Respiratory alkalosis resident survival guide: Difference between revisions
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{{Familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{Familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 35em; width: 30em; padding:1em;"> '''Ask the following questions regarding CNS manifestations'''<br> | ||
---- | ---- | ||
❑If they felt [[dizzy]] or confused recently? | ❑If they felt [[dizzy]] or confused recently? | ||
[[Light-headedness]] and [[Confusion]] due to reduced [[cerebral blood flow]]<br> ❑If they felt [[numbness]] or [[tingling sensation]] on peripheral parts of the body? | [[Light-headedness]] and [[Confusion]] due to reduced [[cerebral blood flow]]<br><br> ❑If they felt [[numbness]] or [[tingling sensation]] on peripheral parts of the body? | ||
Acral [[paresthesia]] due to reduced blood flow to the skin<br> ❑Ask if they had experienced [[tremor]] of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings to check Asterexis<br> ❑If there is any history of loss of [[consciousness]]<br> ❑Ask about any event of [[seizues]]</div>}} | Acral [[paresthesia]] due to reduced blood flow to the skin<br><br> ❑Ask if they had experienced [[tremor]] of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings to check Asterexis<br><br> ❑If there is any history of loss of [[consciousness]]<br><br> ❑Ask about any event of [[seizues]]</div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask the following questions regarding Cardiovascular manifestations'''<br> | ||
---- | ---- | ||
❑Ask if they felt any chest discomfort or pain? | ❑Ask if they felt any chest discomfort or pain? | ||
Chest pain due to vasoconstriction<br> ❑If they felt their heart was racing? Ask about cardiac Arrythmia<br></div>}} | Chest pain due to vasoconstriction<br><br> ❑If they felt their heart was racing? Ask about cardiac Arrythmia<br></div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask the following questions regarding [[Metabolic]] effects'''<br> | ||
---- | ---- | ||
❑Ask if they have experienced perioral [[tingling sensation|tingling sensations]]<br> ❑[[Tetany]]<br> ❑Ask about any symptoms of mild hyponatremia, [[hypokalemia]], and [[hypophosphatemia]]</div>}} | ❑Ask if they have experienced perioral [[tingling sensation|tingling sensations]]<br><br> ❑[[Tetany]]<br> ❑Ask about any symptoms of mild hyponatremia, [[hypokalemia]], and [[hypophosphatemia]]</div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | B01 | | | |B01= Do complete physical examination}} | {{Family tree | | | | | | | B01 | | | |B01= Do complete physical examination}} | ||
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{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''[[Vital]] signs'''<br> | ||
---- | ---- | ||
❑Decreased blood pressure([[hypotension]]) due to [[hypoxemia]] <br> ❑Increased heart rate due to [[fever]], [[anxiety]]<br> ❑Increased [[temperature]] due to [[infection]] or [[sepsis]] <br> | ❑Decreased blood pressure([[hypotension]]) due to [[hypoxemia]] <br><br> ❑Increased heart rate due to [[fever]], [[anxiety]]<br> ❑Increased [[temperature]] due to [[infection]] or [[sepsis]] <br> <br> | ||
❑[[Tachypnea]] due to [[Arrhythmias]], [[hypoxemia]], [[pulmonary disease]]<br> ❑Orthostatic changes due to reduced plasma volume<br> </div>}} | ❑[[Tachypnea]] due to [[Arrhythmias]], [[hypoxemia]], [[pulmonary disease]]<br> <br>❑Orthostatic changes due to reduced plasma volume<br><br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Examination of respiratory system'''<br> | ||
---- | ---- | ||
❑Inspiratory [[crackles]] if patient has | ❑Inspiratory [[crackles]] if patient has pulmonary edema<br><br> ❑Inspiratory [[ronchi]] and [[crackles]] in patient with [[pulmonary fibrosis]]<br><br> ❑ | ||
[[Tachypnea]], pulmonary rub in [[Pulmonary embolism]]<br> ❑Prolonged expiratory [[wheezing]] in patient with [[Asthma]]<br> </div>}} | [[Tachypnea]], pulmonary rub in [[Pulmonary embolism]]<br><br> ❑Prolonged expiratory [[wheezing]] in patient with [[Asthma]]<br><br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Cardiovascular System'''<br> | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Cardiovascular System'''<br> | ||
