6 {rJrutrlarq +s 1fi:"rn'r:iiqdatflu community acquired pneumonia lru:dtfr

rn?o.:rirurr!'lc 'ld fio, rrirfi':.i 0.6 tidal volume 400 a. o-fi:rnr:fl1u'tq r s ni,Jrisurfi ld

paco, ri1fiu s0 ruJ. rayr dornrtlfll rniauirunrulclfilddr Paco, !r,i1riu 40 rJrJ.dlor eJ
da.:rJ:"1 rnd o.rdr wr u'lco rir,tl:

qtnnr,ltJdllduf:;r'iro eacq rrd; minute ventilation

(PaCO, x lVlV), = (PaCO, x M\4,

50 x 400 x15 = 40xMV
= 50 x 400 x15

40

= 7,500 iln. (7.5 6nr)

Artedai Blood Gas Aralr.sis and Clinical Applicarion on:tuni nfrfrt1ry 499

o.,rriu o;fio,,rr-litrniomirurnrulohild minure ventitation rlri:J 7.5 6flr

fi n"rnr il oi obi'irc : r6on:Jil tidal votu me r?o respi ratory rate'lfirtlr:m.j.r

t; rdan:Jfi tidal votume n:niii peak inspiratory pressure bjqrrfiu 30-3s rrJ.!Y1 fiia

plateau pressure lrirfiu so rr.;h

z1 16on:Jil respiratory rate ntfififiilrulrjfinrx; auto-pEEp

s) fir'Iilfi peak inspiratory pre""ure dd,,r fiiolrjfi auto-pEEp oirfisn!:"! tidat votume
uia respiratory rate fi'ld lilfinrrrlrnnsirrfiu

{:-hrfinond:r.a:lu:ftoin-PrlEdErPJnfii{rrfiia8lfilrdfi1eddlueand:fisdp{archeu'olr:ilfriiaoeuararn"rpJ"i"leefairciaob. iTrfnioufllrdynnrrnrrr:irfrriue d.r

ld

tfiamrnnr:rrfilgn1?y auto-PEEP riur;do.rufiltTnunrtfla minute ventitation rfroriunr:nn

a1n1Frfr6'1.radhdx{y1u'laoonq0oonl:J 6,ldrldloanrtna tidat votume uny/riono respirarory

rare

Acid-base disorder

nrr:aan:ooir.rdfio nA (acid base disturtcancel arlr:nu .:Idrflu q sfio d'ld

1. fMetabolic acidosis
2. Metabolic alkalosis

3. Respiratory acidosis Lttj.ttflu 2ltytnr fio acute respiratory acidosis ,ffy chronic

respiratory acidosis

24. Respiratory alkalosis rrrje rflu TJlnfl 6o acute respiratory alkalosis ltfl: chronic

respiratory alkalosis

uanclnd Rrr: acid-base disorder atqfinr:uld n-ula.: z nrrc y5o g nmydrrfiufi.l6'

snrm.:d uonrnrrrfi o:Jn6qonrooi'roulloir,rl

Metabolic alkalosis I 1
Respiratory acidosis
Fiespiratory alkalosis t

t
I

urtuur: ann:niroimrrra;r6ru uoc.tfi,l primary disorder fi rflunrturnro,tqnn:ndr,tfr nft nff

500 rrtrirdolnqndunru

prfr
yli n uan,t normogrum tiatitu'luntwJaafr acid-base disorders si't,t'l

Metabolic acidosis
tunrrvfiironrufi metabolic acidosis riu liiofi hyotog"n ion d'o evfltfr serum bicartonate

Innn\: clnn'nfii1{nru4n'ld bicarbonat" }Jrfiarflu buffer niLl hydrogen ion iin"t d'trrn'nn'

auntzfi 9 H- + HCO"- <-) H2CO3 <--+ HrO + CO, I

lnurJ$fi iurmvrnlognrd,,rd'lurau'ltf carbonic anhydrase

rfiodrrnruodtunllv melabolic acidosis 1vn::qunufnr:vrltl (respiratory center)'tti
vrfl'lcr5rrt*tr de riunn-naru;nrrfl1ulc tdud'jr Kussmaul breathing d.:rir}i e"co,lutfionaoa.t

rflul:Jcrrrornr:d to

'1ornli,o tPaCO, = (1.5 x HCO.-) + 8 2

fi{onr::;r-.:6a n'l{fidl HCo3- lfi'ldrir u"nous HCo,- tdottrnrir HCo"-'lu arterial

blood gas rflurirfilficrnnr:n'rulruql Handelson-Hassalbach equation

pH iu{:Jruduflu metabolic acidosis fl1 llnnhu?rulfi?1n predicted PaCo,loutunrrv

metabotic acioosis iirfllodr': rdrtiu pH q;fiFir!:v rru 7.thco, 'ii pH tJlnn'j1 7.10 Ldu 'lu
{:lrudfi Hcq- 8 mEq/L fir{rJ'lurflu pure metabolic acidosis drutru predicted Paco, ld
wiT rir (1.5 x 8) + I +/-2 = 20 +l-2 d'triur{r pu lnurJrvillruwilri! 7.20 ttrif,lri1 pn ritrrnl rdu

dr oH or'rn iT z.o nr:l'fi iideirfildovn nrc rRdourr n

Arterial Blrxrd Gas Alralysis and Clinical .A.pplication nniuni 7fifrt1rg SOI

lonalnd01af'r"luxru predicted paco, firfincrn metaboric acidosis ldarn oredicted
PaCO, finaa.: = 1.2 x AHCOJ

rfionrfirhufrinr':; metaboric acioosis d.rfifiotfiel:ill$io'lt fio anion gap d,rrrrufi.:
:u onrfi'lriorlr:ninldlu16oo (unmeasured anionl Iouoernnr:niurrudr anion gap .irnirr

IrSounu d.:aur:nr{rurn-rldnrrornr:d t t
guntefi t1

ra'rrlnfito'r anion gap rvi'rrir.r tzt+ rir anion gap fioun'ir to 6o.irrflu metaboric acidosis

llrfla normar anion gap fir anion gap Hrnn'ir 16 fia,irtfiu metaboric acidosis lund wioe

anion gap 6.:flt r:nltunnrtyuflo{ metabolic acidosis ld

tufirlrtrfi::n'l albumin 611 dotfint: conect anion gap Tosiayflnnr:ir fi1n serum
'lunr:o'rurrudr anion gap fio,:6otdryr
albumin sl'ra'r '1 n./gN. nir anion gap ertrarr{r z.s

2serum arbumin d q-o !n"/on. miu rit serum arbumin n,/od. Iqunhu,r rir anion gap ld t6
2ot-.ruru!fia serum albumin mrtn{ n./on. rir anion gap qy[!n!Ld']6n 5 n-.tr?u correct anion oaD

ldMrril to+s = zr

nr:r'rfi 6 ufls{f,1rfiq1o{ metabotic acidosis dllriat

Wide anlofl gap f,lormal anion gap

Lactic acidosis (type A B) Dianhea
Renal tubular acidosis (type 1, 2, 1,
Ketoacidosis
Diabetic ketoacidosis Early renal insufficiency lGfn t Z0 lolurfrl
Starvalion ketoacidosis
Alcoholic ketoacidosis Excessive saline loading
Amino acid infusion
Uremia Ureterosigmoidostomy
Flhabdomyolysis
Drug intoxicaiion

Salicylate
Ethanol, methanol, ethylene glycol

luul,rn:ni nr:dfi *ioe anion gap metabotic acioosis riuaralrjldfiuruf,.rnr:ddlhufi

ItnR't?; gap metabolic acidosis lln'1fi l.torir,tl6lr fi:-huorofinttg normal anion

gap metabolic acidosis nianrl: metabotic alkatosis d?ld?uflld r',re:da.:rfrurrunr:ujfiwu n''r

?o't anion gap (Aanion gap) nJiul lfruln"lnrrr:lfiturnJn.,na,t HCO3- (aHCO3-)

axntzi tz Aanion gap Anion gap - 12
aHCO3- 24 - HCO3'

502 lrtr.irrininqordugru

g.i{d'l llntt)l{,r.t0 o-nu3

1. Aanion gapl AHCos nirfli-r 1 vrraRmuj, anion g.p iirfjildu rdouJsulrfisuril
Hco" rflulJlud'n:rdrufitrirriu6arl:v 1au .l: 1 rr6[n{i1 wide anion gap riurfinernnm; wide
anion gap metabolic acidosis rfifl{oclr,:16ur ldu n1?: diabetic ketoacidosis dd'rlrjld:"lnr:

inu'r

2. Aanion gap/ AHCo, rioun'jr t v 'luft'lltJ'jl anion gap frrfrrduriu rrijrldurioErn'jr

Hco3 fifloa,r rdor rqln anion rfu'lrjodlur6on rrrifin'r:gqnrulilrrtdu triu rrtfloarr; ri',t

riunr:fi Aanion gap/ AHCO.- rjosn'ir t ittlrafi.rnr:fifi wide anion gap i'lrn"l normal

anion gap metabolic acidosis niu diabetic ketoacidosis fi1fifinr:dnsrdruo't:u=ruav6uadu

ufir

3. Aanion gap/ AHCo. lltnn'jr 1 tlranlvjr anion gap fi tril'fiuriu lfir.rdur.rrnn'jr

lcq'fiooo,: rda{ re'rnfinr:oir,r Hcq rfilrrna;u'luri'r{rht n5orfioornnr:fi{rhu16:11 ucq
elnnruuon (niu nlrldi! sodium bicarbonate) ra''.triunr:d Aanion gap/ AHcor'*trnn'ir 16,t

nunfirnr:fifi wide anion gap iun'l metabolic alkalosis niu diabetic ketoacidosis fifinr:

arr6uu fi volume depletion atir.lrrn n?o'ld'il 7,5% NaHCo, 'hnr:tnur

nrfl.rii z [oq':nr:ifioi'uuannrt:oirl1 tiatu rid" anion gap

: Aanion gnp/ AHCO"-

r*in'u 1 (o.B-r.2) Pure wide anion gap metabolic acidosis
Wde anion gap metabolic acidosis with normal anion gap metabolic acidosis
rloernilt {. o.e) \ryide anion gap metabolic acidosis with metabolic alkalosis
lnfl'jl 1 (> 1,2)

Metabolic alkalosas
n'ny metabotic atkatosis rflunrr:dir'rnrufi Hcoi n-{ rirzun}lnnqutinr:n, U'lcril}i

PaCO. a".l o,:A nr:fi tS

auntd ts PaCO, = (0.7 x HCO,-) + 2012

odr.il:finu4n:'lunr:n'rurru predicted Paco, dtfiotern metabolic alkalosis fifln1ufln:

rrj! Hco.- rfildu t reqlr a:rirtri eaco, rfirdu o.z mmHg t€ooroa"rurruldrrn predicted
PaCO, = (0.9 x HCO,-) + 15 ! 2

d1rflqno\:n11J metabolic alkalosis 'luvrl: frj6crm:nuunldrfru Z n{l 6a
fi1. Chloride-responsive metabolic alkalosis lufin n'l'lc metabolic alkalosis riuna:l
nuo,rsionrr (fiar:dgr rfiio'rornfeiinlru n(une,j:.Erfiago1unrrv volume depletion {'tfinr:n:;{urvll renin-

Afterial Blood cas Analvsis and Clinicr Applicati()n nniunf nfrfiftg 505

MEIABOLIC ACIDOSIS Suspected

rey lnri t' ts Na-. K+, Cl-. HCO3 . anion gap

drntin6":yriofiadT uucrr; puor, p"cor. pH. base exc6s (deficit)

Metabolic acidosis confirmed

pH > 7.43 pH < 7.39

I +

Respiratory alkalosis M€tabolic acidemia

Anion gap > 12 mEp/L Anion gap < 12 mEp/L

Ketoacids ln blood or urine I

No ketoacids in blood or urine

Glucose > 200 mgr'dl Glucose < 200 mg/dl lv Creatinine

V I Creatinine < I mgr'dl
> 8 mo/dl
Diabetes melitus Suspect alcoholic Predisposing
ketoacidosi$ or I factor for
IV Fluid starvation lactic acidosis
Insulin Flenal failure
ff pH < 7.2. l'l€HCO3. lV
I

Consder
0ialysis
lf pH < 7.1.
NaHCOr. lV

L-lactate LJactate
> 2.5 mrnol/L < 2.5 mmol/L

f I

Lactic acidosis o-racrate
> 0.0 mmol/L
Treat Undarving cause
lf pH < 7.1. NaHCO3. lV i

gut iora

J
II ANonntaibbsoiobatbicls II
I
I

Dtrtu-a Excess lluid Small or large Fenal loss HCO'
bowel fluid loss
Stop Expansion J
drug acldosig Cafbonic
anhydrase Clinic€l
i susspicion of
inhibitor aldosterone
Observe
Festrict V deficlency

fluid Stop drug .It

HyponatrE nia I r pu . r.t, H"Hco* rv

A$ess Urine pH

Blood Sample for Cortisol level
Hldrocortisone, 100 ng q6h

zueu4fid r.f,6nuu1n1n1un1i awroach ffilzuifi metabolic acidosis

504 rrtdrfninqmdlnru

angiotensin-aldosterone (RAA system) tflurun'lfrfinr:ta-,: aldostrerone rrijr.r6'u6.:vrh'hifinlr;
metabolic alkalosis rfiodu triu nr:ortiEju n1:ldillt11Tufl6[611't:tJ'lulu (remote diuretic use)

2. Chloride-resistant metabolic alkalosis rlrufi'l n']?; metabolic attatosis filrifio!

fliro{rionlr'lfidrni1 rfiaternnr:n:v{u RAA system lerufiirtnrolrjldaqliunr'tv volume depletion

[ti! primary hyperaldosteronism. renin producing tumor, renal artery stenosis ddund dcv

en?qllunxlrrd'uTnfinq*r nio lfincrnnl'r:fi'hjfin1:nrrqu FAA system niu nr:ldiu bicarbonate
solution, n't't: hypokalemia, n1'tt hypomagnesemia ttn:nt:'ld:":turn"ulon,r:'lurixtt:n (recent

diuretic use) ffulunnjldnr, ldulafi nrvogturnrudrJnfi

gErT :r,rd rtflu{dlrfi qfl o.rnllt metabolic alkalosis

Gastric fluid loss (eg, vomiting, NG drainage) Chloride.r€sistant
Volume contraction
Long-term diuretic therapy Primary aldosteronism
Congenital chloride diarrhea Bartler's syndrome
Posthypercapnia syndrome DOC excess syndrome
Liddle's syndrome

Excessive ingestion of licorice
Chronic potassium depletion

Primary reninism
N/ilk-alkali syndrome
Short-term diuretic therapy
Severe hypokalemia
Severe hypomagnesemia

Respiratory acidosas

nr':! respiratory acidosis rilunmsiiir.rnrufi eacq a'{fj':tfluzuacrnnm; hypoventitation

d.rnrntrilwirnrirfilun'r:rfiurYn Hco"- ftlfi HCo.- lur6aoo.: our:nuanldlflu 2 li:rnyr

1. Acute respiratory acidosis liifr.'] nl?: respiratory acidosis fiO1n1:lfiodusdr,r

:ror5r lsr6.:ri,ilrio'rrr:nrfiln"n Hco,- ldlilrfrlrfi c',:frtfi Hco.- tur6aot7,:lrio*rrn d,:rlntrl pH

n'rnirdrr-ln6 lquri'r'lt rda e"co. uijrdu 10 rJ .lrovr o:rhtr{ ucq- rfirr*u t req d.rnn'hi pn

nonroirn'irrir n6 o.oe

2. Chronic respiratory acidosis fiu1ufi.I n1'tc respiratory acidosis fiarnr:rfloduorir-r

riourfluriou}l lnour:nrfiln"n HCo3- ldrffxii irrirhl uco,- 'lu16ooa'.ro,uJrnn'jrfirulunm:

rr.acute respiratory acidosis d.,truoltl pH 1nir6uodriln6 loafr'r'b.l rfio eaCo, nirdu i 0 :avr
r:frtri lco,- ldiltj*u c rrq ritflntri pu nontorhn'irrirr.lnfi o.os

Afierial Blood Cas Analvsis rnd Clinical Applicxrion nnSunf nfrfr[1Jg 505

Urina chloride

<2onEqtL/.,.// \"orr'aq^

-.t \
Chlofi de responsive alkalosis Chloride unresponsive alkalosis
- gaslric fluid loss

- non-reabsorbable aniofi delivery II
- diuretics
- post hyp€rcapnsa Urine potassium
- villous adenoma
< ?O mEqlday...-...' -\" gO tedoa

