DR BINOD KUMAR SINGHDR BINOD KUMAR SINGH Associate Professor, PMCH, PatnaAssociate Professor, PMCH, Patna
CIAP Executive board member- 2015 CIAP Executive board member- 2015 NNF State president,Bihar- 2014NNF State president,Bihar- 2014
IAP State secretary,Bihar-2010-2011IAP State secretary,Bihar-2010-2011 NNF State secretary,Bihar-2008-2009NNF State secretary,Bihar-2008-2009
- - Consultant Neonatologist & PediatricianConsultant Neonatologist & Pediatrician
Shiv Shishu Hospital :K-208, P.C Colony.Hanuman Nagar, Patna – Shiv Shishu Hospital :K-208, P.C Colony.Hanuman Nagar, Patna – 800020800020
Web site : www.shivshishuhospital.comWeb site : www.shivshishuhospital.com
ABG ABG INTERPRETATIONINTERPRETATION
ABG InterpretationABG Interpretation
First, does the patient have an First, does the patient have an acidosis or an alkalosisacidosis or an alkalosis
Second, what is the primary problem Second, what is the primary problem – metabolic or respiratory– metabolic or respiratory
Third, is there any compensation by Third, is there any compensation by the patient – respiratory the patient – respiratory compensation is immediate while compensation is immediate while renal compensation takes timerenal compensation takes time
ABG InterpretationABG Interpretation
It would be extremely unusual for It would be extremely unusual for either the respiratory or renal system either the respiratory or renal system to overcompensateto overcompensate
The pH determines the primary The pH determines the primary problemproblem
After determining the primary After determining the primary problem and compensatory problem and compensatory acid/base balance, always evaluate acid/base balance, always evaluate the effectiveness of oxygenationthe effectiveness of oxygenation
Normal ValuesNormal Values
pH - 7.35 to 7.45pH - 7.35 to 7.45paCOpaCO2- 2- 36 to 44 mm Hg 36 to 44 mm Hg
HCOHCO33 -22 to 26 meq/L -22 to 26 meq/L
Abnormal ValuesAbnormal Values
pH < 7.35pH < 7.35 Acidosis (metabolic Acidosis (metabolic
and/or respiratory)and/or respiratory)
pH > 7.45pH > 7.45 Alkalosis (metabolic Alkalosis (metabolic
and/or respiratory)and/or respiratory)
paCOpaCO22 > 44 mm Hg > 44 mm Hg Respiratory Respiratory
acidosis (alveolar acidosis (alveolar hypoventilation)hypoventilation)
paCOpaCO22 < 36 mm Hg < 36 mm Hg Respiratory Respiratory
alkalosis (alveolar alkalosis (alveolar hyperventilation)hyperventilation)
HCOHCO33 < 22 meq/L < 22 meq/L Metabolic acidosis Metabolic acidosis
HCOHCO33 > 26 meq/L > 26 meq/L Metabolic alkalosisMetabolic alkalosis
Putting It Together - Putting It Together - RespiratoryRespiratory
SoSo
paCOpaCO22 > 44 with a pH < 7.35 represents a > 44 with a pH < 7.35 represents a respiratory acidosisrespiratory acidosis
paCOpaCO22 < 36 with a pH > 7.45 represents a < 36 with a pH > 7.45 represents a respiratory alkalosisrespiratory alkalosis
For a primary respiratory problem, pH and For a primary respiratory problem, pH and paCOpaCO22 move in the opposite direction move in the opposite direction For each deviation in paCOFor each deviation in paCO22 of 10 mm Hg in of 10 mm Hg in
either direction, 0. 08 pH units change in the either direction, 0. 08 pH units change in the opposite directionopposite direction
Putting It Together - Putting It Together - MetabolicMetabolic
AndAnd
HCOHCO33 < 22 with a pH < 7.35 < 22 with a pH < 7.35 represents a metabolic acidosis represents a metabolic acidosis
HCOHCO33 > 26 with a pH > 7.45 > 26 with a pH > 7.45 represents a metabolic alkalosisrepresents a metabolic alkalosis
For a primary metabolic problem, pH For a primary metabolic problem, pH and HCOand HCO33 are in the same direction, are in the same direction, and paCOand paCO22 is also in the same is also in the same directiondirection
CompensationCompensation
The body’s attempt to return the The body’s attempt to return the acid/base status to normal (i.e. pH acid/base status to normal (i.e. pH closer to 7.4)closer to 7.4)
Primary ProblemPrimary Problem CompensationCompensation
respiratory acidosisrespiratory acidosismetabolic alkalosismetabolic alkalosis
respiratory alkalosisrespiratory alkalosis metabolic metabolic acidosisacidosis
metabolic acidosismetabolic acidosis respiratory alkalosisrespiratory alkalosis
metabolic alkalosismetabolic alkalosis respiratory acidosisrespiratory acidosis
REMEMBER BY HEARTREMEMBER BY HEART
CO2 IS A RESPIRATORY ACIDCO2 IS A RESPIRATORY ACIDPh and HCO3- Move in same direction.Ph and HCO3- Move in same direction.pH and PCO2- Move in opposite pH and PCO2- Move in opposite
direction.direction.HCO3 and PCO2- Move in same HCO3 and PCO2- Move in same
direction-simple disorder.direction-simple disorder.HCO3 and PCO2- Move in opposite HCO3 and PCO2- Move in opposite
direction-mixed disorder. direction-mixed disorder.
