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RESPIRATORY AND
METABOLIC ACIDOSIS
& ALKALOSIS
By Monisha Jayabalan
Ist MSc Medical Biochemistry
Dr.A.L.mudaliar post graduate institute of basic
medical sciences, University of Madras, Taramani.
14-03-2015 1
• Acids are hydrogen ion whereas A base is an
ion or a molecule that can accept an H+.
• H+ regulation is essential because the
activities of almost all enzyme systems in the
body are influenced by H+ concentration
• Acid-Base homeostasis is concerned about the
proper balancing of acid and bases, also called
the pH
14-03-2015 2
ACIDOSIS is the reduction in the pH due to
the presence of excess H+ ions
ALKALOSIS is the decrease in the pH
14-03-2015 3
Defences Against Changes in Hydrogen Ion
Concentration
1.Chemical acid- base buffer system
2.Respiratory centers
3.kidneys
14-03-2015 4
CHEMICAL ACID –BASE BUFFER SYSTEM
• This is the first line of defense.
• Chemical buffers include bicarbonate buffer,
phosphate buffer and protein buffer
• The bicarbonate buffering system is especially key,
as carbon dioxide (CO2) can be shifted through
carbonic acid (H2CO3) to hydrogen ions and
bicarbonate (HCO3-)
14-03-2015 5
Respiratory Regulation of Acid-Base Balance
• This is the second line of defense in acid-base
disturbances
• An increase in ventilation eliminates CO2 from
extracellular fluid, which, by mass action, reduces the
H+ concentration.
• Conversely, decreased ventilation increases CO2, thus
also increasing H+ concentration in the extracellular
fluid.
14-03-2015 6
• The buffering power of respiratory centers are one
to two times as great as the buffering power of all
the chemical buffers in the EC fluid combined
14-03-2015 7
RESPIRATORY ACIDOSIS
• Respiratory acidosis is a medical emergency in which
decreased ventilation causes increased blood carbon
dioxide concentration and ultimately leads to
decrease in the pH level
• During Alveolar hypoventilation there is an increase in
CO2 thus leads to an increased PaCO2.
Acidosis refers to disorders that lower
cell/tissue pH to < 7.35
Acidemia refers to an arterial pH < 7.3
14-03-2015 8
TYPES OF RESPIRATORY ACIDOSIS
ACUTE RESPIRATORY ACIDOSIS
CHRONIC RESPIRATORY ACIDOSIS
14-03-2015 9
ACUTE RESPIRATORY ACIDOSIS
• PaCO2 is elevated above the upper limit of the
reference range (over 6.3 kPa or 45 mm Hg) with an
accompanying acidemia (pH <7.36).
• occurs when an abrupt failure of ventilation occurs
• failure in ventilation may be caused by depression of
the central respiratory center, inability to ventilate
adequately due to neuromuscular disease, or airway
obstruction related to asthma or chronic obstructive
pulmonary disease (COPD) exacerbation.
14-03-2015 10
CHRONIC RESPIRATORY ACIDOSIS
• Chronic respiratory acidosis may be secondary to
many disorders,including COPD
• Chronic respiratory acidosis also may be secondary to
Pickwickian syndrome, neuromuscular disorders, and
severe restrictive ventilatory defects as observed in
interstitial fibrosis and thoracic deformities.
14-03-2015 11
MECHANISM
• acute respiratory acidosis, compensation occurs in 2
steps.
• The initial response is cellular buffering that occurs
over minutes to hours. Cellular buffering elevates
plasma bicarbonate (HCO3
−) only slightly,
approximately 1 mEq/L for each 10-mm Hg increase in
PaCO2.
• The second step is renal compensation that occurs
over 3–5 days. With renal compensation, renal
excretion of carbonic acid is increased and
bicarbonate reabsorption is increased. For instance,
PEPCK is upregulated in renal proximal tubule brush
border cells, in order to secrete more NH3 and thus
to produce more HCO3
−
14-03-2015 12
RESPIRATORY ALKALOSIS
• Respiratory alkalosis is a medical condition in which
increased respiration elevates the blood pH beyond
the normal range (7.35-7.45) with a concurrent
reduction in arterial levels of CO2.