- congenital chlorklonhea

Sunu{,frd ufranuu'Jn1oluml approach fiLl2a metabotic alkalosis

Respiratory alkalosis

n'r?: respiratory alkalosis rflun'r?yfidrtnrufi PaCO, flgn\r 6,:riluaracrnnm: hyper-

ventitation d'rnnhilonirnrirfi'lunr:rfu Hco"- drlfi Hco,-'lurdoooi'r o'rrJtnrrunldrflu 2 ::ml

'1. Acute respiratory alkalosis 14tJ1ufi{ n1?y respiratory altalosis frarnr:rfiatiuadr.r

r1or5x 1n6{rinhjal lrnr'! Hco:- ld'ldrfirfi furirtri Hcq- lurf,oorT.rlrirrirlrn d.raral,rl pH g.:

10n'jreirrina loEjr'rl:l riia eaco" noa{ . rar l:rirtrl tco.- nafl\r 2 mEq d,rrunlfi pH q,l

n'i1Fi1iln6 o.o8

2. Chronic respiratory alkalosis 14 1ufi.i nlxc respiratory alkalosis fiornr:tfiodu

adr':rioHufludaulil lnarrur:nril Hco.- ld#lii i,rrhtri Hcq- lu16oersr:1n.jrfiil!'lun.l1: acute

tl.respiratory atkatosis rirnrnlfi pH 1n&r6a.,rcitJn6 Tourir}J rfro FbCo, flon\r to :arn e:rirfti

HCq- aafl',r s meq dlalnlfi pH {.Jn'j1ri1tna 0.02

50,6 remirrininqnCl5ru

In1l1€d r!f,s,tfl1rfiq?0{n'r')v respiratory acidosis

Extrathoracic airway lesions

. Infections - Ludwig angina" laryngotracheobronchitis (croup)
. Congenital lesions - Subglottic stenosis. laryngomalacia craniofacial abnormalities
. Thermal airway burns
. Tonsillar and adenoidal hypertrophy

Intrathoracic airway obstruction - asthma, vascular ring

Depression of central respiratory control

. Drug inducsd - opiaies. sedatives, anesthetics. alcohol

Infsction - meningitis, encephalitis

Stroke

. Hypoxic encephalopathy

Increased dead space - wasted ventilation

. Pulmonary embolism
. Pulmonary vascular disease
. Low cardiac output

Acute lung injury

. Pneumonia
. Pulmonary edema
. Lung contusion
. Bronchiolitis

Chronic lung disease

. Bronchopulmonary dysplasia
. Cystic fibrosis
. Chronic bronchitis
. Chronic obstructive pulmonary disease

Flespiratory muscle weakness leading to hypoventilation

. Poliomyelitis
. Guillain-Bar"syndrome
. N4yasthenia gravis
. Muscular dystrophy
. Spinal cord injury

Chest wall restriction

. Flail chest
. Pneumothorax
. Pleural effusions
. Kyphoscoliosis

Increased CO, production

. Malignanthyperthermia
. Extensive burns

Arterial Blood Gas ,{nal,vsis and Clinical Applicarion nn?uvi {!fifitxg 507

nf1,\td 1O LrflqsflTrfinl8\rfl 't?: respiratory alkatosis

Hypoxia and hypoxemia

. Altitude/ low fraction of inspired orygen (FiOr)
. Anemia
. Hypotension
r Lung disease

Pulmonary disorders

. Edema (hydrostatic or permeability)
r Embolism
. Airway obstruction/ inllammation
. Pneumonia
. Interstitial lung disease

Mechanical ventilation: Respiratory alkalosis could result trom a ventilatory rate or tidal
volume that is loo high or from the patient lriggering excessive additional breaths.

Extrapulmonary disorders

. Anxiety, stress
. Neurologic disease (eg, stroke, inlection, trauma, tumor)
. Hormonevdrugs (eg. catecholamines, progesterone. methylxanthines. salicylatev

doxapram. nicotine)

. Pregnancy
. Hyperthermia
. Liver failure. especially with hepatic encephalopathy
. Sepsis
. Recovery from metabolic acidosis

n11lsri 11 r[do.rn?1 fr fl]tf,rsx'j1{ paoq, HCOs- lral pn lunrrv respiratory acidosis uflv respi

ratorv alkalosis

Acute respiratory acidosis 10 1 0.08

Acute respiratory alkalosis I ro t^ I 0.08

lChronic respira'tory acidosis ro f+ I o.oe

lro isChronic respiratory alkalosis 1o.oz

508 remirrininqorfiugru

fieod, rn'nuila Ha?an:oldtl

ri'rorir.rii 7 pH 7.20, Paco, 20 mmHg, HCor- 8 mEq/L
pu rioun'ir z.+o afltunrrv acidosis
fllrfiqflo\r acidosis tfiqr1fl HCO3- oi, 6.:tflu metabolic acidosis

=r{'tuxfu predicted PaCO, (1.5 x HCO.-) + I +l- 2
= (1.5 x 8) +8+/-2=20+l-Z

PaCO, Lyilriu 20 mmHg og'ludroloe predicted Paco,

nxl ftFr n6ro\:qfln?qdT {ttli1ud6,rtflu pure metabolic acidosis

Ineorir.rii pH 7.15. PaCo.30 mmHg. HCQ- 8 mEq/L

ptt riaun'lr 7.40 odhnl?r acidosis

ifi'r111910\r acidosis lfi0e1fl Hco3- fi"] fiU metabolic acidosis
fh lru predicted PaCO, = (1.5 x HCO.-) + I +/- 2

= (1.5 x 8) +I+/-2=20+/-2

PaCO, Mrrir 30 mmHg tfiurjr.:ra.,t predicted PaCO, ltflq.t'j1 PaCO, q{n'jla?rx

rfluc3t llcn.o'jrfi re-spiratory acidosis ilrdrtt
n':trfin:Jnfiia.:qanrodr'tlilfludin!flrr metabolic acidosis ilrnl; respiratory acidosis

deorir.rl" g pH 7.25, t%Co, 15 mmHg. Hco3- 8 mEq/L

pH riaun'jr 7.40 o{tunrr: acidosis
fllrfiqro\r acidosis rfi91'tfl HCO3- 0i1 ittflu melabolic acidosis

=Fi'rulu predicted PaCO, fl.5 x HCO3-) + 8 +l- 2
= (1.5x E) +E+/- 2=20+/ 2

PaCO, tvild! 15 mmHg tiouni'tdr.lgo,,t predicted PaCO, rrflg*r'jr PaCO, ol'rn'lr

nxl rfluein ufln{'j1fi respiratory alkalosis irrdra

neufio n6ratonnrndt{'tur1udi,:tflu metabolic acidosis drrnir.r respiratory alkalosis

n-xori1\:i 10 pH 7.50, PaCO2 42 mmHg. HCO3- 30 mEq/L

pH rnn'jr z.+O oqjlunrr: alkalosis

fl1rfiq100 alkalosis rfioc1fl HCO3- fl" 6r: rflu metabolic alkalosis

x6h predicted PaCO2 = (0.7 x HCO.-) + 2O +/- 2

= (0.7x30) +2O+/-2=41 +l-2

Arterial Blood cas Analysis and Clinical Applicarion nn:runi qfrfrft! 509

PaCO, rvitn"r 42 mmHg oglutir':1a,r predicted paCO,

ax1 ftn n6flo,,rqnniodl.itur, Udi, flu pure metabolic atkatosis

n"'lorj1\rd 1't pH 7.45, paco, so mmHg, HCO3- 30 mEq/L

pH 1nn'j'r 7.40 adtun'rxy atkatosis

6[1!fi'|1an alkalosis rnnfln HCO3- {.r 6t tflu metabolic alkalosis

nhul{u predicted PaCO, = (0.7 x HCO3-) + 2O +/- 2
= (0.7x30) +20+/-2=41 +l- 2

PaCO. wirfii 50 mmHg rfiud't.tron predicted paCO, rrda{'jt FbCO, fl\:n.j1n?.1

tiluoi,: uanvjrfi respiratory acidosis dudrl
nrr fia n6flo\tqnnrofil{turlfld6,irfl! metabotic atkatosis i':lri:t respiratory acidosis

q-xod1\rd 12 pH 7.60. PaCO, 35 mmHg, HCO.- 30 mEq/L

pH rnn'jl 7.40 ali'luntxv atkatosis

6t1L11qro\: alkalosis rfioetn HCOs- q.t i,rtflu metabolic alkalosis

ilu?ru predicted PaCO. = (0.7 x HCO"-) + 2O +/- 2
= {0.7 x 30) + 2O +/- 2 = 41 +/- 2

PaCO, lillfi'il 35 mmHg rioun'jrtirolal predicted PaCO, udn,]'jr PaCO, 0't"tn,j1

nxrlrlihqt{ udo.'rirfi respiratory alkalosis irrdru
n11 fio n61o{enn?66''1,,t'lur1ud6':rfl! metabotic atkalosis dufli respiratory atkatosis

n-rorir,:d B pH 7.24. co? 60 mmHg, HCO.- 28 mEq/L

ptt riarn'jr 7.40 0Ej'lun11: acidosis
f,rlfiqflo,] acidosis rfioc'rn PaCO, fl.i iolilu respiratory acidosis
pH ttfiuuu d,r 'ln 6'r6ofi': acule respiratory acidosis
'lu acute respiratory acidosis riu PaCo, trilr.r 10 rJ .r.l:o Hco.- rdrJ 1 mEq/L

lu:rud euco, rfi (60-40 = 20) rrJ. rDlr Hcq- rdl 2 mEq/L

nhulru predicted HCO.- trirn"r 124 + 2) +/- 2 = 26 +/- 2 mEqtL
HCo3- lyi1fl! 28 mEq/L 6':a{1u:ir',not predicted HCO3- fir{ru'lruld

n11 ofi nfirta{nan:ooir,rll:rfldi,irflu acute respiratory acidosis

nradrd 14 pH 7.18, PaCO, 60 mmHg, HCQ- 22 mEq/L

pH rioun'lr 7.40 odtun'rxy acidosis

510 rernirriolnqndugru

6t'1[x0!1fl{ acidosis lnne1n PaCO, g\t i.ltiu respiratory acidosis

pH trlduuu:Jn,:lrn io6o6,: acute respiratory acidosis

tu acute respiratory acidosis #u eaoo, ldl 10 tJtJ.lloYl HCq- Ldil 1 mEq/L
tumad e"cq rfrl (oo-+o = 20I xu.:hovt Hco3- tfitJ 2 mEqlL

i']u'rru predicted HcO3- [1iltY:J (24 + 2) +/- 2 = 26 +/- 2 mEq/L
HCo.- wirnil 22 mEq/L rioun'jrdr.tto'l predicted Hco.- iirilu'l.uld 6'lriu6':51
metabolic acidosis dtrdru
c?1llfi q:JnAno{qfln:od'\t'lul,rudi{lfru acute respiratory acidosis dlln-:j metabolic

acidosis

dradrod 15 pH 7.30, Paco,60 mmHg, HCo.- 32 mEq/L

pH rioun'ir z,4o a{'lunrr: acidosis

f,l!?gl?o{ acidosis Lnoqln PaCO, fl\: 6.:tflu respiratory acidosis

pH t:Jduurrln't 1n flt6nfi.: acute respiratory acidosis

10'iu acute respiratory acidosis riu eaCO, tfh . :oYl HCO.- lfitJ 1 mEq/L

'lurrud e"cq rfir 1oo-+o = 20) ur.rhou HCo"- rfir 2 mEq/L

n"r lru predicted HCO"- willi! (24 + 2) +/- 2 = 26 +/- 2 mEq/L

HCO.- rvi'rfu 32 mEq/L rrnn'jrdr.:so't predicted Hcq- iiniurru-ld d.rusuiofi

metabolic alkalosis dtudru

6?1uDt'q flq'r0\:qnn:eroir-rlu:rud6.:rflu acute respiratory acidosis ielnil metabolic

alkalosis

#rorjrsfi 16 pH 7.56, Paco, 20 mmHg, HCo.- 18 mEq/L

pH 'rnnil 7.40 oqlunl?v alkalosis

fl1ruEnon alkalosis fial1n PaCO, dl 6.:tflu respiratory alkalosis

pH tiduuu ot''],ln 6.,r6n6.r acute respiratory atkalosis

'h acute respiratory alkalosis ril Paco, ffo 10:ttJ. to1t Hco3- fln 2 mEq/L
lulud R"co, flo (40-20 = 20) rr. :ovr Hcq- nq 4 mEq/L

n'ruru predicted Hco.- rvirfiu (24 - 4l +l- 2 = 2Q +/- 2 mEq/L
HCo.- uvirriu 18 mEq/L i,rog'lurjreto.l predicted Hco,- iitiluxil-ld

n'r1 fi n!nfirto'tqnn:ndrflu:rudi'triiu acute respiratory alkalosis

Anerial lllcxrd Gas Analysis and Clinical Applicarion Lan:1ani nfrfiftn Sl7

frrorir.rfi 17 pH 7.s0. paCO, 20 mmHg, HCO3- 12 mEq/L

pH 1nnil 7.40 odlunlx: atkatosis

6[1[7qno{ alkalosis rfigetn PaCO, nt 6lrfu respiratory alkalosis

pH nlduuurjoolrn {.:60fi.r acute respiratory atkatosis

10tu acute respiratory alkalosis lfu PaCO2 on . :oyl HCo3- nn 2 mEq/L

'lu:rud e"co" ae (40-20 = z0) rJ .lioyr Hco3- ffo 4 mEq,/L

g"lu'l predicted HCO3- ryilriu (24 - 4\ +/- 2 = 20 +/- 2 mEq/L

Hco3- M1fiu i2 mEq/L 6{q"in'j'nj't,,11,o.,t predicted HCo.- dn".tu?culd r'.,rfi metabotic

acidosis irlfiru

Bx'r:.Jfior.lnfisa.r0nflraci't,tturlfldfi't Lflu acute respiratory atkatosis d,ltrrYl metabolic
acidosis

firarir.rd 18 pH 7.62. paCO, 20 mmHg, HCO.- 25 mEq/L

pH 1nn'j't 7.40 orilun1?: alkatosis

611[lrtq,Ir0{ alkalosis fioe1n PaCO, ti't 6lrflu respiratory alkalosis

tpU fiuuu n\tlrn r'06nfi.: acute respiratory alkalosis

'lu acute respiratory alkalosis riu PaCO2 nn i0 lu.tl:oyt HCO3- dFt z mEdL
'lu:rud eaco, nn (40-20 = 20) rJ,fioyl HcoS- ao 4 mEq/L

Rhu?fu predicted HCO3- [vi1d'u (24 - 4l +/- 2 = 2O +/- 2 mEq/L

HCo"- Mrrfil 25 mEq/L ?'.rd.rnithlra,,r predicted Hco.- drilu'rruld iofi metabolic

alkalosis ittd'tu

ixaxi fie flAta{qnn:opir,:'lu:rudl'rrflu acute respiratory atkatosis rYu metabotic

alkalosis

n-?orj1nfi 19 pH 7,40, t%.CO, 15 mmHg, HCO,- 12 mEq/L

pH wi'rrYr 7.40 olrd?rfifiou!flu normat acid-base

uddr PacO, uo: Hco3- fter:Jn6ns.: z nir unn,,r'jrhjl:i normat acid-base dorfinrru
finlnfita,r acidosis ufly alkatosis irrfi'ri,l?ylfi pH a{tunirr.tnfild Toanxl finln6

fia.,ltflun'nrfto:Jn6r1n metabotic 0 :1y Hco3- fiorJnfi1 drlrYrnrufinrJn6rro res-

piration ([l'|l'r: PaCO, ftFrlnfi)

HCO3- crh 6,t lflu metabolic acidosis

PaCO, at1 dtrflu respiratory alkalosis

nrufin nhtatqnn?ofi'},l11ud6,Jrflu metabolic acidosis dllni:j respiratory alkatosis

