I. TITLE: pH AND ACID-BASE BALANCE II. OBJECTIVES III. DIAGNOSIS: Hyperventialtion Syndrome IV.

DEFEND DIAGNOSIS: Hyperventilation syndrome (HVS; also chronic hyperventilation syndrome or CHVS) is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly (hyperventilation). HVS may present with chest pain and a tingling sensation in the fingertips and around the mouth (paresthesia) and may accompany a panic attack. People with HVS may feel that they cannot get enough ai. In reality, they have about the same oxygenation in the arterial blood (normal values are about 98% for hemoglobin saturation) and too little carbon dioxide in their blood and other tissues. While oxygen is abundant in the bloodstream, HVS reduces effective delivery of that oxygen to vital organs due to low-CO2-induced vasoconstriction and the suppressed Bohr effect. The hyperventilation is self-promulgating as rapid breathing causes carbon dioxide levels to fall below healthy levels, and respiratory alkalosis (high blood pH) develops. This makes the symptoms worse, which causes the person to try breathing even faster, which further exacerbates the problem. The respiratory alkalosis leads to changes in the way the nervous system fires and leads to the paresthesia, dizziness, and perceptual changes that often accompany this condition. Other mechanisms may also be at work, and some people are physiologically more susceptible to this phenomenon than others. It is then evident that the patient s signs and symptoms (light-headedness, sensation of pins and needles on her hands and around her lips and the positive response to the paper-bag treatment) are congruent with the diagnosis of Hyperventialtion Syndrome V. BIOCHEMICAL BASIS: 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 according to the following reaction

The net result of this is decreased circulating hydrogen ion concentration, and thus increased pH (alkalosis). There is also a decrease in ionized blood calcium concentration. VI. ANSWERS TO QUESTIONS: 1.What would be the expected acid-base picture in this case? The expected acid-base picture in this case would be most probablly be Resipiratory Alkalosis 2.Explain the biochemical basis for the primary acid-base abnormality An acid base disorder is a change in the normal value of extracellular pH that may result when renal (Metabolic Changes) or respiratory function (Respiratory Changes) is abnormal or when an acid

or base load overwhelms excretory capacity. Acid base status is defined in terms of the plasma pH. Acidemia is a decrease in the blood pH below normal range of 7.35 -7.45 While Alkalemia is anElevation in blood pH above the normal range of 7.35 7.45 Clinical disturbances of acid base metabolism classically are defined in terms of the HCO3- /CO2 buffer system. Acid base status is defined in terms of the plasma pH. Acidemia is a decrease in the blood pH below normal range of 7.35 -7.45 While Alkalemia is anElevation in blood pH above the normal range of 7.35 7.45 Clinical disturbances of acid base metabolism classically are defined in terms of the HCO3/CO2 buffer system. It is important to note that though acidosis and alkalosis usually leads to acidemia and alkalemia respectively, the exception occurs when there is a mixed acid base disorder. In that situation, multiple acid base processes coexisting may lead to a normal pH or a mixed picture. Since PCO2 is regulated by respiration, abnormalities that primarily alter the PCO2 are referred to as respiratory acidosis (high PCO2) and respiratory alkalosis (low PCO2). In contrast, [HCO3-] is regulated primarily by renal processes. Abnormalities that primarily alter the [HCO3-] are referred to as metabolic acidosis (low [HCO3-]) and metabolic alkalosis (high [HCO3-]). The following table will summarize the concept of acidbase balance and abnormalities Decrease in level < 7.35 General Acidosis <35 Respiratory Alkalosis <22 Metabolic Acidosis Normal 7.35-7.45 35-45 22-26 Increase in level >7.45 General Alkalosis >45 Respiratory Alkalosis >26 Metabolic Alkalosis

pH pCO2 HCO3

Compensatory mechanisms are present to maintain a normal pH in cases where there are changes in the respiratory and renal function. Once these mechanisms are unable to maintain a normal range of blood pH, then acid-base imbalance will occur. The following table shows the relationships Changes <35: Respiratory Alkalosis >45: Respiratory Acidosis HCO3 <22: Metabolic Acidosis >26: Metabolic Alkalosis Compensation Decrease in HCO3: <22 Metabolic Acidosis Increase in HCO3: >26 Metabolic Alkalosis Decrease in PCO2: <35 Respiratory Alkalosis Increase in PCO2: <45 Respiratory Acidosis Result Changes geared to normal pH 7.35-7.45

pCO2

3. What is the rationale for the improvement of the symptoms with the use of the small paper bag? When breathing into a paper bag (more calmly and slowly, if possible) it will increase the carbon dioxide level in the bag. Then, as one rebreathes the air the person just exhaled, the increased level of carbon dioxide in the air the person is intaking will increase the level of CO2 in the bloodstream and restore the calcium levels

NOTE: The problem with paper bags is not that true hyperventilation syndrome patients are at risk from the treatment. On the contrary, while it hasn't been shown to really help hyperventilation syndrome patients, it hasn't been shown to hurt them, either. What paper bags do hurt are the dangerous medical conditions that look like hyperventilation. Heart attacks and asthma are most commonly confused with hyperventilation syndrome. Breathing into a paper bag restricts the fresh air you are able to get. Without fresh air, too little oxygen is in the air you're inhaling. So, breathing into a paper bag dangerously lowers the amount of oxygen in your bloodstream. There have been several documented cases of heart attack patients incorrectly thinking they had hyperventilation syndrome and fatally worsening their heart attacks by breathing into a paper bag. To make matters worse, several studies now show a link between high concentrations of CO2 and panic attacks, which means that artificially increasing CO2 in inhaled air is likely to trigger more feelings of panic in patients who suffer from anxiety. VII. CONCLUSION Respiratory alkalosis is a clinical disturbance due to alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure of arterial carbon dioxide (PaCO2), or partial pressure of carbon dioxide (PCO2). In turn, the decrease in PCO2 increases the ratio of bicarbonate concentration to PCO2 and increases the pH level. The decrease in PCO2 (hypocapnia) develops when a strong respiratory stimulus causes the lungs to remove more carbon dioxide than is produced metabolically in the tissues. Respiratory alkalosis can be acute or chronic. In acute respiratory alkalosis, the PCO2 level is below the lower limit of normal and the serum pH is alkalemic. In chronic respiratory alkalosis, the PCO2 level is below the lower limit of normal, but the pH level is normal or near normal. VIII. RESOURCES http://fitsweb.uchc.edu/student/selectives/TimurGraham/Introduction_to_Acid_Base_disorders.html http://www.nda.ox.ac.uk/wfsa/html/u13/u1312_02.htm http://emedicine.medscape.com/article/301680-overview