Alkalosis refers to disorders that elevate
cellular pH to > 7.45.
Alkalemia refers to an arterial pH > 7.45.
14-03-2015 13
TYPES OF RESPIRATORY ALKALOSIS
ACUTE RESPIRATORY ALKALOSIS
CHRONIC RESPIRATORY ALKALOSIS
14-03-2015 14
ACUTE RESPIRATORY ALKALOSIS
• Acute respiratory alkalosis occurs rapidly. For every
10 mmHg drop in PCO2 in arterial blood, there is a
corresponding 2 mEq/L drop in bicarbonate ion due to
acute compensation. During acute respiratory
alkalosis, the person may lose consciousness where
the rate of ventilation will resume to normal.
14-03-2015 15
CHRONIC RESPIRATORY ALKALOSIS
• Chronic respiratory alkalosis is a more long-standing
condition. For every 10 mmHg drop in PCO2 in arterial
blood, there is a corresponding 5 mEq/L drop in
bicarbonate ion. The drop of 5 mEq/L of bicarbonate
ion is a compensation effect which reduces the
alkalosis effect of the drop in PCO2 in blood. This is
termed metabolic compensation.
14-03-2015 16
CAUSES
• psychiatric causes
• CNS causes
• drug use: doxapram, aspirin, caffeine and coffee
abuse
• moving into high altitude areas, where the low
atmospheric pressure of oxygen stimulates increased
ventilation
• lung disease such as pneumonia
• fever
• pregnancy
• high levels of NH4+ leading to brain swelling and
decreased blood flow to the brain
14-03-2015 17
MECHANISM
• Respiratory alkalosis generally occurs when some
stimulus makes a person hyperventilate. The
increased breathing produces increased alveolar
respiration, expelling CO2 from the circulation. This
alters the dynamic chemical equilibrium of carbon
dioxide in the circulatory system, and the system
reacts according to Le Chatelier's principle.
Circulating hydrogen ions and bicarbonate are shifted
through the carbonic acid (H2CO3) intermediate to
make more CO2 via the enzyme carbonic anhydrase.
14-03-2015 18
RENAL COMPENSATION
• Renal compensation is a mechanism by which the
kidneys can regulate the plasma pH. It is slower than
respiratory compensation, but has a greater ability to
restore normal values.
• In respiratory acidosis, the kidney produces and
excretes ammonium (NH4
+) and monophosphate,
generating bicarbonate in the process while clearing
acid.[1]
• In respiratory alkalosis, less HCO3
− is reabsorbed,
thus lowering the pH.[2]
14-03-2015 19
METABOLIC ACIDOSIS
• Metabolic acidosis is a condition that occurs when the
body produces excessive quantities of acid or when
the kidneys are not removing enough acid from the
body
• If untreated it leads to ACIDEMIA
• The consequences are so serious leading to coma and
death
14-03-2015 20
Signs and symptoms
• Symptoms are not specific
• Symptoms may include chest pain
• , palpitations,
• headache,
• altered mental status such as severe anxiety due to
hypoxia,
• decreased visual acuity,
• nausea,
• vomiting,
14-03-2015 21
• abdominal pain
• altered appetite and weight gain
• muscle weakness
• bone pain and joint pain.
• Extreme acidemia leads to neurological and cardiac
complications:
• Neurological: lethargy, stupor, coma, seizures.
• Cardiac: arrhythmias (ventricular tachycardia),
decreased response to epinephrine; both lead to
hypotension (low blood pressure).
14-03-2015 22
CAUSES
• Metabolic acidosis occurs when the body produces too
much acid, or when the kidneys are not removing
enough acid from the body. There are several types
of metabolic acidosis. The main causes are best
grouped by their influence on the anion gap.