5rz r,)uu, Uo?nqfrxfluslu

n'rorirod 20 pH 7.4o, Paco, 60 mmHg. HCq- 36 mEq/L
pH [?i1riu z.+o qufiT rnfiaulflu normal acid-base
rrrinir eacq rrfl; HCoo- fiorJndns.J z nir uan.r'jrlritd normat acid-base fia,:iprlrl

fior.lnfi:rot acidosis ufl: atkatosis d'ufiuiro:lfi px a{1udrrJn6ld TnflnrrrJfiailnfi
da.:rflunrlrfin n6r'},,r metabolic (r :1r Hco3- ftorJnfl dudrorufta n6rt,: res-

piration ([vrr1Y Paco, fio:Jn6)
Hco3- g.r {t tflu metabolic alkalosis

PaCO, N t'otflu respiratory acidosis

ax1rJfi6!nfirl0,rEnn:qFir,i:rudq'{ rflu metabolic atkalosis drlrfii respiratory acidosis

nr::Jilqfldn,t:urJf,$f, arterial blood gas luilfinefin

d'rau'r.tfi zr {rhtrtruarq +o fl fi1lluro{rhflfiruarnrru ufio,: n:'red't,rn1ut'{ mitd anemia,

liver span 3 FB below right costal margin. huge splenomegaly tt5'18 arterial blood gas (room
atr\ '. pH 7 ,42, PaO, 55 mmHg, PaCO, 38 mmHg, HCO.- 24 mEq/L- SaO, 88% nT?q peripheral
blood smear fil ttdFr.l

. l- -a
ttln 5

1, Orygenation

Pao. rvirrir.r 5o rll.r,r.J:oyr lltru;fitd room air fla'jrfi moderate hypoxemia rroi{rJrt

nuru6 i.ida,rFo'jrfiarrrqfrrirlfi{1ru!no pseudohypoxemia n?olrj ornnrn:le peripherat btood

smear :i'irsirururfio 16oolrro.:lrn t!t!fld'nntcurto,i myeloid series dt tTun:roir-:nrull
hepatosplenomegaty {,:rit'hi6ofi,r chronic myetoid leukemia lrnion dtl,rl hyperleukocytosis
ldlouiirfiordootrrrflumn6dfiurnr!a66rr${ irrflumndiildoan6rourrn i.nirlirfln pseuoo-
hypoxemia ld n-':rlru6,,:nr:io oxygen saturation yl1\r putse oximetry dru ddu:ruiiinld sg"/

dtrfl ucirrlnfi i..r'hifi o{fnsfl ounr:hioonfi rou

Artcrial Blood Gas Anah6i$ :rnd Clinical ,{pplication @n?uni nfrfir1tT 5L3

2. Ventilation

PaCO, tyilrt:J 38 royt lutru:d pU :Jnfi 6,:fiorflu normal ventitation

'J.
3. Acid-base imbalance

pH 7 .42, PaCOr 3S tJrJ.rhoyr, HCO3- 24 mEq,/L 6oiloan:orir,to{lurnrudrJn6

n-eod'xfi 22 fi:humuoru +o fl ldfinr:ifiodu'jrrflu severe community acquired pneumonia

flruvftd:-rnr:fnurToulaiyiorirafirule uncldraio,:1i:uy'1fl'lq vcv mode, Fio, 0.8. ry 400 a.,

S0PIF 50 An:$ioulfi, RR le n*oeiourfi nrxe ABG ldr.tnlfltl pH 7.14. paCO, . :syt. pao, 60

r.n. :ov n:rq blood chemistry 1finrnrflu Na 140 mEq/L. K 5.5 mEq/L, cl 102 mEq/1. HCo,-

15 mEq/L ri'nunrcnrT,Jriruf{fir:r'tonnuliu diffuse alveolar infiltration lnufitrurntro,ry'rlor.ln6

1. Orygenation

60?1n ABG rdr PaO, rrirriu .ilolr 6rrnrn"l oxygen saluration so"/" 'lutru:fild

Fio, rvirrir 0.8 a'luxruri'r paol Fio, rvirnir zs ii.rr-j,rlon'jr hypoxemia lu:rfld ro; lfincrn

shunt sd,r'lu:rrdfio,raldair lfin nRos duudrrr:r:rir pao,/ Fio, lioun'j1 200 rlnyrlulofla{

rirlc:lnfi Fr".Ifunr:rfh Fio, hfuvirrfll r.o filririrtr4 oxygenation 6riun'jr rdll'rnrin o*.rriuirnr:

1ufinrr: hypoxemia 'lu:rudTounr:'tai eere udrnioul na rio, n.r'hi1drhr 0.6 lnuinrl

::dtt oxygen saturation lfiaqjfitJ::rrru soZo

2. Ventilation

ern ABG Fi'r PaCo, ryirn'r s0 rr.:J:oyt t-irlonfl.,r'lr{rJruo{lunrr; hypoventitation

rda':ernfi:-hulumuftd:-rnr:ifiod'urflu community acquired pneumonia drTnurlnfitunr, zri

ABG eyw-in'nu r acute respiratory alkalosis 6or{tto.r PaCO, al:cg0{'tnit:Jnfi rflo,rqrnfiriru

vrulq r5rlerunr:nr:{udru J-receptor uri'tu:'rrdeir eaco, o,:n'irrir:JnF fi.,rri..:uonfi,r'j'ruu'rB
onrr,rtu oqudooatirrun ri'rriurfiofilr:ruriuniuirtu:rudo.rdriirfi ARDS i-rrrfi-rfl n-r:inB1
lnunr:'l6i peep fil:rir'tfi atveotar ventitation fidudufluorocrnnr:d peep oru:nlioq.,rar.r rir1fi
fi nr:unnula'uuffrrddulfi fi.:rirlrfi paco, non.l

3. Acid-base imbalance

lu:rad pH rvirn'r 7.14 dtfioirlflu acidosis Toudrr Elo,: acidosis tu:rfldrfinqrn
irlfilmetabolic acidosis
respiratory acidosis iJfltf]u

6[1rfiE1onn1lJ metabolic acidosis tdorc'rurrud'] anion gap ldnirfiu 14o-102-15
rrirriu zs nh xrudl Aanion gap/ AHco.- wirrYl eg-p)/(24-151 rvirriu t.t filfio'firflu pure

wide anion gap metabolic acidosis flr mq'lu:rrdifio.rFnfu6a flrJruoglunrr: lactic acidosis

fi50 ketoacidosis ySobj odr,ilrfinli lu:rudfi hyperkalemia irildru q'{nr:60fi{n1r: tactic

acidosis tJ'rnfli'r ketoacidosis tfia{ern lactic acidosis rjreyd ylTudrilnrr: septic shock [Ln:

acute renat failure d,:rfiold"lu:rud o''.rriu6.:nr:rirnr:o:?q BUN uny creatinine dl n'!nr:6qntl

rl3lrruf, oorryoeirllndin

514 r':tdrrininqnrfiugru

rir predicted PaCO, e{rurnrldorn (1.5x15) + I + 2 Mrfiu 30 Lrflo,r'j't pH firfinernnm:
metabolic acioosis fio:firirTou ::rrru 2.30 d:lriulu:rudddr paCo, rJtnn?1 predicted paco,

noniurculd 6,rfi0.:fi nm: respiratory acidosis drtdru

tdaurnrry respiratory acidosis fiorrtf,t!fiqrial:J'j'rrfigitn acute respiratory acidosis

ria chronic respiratory acidosis r6ovru,:aarnrr;nglfiu'lumudnir paCO, rfjutnn'irri.r predicted

Pacor 20 rJ!.:hoyr (e'tn 30 rJ:1.:J:ay rflu sO r.]|l.rJ:o 1 n-':usufil6o'jtrnne.tnnl?: acute respiratory

acidosis pH r;fia,raoa.rl lrn 7.30 6n 0.16 lcrnoruf,ilvriuS'lun'ni acute respiratory acidosis

:afi'jr rir paco, rfrrdu to x,uJ. pH acfio{aos\: o,os) ri',iliudr pH'lu:rudi,rrrirn-u z.t+ d.r

o:{rfueir ngc'lu:',ud r'-,rr?unrr; respiratory acidosis 'lu:rtdr-.trfioq'tnnr't; acute respiratory
acidosis otirttdur {itnr:tuibnrr: respiratory acidosis tu:radfio,: ufibnrrv hypoventilation

d.ildniir rfi ,:Ll udrh.rn audu

n-.,lu"u qnnrn,irrfifior.lnfi'lu{f T u:T ud6lrflu *io" anion gap metabotic acidosis dllfiu

acufe respiratory acidosis

nr:rrfi 12 rrfln,:nr:rr:Jon:n PaOr/Fio, rjoln'jr g0O

'1. ARDS da,:n:xrnru.rinr:ifiod'rrlnio (Berlin definirion 2012)

2. Severe heart lailure lun:nifi volume status tntr (pcwp lounJ'iilMnn,jr tB uu.:J:ovr1

3. Dead space ventilation ttiu pulmonary thromboembolism, lower airway obstruction'h

nkirln: nintnru rir ar i.r fi n m,: o i nf i ttrat ion ti'o L3 u

qrfl# tg lrnatonr:r fisutt!a,Jno,: arterial blood gas 'lu pneumonia

1. Pneumonia iiii*eruruu:olrilrn

Hypoxemia rfiortrn V/Q mismatch

Hypocapnia qrnnrrn:sduquJnr:rra'lqnjru J-receptor
Acid-base alteration tflu acute res9iratory alkalosis
2. Pneumonia dfiaTu:uu:.clrn
Hypoxemia tfiontn severe shunt fiolrjqauaua,ro{a FiO, LO

Hypercapnia !fi s91n alveolar hypoventilation

Acid-base alteration tflu acute respiratory acidosis

{ id'rorirri zo rumuoru 4s ldiln1iificd'a.ir rflu hepatic encephatopathy e1n atcoholic

cinnosis ldiunr:ld nasogastric tube rfiorcrnfio,,r6o ld f'fC conlent ooniud: gOO llc. oiaiu
rrule room air n:ro ABGldarntiJu pH 7.69, PaCOr 30 rJrJ. lafl, Fraor 80 r.trJ, :oT ntlo blood

chemistry lderntfll-l Na 134 mEq/1, K 3.3 mEq/l, Ct 84 mEq/l. HCO,- 35 mEq/L

Arterial ljlood Gas Anah'sis and Clinical .{pplicarion @niwi nfifi&Js 5lS

1. Oxygenation

tu:rud e.o, rvirriu go rir.r.:hofi o:,rfi! sao, 95% turru:dlfi room air f,'rrfia
a'rurrurir Pao2t Fio.li +oo fjrn'rn.jreir:Jn6 d{rjrq:rfinq1n v/e mismarch rrnfrqn ti.r vtO

mismatch luludortrflnqrnnr:iifio,ro'o c'rvri'lftJirrn: aonoar ri'rtfi ventitation nnflnhif,xann-Ll
perfusion dilnfi liaor*fiootnnnln hepatopulmonary snunt lt4.,rrrrtlld'iu{:j?u cirrhosis

2. Ventilation

PaCo, ryi1fi! 30 rJl,rJ:oyr 6.:nirn.jrrirrlnfi uoo.tirfiilrufi hyperventitation fird.lrfiEflo.t

hyperventitation 'lurrudore lfinldornnr:iifirhufio,r6o $i,:ororfioornnr:fifi ascites ria bowel

ileus olnRr?: hypokatemia) rirhhJilrn:rJaanoa.: 6.,rrir1fifinr:n::{utfifinr:nrafulrndu nia
o'retfioornn'trt hepatic encephatoparhy 'lurir,: u:n1 firfinr:n::fiuqurinr:yrrL'lq'hifinr:yrfltc

11n',tfluL9

3. Acid-base imbalance

'lu:rud pH whffu 2.69 rldnn'jlfi atkatosisloud e"cq n''ruo: Hcq cl donrrrmo.r

2alkalosis rfluld :yn1: 6o?'tn metabolic alkalosis rtot resplratory atkalosas

d1Lfiqfl0{n1ti metabolic atratosis 'lu:rud rc:rfiocrnnr:iifi NG content lnurija

finrrr6h ltc content 00fl1 ?rnir.:nra ua;finrlfiu NG content dfin:nrflud.:ur.l:yna! rilfi

finr:n::{u renin-angiotensin-aldosterone system lotrdrfiofinr:n:yduaofllu aldosterone ?t
d'r1fifinr:rfirn"n sodium uovn::fiutrifinr:nil potassium ufl: hydrogen ion oonm,:flfldr,::
rflunrntfiirunrro{lunrr: metabolic atkatosis 'lufirhfl:rtdi.rnr:inur metabotic alkalosis 1os
nr:lrigr:rirfrfi chloride lfludrurJ:vnol niu Nact, Ringer's acetate sotution '[rinr:'ld ningers

{ilactate sotution rfro,,rlrnfirhuludrflu ctnnosis riaur:nulfiau tactate riu bicarbonate ld'

nr:lfi or:rihtfi ndo'rllir'hirfi onrrc tacric acidosis el1ru.J1

finrTrc'rrfluodr.xEi'rfiq:fio,rufibnrr: metabotic atkatosis ua: hypokatemia 'lu:ter

d rfjaierniltr z nrr;driuflqe-rlfl?Jdu (precipitating factor) drir'hi nepatic encephatopathy

:uu:odu riLtaiauiiili ft:-lrufic:ir-ri0,,t urulodro,,r rflunrqrirl,rirfior respiratory acidosis Rflrfia.t
ldvioriruyrute0rrr r

orrr:nn"rurrurir predicted paCO, lfiorn (0.7x3S) + 20 + 21dM1n"il 44.s rJrJ. toyl

uoirdr Paco, luluftd 30 r.l. :or dror'rn.jrir predicted eaco" frniurru1d lrdn{'j'tfin.txt
respiratory alkalosis i? d'tu

nrarir.rd 24 fi rurruoru t o fl lifunr:ifiqdurflu diabetic ketoacidosis ftr?s btood sugar
ru:n:"r:ld 600 n,/nn. nn,rld'irnr:fnsrTerul?icrrfl ua;iufldurflurraruru 3 drl .r n:rq

rirnrnturfiosld 300 rtn-/ofl. fi:Jrunratl room air nl.te ABG -ldnoriu pH 7.40. paco, 40

516 rettirrialnqnfiugru

Reabsorption In Distal Tubule & Collecting Duct

A-TF Na
H'

cell :Net Na'- reatEorptun & K

H.

tf
K

Fr9.?$11

Pti a uanviunr),tluntzoonqnfna,t aldosterone d pnncipal cell fi late paft tan distal tubute fi
iuiragn sodium n{u potassium L[ay hydrogen ion aannNflgg't'lz ri']'|fiffits hypokalemic

metabolic alkalosis

l+nrlrod tlfifln precipitating factors 10{ hepatic encephalopathy

L Uremia/azotemia Sedatives, benzodiazepines
Gastrointesti nal bleeding Barbit u rates
Dehydration Hypoxia
Metabolic alkalosis Hypoglycemia
Constipation Hypokalemia
Excessive dietary protein Hypothyroidism
Infection Anemia

r.l .:hoyr, PaOr 95 rJrJ. :oyr errx? blood chemistryldrunrflu Na 143 mEq/1, K S.0 mEq/L, Ct 95
mEq/L. HCO3- 24 mEq/L

1. Oxygenation

lu;rod e"o,'ld 9s rJ.lro tulru:yrtld room air fia'jrlrifiRl?c hypoxemia unslrj

rirfinurionrilfiiloo

Arterial lllood Ga-s Anall'sis and Clinjcal Applicarj()n nn?uni nfrftntg 5L7

2. Ventilation

tu:rld e"co" Mrril +o ur.rhavr dtfia.j.rlrifi venritation fifia n6

3. Acid-base imbalance

lu:rudfirerrfiu,:firrfiuntnol'j'r rflu normat acid base Lr,n.t: pH M.rrYl 7.40 paco,