Expected CompensationExpected Compensation
Respiratory acidosisRespiratory acidosisAcute – the pH decreases 0.08 units for Acute – the pH decreases 0.08 units for
every 10 mm Hg increase in paCOevery 10 mm Hg increase in paCO22; ; HCOHCO33 1 mEq/liter per 1 mEq/liter per 10 mm Hg paCO10 mm Hg paCO22
Chronic – the pH decreases 0.03 units Chronic – the pH decreases 0.03 units for every 10 mm Hg increase in paCOfor every 10 mm Hg increase in paCO22; ; HCOHCO33 4 mEq/liter per 4 mEq/liter per 10 mm Hg paCO10 mm Hg paCO22
Expected CompensationExpected Compensation
Respiratory alkalosisRespiratory alkalosisAcute – the pH increases 0.08 units for Acute – the pH increases 0.08 units for
every 10 mm Hg decrease in paCOevery 10 mm Hg decrease in paCO22; ; HCOHCO33 2 mEq/liter per 2 mEq/liter per 10 mm Hg paCO10 mm Hg paCO22
Chronic - the pH increases 0.03 units for Chronic - the pH increases 0.03 units for every 10 mm Hg decrease in paCOevery 10 mm Hg decrease in paCO22; ; HCOHCO33 4 mEq/liter per 4 mEq/liter per 10 mm Hg paCO10 mm Hg paCO22
Expected CompensationExpected Compensation
Metabolic acidosisMetabolic acidosispaCOpaCO22 = 1.5(HCO = 1.5(HCO33) + 8 () + 8 (2)-winter’s 2)-winter’s
formulaformulapaCOpaCO22 1-1.5 per 1-1.5 per 1 mEq/liter HCO1 mEq/liter HCO33
Metabolic alkalosisMetabolic alkalosispaCOpaCO22 = 0.7(HCO = 0.7(HCO33) + 20 () + 20 (1.5)1.5)
paCOpaCO22 0.5-1.0 per 0.5-1.0 per 1 mEq/liter HCO1 mEq/liter HCO33
Classification of primary acid-Classification of primary acid-base disturbances and base disturbances and
compensationcompensation Acceptable ventilatory and metabolic acid-Acceptable ventilatory and metabolic acid-
base statusbase status Respiratory acidosis (alveolar Respiratory acidosis (alveolar
hypoventilation) - acute, chronic hypoventilation) - acute, chronic Respiratory alkalosis (alveolar Respiratory alkalosis (alveolar
hyperventilation) - acute, chronichyperventilation) - acute, chronic Metabolic acidosis – uncompensated, Metabolic acidosis – uncompensated,
compensated compensated Metabolic alkalosis – uncompensated, Metabolic alkalosis – uncompensated,
partially compensatedpartially compensated
Acute Respiratory AcidosisAcute Respiratory Acidosis
paCOpaCO22 is elevated and pH is acidotic is elevated and pH is acidoticThe decrease in pH is accounted for The decrease in pH is accounted for
entirely by the increase in paCOentirely by the increase in paCO22
Bicarbonate and base excess will be Bicarbonate and base excess will be in the normal range because the in the normal range because the kidneys have not had adequate time kidneys have not had adequate time to establish effective compensatory to establish effective compensatory mechanismsmechanisms
Acute Respiratory AcidosisAcute Respiratory Acidosis
CausesCausesRespiratory pathophysiology - airway Respiratory pathophysiology - airway
obstruction, severe pneumonia, chest obstruction, severe pneumonia, chest trauma/pneumothoraxtrauma/pneumothorax
Acute drug intoxication (narcotics, Acute drug intoxication (narcotics, sedatives)sedatives)
Residual neuromuscular blockadeResidual neuromuscular blockadeCNS disease (head trauma)CNS disease (head trauma)