The anion gap is the difference in the
measured cations and the measured anions
in serum, plasma, or urine.
14-03-2015 23
INCREASED ANION GAP
• lactic acidosis
• ketoacidosis
• chronic renal failure (accumulation of sulphates,
phosphates, urea)
• intoxication:
o organic acids (salicylates, ethanol, methanol, formaldehyde,
ethylene glycol, paraldehyde)
o Sulphates, metformin(Glucophage)
• massive rhabdomyolysis
14-03-2015 24
NORMAL ANION GAP
• longstanding diarrhoea (bicarbonate loss)
• bicarbonate loss due to taking topiramate
• pancreatic fistula
• uretero-sigmoidostomy
• intoxication:
o ammonium chloride
o acetazolamide (Diamox)
o isopropyl alcohol
• renal failure (occasionally)
• inhalant abuse
• toluene
14-03-2015 25
COMPENSATION MECHANISM
• Metabolic acidosis is either due to increased
generation of acid or an inability to generate
sufficient bicarbonate. The body regulates the
acidity of the blood by four buffering mechanisms.
• bicarbonate buffering system
• Intracellular buffering by absorption of hydrogen
atoms by various molecules, including proteins,
phosphates and carbonate in bone.
• Respiratory compensation
• Renal compensation
14-03-2015 26
METABOLIC ALKALOSIS
• Metabolic alkalosis is a metabolic condition in which
the pH of tissue is elevated beyond the normal range
(7.35-7.45).
• This is the result of decreased hydrogen ion
concentration, leading to increased bicarbonate.
14-03-2015 27
CAUSES
Chloride-responsive (Urine chloride <
20 mEq/L)
Chloride-resistant (Urine chloride > 20
mEq/L)
14-03-2015 28
CHLORIDE RESPONSIVE
• Loss of hydrogen ions - Most often occurs via two
mechanisms, either vomiting or via the kidney.
o Vomiting results in the loss of hydrochloric acid
o Severe vomiting also causes loss of potassium (hypokalaemia)
and sodium (hyponatremia). The kidneys compensate for
these losses by retaining sodium in the collecting ducts at
the expense of hydrogen ions (sparing sodium/potassium
pumps to prevent further loss of potassium), leading to
metabolic alkalosis.
• Congenital chloride diarrhea - rare for being a
diarrhea that causes alkalosis instead of acidosis.
14-03-2015 29
• Contraction alkalosis
• Diuretic therapy - loop diuretics and thiazides
• Post hypercapnia - Hypoventilation (decreased
respiratory rate) causes hypercapnia (increased levels
of CO2), which results in respiratory acidosis. Renal
compensation with excess bicarbonate occurs to
lessen the effect of the acidosis. Once carbon
dioxide levels return to base line, the higher
bicarbonate levels reveal themselves putting the
patient into metabolic alkalosis.
• Cystic Fibrosis
14-03-2015 30
CHLORIDE RESISTANT
• Retention of bicarbonate
• Shift of hydrogen ions into intracellular space -
Seen in hypokalemia.
• Alkalotic agents - Alkalotic agents, such as
bicarbonate (administrated in cases of peptic ulcer or
hyperacidity) or antacids, administered in excess can
lead to an alkalosis.
• Hyperaldosteronism
14-03-2015 31
• Excess Glycyrrhizin consumption
• Bartter syndrome and Gitelman syndrome -
• Liddle syndrome
• 11β-hydroxylase deficiency and 17α-hydroxylase
deficiency - both characterized by hypertension
• Aminoglycoside toxicity can induce a hypokalemic
metabolic alkalosis via activating the calcium sensing
receptor in the thick ascending limb of the nephron,
inactivating the NKCC2 cotransporter, creating a
Bartter's syndrome like effect.
14-03-2015 32
RESPIRATORY COMPENSATION
• Respiratory compensation is a mechanism by which
plasma pH can be altered by varying the respiratory
rate. It is faster than renal compensation, but has
less ability to restore normal values.