[rvirni:.r +o rJr].lroyl rlflr HCo3- 1n-u 24 mEqlL llrd rdonla'nunry arterial btood gas niudo;

do,,rn'1rurru anion gap rdrJo 'lurludri't '1ru anion gapld eq d,:lrnnirrir n6 uon,l.jrrflu wide
anion gap sr"rurcudr Aanion gap/ AHcos- Li1f,rr lz4-1zy(24-24) ldrirofud (infiniry) uff6\:i1
acid-base im balance lu:r udtfioqrn metabolic acidosis (wide anion gap) rlfl; metabolic alkalosis

ilfirJriu

fl'rrfin1,o\r metabolic acidosis'lu diabetic ketoacidosis rfutfincrnnr:dfi t"ton"

bodies (acetone. acetoacetic acld. beta-hydroxybutyric acid) rfluirncrnnr:fidr,in1uflo1UnlFl

ltfu uio.rernironrrlhiorrrrnldrirnrnhrfionld d.rrir'tfi lfi n rflu wide anion gap merabotic

acidosis u.r'orirnr:inur diabetic ketoacicosislounr:'lfinr:rir*ac6ucfiuaEir,:lfi rco [d.] :yl.l.ir,r

nr:inbre:tfia metabolic acidosis flfio normat anion gap rdororn 6ofinr:1fi6uqfiu dr,,rnru
qraur:ntdrirnrnld hifin':treirflufio,r'tfi ketone rfluuyoirra-r,:ru6nsiollj vribl ketone anion

fitflulrvcnloon rrr,::Jdnrt: vrh'lfi anion fr rnua'{turR'aonoa.r rirhinJfiuucnrviern wide anion

gap tflu normal anion gap metabotic acidosis rdonhnrtinnt diabetic ketoacidosis ? T:G',u
:1, {n1un69y !Lt'JdtJoRnluo,1{v',tiraun!nna
u,!-'tn't-R-<L u!n'.fi r ':
[[fl

irruoilu:rudrru:rirnllfnut u'j'lfi nlx: metabotic atkatosis dru crlyfi fivliidiou6o

nrrlt{ sodium bicarbonate rru:d1fl1tinur diabelic ketoacidosis rfiorornir,rnluoglunlxy

rflun:nadlt:uu:.: lrriu pH riaun'ir z.o1 niorfioernnr:trlar:rirhjrfiu.,rr,,ra rirtrifinr:n::{u
aofhu aidosterone lir'hii'rrnruoqjt nl?; metabotic atkalosjs ria rflunrnc1fln1ififirlxuo.t rc'uu

rirtfifinr:qrg rdurhlurfian uayfinr:n:cfiurro,i aofl u aldosterone o'rriulutrud6,:nr:nrr

rj::i6nr:1fi sodium bicarbonate ::uir,,:nminur yruytl! ?rJ1 fl'ltrird'lriir nns,Jytoyialil

sr-xad1rfi es fiilrurf,,: 0'rEl 1s fl ldilnT:ifiqdurflu diabetjc ketoacidosis ::d'lr.Yrnrn'[urdan
rL?fliur lni:J 600 n./en. riiorirnrrinurlilli z rirTru or:'ro:;n'rrihnrntu16onld aoo n./ern.

r{rJelnrulc room air qi?? nec ldaarilu pH 7.12. paco, t6lrJ. ?ar, pao,95 . :or nl.te

blood chemistry ldnrnrflu Na 137 mEq/L, K 3.6 mEq/L ct 114 mEq,/L HCo"- 5 mEq/L

1. Orygenation

lu:rud pao, ld gs lr,rJ:oyr tulnryi,rttfi room air fio.jr'lrjfinrr: hypoxemia ud;

lririrfi rurr^nnrnfi rJoo

5t d rlulj1un',lnflBl{xus'rll

2. Ventilation

iulud eucq rrirn-r 16 rl.il:avr drfis'jrfi hyperventitation drl;fiotrrcrrrqdo

}J'jrrfioornnrrv respiratory alkalosis u3otflutfiu{nlrnouf,uo{ernnl't: metabolic acidosis

3. Acid-base imbalance

tu:rud pH ryi'riu 7.12 fio'jri acidosis dotu:rudirir ucq- oitnndo 5 mEq/L

lrf,fN'irfi metabolic acidosis Riu'lrueir anion gapldorn 137-114-5 rvirn"u 18 n'rurrurir Aanion
gap/ AHCO.- ldo:n (8-12)/(24-5) ryirrf! o.s uoer,,:'jrriu wide anion gap metabotic acidosis

it n-u normal anion gap metabolic acidosis d.:firtfis?Jlu::r'jr,'tnr:inrr diabetic ketoacidosis

noovjrfinr:tfiar:riruo;6uqfiuadrorfirrvroudr uonvj'rd'l,rnruarrrroldrirnrald llifinT l.r
'irrfludorlfi ketone rfruutriorn'r,rruufir 6.ofifi ketoanion oonrrvrrflf,f,rrv d'rrfufi,o*r('ir pn
rrirriu z.tz fi1rifin':tn"tfluddo,:'hi sooium bicarbonate udodr{tn uovrdafior:rurcrn:;oil
rirnrntunr:ins, dlonn.lrodu 100 rJn,/ca. aiottrll,,: fia'fi {rhuorououa{donr:fncr

drurrueir predicted Paco,ldeln (1.5 x 5) + a + z Mrni! ts.s d,rtndr6u,iri! totu:rtrd

d,,:riuo?rr.rfiorJnfisarEnn:ooir.:1u:ruditriu wlde anion gap drunir normal anion gap metabotic
acidosis

n-eori'r.rd z6 {ilrurruorq 65 f, lditnlrifiifurflu CoPD with acute exacerbation n':mdr,cnrs
'y,r:r expiratory rhonchi and wheezing rlo,,rrlaq#,: z firr ldiunr:tdyiadrunrulcttny'ldrnio.l

drunrulc mode CMV: Fiq 0.4, TV 550 4.. PF qo fin:dourfi. RR zO urfi ninr:n:rc arterial

ilblood gas : pH 7,20. PaOr 60 .!ro1l, PaCOr S0 tJ .:J5or, HCO,- 34 mEq/L oxygen saturation

90% uonrrnnrt'lfiurnuruttnaqn lrn;nr:hi corticosteroids udr tfilonllurvn,:nrdilrndoo

dranrule'lu{rJru:rud

1. Oxygenation

'l(uu::rrrfldd"tldd rioo,, rvirrir 0.4'[L6d pao, wirn"u oo ur.!:ay uao,:'jrfi hypoxamia lou
nolntJon hypoxemia lu:'rudrjroyrfioelfl ventilation perfusion mismatch lrnfrqn rfiolcrn

fi:Jrufi bronchospasm d,:qyfi ventitation'1 6

2. Ventilation

rnxs Pacor ldr rn"r.r 80:lr.J:oyr uoovjrfi hypoventitation d,rdoonrcrrnnojalil.jr

hypercapnia itfionrurfluqrnn'r lvm'[q lnuorcrflu carbondioxide production firfirlsu, respiratory

rate finornt, tidal volume aon,r uia dead space volume tdldu lur,udfi bronchosoasm

1uu:.,r iudo,r:vdnliralo'jr{il'rufiI0n1flrnff auto-pEep d.:tflunrryfiornrRdr.:nau rulcoon
q0 (end of expiraiion) g1tflu oeaa space liluf,rmnrirlfrrfin hypercapnialfi

Anerial lllood cas ,{nahsis and Clinical Applicatir)n @nfluni TfrfislT Slg

3. Acid-base imbalance

S0tu:rud pFl Mrn-u Z.ZO drln-l paCOr . ?ofl 6.0rflu respararory acidosis f,.trJ1?fi

orY.,rol1163ru1d6'rd

n. drftJ'lariu acute respiratory acidosis otir.:tdur
PaCO, rri:ldu 10lll.:l:oyr pH eyann{ 0.08
PaCo, rfi asu 40 lll.r.rl:ovr (80-40) pH ?:flofl{ 0.32

diusuFir pH dnr:ol lfluryirril 7.40-0.32 Mrn-l z.oa dtriuq',r lfll acute resoiratorv
acidosis odr'Jrdurlrjlfi dorfi chronic respiratory acidosis rflufi'ugruori16r niofinrr: metabotic
alkalosis irudtu

t. fir{r-hlrflu chronic respiratory acidosis orir{to'rlt
paco" rfiuiu .10 t.ula pH oyflnfl{ 0.03

paco. rfiNdu 40 un. :ay (80-40) pH e:aflR.'] 0.12

n'triurir pH dnr:ocrfl!ryirni! 7.40-0.1zrviT rir z.za dtririo lflu cnronic respiratory

acidosis odr.lrdur'lrild fia$ acute respiratory acidosis r5ofinn; metabotic acidosis i.rrdla
-hifi
rfi ofior:rurlrndorfi clS.rdhlfl metaboric acidosis ria meta-
r flo{u1ado6mu

bolic alkalosis tu{rJ,u:rud o'rriuqnn:noirr'lu:rrdi,lflu acute on top chronic respiratory

acidosis 'rnfiqn

nr:ufih respiratory acidosis tu{rhu:ruri da.rr]lur{l1 dead space rfludrdriJ

loflnr:ufil1 auto-pEEp fi.:fiorufiblounr:nn tidal vorume uncnndsrln.r:yrulq nnrqrnfiirl

sedation fi rrudr hildufilrlnunr:rfi tidat votume Sarfi o'n:.rnr:rlulofi,:q:d.rarn1fifi auto-

peep undu

n:nifrrfiot auto-pEEp {i..rdo{ms.l respiratory rate oon,tLdonfl auto-pEEp fifi usifil

{ilrutirn,rnrulo 6r n:rfiu:nrnnrrnuto rir'lil'ldfifiocrna.*nqdufrinu.rld nr:'tfi sedation

A'rarjrri 2z {il?urlu fl'rr 20 il ld5lnliificduriu astrma rns,rlrdarq z fl t iurioufiarnrrld

lo lRlnvfirfiur s d'rTil.rdo!il{:,:uuurn {drufiorn'rrr.rorrJ1fl rnjuar udrornr:hifidu n:ro

dr',,:nru RR 34lmin, poor air entry both rungs tfinr:tnnrd?uulnurufinoon rYrnrlo s ni,r n:ro
:1'1n1u RR 30/min, retraction of intercostal muscles. poor air eniry both lungs. l"n pulse
oxygen saturation ld ozx 'lfi o*ygen cannura s fin:rdaurfi nr?9 arteriar brood gas : pH 2.40,
PaO, 100 mmHg, PaCO,40 mmHg. HCO,-24 mEq/l. Na 135 mEq/1, K4.0 mEq/1. Cl 100

mEo/L

1. Oxygenation

rrl;{ilru1d oxygen cannuta 5 io:riourfi yrute s0 nit rio, dldo-lrjaun.j.r 0.4

nr:nruteLiilnd udrrnn'ir o.z ril':r;lrildfirulolqutd ,.oom arr o',{riufi:1.:u:rude1fi e"oyno,

520 rrtrirriainqnduSru

finltnfi do'lu:rudr.ilat!fin91n ventilation pedusion mismatch il1ndqo rilr, vfi poor air entry

fi.:fii,r.jr{rJrufi bronchospasm frpu:t nr:frfi bronchospasm rYurirlfi ventitation non.rlrj

drvr."u6'n"l oedusion

2. Ventilation
Paco, ryi'riu 40 tJ:J.ttor d,lrflurir:.Jnfi rroi{rJrut'ru'lo so Fri,tdourfi fir{rhunru'lo

so ni,lrdourfiot.r Paco, evfio-tflon.ltdo,torndr,tnluo{trlnrr: hyperventilation ttoi:rud Paco"

rJn6 rrao,,r'jr tidal volume nan{0r.i'Ntl'ln luntl: acute asthmatic attack d1 eaCO, 'lu:la:

$:nnsa{rdo.,rcrnfi rsvru'lot5r qunr;rtrrfro{r-trunrulolrilvlrdr rir eaco. fil:naltrl[iuilnfi

r[fl;{\rl1.lTqfi

3. Acid-base imbalance
pH 7.40. Pa.COr 40 mmHg, HCO3- 24 mEq/L n"1u'lru anion gap silnju 135- (100 +

tz+1 = t rfiu normal anion gap {:Jru acute asthmatic attack 6?5fi acute respiratory alkalosis

d,:nr:fi Paco, sir urilu:rud Paco, :Jnfi rroo,r'jrrir Pa.co, fl{n'jrn11 rfluoil d':rroot'ir{il'lu
fin-n: acute respiratory acidosis dudru lnuriaufi acute asthmatic attack lytiJu acute
respiratory acidosis orrfidr Paco, ilnF'ld ii,lritlonir{ilruod'lunlxv impending respiratory

irrfiitailure dfio.:lfifinr:tirumulcniur6urnlu o-tr?u acid-bas" h:r Eid6{ tflu ""ute respiralory alkalosis

acute respiratory acidosis dldotnrii-ntr{nunlrldviorirufirulctto;ldtnio,,:rirunrutc

nrercd ts ltf,o\'fl1: approach normal arterial blood gas

rdofl! AeC : pH 7.40, PaCO,40 mmHg, HCO3- 24 mEq/t n"nrru:qnn:ooi't.:orlrflu'1fi S !uJ!

9\tU

1. Normal acid-base status .......,,..norma1 anion gap
2. Metabolic acidosis + metabolic alkalosis,,.wide anion gap

lau Ancv AHcq- > 1.2
3. Respiratory acidosis + respiratory alkalosis.,.normal anion gap

fi o.rard'erdnuruvvrtnff fi n :cnaudrfl

drodrri za {rJrutraorq zs iJ rrdfiotqnriuldo.tqrnfiarnr:drut?ra':tt'tfltJ't zo ni.:riourr
1:{ urilrn rlreeir''nts BP 110/80 mmHg, PFt lso n:ttrdaurfi. RR zo cri,rsiourfi dry lips, dry
tongue, poor skin turgor, increase bowel sound in oxygen saturation ld gz% snrlir.tnru

T'tn:J!1j1nuh nG na arterial blood gas : pH 7.30, PaO2 65 mmHg. PaCO, 30 mmHg, Na .l25
mEq/L K 3.0 mEq/L, Cl 100 mEq/L, HCO3- 15 mEq/L

l. Orygenation

Pao, 65 mmHg fio'irfi hypoxemia 6f'ltfiqs8{ hypoxemia lu:rsd nr:tn']cir''Jnru

1\:r:tlulflu'laaqjtulnrurirln6 d',:riunrrtqrjrtvrfi6cln v/Q mismatch rrndqo lnutfioorn severe

.rmerial lJlood cas Anallisis and Clinical ,{pplicarion en?utli ?frfit1tr S2l

dianhea dr}irfio row perrusion }lii:Joo lannorrar pertusion) nlrinllnr.rv hypoxemia tu
:fr:rud6onr:hia,
(fl uid reptacement)

2. Ventilation
PaCO, 30 mmHg ia.irfi hyperventilatjon

3. Acid-base imbalance

pH 7.15. HCO.- 1S fia'jrfi metabolic acidosis q'ruru predicted paCO, = (1,5x1S) +
8 +/- 2 = 30,5 +/-2 d1U1ru anion gap = 125- (100+15) = tO r",r rflu normal anion gap metabolic
acidosis 6{0fi uruldotn dianhea

nlaNfi 16 rreeonr:r duu[dnwa,:non:orir u volume depletion

| 1. volume depletion lei:urr:.r onn:qdrorfiu metaboric alkarosis untilt diarrhea riJu meta-
bolic acidosis tis normat anion gap (anriu dianhea dfinr:oqrdu potassium altnl rdu

villous adenoma ?ytf,u metabolic alkalosis)
2. volume depletion f!ra:urt:'rqufi poor tissue perfusion tflu metaboric acidosis (wide anion

gapl fi.,rtfintrn lactic acidosis _l

frestirtfi 29 {rJrur{.,: a'rEl 25 fl ld5lnr:ifieq"urflu beta-rharassemia hemogrobin E disease
tl,rfl!Lr r6fixua1nr:1dg,t numd'u :hofio,rtfitruTar,rmr z riudou.t'rT:{uu1ll.tn fl:?airnfllu
trllj BT 39.5 c. PR 130/min, BP 90/40 mmHg. RR 26lmin, moderately pale, mild jaundice.
cardiomegaly. RS : clear. Abdomen : moderate tenderness at RUe reglon, Murphy,s slgn

positive d\:mT?a arterial blood gas, room air : pH 7.44, pa.O, 9E mmHg. paCO2lZ mmHg. Na