Chronic Respiratory AcidosisChronic Respiratory Acidosis
paCOpaCO22 is elevated with a pH in the is elevated with a pH in the acceptable rangeacceptable range
Renal mechanisms increase the Renal mechanisms increase the excretion of Hexcretion of H++ within 24 hours and within 24 hours and may correct the resulting acidosis may correct the resulting acidosis caused by chronic retention of COcaused by chronic retention of CO2 2 to to a certain extenta certain extent
Chronic Respiratory AcidosisChronic Respiratory Acidosis
CausesCausesChronic lung disease (BPD, COPD)Chronic lung disease (BPD, COPD)Neuromuscular diseaseNeuromuscular diseaseExtreme obesityExtreme obesityChest wall deformityChest wall deformity
Acute Respiratory AlkalosisAcute Respiratory Alkalosis
paCOpaCO22 is low and the pH is alkalotic is low and the pH is alkaloticThe increase in pH is accounted for The increase in pH is accounted for
entirely by the decrease in paCOentirely by the decrease in paCO22
Bicarbonate and base excess will be Bicarbonate and base excess will be in the normal range because the in the normal range because the kidneys have not had sufficient time kidneys have not had sufficient time to establish effective compensatory to establish effective compensatory mechanismsmechanisms
Respiratory AlkalosisRespiratory Alkalosis
CausesCauses PainPain AnxietyAnxiety HypoxemiaHypoxemia Restrictive lung Restrictive lung
diseasedisease Severe congestive Severe congestive
heart failureheart failure Pulmonary emboliPulmonary emboli
DrugsDrugs SepsisSepsis FeverFever ThyrotoxicosisThyrotoxicosis PregnancyPregnancy Overaggressive Overaggressive
mechanical mechanical ventilationventilation
Hepatic failureHepatic failure
Uncompensated Metabolic Uncompensated Metabolic AcidosisAcidosis
Normal paCONormal paCO22, low HCO, low HCO33, and a pH , and a pH less than 7.30less than 7.30
Occurs as a result of increased Occurs as a result of increased production of acids and/or failure to production of acids and/or failure to eliminate these acidseliminate these acids
Respiratory system is not Respiratory system is not compensating by increasing alveolar compensating by increasing alveolar ventilation (hyperventilation)ventilation (hyperventilation)
Compensated Metabolic Compensated Metabolic AcidosisAcidosis
paCOpaCO22 less than 30, low HCO less than 30, low HCO33, with a , with a pH of 7.3-7.4pH of 7.3-7.4
Patients with chronic metabolic Patients with chronic metabolic acidosis are unable to hyperventilate acidosis are unable to hyperventilate sufficiently to lower paCOsufficiently to lower paCO22 for for complete compensation to 7.4complete compensation to 7.4
Elevated AGElevated AGMetabolic AcidosisMetabolic Acidosis
CausesCausesKetoacidosis - diabetic, alcoholic, Ketoacidosis - diabetic, alcoholic,
starvationstarvationLactic acidosis - hypoxia, shock, sepsis, Lactic acidosis - hypoxia, shock, sepsis,
seizuresseizuresToxic ingestion - methanol, ethylene Toxic ingestion - methanol, ethylene
glycol, ethanol, isopropyl alcohol, glycol, ethanol, isopropyl alcohol, paraldehyde, tolueneparaldehyde, toluene