• In metabolic acidosis, chemoreceptors sense a
deranged acid-base system, and there is increased
breathing.
• In metabolic alkalosis, the breathing rate is
decreased.
14-03-2015 33
14-03-2015 34

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Acidosis and alkalosis

  • 1. RESPIRATORY AND METABOLIC ACIDOSIS & ALKALOSIS By Monisha Jayabalan Ist MSc Medical Biochemistry Dr.A.L.mudaliar post graduate institute of basic medical sciences, University of Madras, Taramani. 14-03-2015 1
  • 2. • Acids are hydrogen ion whereas A base is an ion or a molecule that can accept an H+. • H+ regulation is essential because the activities of almost all enzyme systems in the body are influenced by H+ concentration • Acid-Base homeostasis is concerned about the proper balancing of acid and bases, also called the pH 14-03-2015 2
  • 3. ACIDOSIS is the reduction in the pH due to the presence of excess H+ ions ALKALOSIS is the decrease in the pH 14-03-2015 3
  • 4. Defences Against Changes in Hydrogen Ion Concentration 1.Chemical acid- base buffer system 2.Respiratory centers 3.kidneys 14-03-2015 4
  • 5. CHEMICAL ACID –BASE BUFFER SYSTEM • This is the first line of defense. • Chemical buffers include bicarbonate buffer, phosphate buffer and protein buffer • The bicarbonate buffering system is especially key, as carbon dioxide (CO2) can be shifted through carbonic acid (H2CO3) to hydrogen ions and bicarbonate (HCO3-) 14-03-2015 5
  • 6. Respiratory Regulation of Acid-Base Balance • This is the second line of defense in acid-base disturbances • An increase in ventilation eliminates CO2 from extracellular fluid, which, by mass action, reduces the H+ concentration. • Conversely, decreased ventilation increases CO2, thus also increasing H+ concentration in the extracellular fluid. 14-03-2015 6
  • 7. • The buffering power of respiratory centers are one to two times as great as the buffering power of all the chemical buffers in the EC fluid combined 14-03-2015 7
  • 8. RESPIRATORY ACIDOSIS • Respiratory acidosis is a medical emergency in which decreased ventilation causes increased blood carbon dioxide concentration and ultimately leads to decrease in the pH level • During Alveolar hypoventilation there is an increase in CO2 thus leads to an increased PaCO2. Acidosis refers to disorders that lower cell/tissue pH to < 7.35 Acidemia refers to an arterial pH < 7.3 14-03-2015 8
  • 9. TYPES OF RESPIRATORY ACIDOSIS ACUTE RESPIRATORY ACIDOSIS CHRONIC RESPIRATORY ACIDOSIS 14-03-2015 9
  • 10. ACUTE RESPIRATORY ACIDOSIS • PaCO2 is elevated above the upper limit of the reference range (over 6.3 kPa or 45 mm Hg) with an accompanying acidemia (pH <7.36). • occurs when an abrupt failure of ventilation occurs • failure in ventilation may be caused by depression of the central respiratory center, inability to ventilate adequately due to neuromuscular disease, or airway obstruction related to asthma or chronic obstructive pulmonary disease (COPD) exacerbation. 14-03-2015 10
  • 11. CHRONIC RESPIRATORY ACIDOSIS • Chronic respiratory acidosis may be secondary to many disorders,including COPD • Chronic respiratory acidosis also may be secondary to Pickwickian syndrome, neuromuscular disorders, and severe restrictive ventilatory defects as observed in interstitial fibrosis and thoracic deformities. 14-03-2015 11
  • 12. MECHANISM • acute respiratory acidosis, compensation occurs in 2 steps. • The initial response is cellular buffering that occurs over minutes to hours. Cellular buffering elevates plasma bicarbonate (HCO3 −) only slightly, approximately 1 mEq/L for each 10-mm Hg increase in PaCO2. • The second step is renal compensation that occurs over 3–5 days. With renal compensation, renal excretion of carbonic acid is increased and bicarbonate reabsorption is increased. For instance, PEPCK is upregulated in renal proximal tubule brush border cells, in order to secrete more NH3 and thus to produce more HCO3 − 14-03-2015 12
