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Alveolar-arterial O2 gradient or A-
a gradient= PAO2-PaO2
Respiratory Membrane
A-a gradient
A-a gradient
• The alveolar arterial oxygen difference can be
calculated by subtracting measured PaO2 from
calculated PAO2
1. Decrease in inspired O2
2. Hypoventilation
3. Shunting
4. Ventilation/Perfusion V/Q mismatch
Mechanisms
• Problem:
– nervous system defects (CNS, NM junction)
– toxic drug effects (barbiturates, morphine)
• Solution:
O2 supplementation
– mechanical ventilation
– respiratory stimulants
• Diffusion Impairment
• ↓DLO2 ↓PaO2 ↑A-a gradient
• Problem:
– interstitial fibrosis (thickness of alveolar capillary
membrane)
– interstitial pneumonia ( thickness of alveolar cap
membrane)
– pulmonary edema with alveolar flooding (↓area gas
exchange)
• Solution:
↑ PAO2, but beware of oxygen toxicity
– acute 100% O2 (< 2 days) induces pulmonary
capillary permeability and alveolar edema
– chronic 100% O2 (> 2 days) induces interstitial
fibrosis
• Shunting → ↑A-a gradient + ↑ PaCO2
Problem:
• normal shunts: venous drainage from bronchial circ
• abnormal shunts: atrial or septal defects, patent ductus
arteriosus
Solution:
• surgical repair of arterial-venous anastomosis
• oxygen administration will not help (diagnostic test for
shunt)
• PaCO2 may not be raised above normal (40mm Hg)
• V/Q Mismatching → ↑A-a gradient + ↔↑ PaCO2
Problem:
– chronic obstructive pulmonary disease (COPD)
(emphysema, bronchitis)
– pulmonary embolism
Solution: ↑PAO2
– PaO2 is still improved with oxygen supplementation
• Diarrhea:
Loss of HCO3 in diarrhea
• Renal Tubular acidosis:
Urinary loss of HCO3 in proximal RTA; impaired
tubular secretion in distal RTA
Anion gap Metabolic Acidosis
• Lactic acidosis:
Tissue hypoxia (e.g. shock) or liver disease
• Aspirin poisoning:
Accumulation of salicylates
• Methanol poisoning:
Accumulation of formate
• Renal failure:
Accumulation of organic acids
• Diabetic ketoacidosis:
Accumulation of ketones with hyperglycemia
• Isopropyl alcohol, ehylene glycol poisoning:
Accumulation of glycolate, oxalate
Management
• Identifying and correcting the cause