136 mEdL K 5,5 mEq/L, Ct 106 mEq/l, HCO3- 8 mEq/L flfld1?;aan 25 rrn./r . d{el?c

ultrasonography y, .] gall stones uny gall bladder wall l4U1

1. Oxygenation

lu:rud euo" ld gs u.r.l:au iurLru:frl.fi room air fio.jrl finrry hvDoxemia un:

lririrfi nuricnryrfr rJaa

2. Ventilation
PaCo, 12 mmHg 6oirfi hyperventilation uritu:rudnr:n:redt,:nruvtrr:y:.rlyrolo

:Jnfi nftu"u paco, fi otidilililrfi nrrilfi nrlnfi vr':Jon

3. Acid-base imbalance
pH 7,44 rioudl,J nfi |'|'si paCO. ol"r uo: HCO.- n'r uoa,:irrilu metabotic acidosis

i'lrJfi'! respiratory acidosis

522 retrirriai n q nfrugru

fi rufi metabolic acidosis rilurru predicted PacO, = (1.5x8) + 8 +/- 2 = 20 +l- 2

nhu?ru AG = 136 - (106+8) = 22 $ovd1u?ru AAG/ AHco3- = e212\/124-8\ = to/to d.:riau
n'Jr o.a er'.rr?uqon:q0irn1u:rud6ttfl metabolic acidosis (normal gap with wide gap) with
acute respiratory att<atosis lutrudfi hyperkalemia un:tld6['lxcoonfiou i'!tJfl"Ll metabolic acidosis
i{do'rdqfi,t acute renal taiture {i.r1u:rudfi6i'lulo't normal anion gap metabolic acidosis o{dru

ti!!f,rhrl1 glomerular liltration rate (GFR) rinea.,ttJrn nr:1finr:inurdrugrahatir'.rflot5' nu

n1?'ld early goal directed therapy drr:riunrrn?:Jq srelllfi ,t1o,rnr:fioldolou}ilrrJfifiru;d

n4lr1:fl e:riltfi acute renal taiture lufluddduld

tznrrtii !tdn{fl1lvqqo\: respiratory alkalosis lufltJ'lu sepsis

1. severe seosis drfisdr dulanfisrda
2. severe sepsis filrildrfiscrnn, :finr#o'lurJan lqufiscrnar:dona1{ (mediators) tu seuer

sepsis inrv{u4luinr:vruto d.rrir'lfiurerlcrirdl

iT odr.lii eo {:Jrutruorq so i ldiunr:ifioauliu seuere community acquired pneumonia 16

iunr:inurlnuldrnda':rirufirflte c|\rv mode: FiQ 0.6, TV 450 mL, PF 40 LPM, PEEP 5
cmHro. RR t+ ni,,rdourfi gl?c arterial blood gas: pH 7.54, PaCO, 25 mmHg, PaO, 150

mmHg. HCo,- 20 mEq/L {rJrunrt'h so ni,lsiourfi e.lron[ru?T']{lunr: fi rnia.rrhuvrulq

luffJrmrud

1. Orygenation

n'rurru eaq /rio, = 150/ 0.6 = zso douiudrn'rndflJnfi orrnqrfluo'ln V/Q mismatch
rrnfi qofitoirruldoln pneumonia

n'rflhn1?nn Fio, fl,l [iia{e1n Pao, xlnrn Teuldqn: eaor/Fio,)1 = (Pao1Fro"l,

louinurr; (i':fi a.r oxygen saturation Ufr so-gz 96

2. Ventilation

PaCO2 25 mmHg durit-rfi pH figln'i Jnd ri.ruandl hyperventilation

3. Acid-base imbalance
pH 7.54, PaCO, 25 mmHg, HCO"- 20 mEq/L tflu respiratory alkalosis 6.,,:d0lfi1't:rur

riol:Jirtflu acute respiratory alkalosis uia chronic respiratory alkalosis

n. rir{rJrr rflu acute respiratory alkalosis adr{t6ur

Fbco, nnfl{ to u.rJror pH ntldu o.oe
PaCq flnn,J 15 tJtJ. toll pH rdml:u O.tZ

a'1u?6u oredicted oH = 7.4O + 0.12 = 7.52 +/- 0.05

ir pH z.sa 6la{turi'r.no,,r predicied pH firq'rurtulfi

Arterial Blood cas Anal-vsis and Clinical Applicarion oniuni qfrfiA,S S2S

l. fir{:Jrurflu chronic respiratory alkalosis

PaCO? nqfln 10 rl. rofl pH rfiudu o.oz

ll.paco, ngfl,, 15 :oyr pH rfiu6'u o.os

fh ?ru predicted pH = 2.40 + 0.03 = 7.43+/- 0.05
rir pl z.s+ i,ilrjou'lurjrrual predicted pH fir{rurru'ld

ri'.rriu q nn:ooirrlu {:Jr ul ud6.r rfl u ac ute respiratory at katosis

irprTjre;rJilrnSo,rdrunruleoLir.t'li fior:rurld'lrnon: MV, x (paCo"), = MV, x (paCo,),
rfioo"rulru minute ventilation ldlrd? dooficr:rurDiolj.irc:rfion iu tioal vorume uio respiratory
rate drnfi{rJru:rudrfion:Jfi respirarory rare'hjld rdorqrnfirhur,rra'lor5urno{ ufirfio so

ni,lciourfi nrlflq respiratory rate e:r{rtfi{:JrrvrErteririrtulil6n rf,o{qrn lnia''jdruyrr1lqdr!
{rJruriauo,l lumurinrajfiao tidal volume oror:riauaq minute ventitation ntld urdrdorlil
rud, fia':4r{ru'jr{rJrrdarnr: tidar vorume rrnr*ulldnviahj rrnfirhudatn'r: tidar vorume ln
rtul:Jdnnruya-riatiltlnn }irjiu tidar vorume lrnrtu uoid.:drfrn'rprl'on6o n.t:rro',,nnro{ acute

respiratory alkarosis lufi ru community acquired pneumonia dldrnia.rrirayrulc r?iu

bronchospasm. volume overload, pneumothorax. progressive pneumonia In;orc'[$ sedation

n1?1rlJU

eTroritd 31 fi:hufl1u Elri 70 fl ldilnr:iiod'u'i1fru chronic obstructive purmonary disease

(coPD) rJ'rlru s fl rrfir{o,rqn rdrufio.,rornfiarnr:rvdou vluiqhj6'ililr s drTu,rriau rT:,r urua

tll??:1\tnluvur prolong expiratory phase druriurfiu.'r rhonchi rfiniau in oxygen saturation ld

soo/o ur'rrffilio,ron riulfinr:fnurToulfi oxygen mask 6 fim:siot.trfi r-o oxygen saturation 16

80sso4 z t'rlrl.tgiorJ1 n?xq ABG ldiJariu pH 7.22. paco, 80 rJ.!:or, pao, .:J:oyt 6:x?
blood chemistry ldotn rfju Na .141 mEq/1. K 4.3 mEqA_, Ct 99 mEq/r_ HCo.- 32 mEq/L

1. Oxygenation

'lumud eao, ld so rJil.il:ail dtfio.iroirrfroi.ff oxysen mask o dn:siaurfi fi{tu:ru
domrfluldmnd'rI:n copD iifi v/e mismarch niorfluqrnnrninn.rnllrJaodul dorrur:nrfin
drr'ldrTr copo niu rJaoo"nrar (pneumonia) niarirvirr:Jon (purmonary ecema; drfi'ordrnrr

filfiun'rcrrumsia'l:J

nrrinrrlunauu:nfilfi oxygen masr lu:rafhjrurr:ou riiorlrnnr?? oxygen

saturation ld so"/6 {fufi0'jru4u':noufirtu{:Jru copD (rT:Jru copD n'rrinur:r0i:r oxygen

saturation lirrnn'ir aaozl firtrioonfireuilrnrfiililecLlilnnsunnlnnr:nr:dunr:nrutc'lu copo

d,roiilrundildvrulqdlu hypoxic orive drllnlfrrfirrnr?! acure respirarory acidosis n1 1

2, Ventilation

lu:rud e"co, '[d eo ur.rl:oyr uan,r.jrfi hypoventitation fiiorryeluludilrrl rilu

524 rrttilioinqndugru

aTnfi{rn coPD !o,:dc:fi chronic respiratory acidosis oqjttd'l drlrilnr:lfi oxygen mask rir]ti
ldoonfirourrnrfiul runonr:nrulo 1f,:-harrulodrunaln hypoxic orive 1rilfl 6.rrir1fifi acute

respiralory acidosis drudru

3. Acid-base imbalance

iruil'lu:rurj pn titf,v t.zz eaco,80 tJtJ. ?avl 6'1rflu respiralory acidosis 6l'lu1ln
FZl\rflx4n^!1u \trnga-J{u

n. fir{ilTurflu acute respiratory acidosis odr.:tdut

eaco, ldudu 1o tJ,:Jtor pH lvngn-t 0.08
eaCO. rfirdu 40 u.l-l:or (80-40) pH ocanan 0.32

n'.rriurir pH finr:orriuMrrYr 7.40-0.32 MrritL z.oa n-.:rfu6,,r rflu acute respiratory
acidosis otj't{t6flrlril{ rfatfi chronic respiratory acloosis lfluduXruoqirdl ntofinrr; metabolic

alkalosis d? dxu

t. fir{rJrurflu chronic respiratory acidosis odr.:tdut

eaco, nildu 1o ,J.:Jtor pH aYeon\: o.o3

40 .tloRaco, uirdu (80-40) pH ?vafin\: 0,12

d'rriudr pH iinr:e:rihrvirrir 7 .4o-o.12 rrirril z.za o'',lriu{nrfl chronic respiratory

acidosis odr.ttdur'hjld do{fi acute respiratory acidosis viafinr':: metabolic acidosis irldru
rdoficr: rqrndarficci.:rtlfitJr lilfi:hdu'lofia6lru metabolic acidosis rio meta-

botic atkatosis tufirlru:ruit d'.:usuqantooir''rtu:TUd6{lilu acute on top chronic respiratory

acidosis mnii4n

n"1ori1.ri sz {rlrtrtruarq oo fl'[di!nr:ificdutflu alcoholic liver cirrhosis dtrtT:.t spontaneous

bacteriat peritonitis (sBP) bitnuldurd'r.rflag1?vxlda lru:iillir"nu1"lulr.Jvlu'l:r1n'ld 5 iu

!{:Jrudlo'r nr1ai1{nl! hyperreflexia ututrdrufru extensor plantar response dtud'ltt

fi1ut?Tafl'ld oxygen cannula s hn:dourfi ntxq ABG lfizunrflu pH 7.54, Paco, 12 utJ. 5or,

PaO, 120 rr.J. :ar n:rq blood chemistry ldcrotflu Nla 132 mEq/L, K 9.2 mEq/L. Cl 107 mEq/
L, HCO3- 12 mEq/L

1. Oxygenation
rir Pao, Mrn-r 120 :ru,:Jtav {itniau'firtdrtu{drrLfild o*yg"n cannula 5 6n:daurfi

tnelnr-lro; tfinern ventilation perfusion mismatch r.nnfiqo d.:orlrfiq?1nfiu'l6dn1 anfi

drrirffi':l cirrhosis rriu rfinqrnnr:dfio.r6ordoocrnfi ascites dorirtfiilitJlnrrlaonnn.: ril'hl
ventilation nna.ilrjnlqnfii perfusion iirlnfi fiisarq rfinl'lnnaln hepatopulmonary shunt do

rr.r1ff1u{rh u cinnosis

Anerial Blood Gas Anahsis and Clinical Application nnhJni {,frfrt1Jg SZs

2, Ventilation
rir paco, ryild:J 12 r.u.:J:avr d.,r6o.irsrhx1n rflfhri,tfirhuod'lunr?y hyperventitation

{ircrrunro.: hyperventitation tu:ruda, orfluqrnrj3rrru ascites drrn ri.{rirJ?rnnr:Jonoan,,r 6,:
finr:nrvfiunufrtruh'lfifirularirrsu irrriuarofirauT:n'luo or (intracerebrat tesion) runlrn.rl

n:tvdr,,tnruytr'::zlr"r :ygryfi n nfr

3, Acid-base imbalance

n'r pH rvirriu Z.S4 ilr.fix eaCq rvirrYu 1Z ul.rftor d.,ruflol.ilfi respkatory atkalosis
'hirirnr:omeoauoiah'jrliu acute respiratory alkalosis nio chronic respiratory alkalosis uio

rfi nqrnfr,tso.,:nr?:ilrnYulnun.nfr.lol$3rur,r"',,:d

n. rir{rhu lfll acute respiratory alkalosis orjrlrdtr

FbCO, flna\: 1O NrJ.tror pH l;rrildu o.oe
paCO, nnn{lh J1ru 30 rJ. :0r (40-12) pH o:rfildu o.z+

n-otiu pH dnrrlfluniurruldrln 7.4o+o.24 rvirryu z.oa d'.,rrfurirfildrrnn,jr z.s+
llao.o'lr{:-hr:rudlrildliu acute respiratory atkatosis atirr16ur lrsifio.,rfi chronic respiratory

alkalosis t13o metabolic acidosis iudru

ruclu:r adfi metabotic actdosis itrdru-lrild rdamr n fir

PaCO, nnn,J 10 . :OT HCO3- ryflnfl{ Z mEq/L
Fbco, aon,l ,:vrJ'tru 30 rJr.t. tor (40-12) Hco3- o:aoo{ 6 mEq/L

a'rrfudr xco,- dnr:e; rflurirurruldq.rn z4-6 rvirriu t a meq/L ucflu:rud Hco.-

ftlurfionld mEq/L dtfinr:non,rra.r Hco.- rvirn-r 18-12 = 6 meq/L r;r"'.,rfu pH frr:Jduuulnr

6rrirurruldern APaCo, = A(1.s x Hco3-) +g + z trrr{rurruldrrirril 1r.sxo1 +B +Z =17 +2
d',rrfu pH c:dooaaalrrirfi:.1 o.17lrn pH 7.64 rd1ffir z.+z d'lriudtfiu acure respiratory atkatosis
d:rn"unttl metabolic acidosis d.:nr:fi oH tli'tn"u 7.47

t, fi'r{ilruriu chronic respiratory atkatosis orj.t,l[6u.1

Paco, flFtfl\r 10 rJ . lafl pH lrllirJ?8u 0.02

FbCO, n6n{rhy lru 30 urr.:Jrafl (40-12) pH et r$ir.rr*u o.oo
d,lrfu pH dnr:o:rflun"rurruldorn z.+o + 0.06 rilniu z.+o d',criurirdldrjaun.jr
z.s+ ttoou'jr{ ru:ruflrildrflu cnronic respiratory atkatosis otir,o16rr urifiolfi acute respiratory

alkalosis llig metabolic alkalosis drld'tu

lusierndorficc?,cnrlTrvrritilldslduinlfinrl; meraboltc alkatosts rudru d'rr
utuorqnnrneirrdfinilnfilu:rudir rflu acute on top chronic respiratory alkalosis dl chronic

respiratory alkalosis rirevfinvrn alcoholic liver cinhosis d'turitr ascites ir...| rijulruru dru

acut€ respiratory alkalosis rjrqctfioorn:atT:nluala.:tflo,,rernnr:n:rqdr,tnturt.r:c!:J:Jt:d.tyt

n^nrlnG t*ada,rc,r{u intracerebrar hemonnage udo.olrn4':Jrun{rrinro:i6nr:nita.,:r6oooondrflnra,r

526 urtdrr-ninqmdugru

(spontaneous bleeding) lfigt tu:ruftdutrflr-l':ul:Jor:renarri? ra05tLflnt,t1E.tfltJo.:vrjrfi 16oel

oonruro'tnrgd basal ganglia drunrr {itfinr:rru'[edfio:JnGttil! chyne-stroke r5otflu central

hyperventilation d,roT.rr:o oBlr unl'l: acute respiratory att<atosis lu{tlT u:rufld

n-eodrrfi 33 {ri?ut'ru Brq 70 fl .lfi:1unr:iicdu tilu coPD rrvu rrvrrtidruriotfirir'lcfiau
lydourrndu o ti,truriou t iuriourrl:.:uurrrn {rJrufiornr:riru rvatrflurlr :J:lrrru 10 ni.t
niou*, t ufirrltr n:rqdr*rnru BP 140/90 mmHg, PR 120/min. RH za n{,ttioulfi, not pale, no
edema. wheezing both lungs, iot pulse oxygen saturation -16 ea"/" lfinrrr"nutdtu oxygen
cannula 2 an:dautfi dufiuuuarsllaooat.] n:2c arterial blood gas: pH 7.08, PaCO, 65

mmHg, PaO,60 mmHg, Na 136 mEq/L, K 3.3 mEq/L, Cl 105 mEq/L, HCO3- 19 mEq/L

1. Oxygenation

lurrud e"q ld oo rr.rl:ovr dtfio'jrrirrfrold oxygen cannula e fin:dourfi d.itu

:rudore rflu1dr1n

t) 6'r1:n coPD fifi v/Q mismatch fiio

z1 riucrnriurinnrvi'lurJao6ul fioru'r:o rfinirlldni! coPD niu looo"nlal lpneu-
monia) riorjrriru oo (pulmonary edema)

2. Ventilation
PaCor 65 mmHg fia'jrfi hypoventilation fi0.:6nfi.rnrlrq + :J::nr:n'vrh'hi eaCo, d,r

ldrrfi carbondioxide production uandu. tio"t volume floa,l. respiratory rate flFtfl.t vio dead

!sp""" nirt*u tu:ludn:rqd'r{nru wheezing boih lungs {i.:fflonrndornrso:6'r,r'luqon*r ria