  • 13. RESPIRATORY ALKALOSIS • Respiratory alkalosis is a medical condition in which increased respiration elevates the blood pH beyond the normal range (7.35-7.45) with a concurrent reduction in arterial levels of CO2. Alkalosis refers to disorders that elevate cellular pH to > 7.45. Alkalemia refers to an arterial pH > 7.45. 14-03-2015 13
  • 14. TYPES OF RESPIRATORY ALKALOSIS ACUTE RESPIRATORY ALKALOSIS CHRONIC RESPIRATORY ALKALOSIS 14-03-2015 14
  • 15. ACUTE RESPIRATORY ALKALOSIS • Acute respiratory alkalosis occurs rapidly. For every 10 mmHg drop in PCO2 in arterial blood, there is a corresponding 2 mEq/L drop in bicarbonate ion due to acute compensation. During acute respiratory alkalosis, the person may lose consciousness where the rate of ventilation will resume to normal. 14-03-2015 15
  • 16. CHRONIC RESPIRATORY ALKALOSIS • Chronic respiratory alkalosis is a more long-standing condition. For every 10 mmHg drop in PCO2 in arterial blood, there is a corresponding 5 mEq/L drop in bicarbonate ion. The drop of 5 mEq/L of bicarbonate ion is a compensation effect which reduces the alkalosis effect of the drop in PCO2 in blood. This is termed metabolic compensation. 14-03-2015 16
  • 17. CAUSES • psychiatric causes • CNS causes • drug use: doxapram, aspirin, caffeine and coffee abuse • moving into high altitude areas, where the low atmospheric pressure of oxygen stimulates increased ventilation • lung disease such as pneumonia • fever • pregnancy • high levels of NH4+ leading to brain swelling and decreased blood flow to the brain 14-03-2015 17
  • 18. MECHANISM • Respiratory alkalosis generally occurs when some stimulus makes a person hyperventilate. The increased breathing produces increased alveolar respiration, expelling CO2 from the circulation. This alters the dynamic chemical equilibrium of carbon dioxide in the circulatory system, and the system reacts according to Le Chatelier's principle. Circulating hydrogen ions and bicarbonate are shifted through the carbonic acid (H2CO3) intermediate to make more CO2 via the enzyme carbonic anhydrase. 14-03-2015 18
  • 19. RENAL COMPENSATION • Renal compensation is a mechanism by which the kidneys can regulate the plasma pH. It is slower than respiratory compensation, but has a greater ability to restore normal values. • In respiratory acidosis, the kidney produces and excretes ammonium (NH4 +) and monophosphate, generating bicarbonate in the process while clearing acid.[1] • In respiratory alkalosis, less HCO3 − is reabsorbed, thus lowering the pH.[2] 14-03-2015 19
  • 20. METABOLIC ACIDOSIS • Metabolic acidosis is a condition that occurs when the body produces excessive quantities of acid or when the kidneys are not removing enough acid from the body • If untreated it leads to ACIDEMIA • The consequences are so serious leading to coma and death 14-03-2015 20
  • 21. Signs and symptoms • Symptoms are not specific • Symptoms may include chest pain • , palpitations, • headache, • altered mental status such as severe anxiety due to hypoxia, • decreased visual acuity, • nausea, • vomiting, 14-03-2015 21
  • 22. • abdominal pain • altered appetite and weight gain • muscle weakness • bone pain and joint pain. • Extreme acidemia leads to neurological and cardiac complications: • Neurological: lethargy, stupor, coma, seizures. • Cardiac: arrhythmias (ventricular tachycardia), decreased response to epinephrine; both lead to hypotension (low blood pressure). 14-03-2015 22
  • 23. CAUSES • Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. There are several types of metabolic acidosis. The main causes are best grouped by their influence on the anion gap. The anion gap is the difference in the measured cations and the measured anions in serum, plasma, or urine. 14-03-2015 23