Renal failure - uremiaRenal failure - uremia
Normal AG Metabolic AcidosisNormal AG Metabolic Acidosis
CausesCauses Renal tubular Renal tubular
acidosisacidosis Post respiratory Post respiratory
alkalosisalkalosis HypoaldosteronismHypoaldosteronism Potassium sparing Potassium sparing
diureticsdiuretics Pancreatic loss of Pancreatic loss of
bicarbonatebicarbonate
DiarrhoeaDiarrhoea Carbonic anhydrase Carbonic anhydrase
inhibitorsinhibitors Acid administration Acid administration
(HCl, NH(HCl, NH44Cl, Cl, arginine HCl)arginine HCl)
SulfamylonSulfamylon CholestyramineCholestyramine Ureteral diversionsUreteral diversions
Effectiveness of OxygenationEffectiveness of Oxygenation
Further evaluation of the arterial blood gas Further evaluation of the arterial blood gas requires assessment of the effectiveness requires assessment of the effectiveness of oxygenation of the bloodof oxygenation of the blood
Hypoxemia – decreased oxygen content of Hypoxemia – decreased oxygen content of blood - paOblood - paO22 less than 60 mm Hg and the less than 60 mm Hg and the saturation is less than 90%saturation is less than 90%
Hypoxia – inadequate amount of oxygen Hypoxia – inadequate amount of oxygen available to or used by tissues for available to or used by tissues for metabolic needsmetabolic needs
Mechanisms of HypoxemiaMechanisms of Hypoxemia
Inadequate inspiratory partial Inadequate inspiratory partial pressure of oxygenpressure of oxygen
HypoventilationHypoventilationRight to left shuntRight to left shuntVentilation-perfusion mismatchVentilation-perfusion mismatch Incomplete diffusion equilibriumIncomplete diffusion equilibrium
Assessment of Gas ExchangeAssessment of Gas Exchange
Alveolar-arterial OAlveolar-arterial O22 tension difference tension difference A-a gradientA-a gradient PAOPAO22-PaO-PaO22
PAOPAO22 = FiO = FiO22(BP - PH(BP - PH22O) - PaCOO) - PaCO22/RQ*/RQ* Arterial-Alveolar OArterial-Alveolar O22 tension ratio tension ratio
PaOPaO22/PAO/PAO22
Arterial-Inspired OArterial-Inspired O22 ratio ratio PaOPaO22/FIO/FIO2 2 * *
Respiratary quotient= 0.8 Respiratary quotient= 0.8
Assessment of Gas ExchangeAssessment of Gas Exchange
A-a DO2={(FIO2)(760-47)-(1.25)(PaCO2)}-A-a DO2={(FIO2)(760-47)-(1.25)(PaCO2)}-PaO2PaO2
Normal A-a gradient -10-20 mm HgNormal A-a gradient -10-20 mm Hg Increased A-a gradient with hypoxemia- Increased A-a gradient with hypoxemia-
oxygenation failure /V-Q mismatch/lung oxygenation failure /V-Q mismatch/lung disorderdisorder
Normal A a gradient with hypoxemia- Normal A a gradient with hypoxemia- ventilation failure/hypoventilationventilation failure/hypoventilation
Assessment of Gas ExchangeAssessment of Gas ExchangeABGABG A-a gradA-a grad
PaOPaO22 PaCOPaCO22 RARA 100%100%
Low FIOLow FIO22 N*N* NN
Alveolar hypoventilationAlveolar hypoventilation NN NN
Altered gas exchangeAltered gas exchange
Regional V/Q mismatchRegional V/Q mismatch /N//N/ N/N/ Intrapulmonary R to L shuntIntrapulmonary R to L shunt N/N/ Impaired diffusionImpaired diffusion N/N/ NN
Anatomical R to L shuntAnatomical R to L shunt
(intrapulmonary or intracardiac)(intrapulmonary or intracardiac) N/N/ * N=normal* N=normal