+t!failflG dead space lglfl

3. Acid-base imbalance

pH 7.09. PaCO, 65 mmHg, HCO.- 19 mEq/L nrr fiadnfito',rqnn:ndrrtflu metabolic

acidosis i?xliu resplratory acidosis
fiar?rur metabolic acidosis n'1u?ru AG = 136 - (105+19) = 12 rrflo,i'i1Liu normal

anion gap metabolic acidosis oi:ttd611fl diarrhea n'luxru predicted PaCO, = (1.5x19) + 8 +/
- 2 = 36.5 +^ z n'',otiu oH fitfincrn metabolic acidosis 6.ofieir11:c ']ru 7.36

flqur respiratory acidosis 6o':ficr:rursio'hir tflu acute respiratory acidosis tia

chronic respiratory acidosis

n. Acute respiratory acidosis

PaCO, $il.r 10 r.l:ovr pH nofl{ 0.08

PaCO, uir.r (65-36 = 29) ur.tJ:or pH aun,i 0.24

ti'tu?ru oredicted oH = 7 .36-0.24 = 7.12

Arterial Blood cas ArEl.vsis and Clinical Application tsn?uni nfrftLug SZ7

ir pH z.oa ol'rn'ir predicred pu dr{rurnrlfi uontirfio,rfi metaboric acidosis
'trilrf
rio chronic acidosis dr drfl usilu:rudq:lflu metaboric acioosrs lrild rdotorn
respiratory

ldfi clild.r usiqouu:n ude

fl. Chronic respiratory acidosis
paCo, rfir 10 rJ . toyt pH anff,i 0.08

paCO, rfirJ (65-36 = 29) rr. tor pH aon\r 0.09

Riu?ru predicted pH = 1.36-O.09 = T.2T
rfiu'td'ir pH 7.08 m'rn.ir predicted pH dei'rurrulfi uco.,r.irdo.tfi metabotic acidosis

vio chronic respiratory acidosis drrdru rrsr'lu:radr;rflu meiabolic acidosis Lj16' rudo.rrrn
ld6nli ne,,: rrri n ou u: n udr

er'or-rsunrTrfi o:Jnfi rolo n n,: n rir.:'lu:r ud6{ rfl u metabotic acidosis (normat anion

gap) L[nV acute respiratory acidosis on top chronic respiratory acidosis

nr:inrrtu{rjrr:ruri6a nr:trfio,r:rir unvnr:tfiu.uurufinaonrrfioufilt broncho-

spasm

61srhd e+ fl:Jrurru arq zo fl fiI:n:J:;drfi'rrflu copD . T,tr'u'l,rnn*rddrul{10 nour
u'ru s ':iudoumT?{}lu1u.fl inura$dna{rJrunrriryToubiurrJfifiruc uo:tdrnio,r:irunra'h
uru z iu arnr:hjddu rafiru{r-l.lurdlo6grdorcrn multiorgan faiture nr??j1,in1u Bp 90/40

mmHg. HR tOO nfrdaurfi, RR Z+ nt:dautfi, mitdly pate, markedty jaundice, pitting edema
both legs, fine crepitation both lungs. tiver 1 FB below right coslal margin. on pcv mode: Fio,

0.6, lP 25 cmH2O. l:E 1:2, RR 16/min, no pEEp, iofltl:oan 20 l]n-/y .6:1a arterial blood gas
: pH 7.18, Pa.CO,44 mmHg. PaO,60 mmHg. Na i33 mEq/1. K 5.7 mEq/1. Ct 100 mEq/1,
HCO.- 16 mEq/L n1$ri1fli\tfir:rranul diffuse atveolar infittration loadsurnsaora'rto rnfi

1. Orygenation

rdr pao, rvirfi'l 60 rr.r.:J:ar 'lurnr:frid riq ri,rd! 0,6 n'rlrcuri'r pao,/ Fio, = 60/0.6

= too {i..:rjaunirn'r:-lnfi hypoxemia'lu:ruu*rj'rcvrfincrn snunt Toufrn'rvirirui,rdv:rronrr difiuse

alveotar infittration 1uaru;drurmo.,,:rirtrrjnfi iittu:rurido.,ra.,:duir rfin eRos duudrru:r;dr
Paol Fio" riounir soo'ttzru:fi votume sratus n6 or:uflnrrt hypoxemia 'tu:ruiiTorunr:td

PEEP

2, Ventilation

+PaCO2 44 mmHg o"r rfh hypoventilation dotfiofilcrnrqdrirlfi paCO, fii :ynr:

ldlrfi carbondioxide production lrnt*u, tid"l volume aofl{. respiratory rate aon\r r€o dead

"p"". tfirdu ar lfi srtrfl ulill6'1u:r uu*

528 rrtr-irrioinqmCugru

1) ARDS dluu:rrrneu alveolar ventilation Ljrfiu.,:uo o1n166ilrjrd1q,,lntJ aulno

dead space 13u

2) AutoPEEP aln COPD

3. Acid-base imbalance

pH 7.18, PacQ, 44 mmHg, HCO3- 16 mEq/L n'l'l fie n6luqnn:ordrt:rud6,'ruflu
metabolic acidosis dtlti:l respiratory acidosis

If,rufl't metabolic acidosis irutru predicted PaCO, = (1.5x16) + +/- 2 = 32 +/- 2

6'oriu pn drfioern metabolic acidosis itfirJ::rurru 7.32 oh ?ru anion gap = 133 - (100+16)=

t z rflu wide anion gap r'r'lux AAG /AHcq- = \17-121/(24-161 = s/e fitdoun'ir 0.8 ttflo\:
'jrtflu normal anion gap drudt-r wide anion gap melabolic acidosis lu:rudfi hyperkalemia

ua;iaa.]?:osnriou i'txni! metabolic acidosis 6odo't6ofi,r acute renal failut" d.r'lu:rudfidruao,l
normal anion gap metabolic acidosis o{dra ttNo,l'h glomerular filtration rate (GFR) ry':lilno

a{x1n n1?'1fin1:inurdrucr:frodr,,::rnrirlounr:td early goal directed therapy dufiinr:
nrrquo'r nnilao'lnr:6ordaTqu1iur:Jfriru:d nrrrvar.r o;rirlfi acute kidney iniurylu:rudd

f*lu t.ts

flrufil respiratory acidosis fig,:ticr:rur'1r{:Jrurflu acute respiratory acidosis tia chronic

respiratory acidosis

fl. acute respiratory acidosis

e"cq rfi}l '10 :rx. ?ovr pH noa,r o.o8
PaCO !fiil (44-32 = 12) xtr. :or pH onn{ 0.096

ri"ru'rtu predicted pH = 7.32-0.096 = 7.224

rfiuld'jr pg z,te eirn'jr predicted pl dn"rurru.ld ltflo,]'j1dotfi metabolic acidosis
n6o chronic respiratory acidosis dud'la [ritu:r udq; tflu metabolic acidosis'[ ld tdoneln

1d6n1rlnyrurinouu:nudr

L chronic respiratory acidosis

eaco, rdr 10 flfl. ror pH nean o.o3
FbCO, rfirJ g4-32 = 121 ur. :an pH nna{ 0.036

e{'tuxru predicted pH = 7,32-0.036 = 7,284

rfiuli'jr pH 7.18 riln'jl predicted pu frrirurrulfi unq,'r'jrfia{fi meiabolic acidosis

tia chronic respiratory acidosis d? dru uoitumodtvrflu metabolic acidosis lrild [da{e1n

1dfi n}Jfr.r usinauu:nudr

n-rriu nrT *rfiorlnfiluqnntooirlfi ruludd,:rflu normal anion gap and wide anion
gap metabolic acidosis dunit acute on top chronic respiratory acidosis

-Anerial Blood cas Aralysjs and Clinical Applicarion nniuni nfrfrt1ty 529

r xynflunll furnSo.njrsnrulo lu:ludrioudr{u1n nlolmnfi:Jruaqjtunr?: metabotic

acidosis fi,:dounr: tidal volume flutqfl{ dlu ARDS do{nl? tidal volume luton;t dlu

ruu?rl.rlun1flJr1! Laio,lrixuvlu'lqilc: Laontd tidar vorume r.Jlnvioflou njuadrilir'lurrucfu

nrr:'lnrdun'irril mtrdnr:fioorlr arteriar brood gas rflur;u;1 irrfiunr:td respiratory graphic

monitoring dlu

dr:J

nr:n:reiun:r:fi'flrr'lu16oouq,J (arteriat btood gasy fiorrrdrfi'ry ua:uit rfuodrr0,rnr:

qua{tJ':unrin ilfin?lrchrfluadr.:8d{guainurflhuuu"ndolf,rrr:ou notanrrn:r d :ufit

fia,rrilte'jrn1:n:rcirn:r:dffrztu16oeuo{ (arreriat btood gas) Lj16rflunr:n:rcfiifiqd'uTrn
ttsirflun'r:n:refi ,r:Lon'jrornr:urasuurinnrlrfrrfiodulu{,:Jruluriufinru:uu:,:rrnfiaarrfiu.,:to
n'tusunrrrur{rhrfilrdrnmu nrunnr:flr?idrfirrofi.,r6e;#rtila.fa4a;gnAoilrnr:quninur{:-hu

siolil

lf,fld'|lfr',]{6{

'1. Shapiro BA, Hanison RA, Cane RD, Ternplin F]. Clinical application of blood gases,4'- ed. St Louis: year Book

Medical Publishers Inc. 1989.

2, Raffin TA. lndications for arterial btood gas analysis. Ann Intern Med 1386|105:390-9.
3. Weibley RE, Riggs CD. Evaluation of an improved sampling method for blood gas analysis from indwelling arterial

catheters. Cnt Care Med 1989:17{8):803-5.

4. Thorson SH, Marini JJ, Pierson DJ, Hudson LD. Variability of arterial blood gas values in stable patients in the lCU.

chesr 1983:64(11:14-8.

5. lrwin RS. Arterial puncture for blood gas analysis. In Rippe J1,4. lruin RS. Alpert JS. eds. Textbook of Intensive Care

lvtedicine. Philadelphia: Lippincott Williams & Wlkinsi 1999:157 60.

6. John E. Hodgkin, Clarence A. Colleir Blood Gas Ananlysjs and Acid-Base Physiology In: Respiratory cale. George

G. ed. Burton 2" edition. Philadelphia: J.B. Lippincott. lgS4:2j3-30,

7. Williams AJ. Assessing and Interpreting Arterial Blood Gas€s and Acid-Base Balance. BMJ 1998:317:1213 6.
8. Shapiro BA Frankin ML. Templin R. Principles of lnvasive Blood Gas Analysis. ln Critical Care Monitoring: From

Pre-hospital to the lCU. Eds. RL Levine and RE Fromn Jr. Mosby-yearbook, St. Lois lgg5tlgj-207.

9. Kufel TJ, Grant BJB. Arterial Bllod Gas Monitoring: Bespiratory Assessment. In Pdnciples and Practic€ of Intensive

Care l\4onitoring. Ed. MJ Tobin, l\,lccraw-Hill. New York 1998:197-215,

Short Note in Portable

Chest X-ray Inteqpretation

nnTuni gftftmE

nrrnrmnruir6ltlomfi n portaue Isflfdil[[drnr:rirunruvr'rludnrrur ant6ro-posterior
(AP view) runr{rJ,unrlnfnuouo{nlurf,ur usifitflulilldnrrriru'lurir upright ruvd{ilrurird.r

nruhrttfird droroitomnmnnr:nru'loriogrrn ventitator graphic (ffiddtdrnio,:druuruh;

lnursucdrrrsrirurndrdrrf,ousrunl{rl'ru:Jr;mru so dr nT :finr:riun'nioqnrar{ilruddra'q

6o rdrta.:{rhurru;rirunrnf.r6l :J?lrruyrd,,l.:ruflld (KVp $nv mal ritrrnrnrrnruh nnonru
iagnmrnrrriruuruh r:iu tlOat volum6, PEEP unvcir pulmonary mecnanics dinlfi

ruri+iu + rirdor,rdnsiohd

t. nrrlaru4ndoruavvina.: film

2. nflreqrujl'lYltor: film ldrrri exposure, symmetry, inspiration
3- Tub€ and Line
4. o1un1lnJlJ!

1) Soft tissuE
2) Bone
3) Abdomen
4) Diaphragm
5) Costophrenic angle
6) Pleura

4 Lung parenchyma

8) Heart
9) Mediastinum

Shofi Note in portable Chest X-ray Interpretation nnSunl gfifitug EBI

el?en?1il$nfro\t
1. n?1q6ofiil?ufi'uiluurjufl dil.jrn:,rfiur'lialri Tqufio,,rn:rc0u1x6tqnd,?u
2. 0 hospital number (H.N) uny admission number (AN-)
s. iufi'uo: lrnrlfie:{niu tdo.rcln{il?uh tcu o1qfin..rr1i.t portabte chest X_ray fin1u

rni,rluriu rd u rf, a,rlr ni lr q nr: niuil duu uil n.,t

nx?erilro{t film
nr:rira fih chest X+av lu rcu rirutuqirfluli'r portabre chesr x+ay duflurir Ap view

lrfir,ruRTrx,ir usmrndrug,r x+ay rorndruufir (anterior, A) 1:Jii,idruilfl'n (posterior, p)

LOU?I

1. AP view d,,orfiunnnrjndldrhu portabte chest X-ray -nc:triu scaputa ogtu tung
fietd rfiE relnhiflrm:odoliftJrarrulcrhfinrfirlilld uoyccrfiu heart size fiaurohqinir tirm

PA view

2. pA view rfluuniinfi'ldriru titm x+ay1u{:trufinlriiarnr:rrinlouri.ruowcirorndrurn'.o
(posterior, e1 r.rrrhdrunrir {anterior, n1 Toulvrfiu scapura otiuan an rdo,rlrnarm:nd,llfi

{:Jrurnruh rtrqoiurrusdrnr:drr firm ld rdo,,re,rn firm pA view *r-nrfluviru*.rnia0urolo o'oriu

doru air tu slomach

Exposure, symmotry, inspiration
exposure tfigfr midthoracic spine ::o'r.r rs-a Touq intervertebrat oisc o:tfiuml1 d,,:

tian'jr optimal exposure ria good exposure
nrnlrirfiu midthoracic spine rflu {ioriu rit,n dstrfiu}l riun.ir underexoosure

ria underpenetrating firm c;rir'lfirfiu rung marking ria infiltration mnn.irnruriuri,r 'irm

rrnrfiu midthoracic spine dnrrn cclflu firm dr,|.TfiuU riun'll overexposure firm vio
overpenetrating litm eylittfi rliu lung marking fi io inf ittration rioun.jrnruriuei.r

gli t uaatnnfitliann nlnyan tilm lwlzzdu

flat symmetry

532 renitioinqafrugrl

symmetry olad{tnn16i1u"l'jr clavicle ri':oo{fir.run tvirfluvSo'[ri ttsivrnfio.inrrnm
ncr6flo 1n6tr tfinrn rdurr:jtn:'.r spine *n:t-odtoarnl:Jii neac of clavicle v"-rootfiro lourirnr:
uliu! rfiu!:vu:fls.r 2 dr't trn:;uldt.r'lolrnn'i't ttflthtil mediastinum finr: snitt l:Jdruusu

lnspiration lfifiqr:ruljrfi nr:firuloL{1finrfi u{il0 (full inspiration; riohj Toufior:rur

'ldlrnnr:rirl posterior rib 16fi,1 rib d g vSonr:riu anterior rib 1dfi,: riu d o adr,oteroijr'1ilfi'1

rrnnr:nrahudrhitfiu{ro q:l ar lrn:J:; tfiunurntouirhld niatqrntulerfrtctlurn

tn qi rfi u n'lr nlu rfl uo5.r

vrnnr:vru'lqrfl1finrfi ull uil61u{rhudfi nildrnlu:Joorrn niu copo

Tube
rl:vr6ufi6o'rrior:rurdrutnqj6a endotracheal tube uantvfiaelnti trju tracheostomy

tube. intercostal drainage, nasogastric tube

Endotracheal tube

14-{xL

'J1l:3toll1/lna{l,m'l:

r. g'iraqjlu tracnea violri wr:rvorclflulilIdii endotracheal tuoe lrlldaqilu tracnea

Hiu esophageal intubation

2. Diameter no\t endotracheal tube o2:fi?ultlli: 'lfu 2/3 l|o.t tracheal lumen fir
nura diameter r6nl arctfioornnr:tdontutotto.t endotracheal tuoe rfrnrfiu}J n?onl16"1u

vocal cord edema v?o subglottic eoema ri'r'hido'rldtu1orto{ endotracheal tube rfino.:

