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You cannot tell if a respiratory acid-base disorder from the ABG

This is a frequent cause of confusion. I know that I was confused by this when I was a young learner. And I believe the source of this confusion was garbled teaching from a resident that was still struggling with the concept.

Take this ABG:

pH: 7.26

PaCO2: 80


The Henderson-Hasselbalch variables are moving in discordant directions (pH down, pCO2 and HCO3 going up) so it is a respiratory disorder. The pH is decreased so this is a respiratory acidosis.

Now look at the compensation to see if there is a second primary disorder affecting compensation.

  • In acute respiratory acidosis the HCO3 rises 1 mEq/L for every 10 mmHg the CO2 rises.
  • In chronic respiratory acidosis the HCO3 rises 3 mEq/L for every 10 mmHg the CO2 rises.

This patient’s CO2 is 80, an increase of 40, so the HCO3 should rise 4 (4×1) if the respiratory acidosis is acute, yielding a bicarb of 28 (24+4). The actual bicarbonate is 39, too high, so there is an additional metabolic alkalosis if the respiratory acidosis is acute.

If the respiratory acidosis is chronic, to increase in CO2 of 40 should increase the bicarbonate by 12 (4×3), so a bicarb of 36 (24+12). The actual bicarbonate is 39, which is just outside of our ±2 so we’ll call it nearly appropriate with just a touch of metabolic acidosis.

The ABG can be “solved” with either acute or chronic respiratory acidosis. Patients cannot be diagnosed with Occam’s razor so the simpler explanation (chronic respiratory acidosis without the need for additional acid-base disorders) may not be the right one. In medicine we need to assume Hickam’s Dictum “A patient can have as many diseases as he damn well pleases.”

The ABG does not determine whether a patient has acute or chronic respiratory disorder, the physician must do that.

So what’s my beef with the two Bruces? Take a look at this question from chapter 8…

The simple acid-base disorders are:

  1. Metabolic acidosis
  2. Metabolic alkalosis
  3. Respiratory acidosis
  4. Respiratory alkalosis
  5. Respiratory acidosis
  6. Respiratory alkalosis

But this is answers the authors expect…

Since the question stipulates that these are simple acid-base disorders, one can extrapolate the acuity of the respiratory disorder by the degree the bicarb has adjusted, a large adjustment is chronic, and a smaller change is acute. But since patients don’t tell you if they have simple or complex acid-base disorders when the blood is drawn, this trains students to expect the ABG to provide information that it cannot provide.

Stupid book.