---- | ---- | ||
❑Irregular rhythm may be seen<br> | ❑Irregular rhythm may be seen<br><br>❑Palpable P2, right ventricular heave may be seen if patient has [[pulmonary hypertension]]<br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Abdomen'''<br> | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Abdomen'''<br> | ||
---- | ---- | ||
❑[[Ascites]] in [[ | ❑[[Ascites]] in [[liver disease]]<br><br>❑[[Gravid|Gravid uterus]] in pregnany woman<br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of the [[Extremities]]'''<br> | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of the [[Extremities]]'''<br> | ||
---- | ---- | ||
❑[[Cyanosis]] due to [[hypoxemia]]<br> </div>}} | ❑[[Cyanosis]] due to [[hypoxemia]]<br><br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Central Nervous System'''<br> | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Examination of Central Nervous System'''<br> | ||
---- | ---- | ||
❑[[Tremor]], [[paresthesias]]<br>❑ Muscle weakness [[Hypokalemia]], [[hypophosphatemia]] | ❑[[Tremor]], [[paresthesias]]<br><br>❑ Muscle weakness [[Hypokalemia]], [[hypophosphatemia]] | ||
<br>❑[[Chvostek's Sign|Chvostek’s]] and [[Trousseau's sign|Trousseau’s]] signs due to Low ionized Ca2+<br> </div>}} | <br><br>❑[[Chvostek's Sign|Chvostek’s]] and [[Trousseau's sign|Trousseau’s]] signs due to Low ionized Ca2+<br><br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | B01 | | | |B01= Do following tests}} | {{Family tree | | | | | | | B01 | | | |B01= Do following tests}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Serum [[Chemistry]]'''<br> | ||
---- | ---- | ||
❑Persistent hyponatremia, hypokalemia, hypophosphatemia, and low ionized | ❑Persistent hyponatremia, hypokalemia, hypophosphatemia, and low ionized | ||
Ca2+<br> ❑Increased WBC if there is any infection<br> ❑Decreased Hemoglobin if there is [[anemia]] <br> ❑ Increased [[Hematocrit]] which is suggestive of exposure to [[high altitude]]<br> ❑Abnormal [[liver function test]]s in [[liver disease]] <br> ❑Increased T3 and T4 and low [[TSH]] in a patient of [[hyperthyroidism]]<br> ❑Positive urine β-human chorionic hormone if patient is [[pregnant]]<br> ❑When both [[respiratory alkalosis]] and high [[Anion gap]] [[metabolic acidosis]] are present—suspect [[salicylate]] intake</div>}} | Ca2+<br><br> ❑Increased WBC if there is any infection<br><br> ❑Decreased Hemoglobin if there is [[anemia]] <br><br> ❑ Increased [[Hematocrit]] which is suggestive of exposure to [[high altitude]]<br> ❑Abnormal [[liver function test]]s in [[liver disease]] <br> ❑Increased T3 and T4 and low [[TSH]] in a patient of [[hyperthyroidism]]<br><br> ❑Positive urine β-human chorionic hormone if patient is [[pregnant]]<br><br> ❑When both [[respiratory alkalosis]] and high [[Anion gap]] [[metabolic acidosis]] are present—suspect [[salicylate]] intake</div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Do [[Arterial Blood Gas]] (ABG)'''<br> | ||
---- | ---- | ||
❑low pCO2, low serum [HCO3−], high pH<br> ❑In acute respiratory alkalosis, serum [HCO3−] is around 20 mEq/L, | ❑low pCO2, low serum [HCO3−], high pH<br><br> ❑In acute respiratory alkalosis, serum [HCO3−] is around 20 mEq/L, | ||
because the secondary response to [[hypocapnia]] of 20 mmHg is a decrease of 4 mEq/L from normal [[[HCO3]]−] of 24 mEq/L<br> ❑Serum [[[HCO3]]−] from normal level of 24 mEq/L drops to | because the secondary response to [[hypocapnia]] of 20 mmHg is a decrease of 4 mEq/L from normal [[[HCO3]]−] of 24 mEq/L<br><br> ❑Serum [[[HCO3]]−] from normal level of 24 mEq/L drops to | ||
16 mEq/L in chronic [[respiratory alkalosis]] for the same [[hypocapnia]] of 20 mmHg. <br> </div>}} | 16 mEq/L in chronic [[respiratory alkalosis]] for the same [[hypocapnia]] of 20 mmHg. <br><br> </div>}} | ||
{{Family tree | | | | | | | |!| | | | | }} | {{Family tree | | | | | | | |!| | | | | }} | ||
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 3em; width: 30em; padding:1em;"> '''Do [[Chest X-ray]]'''<br> </div>}} | {{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 3em; width: 30em; padding:1em;"> '''Do [[Chest X-ray]]'''<br> </div>}} |
Revision as of 19:44, 31 October 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.