3. nruflo.r endotracheal tuoe tunf.:{rr'todrorfi,:lo,l trachea l5o'lri l:drlfi irritate

firjrfl lo rn:firutaiamirufi rlleld
4. Endotracheal cuff a;o'1tJlnn'j't:Jnfia{ttfio:Jnrulo{ endotracheal tube ti:vr-t cuff

overinllation d.rff.rrnn'ldcrn traoheal cartilage ?! dilate aafl

lliillll nfi pressure lu capillary tvilniu zs rr,:lran d,rr?u i'r
cuff pressure Inuelnu{ ltflFl capi.l.l.ary v.lt1el-fitflor tissue
(\fit/"D)
ischemi.a q9r^ trach- eal necrosrs fr'llllJ'l !e
LLRcT'lltlLnn lFl

lt I I

ztld xga,J endotracheal cuft oveinflation

Shofi -\ote in Ponable Chesr X-rtrv lnrerprearion on?uni qfrfrflr Sji

5. sl.r*vrimol endotrachear tube finrrrel'rn'rynrtrrxlnn"lufiu\rlrirvrrvar oron'rtri

rfio right endobronchial intubation nio endotracheal tuoe rn'aurqold rfidlfin'rr:rurcrn
r:u:qtn nru ETT fi,r carina nr:rflun".,rrio1:jdToufio.rrrflndau.jr Lfluvirfir r,ruvio neutrar gq'rn
lower border of mandibre ii'rda.:gvronr;qn lrihi sott tissue .jra.tjn:,:nir cervicar spine iirvirl:

. n1\t neutral t;oejfi C5 rjnru endotracheal tube olaqjrtfio carina 5 + 2 ttufir qt:

. fintfiu lldrnir cs endotracheal tube rdouo.rlnr:ir cartitage quur-rn,,r lou

ot:1 rrdr endotracheat tube.lrjldrdo! Rtu endotracheat tuber:adrrfia carina

t3 2 mtr6rr.rst:

. ar't!,Ju l:orn'jr C5 endotracheal tuoe tdauniutn:r;,jr carlilage 6ooon Tou

o?'r1 rrdr endotracheal tubelrilirfiau ilarrj endotracheal tube c:otjrufio carina

tz 2 rrufrrNst:

. firu;fiudrmrr o:rirlfi endotracheal tube {nn'jlntt a?.t rtflt'jr trachea 6o

aan Tnraci.,rl !!d't endotracheat tube lrjldlfiau illrndulJdn 1 rsufiuro:rrn

Ft1\t neutral nr.:fi1 tionr,: r,:n

lri'irevnhurruLinrulo\r endotracheat tuue ldodr,rl:frsrr firN aru endotrachear tube
g^
g1-l carina ltoit]uetLiio right endobronchial intubation (n:rit tnu upper border of 1st rib fi

q:liu endotracheal tube o:tdauynn

Tracheostomy tube

fi rl': y r6ud fi a,.: fi q r :nlr o-.rri

t. otitu vactrea yiolri

2. trrolfiur,irunltinnrwal tacheostomy tube nl:fiturn 2/3 no{ tracheal lumen

3. tJfl']u1,oi tracheostomy tube tu tracheal mucosa lialrj border flan mandible
q.
.hifio{Eiru
position 10\: tracheostomy tube tfiu!fi:J tower

rfio{etn tracheostomy tube r:lrifinr:uuTlrdarfiaurYr position 10,:nr-: si1!!y '.:iiryrrcnrJ6a

tlottjlo.r tracheostomy tube e'n0d rrtJ'rfunin fi,iso.,,nvu;vittlrn upper border flo{ 1'1 rib

Qufi.t carina

Intercostal drainage (tCD)

fi r.l:y r6ufi fi o,rfi qr:rur d',id

t. gqnr{ruuar tCO do.:aqjlu inner rib r6rrJ0 rhuurhror nrao.l0 tCD Linx?6inrnu}J

urnrflu rignt tco 1fi::i.r'irovrfinnuiusrirurio inferior vena cava rtn: river eitu left lcD ht
:vi{'irq: rfi otn riusttr urio aorta

z. rdaid tco ufir doto'ir soft tissue li'ruir*ld rco rfufir,roilu soft rissue violri

6,,r rrnnl'jrrfi o subcutaneous empnysema

534 rernhrioinqndugru

gld s uanoshun ,taan right lcD frnn2tqflu1ul iv

chest wall

Nasogastric tube

fi1flrJo,Jrliufllu nasogastric tube qvrfiu'jt aruflluo{lu stomach urioirulndrlo'rrfiu

'[du'rn

Line

drulndolrfu central venous catheter uonn4fio?1ndaYtflu hemodialpis catheter,

plasmaphergsis catheter, pulmonary artery catheter. pacemaker

Central venous catheter
sir [tfi1.i.:i'l6icru central venous catheter fi'ld z ol'rrrni't

1. Internal jugular vein
2- Subclavian vein

nlrtturiraa,r central venous catheter filvtr:d!60 lnlufllunlfo{lu superior vena

cava (SVC) dlo{:rwlr.o anterior border 10.r 1"1 rib ttnclilfintfiu right main bronchus trqfla

dldtftlaraoruaqldnndr right main bronchus tda.torn right "trirr l:oglfi right main bronchus

firn:lnruorElou'lu right atrium o'toli,lfilnn atrial arrhythmia fi6o atrial perforation'ld

Central venous catheter fixalutll;tnr

t. rf,odrln,uoruu6r drulnr!firurisnriu'jr fast cath oi.r1 udraratfiodrflucruiinfin

duilrrfia'hi'ldoru venous catheter atiraduliltuoru fast cath d oju ldstu pulmonary artery

catheter ria'ldf,ru oacemaker nt:'ldfl1 fast cath uoirfiu{stir.:rfiurarolfiondun:rugio superior

dur".n,r"lr{",":u6"':lldrimrdrrac.:foier;nrrn'tdruvorrr,urfriiruurdlnrruanrd'ou[ate;dttoiundterrrnnarl uontrfioo, nddra, u fast cath dou
jugular vein tdotornpT'lcrufiotr.jru

rdu16anfiTd.r6o brachiocephalic vein luurusfiorudaudr.tsl:.r orcdltri6ontiun:ruriarnoqt6oo
+4.

'u tn

z. rfiodarurju aratfindnhnt*uurdotdr-n centrat venous pressure rrnvtfifll?ux{ou
ranrr n-rarulriu6.: atn:nld1dm'rrr.rdrurmun:drudru

SShod Note in Pofialrle Chcst X-ray Inrerpretarion nn?Ufif nfrfr[ S3S

Hemodialysis catheter

srhuflJ.rtro':nr:lda1u hemodialysis catheter 1dl6f{r.r,r internar jugurar vein, subclavian

vein ufl: femoral vein rrsiiie; niulu portable chest x+ay daorhullil internal jugurar vein uac

fsti,ub:Jcararvflioanruvaerincoddnfuinrrud:rha-iu]uar,igrreht:oaatrlinuhmrvlfdiourfgiarJ,lfeiurnonor:rafidrnrir.lJ:ffiln1urrndri:a'lrdysaisracadtihareytseisr catheter

c;l6ulu

rlhuvritfiuriuou biorrr:n irn"rrrrri,:nrrrfrildrrfioufl1u centrar venous catheter dkildnru

lu{'r orhuvrj'rnr:ldarsoruo,:najrrrftrjrl:-Jifflln:ridfiornr:ni ptasmapheresis flio teukapheresis

Ioa1u

fl']fl hemodialysis catheter 6n!::my|tfi,:fi0 permanent catheler (llio6undot i,t perm
cath) lflud'tu hemodialysis catheter r;Lnryutll'rir tunnet rdr}Ilu subcutaneous tissue d.:

rir'hini rnnrj'rfrrfiu skin puncture riuoirunrj,,rdrfu vascutar puncture atjvir,rriutrnn.jri6ldnru

arunrr nG ii'rrirtfinnTonronr:rfio centrat venous catheter infection n1;1d permanent catheter
d ilarrortrdruinqjfio;finr{r}Jiu right atrium miurfiurfiu hemodiatvsis catheter frl:J

Pulmonary artery catheter

nr:tdorucvli elnnr:'lEiora centrar venous catheter tfin u6.,rriau louniruhr!n-nlain.r,r

right jnternal jugular vein udr6',:5ou putmonary artery catheter e1n internal jugular vein'l:Ju-.r

right atrium bti,r rrgnt ventricre ttn;duflofi pulmonary artery drarorirlrrdrul.:ryiadru
drrfild ldruinry'rdrrtdruzrry

rJ:;rfiufidrdq6a fiaoo'ir purmonary arrery catheter o$ifin rfiu.lrJfiiolri rr:rrdrvrnfin
rfi ubjorerfi onrrcun:nf auiici6"q60

1. Pulmonary artery rupture lnurfiodurdadrnrT blow baltoon 10.t putmonary artery
catheter tdovirnt:io pulmonary capi ary wedge pressure (pCWp)

2. Pulmonary infarction rda,llrnnrn'lsiorudnrfiuLJ a.royrhl,rirfioor'lu putmonary artery

'lrjr6"urrjandruriu"l fidun,J filtu po.t.ot" chest x-ray e; ru wedge shape infirtration :o!.i

pulmonary artery catheter

I ...-....'...':......''..'j:.-:...

rt-tfrIt-] frulr.io Swan-Ganz cath€t€r

'l'ip of cath :l dounllufiarlrfiu s rtu6un: l6uri noirdfi putmonary artery lB

: lliu COPD d,rrirhirfin putmonary artery hyper.tenston 1enH1 r,r5o
: pulmonary anery lonrn ria{ilrdfi pAH lrnornrqdu

Li+l-J'r ztlii I uaotohtmi,tatufimutzaulat putmonaty aftery catheter

I

536 rrttirrinSnqndugru

rtrdoir rrnrjra o.: pulmonary artery catheter drr,tlr;olfio sl'rttv .l West's lung zone 3
(P, > P, > e.;' n',lrfurJnru catheter nt:q:d'n't filtflu Wesfs lung zone 1, 2 fi{ pulmonary artery
pressure c:{nn'j'l:lnfi rfiotqrnfi alveolar pressure rJllttn'lu

sgtlfi um,tahun ,nta,t pulmonary artery catheter fiatJatttg'tuaifi left pulmonary artery

Pulmonary infarction

r,ti o ufian wedge shape pulmonary infarction da'ldg'tu

pulmonary artery catheter frnLfiullJ

Pacemaker
rusn.ldrflu z rl:vtnv6o
1- Temporary pacemaker 6'ln-t macnine c:aqjuonn*r{:-lru rdooorndrutnrllo\t temporary

pacemaker e:n::{u right ventricle lorun,:tdoraq:rimrnnr:'ldaru central venous catheter

tfi norstt{,: rrfirnrldrsnr:ldn1u temporary pacemaker orufl'tlsa.: temporary pacemaker
o:oqj'(l right ventricte

2. Permanent pacemare dt.lsi'r machine 10.I pacemat<er e voqjfi subcutaneous tissue

d.rdru'luqjo:oqjrrlfi'udrr lnuofrurdriilaiorufnl:tflu bft subclavian vein Inr ntuflluorl

tiaodtu rignt ventricle right atrium fr'ldrrdrrrsi mode fl0.1 pacemaker

AIoufi a r}lrafu arterial pressure, v }llt,'|!tfi.: venous pressure un: ltlUfi't alveolar pressure

Shofi liote in Ponablc Chest X-rav InteT)reLarion @n?-uni nfifrwT 537

Other equipments

fiarll,r dorn portabte chest X-ray niu

1- fl'ru drain rd'r.,r1 duantttflalln inrercostar drainange rtiu percutaneous drainage
(PCD) lilnififla't intraabdominat intection

z. qrJn:nifirfiurnilnr:tfioon6rou lru nasat cannuta. oxygen mask. face mast< lrda'ld

noninvasive positive pressure ventilation). corrugated tube ?a{ ventilator circuit
3. nruaruadrodufrlrilti centrat venous catheter rriu arrdrudrraoorfion basirica

vein ctnnl:?ir venesection drulnqjo;ogjiiinuS6'ut.:r d,rfio,:lfin.rud,: rnnodl,t ln
+. qrlnrninr:r'iroYn Inuralrr: median sternotomy wire i:',rruldornnrrEirn-orir'lovio

nr:ojrdfnJoo nr:niroi'a thymecromy lufi tu myasthenia gravis

S. qilntnifiaorurilr::r*-rdu1 rdu monitor EKG teads. thermometer dryfunr:inlfi (fn
lrfiintr5l. cuff na{ non-invasive blood pressure monitoring d{o:odfirrau

dru film olillvuu

e;rireirulrn{rruonrdr{r{tu niacceiruorndr.'rtuaandr,ruonfltdtufidr:riruorndr.:uan
r{rdr.rtu Totr6ile'rn soft tissue, bone. abdomen, diaphragm. costophrenic angle, pleura. rung

parenchyma, heart. mediastinum

Soft tissue
u,:; Ioauy4ln' o{11?1:tu'too

'1. Subcutanoeus fat filyrnfinrrrlr,r n.ir:J n6 rtRo,r.irfi raruor 6{fldd1ufir.lhu
malnutrition fiia thyrotoxicosis vrn subcutaneous fat finrrrturrrnn'ir:Jn6 uil61ufuJrsii

liadfu soft tissue edema e1nn1: resuscitation fiio vascular leaxage

2. Subcutaneous emphysema rfi ualfi ror:oslu subcutaneous rat lrildytrunru,jr
do':rfiniurir pneumothorax rora'l:J rir uvilofrfio,:o rflun^lou6o sl"rufixj.ifrldorir intercostal
drainange oirrrrrj'r chest walt u"r'r:1ua1q rtr;Ljnrlirrrufiuna ruu",:r,trjrfior 'lu:.r!firurr:.iaufi
rtr;a{o:lriadlu subcutaneous tat rrirfu rrdorcrrrCiln',Jdu muscte firflurutju:r,tan firfiu
ldtqnudonilfi$1yh pectoralis major muscle Tqucy :-trfluarffiat muscle f6n

Bone

hid,lrnnirfi osteoporosis yio'Iil ftrTnndu{rlrrryatqnialfiilar sreroids uon?tnd

nr:nflarrirf, fracture rio'hi ori*rri,rto.r tracture firdd' os niu rio fracture, ctavicle 1loflQrn

dnr:o spine }iorrroYruoi thoracic spine eufi.o rumbar spine d,rdatfirurnlrnqirsuGaul nrn
spi ne :r dr'ler ol oYr n.: uno,r'jr:; d'lriufi :I1vr {i,: orl rfl u f ractu re nio metastasis

538 rrtd'ttioinqafiugru

ild t usa,tfrtJtpilIdiuntziiqdufiu AqDs'lflfiJn1;ld endotracheat tube TdivntzIdatu intercos-

tat arainage z dudadflfrnuatdlutat vtt-tstttltt1lu subcutaneous tissue fiw#,tnzl,tanfrtu

rtta dtuttl uantuT fufruao ldfitn:7datu putmonary aftety catheter dfiJaluogii ,ignt

putmonary artery Inufraitun 'rrnutrs, ,orq'tndo-onuaxuntnagilu pectomlis maior muscle

nnflA.J?11\t

Abdomen

l; toufl 'rnryTn0{}lo'l:tu'ln{u

1. Bowet gas pattem Trnfiflu?liolrjfi nu'lfflu ascites tJiurrulrn via obstruction

lrnlrryn''lfiu bowel gas tlSurru*trn fio'trirnrrttunsio.[rl'jr rflu oowet obstruction Yio bowel

ileus fi1nl'ru air'lu rectum firrurTriildc:rflu bowel ileus 1nn'i1 bowel obsiruction

2, Calcification 'trtrgerrlroiurvfinu niu vrnlu calcification tu gall bladder 6ofi.: gall

stone fi1flfl! calcification d tion"y llidtu nephrocalcinosis t5o renal stone 'lupJrruloi'r':1

xlnvru calcification fi pancreas 'hihofit chronic pancreatitis

g. Free air lfi oome flo{ diaphragm d'luild'lu pneumoperitoneum ernorttqoirtl

adr,rbfrnrrri'rfi sign fruoo,r'i'ttiJu pneumoperitoneum 6n nju falciform ligament sign, Rigler's

sign. inverted V sign

Diaphragm

trifi cr:rurluil:vrduoir{r siol:Jd

1. Diaphragm d1u111c;q\tn'j1 diaphragm d'udru ::uru 1 intercostal space rfio.te1n

diaphragm f-i'll.l1J'l'r--9r1j0-1-4l l.vfl{f2ll]

Short Note in Portable Chest X-ray Inr€rpretation lsnluti IfifiL g Elg

diaphragm drufiruqln.jr 1{fi0fi1 atetectasis lo,rrlondru$ru, teft phrenic
'1"rn
nerve paratysis, firoaT:nld diaphragm fitu

fi'Ifl diaphragm d'rumtaonir lnruri:Jna 1fi6nfu atslectasis fla\: Eordruart. rtght

phrenic nerve paralysis, firorlT:nlfi diaphragm rt,t

2- :Jn6 diaphragm lil'irdrulndo,,rfifrnuruv[flu curve nr.:dru raterar olduqnfi cnest
wall lfigrflu costophrenic angle