INDICATION FOR ECMOINDICATION FOR ECMO
IF iNO VENTILATION INCLUDING HFO VENTILATION UNABLE TO SUSTAIN LIFE
IF AO2-aO2 GRADIENT OF MORE THAN 600 mmHg FOR 6 TO 12 hrs
VENTILATION INDEX= [ (RR * PIP * paCO2 ) / 1000 ] , of more than 90 for 4 hr
OXYGENATION INDEX= (MAP * FiO2) Post-ductal paO2
, of more than 40 in two ABGs at 1 hr apart
ABG REPORT - SHIV SHISHU HOSPITAL PATNAABG REPORT - SHIV SHISHU HOSPITAL PATNA DATE/TIME 27:07:2011 12:12DATE/TIME 27:07:2011 12:12 SAMPLE No- 5388SAMPLE No- 5388 Pat ID B N 5 Pat ID B N 5 Sample type arterial blood Sample type arterial blood BARO- 747.2mm HgBARO- 747.2mm Hg Temp- 37.0 CTemp- 37.0 C A/F FETALA/F FETAL PO2 82.5 mmHg(80.0-100.0PO2 82.5 mmHg(80.0-100.0 PCO2 36 mmHg(-)(35.0-45.0)PCO2 36 mmHg(-)(35.0-45.0) pH 7.393 (7.350-7.450)pH 7.393 (7.350-7.450) Na 143.1 mmol/L(135.0-148.0)Na 143.1 mmol/L(135.0-148.0) Cl 104.1 mmol/L(98.0-107.0)Cl 104.1 mmol/L(98.0-107.0) Ica 1.267 mmol/L(1.120-1.320)Ica 1.267 mmol/L(1.120-1.320) K 3.74 mmol/L(3.50-4.50) K 3.74 mmol/L(3.50-4.50) Hct 49.7 % (35.0-50.0)Hct 49.7 % (35.0-50.0) BE -3.6 mmol/LBE -3.6 mmol/L BEecf -4.5 mmol/LBEecf -4.5 mmol/L CHCO3st 23 mmol/LCHCO3st 23 mmol/L P50 21.5 mmHgP50 21.5 mmHg ctO2 20.7 vol%ctO2 20.7 vol%
ABG REPORT- SHIV SHISHU HOSPITAL PATNAABG REPORT- SHIV SHISHU HOSPITAL PATNA
DATE/TIME 27:07:2011 12:17DATE/TIME 27:07:2011 12:17 SAMPLE No- 5389SAMPLE No- 5389 Pat ID B N 15Pat ID B N 15
Sample type arterial Blood Sample type arterial Blood BARO- 747.0mm HgBARO- 747.0mm Hg Temp- 37.0 CTemp- 37.0 C A/F FETALA/F FETAL PO2 153.2 mmHg(+)(80.0-100.0)PO2 153.2 mmHg(+)(80.0-100.0) PCO2 59.3 mmHg(+)(35.0-45.0)PCO2 59.3 mmHg(+)(35.0-45.0) pH 7.262 (7.350-7.450)pH 7.262 (7.350-7.450) Na 136.3 mmol/L(135.0-148.0)Na 136.3 mmol/L(135.0-148.0) Cl 99.4 mmol/L(98.0-107.0)Cl 99.4 mmol/L(98.0-107.0) Ica 0.977 mmol/L(--)(1.120-1.320)Ica 0.977 mmol/L(--)(1.120-1.320) K 4.38 mmol/L(3.50-4.50) K 4.38 mmol/L(3.50-4.50) Hct 38.4 % (35.0-50.0)Hct 38.4 % (35.0-50.0) BE -2.1 mmol/LBE -2.1 mmol/L BEecf -0.9 mmol/LBEecf -0.9 mmol/L CHCO3st 22.1 mmol/LCHCO3st 22.1 mmol/L P50 21.5 mmHgP50 21.5 mmHg ctO2 21.2 vol%ctO2 21.2 vol%
ABG REPORT-S SHIV SHISHU HOSPITAL PATNAABG REPORT-S SHIV SHISHU HOSPITAL PATNA
DATE/TIME 27:07:2011 11:08DATE/TIME 27:07:2011 11:08 SAMPLE No- 5386SAMPLE No- 5386 Pat ID B N 3Pat ID B N 3
Sample type arterial Blood Sample type arterial Blood BARO- 747.2mm HgBARO- 747.2mm Hg Temp- 37.0 CTemp- 37.0 C A/F FETALA/F FETAL PO2 57.5 mmHg(--)(80.0-100.0)PO2 57.5 mmHg(--)(80.0-100.0) PCO2 26.6 mmHg(-)(35.0-45.0)PCO2 26.6 mmHg(-)(35.0-45.0) pH 7.482 (+) (7.350-7.450)pH 7.482 (+) (7.350-7.450) Na 139.6 mmol/L(135.0-148.0)Na 139.6 mmol/L(135.0-148.0) Cl 101.0 mmol/L(98.0-107.0)Cl 101.0 mmol/L(98.0-107.0) Ica 1.006 mmol/L(--)(1.120-1.320)Ica 1.006 mmol/L(--)(1.120-1.320) K 3.41 mmol/L(3.50-4.50) K 3.41 mmol/L(3.50-4.50) Hct 57.3 %(+) (35.0-50.0)Hct 57.3 %(+) (35.0-50.0) BE -2.3 mmol/LBE -2.3 mmol/L BEecf -4.0 mmol/LBEecf -4.0 mmol/L CHCO3st 22.4 mmol/LCHCO3st 22.4 mmol/L P50 21.5 mmHgP50 21.5 mmHg ctO2 20.2 vol%ctO2 20.2 vol%
ABG REPORT- SHIV SHISHU HOSPITAL PATNAABG REPORT- SHIV SHISHU HOSPITAL PATNA