  • 24. INCREASED ANION GAP • lactic acidosis • ketoacidosis • chronic renal failure (accumulation of sulphates, phosphates, urea) • intoxication: o organic acids (salicylates, ethanol, methanol, formaldehyde, ethylene glycol, paraldehyde) o Sulphates, metformin(Glucophage) • massive rhabdomyolysis 14-03-2015 24
  • 25. NORMAL ANION GAP • longstanding diarrhoea (bicarbonate loss) • bicarbonate loss due to taking topiramate • pancreatic fistula • uretero-sigmoidostomy • intoxication: o ammonium chloride o acetazolamide (Diamox) o isopropyl alcohol • renal failure (occasionally) • inhalant abuse • toluene 14-03-2015 25
  • 26. COMPENSATION MECHANISM • Metabolic acidosis is either due to increased generation of acid or an inability to generate sufficient bicarbonate. The body regulates the acidity of the blood by four buffering mechanisms. • bicarbonate buffering system • Intracellular buffering by absorption of hydrogen atoms by various molecules, including proteins, phosphates and carbonate in bone. • Respiratory compensation • Renal compensation 14-03-2015 26
  • 27. METABOLIC ALKALOSIS • Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35-7.45). • This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate. 14-03-2015 27
  • 28. CAUSES Chloride-responsive (Urine chloride < 20 mEq/L) Chloride-resistant (Urine chloride > 20 mEq/L) 14-03-2015 28
  • 29. CHLORIDE RESPONSIVE • Loss of hydrogen ions - Most often occurs via two mechanisms, either vomiting or via the kidney. o Vomiting results in the loss of hydrochloric acid o Severe vomiting also causes loss of potassium (hypokalaemia) and sodium (hyponatremia). The kidneys compensate for these losses by retaining sodium in the collecting ducts at the expense of hydrogen ions (sparing sodium/potassium pumps to prevent further loss of potassium), leading to metabolic alkalosis. • Congenital chloride diarrhea - rare for being a diarrhea that causes alkalosis instead of acidosis. 14-03-2015 29
  • 30. • Contraction alkalosis • Diuretic therapy - loop diuretics and thiazides • Post hypercapnia - Hypoventilation (decreased respiratory rate) causes hypercapnia (increased levels of CO2), which results in respiratory acidosis. Renal compensation with excess bicarbonate occurs to lessen the effect of the acidosis. Once carbon dioxide levels return to base line, the higher bicarbonate levels reveal themselves putting the patient into metabolic alkalosis. • Cystic Fibrosis 14-03-2015 30
  • 31. CHLORIDE RESISTANT • Retention of bicarbonate • Shift of hydrogen ions into intracellular space - Seen in hypokalemia. • Alkalotic agents - Alkalotic agents, such as bicarbonate (administrated in cases of peptic ulcer or hyperacidity) or antacids, administered in excess can lead to an alkalosis. • Hyperaldosteronism 14-03-2015 31
  • 32. • Excess Glycyrrhizin consumption • Bartter syndrome and Gitelman syndrome - • Liddle syndrome • 11β-hydroxylase deficiency and 17α-hydroxylase deficiency - both characterized by hypertension • Aminoglycoside toxicity can induce a hypokalemic metabolic alkalosis via activating the calcium sensing receptor in the thick ascending limb of the nephron, inactivating the NKCC2 cotransporter, creating a Bartter's syndrome like effect. 14-03-2015 32
  • 33. RESPIRATORY COMPENSATION • Respiratory compensation is a mechanism by which plasma pH can be altered by varying the respiratory rate. It is faster than renal compensation, but has less ability to restore normal values. • In metabolic acidosis, chemoreceptors sense a deranged acid-base system, and there is increased breathing. • In metabolic alkalosis, the breathing rate is decreased. 14-03-2015 33