. yrnro,o'hirfiu diaphragm dru'lo

1) lificfi{ifi tobe sa.,:rjoofilr Sithouette flu diaphragm druu"u nrrfidi obe ro,,:

rlonfix'r silhouette n" diaphragm 6rurn 'lfifinfisauT:ndrflu right rower tobe d.'rarclflu
consolidation fiio atelectasis mnfi tobe ro,:rjondrr sithouette fi:L diaphragm drufiru 'hi

6nfit:auTrndtflu left tower lobe d,:orcrflu consolidation nio aietectasis

2) Pleural effusion to{ ao{rtusu

. nrn'lrirfiun'nrru; curve rDl diaphragm rrdrfiurflu flat diaphragm dllriufi

fl"nnruy hyperinflation ra.:iloar '1fi6nfi.1 obstructive airway disease d,:u d'lu

copD, asthma y5o'lu:rudof.lniooriruyruhudrfinrrv auto-pEEp rfi ndu

. trno'nuru: curve 1o\r diaphragm finr:T6.,rnr.,tdru mediat lrd!fllrld ni,,tl,t.tn

d1u taterat'Ififi nfir'j.rar+flu subputmonic efluson

Costophrenic angle

lnu:Jnfi costophrenic angle fio..rrfiudnrou

1. Blunt costophrenic angre d'uluqirflu preurar effusion uanornduldlu deural

thickening 'lu chronic lung disease
2. Costophrenic angte ddnn,jr nfi 1fin,r#u,jrortriu deep sulcus sign d.:rflu sign

uo*r pneumothorax tuvirusu rdoocrnluvi11lou uo;uaflrr,,rdrunrjltrnyqcrrr:!?12.u costo-

pti a umt Eft costophrenic anga ifrnnh nh

d,tfiu sign tat pneumothonx ?uiuau

540 nrruhrininqadugru

phrenic angte lfifinbrieu1 Eurfiqrflu deep sulcus sign ltrulrje'rriudotlfiu visceral pleural

line
Pleura

ffinfie1'rru' d z il:vrfu
1. Pneumothorax'tu:radtqrouc:!fiu visceral pleural line [!fl: distal sioctn visceral
pteurat line o;Ljfi trng marking d.tdatuuneln skin fotd d,l skin fold tfintiofin'uflao pt"t" d
ld'lunr:vri portable chest x-ray rr,tdrutn'ctatddlu rir'ltitfinnrrvr-lta.:firfirirduilr qcrfiu

riurdundru visceral pleural line ttflntrnfiufou distal tjo line 10{ skin {old o:ti':nttfiu lung
marking uflra1e6'ltJ line no{ skin lold ldlildouonu:rron nrnrrunlrildt'otru'lfiqdnr*nrvnrt
n6finto.r{rhuun:rir portable chesr X+ay #'t

uonmndarolriuu visceral pleural line na1rfia pneumothorax uliuulfiu deep sulcus
sign ltyru

Vtii s uaot s*in tou ltfrirnt,tdluvttuazfrlu#'ts lidtnnh distat tia sdn fold ltvtu'hfr tung

ma*ing dzu dtuaa,ti'itflti viscerat pleunl tine

2. pteurat effusion tuvir:Jn6esl,tulflu fluid curve udlu{rJraurind.ro{luriruou rircvltJ
o$'lurirrru loose area tdu upper lung ns.t 2 {ro d{qctfilriu apical cap sign firlrndur;triu
lfludrutr,rroo chest wall lflu lateral cap sign sioilrtJrndurliu fluid in minor fissur" fiurndu
fr rfi uriu naziness to.:rjoodr.rrfu

Lung parenchyma

lirirnr:rrundlflulonn"r (black lesion) i0 onnl? (white lesion)

n:rfifiill black lesion nju pneumothorax. pulmonary embolism, OOPD niofiflq{ufi

rdur{o,IfiunrT tdlnio,:rirafirfl'le niu auto-PEEP, n1rld tidal volume dntntflu
n:tfldrflu white lesion'hirrun'irrflu infiltration. atelectasis, mass

Shon \ote in Portable Che.sr X-.ay tnterpreration ron:runi nfifrntg 541

,il- 1il*En

aJi to uantntttirll pteunl eftusion'lui'tuau Iaa#xe'tn apical cap sign, laterat cap sign tLsJ fluid

?u minor fissure ntttti'tdt

lnli ltration

1. Alveolar intiltration rilun'nurucnrrttn{r fuournnlrjdn rouunyfidnunrcdrrnrt6a air

bronchogram finrwrflu lobar vio segmental distribution tu local disease ni! pneumonia

ttn:tfru butterfly appearance 'lu diflused disease rtiu cardioqenic pulmonarv edema lsu
putmonary edema tufirlsinqnuunaanldriu z rl:crn fia

r Cardiogenic pulmonary edema rflu pulmonary edema d tfiotcrnnrruqtrootrh

ocu]Jrtroloifir'tltr,,r4du nl perihitar infittration flrornr:rflulrnrluqyl,qJ6l'nuru;

butterfly appearance

. Non-cardiogenic pulmonary edema Touy"dlluro:rartr-':lq nfi n:i61u enos

yrnr{rrnrudnr:ifitdg

2. Interstitial infittration rflur,nflrfirro:t1 unannr finujaudo peribronchial cuffing
v5O tram tracking d"nfu: redistrlbution aa{ pulmonary btood flow !!flJ Kerley e fine riolflu
rfiufiurr#u1 oirornn'rruftr:rronflruflln n1 r'rrJiro\r interstitiat infittration 6oocrfiurffurflu

: ir'r uy grur:nutnorruqla.:nr1fio interstiliat infittration iinUrjauldri'.rd
. tlL 1ufi.t Vmphatic triu lymphangitis carcinomatosis
. | fitJlufi\r infection, idiopathic ttiu interstitial pneumonitis

. F l1tJlufi,J fibrosis
. E u'1u6.,,: edema

3. Putmonary nodutes nia cavities fir,lutunafi:.l.luinqoortfinr:if,cduulnl:nldnnrsnjor

ldttri abscess dtarorflu local lesion n?orflu oiffuse lesion tio metastatic disease

4. Pulmonary infarction rflufirltr:1larr ryfiulfigrurflunouuon (periphery) flfl\:doq
arc u'ldlr.tnrr: pulmonary embolism

542 retrirriainqorduSru

lun:rfiii u:.lnzunld'irfi infiltration udr nr'::.lonn"rutti{ga,.::auI:nd'ld

t. uun'jtf urfl u:oul:n ruin':vcrfl (diff use) nio:auI:n tanr:d (localizel

2, yrnrflu:oaT:nlavrr:d'lrtrondrtla,tilaodtflu uflytlon tobe frfinurfionrr nrnrflu
alveolar infiltration tfilon too" toltJsofifirnrurionrulnuorduudnto.! Silhouetie sign dl:d

. :aul:nd silhouette ri:.r right side heart border uon{ir:ouI:ntfiod right middte

tobe

. :atrl:nd sithouette fiu right diaphragm [an$r:au1:nrflnd right lower lobe
. raul:nd sithouette ritt left heart border u5ln{dtouT:nrfind lingular segment

flo,I left uooer lobe

. :aul:nd silhouette riu tefi diaphragm uan{'ir:aa1:ntfind left lower lobe

s. lnuilnfififl't heart dornhn'ir liver udfirtrnvdt heart ?'l?wilni! liver tton.:'itfi retro-

cardiac infiltration

Atelectasis
ifiod'uld'Toruord'un1:nr2?vlr primary signs to,t atelectasis 6ar.laod?ufirrlluqcfiutLo't

uflu:oun'rlrr ii.,r:oudc: rfluntr lobe, segmenntloldalaorvr",'rdrt dtu secondary signs:J::no:.t

dra nrr shift ror diaphragm, t?rrlon (hilar area), tt'rlo rto; mediastinal structure nt:tfiu ooq

lfioodrrl t'euoudu ntitfiurjo':6Tn:':lln:Jo,i untnmcu! oofi'rndafi compensatory hyperaeration

rdo rr:.1nrun16'irrflu atetectasis ttfir"lfi ururrr!on tobe itfin atetectasis vrnrfinfrlon
n"l{r.: da.ouunotn massive pleural effusion fnuurnrfu aielectasis o:tfiu primary sign ufl:
secondary sign To\: atelectasis unvtfiu trachea shift 1 u"'Idrudfinuricnrn

h{rJrrvu*n atetectasis dfiotratvrrflufiretudo tett lower lobe atelectasis tdatlrn
uinru left lower lobe o{ua'r rreart uocnt:ftltfltJfi:aonorn lower toue riurirldurnrdamrn
nruinrnro'.r left bronchus fifi nrlrt'uriounir riqht bronchus

Mass

Lung mass dai iJrur uun'irtfllu benign l?o malignant lesion

Hsart
10R?l- e'r:ru'lov{xu

1, tu portable chest x-ray turslo.rf'r'lerv1nnir PA view
2, cardiothoracic ratio flrldorctdririirrnn'j'r 0.55-0,6 tunl:ifiqdu'j't cardiomeoatv
xiohl

3. fi1n!on chamber enlargement'ld

Short Note in Portable Chest X-ra!, Interpret2rion nn:iUnl nfrfrftr 543

. Right atrial enlargement 'lfid.trrnn.jr right atrium rlu ortg" oon:lrrfiun.jr:Jn6

niolri rnufi{uu;rirtfld rnumb sign fiotdiirri'rurjfiavrrlso}Jfi right side border
?o\r thoracic spine 'lunrzuon,irfi right atrial entargement nialri n.rnrol,la.r
right atrium rfiudrrftrrrjfiala.lfin:.n fio.jrfi right atriat entargement un'artfido

ft nfl nrerrda,:lrnruroto,rdrrtrurifi ouria:nulriMrn'u

. cLeft atrial enlargement firt:nnlfiqtn inal angle tJ1nn.j,l ZSfl. left main bronchus

'Unt*u, n:f ful'jrfi double contour sign, nt?Ol'tu prominenl 1O,J left atrial

appendage

. Right ventricular enlargement 0,tin5??yfl] LV apex Undu (6d1uta.J[fitU )
. Left ventricular enlargement tior:rur'ldcrn LV apex dn.loir,l

a- n:rflq:revill globular shape heart 1fi60fi.J multFvalvurar heart disease. oericardial

effusion, dilated cardiomyopathy

Mediastinum

rtfi r,r'trr rur:J:: r6u oi 1 riolJd

1. Aorta tlifl.llnuirfi calcification vSohi 6.,rrr"rldtu atheroscterosis r4oo'rtvuldd arcn
uia descending aorta uantrntitfiq.jrfi aortic ditatation ;ol

2. Pneumomediastinum lourfiur.:ro,tn1fila!1 lo:Ln',r'le fi?o:or"l aodic arch ttfft

descending aorta nr:drunrrtrvirdul niu lateral upright ria decubirus rrrrrioro rfiul,:r

alnrllox'l aorta rfiur6oolud6u1 prevertebral soft tissue uinrffio:rdo! thymus t!flJ suhsternal
space (fialOrorn lateral film) Olent?qllu continuous diaphragm sign arnrO'lU mediasiinum
orq ttr vdulu'luui rrru retropharyngeal space lriu retropharyngeal air v5o retroperitoneum
rir'lfirfiu outtlne talaiurv'lu retroperitoneum d'urdu tufirjraur.,r:r,tuarel,tu subcutaneous

emphysema dtu

s. hifilr:ruljrfi hilar enlargement tiorr,ltr paratracheal mass uiaLj
+. lfificr:rur column zo{ trachea 'irtrirn-un'yiolri rrnru tracheat lumen 6lttnln,l

orefld6"lu paratracheat mass entargement dTnrdrr{rulu

lfi 0 ff.: rnsrn:nifi u chest x-ray n daud'r.::Jn6'trir u.r urr uo,:tt dr oirr oi o1rJd

1. Visceral pleural tine riurdulr.,rl lfinrriloulctfluil'rnul?nru apical area

2. Upper lobe tesion rfio{crnfi ctavicte !rn: rib rJ.u.l-.11i.1'lfi o.,trfiuldlrirl'atrqu ilililiuu
lfruyir density uo,,r oalirrrun',:ndn e fir,: ryirrfurSol firfirulylfi density rJ.tnn'j.t nt1 fic

rJnfilvaqjn'druriu

544 nuirrintnqmdunru

ttgtti unm diaphagm z I'miatfu riunit continwus diryhragm sign i!,rffiifrlu pneumomedi-

aF,tinum

3. Tracheal lumen TnB' nf, tracheal lumen do':lflu column n\t 'tn?\:'l diameter tvirn'u

lfri rapid tapering tff:v'r",:'irfl'rrfi paratracheat mass dlorrirluuu? midline d{ri'fllifin upper
airway obstruction ld

4. Retrocardiac region lnu:Jnhndo heart gldlndl lirer rfio.rlrnndl neart firJooo{
'rnr{1rD{}1fl-,0 heart ii density dt1?ti'uY! liver d'tolflfitildeln consolidation, atelectasis, lung

mass

5. costophrenic angelfifli rnn'irfi blunt costophrenic angte riolil ii.,:uulfflu minimal
pleural eltu$ion ulo peural thickening tu chronic lung disease

6. Diaphragm lfifrirno?ili1{toir diaphragm 'i{f,.tliur.tnfirtolri'hldo!nn'j1 diaphragm

z dr.rCor{unlolri (continuous diaphragm sign; duull pnoumomediastinr. uanerndt1,odasg

dolrt'iri air u1n1fl?BrJ aorta drrfludnurugdfi:ifi'lu pneumomediastinum
7. Subdiaphragmatic air dttilu sign '!4.0 pneumoperitoneum lnutottr;{rl'rud:Jrnfio,r

ri',rdr:do*r,i,rr6.:ddrufiruriufirfirrdo\rq'rflr{aua{ air liliouriu stomach lfi

Management of Acute Kidney Injury

ttfrwgt lawin

nmslnrrurdulunr"u (acutE renat faiture, ARF) tflunrrsdu:-rriou unvrfluflrgnrddrdqp

lunrrgua{rJruturetrJfil'i tnuro?trJrfludusilfurludr nRr 6o nrrsqo.:odr.rrduu niurol

glomerular filtration rate 1Cfn1 rflunrntfifinrrn;clao,:griU (blood urea nitrogen. BUN) Lrfls

ao.:rdu6u1 1u16on ornnrnlrruurnruru'j,ro:jhnr:rdlo'nnnr:6u6ic :1 6,,tnr:inurnrrc

dd.:finr.nrnT nnnruun rds.urmnnrrriruunfiurmoo nRr unnoiroriulu[sis:nr:ilnrr 6.0ii
nr:rirm.ro0uu'hrin'rflulrnqrulouldnh'jr "acute kidney injury (AKl),' u u ,,acute renal faiture,'

unnrrrdfilori,:rrrardomumro,:dnruflnri a1:Juurrn,,:nr *rftr nr:inrr rra;nrrfla,ofiir

R't?s acute kioney injury turrtrJfir)fi

Definition and staging ot acute kidney injury (AKl)
luodnq:Jhnrrniro{ ARF fin'll unnqir{fiuori'l.rrrrn crrrqr.rornnr:d'ldrnrud'tunrr

ifieo'ufi unndr.rrfumnnir go fi uru' rdo'hiirnrurinr:ifirdufr rflurrnqrurdurrfu {rdurmq
ldririluqilurtJtflrifiriun'j, mf LE (Bisk Injury, Faiture. Loss, End stage kidney disease) criteriaz
rni,rnrir{rJruSfirriryrtto,rlnnnno lduyrn'ulflu n, t, !!n; F rrlxn't?r:Jduuu ntto,,:eir creatinine

'lufiiluoyrJ?lrruflssrtv drnlunril r- 6a{rlrudgqrfrunrirfiln rncda*rfnl.rd?u renal

replacem€nt therapy (RRT) urun'jr 4 it:Jnrri uovnoju ESKD (End stags kidnEy disease) 6o
{rl'rudrf; atr"nurdru RRT rr1n n'ir 3 rdsu nrnir RFLE crneria Uldfi fl rym{unrrJfi rifi fi airrfl u

do.:nfluir creatinin€ rhrna,':firjrs i'rfinrrrjflujdul RTFLE criteria uoyrruvrir'lfi'tfrirJr acute

kidney injury (AKl) tutu ARF€