DATE/TIME 27:07:2011 20:16DATE/TIME 27:07:2011 20:16 SAMPLE No- 5324SAMPLE No- 5324 Pat ID B N 5Pat ID B N 5
Sample type arterial Blood Sample type arterial Blood BARO- 740.4mm HgBARO- 740.4mm Hg Temp- 37.0 CTemp- 37.0 C A/F FETALA/F FETAL PO2 52.6 mmHg(--)(80.0-100.0)PO2 52.6 mmHg(--)(80.0-100.0) PCO2 24.6 mmHg(-)(35.0-45.0)PCO2 24.6 mmHg(-)(35.0-45.0) pH 7.255 (-) (7.350-7.450)pH 7.255 (-) (7.350-7.450) Na 134.1 mmol/L(135.0-148.0)Na 134.1 mmol/L(135.0-148.0) Cl 98.7 mmol/L(98.0-107.0)Cl 98.7 mmol/L(98.0-107.0) Ica 1.064 mmol/L(--)(1.120-1.320)Ica 1.064 mmol/L(--)(1.120-1.320) K 3.95 mmol/L(3.50-4.50) K 3.95 mmol/L(3.50-4.50) Hct 56.8 %(+) (35.0-50.0)Hct 56.8 %(+) (35.0-50.0) BE -14.5 mmol/LBE -14.5 mmol/L BEecf -16.5 mmol/LBEecf -16.5 mmol/L CHCO3st 13.2 mmol/LCHCO3st 13.2 mmol/L P50 21.5 mmHgP50 21.5 mmHg ctO2 18.7 vol%ctO2 18.7 vol%
SummarySummary
First, does the patient have an acidosis or First, does the patient have an acidosis or an alkalosis an alkalosis Look at the pHLook at the pH
Second, what is the primary problem – Second, what is the primary problem – metabolic or respiratorymetabolic or respiratory Look at the pCOLook at the pCO22
If the pCOIf the pCO22 change is in the opposite direction change is in the opposite direction of the pH change, the primary problem is of the pH change, the primary problem is respiratoryrespiratory
SummarySummary
Third, is there any compensation by Third, is there any compensation by the patient - do the calculationsthe patient - do the calculationsFor a primary respiratory problem, is the For a primary respiratory problem, is the
pH change completely accounted for by pH change completely accounted for by the change in pCOthe change in pCO22if yes, then there is no metabolic if yes, then there is no metabolic
compensationcompensationif not, then there is either partial if not, then there is either partial
compensation or concomitant metabolic compensation or concomitant metabolic problemproblem
SummarySummary
For a metabolic problem, calculate the For a metabolic problem, calculate the expected pCOexpected pCO22if equal to calculated, then there is if equal to calculated, then there is
appropriate respiratory compensationappropriate respiratory compensationif higher than calculated, there is if higher than calculated, there is
concomitant respiratory acidosisconcomitant respiratory acidosisif lower than calculated, there is if lower than calculated, there is
concomitant respiratory alkalosisconcomitant respiratory alkalosis
SummarySummary
Next, don’t forget to look at the Next, don’t forget to look at the effectiveness of oxygenation, (and effectiveness of oxygenation, (and look at the patient)look at the patient)your patient may have a significantly your patient may have a significantly
increased work of breathing in order to increased work of breathing in order to maintain a “normal” blood gasmaintain a “normal” blood gas
metabolic acidosis with a concomitant metabolic acidosis with a concomitant respiratory acidosis is concerningrespiratory acidosis is concerning
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