Overview
The normal physiological pH of blood is 7.35 to 7.45. An increase above this range is known as alkalosis. Respiratory alkalosis is a state where the body’s pH is more than 7.45 secondary to some respiratory or pulmonary cause.Respiratory alkalosis is characterized by the presence of low pCO2 and high pH (>7.40). Respiratory alkalosis occurs when a person breathes too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to increase and become too alkaline. It is also known as the primary hypocapnia in which patients usually present with hyperventilation. The resultant alkalinization of body fluids is balanced by a decrease in serum [HCO3−]. Secondary hypocapnia should be differentiated from primary hypocapnia, as the former occurs in response to metabolic acidosis. When respiratory alkalosis develops, a decrease in serum [HCO3−] occurs within a few minutes as soon as possible. This is due to nonbicarbonate buffering as well as H+ release from tissues. This buffering from various sources persists for several hours, and the resultant acid-base disturbance is called acute respiratory alkalosis. During acute respiratory alkalosis, the H+ secretion in both proximal tubule and cortical collecting duct is suppressed. When alkalemia persists, renal compensation starts with a decrease in both H+ secretion and basolateral exit of HCO3− in the proximal tubule. This lowers more serum [HCO3−], due to which the pH is maintained close to normal. The complete renal compensation takes 2–3 days to occur, and when a new steady state is established, it is called chronic respiratory alkalosis.
Causes
Life Threatening Causes
Life-threatening causes of Respiratory Alkalosis include
Common Causes
- Central Nervous System related causes:[1]
- Increased Intracranial Pressure[2]
- Stroke
- Head injury
- CNS infection
- Intracranial hemorrhage
- Pontine tumors
- Anxiety Hyperventilation
- Voluntary Hyperventilation
- Sepsis(Cytokine mediated)
- Chronic Liver disease(Toxin mediated)
- Drugs(Salicylates, progesterone)
- Pain
- Hypoxemic causes: Hypoxic stimulation leads to hyperventilation.
- Pulmonary Causes:
- Extrinsic Causes(deliberate or iatrogenic):
- Excessive minute ventilation during mechanical ventilation
Diagnosis
Shown below is an algorithm summarizing the diagnosis of Respiratory Alkalosis:[3][4]
Patient with Acute Respiratory Alkalosis | |||||||||||||||||||||||||
Take complete history | |||||||||||||||||||||||||
Ask the following questions regarding CNS manifestations ❑If they felt dizzy or confused recently?
Light-headedness and Confusion due to reduced cerebral blood flow ❑Ask if they had experienced tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings to check Asterexis ❑If there is any history of loss of consciousness ❑Ask about any event of seizues | |||||||||||||||||||||||||
Ask the following questions regarding Cardiovascular manifestations ❑Ask if they felt any chest discomfort or pain? Chest pain due to vasoconstriction❑If they felt their heart was racing? Ask about cardiac Arrythmia | |||||||||||||||||||||||||
Ask the following questions regarding Metabolic effects ❑Ask if they have experienced perioral tingling sensations ❑Tetany ❑Ask about any symptoms of mild hyponatremia, hypokalemia, and hypophosphatemia | |||||||||||||||||||||||||
Do complete physical examination | |||||||||||||||||||||||||
Vital signs ❑Decreased blood pressure(hypotension) due to hypoxemia ❑Orthostatic changes due to reduced plasma volume | |||||||||||||||||||||||||
Examination of respiratory system ❑Inspiratory crackles if patient has pulmonary edema ❑Prolonged expiratory wheezing in patient with Asthma | |||||||||||||||||||||||||
Examination of Cardiovascular System ❑Irregular rhythm may be seen ❑Palpable P2, right ventricular heave may be seen if patient has pulmonary hypertension | |||||||||||||||||||||||||
Examination of Central Nervous System ❑Tremor, paresthesias ❑Chvostek’s and Trousseau’s signs due to Low ionized Ca2+ | |||||||||||||||||||||||||
Do following tests | |||||||||||||||||||||||||
Serum Chemistry ❑Persistent hyponatremia, hypokalemia, hypophosphatemia, and low ionized Ca2+❑Increased WBC if there is any infection ❑Decreased Hemoglobin if there is anemia ❑ Increased Hematocrit which is suggestive of exposure to high altitude ❑Abnormal liver function tests in liver disease ❑Increased T3 and T4 and low TSH in a patient of hyperthyroidism ❑Positive urine β-human chorionic hormone if patient is pregnant ❑When both respiratory alkalosis and high Anion gap metabolic acidosis are present—suspect salicylate intake | |||||||||||||||||||||||||
Do Arterial Blood Gas (ABG) ❑low pCO2, low serum [HCO3−], high pH | |||||||||||||||||||||||||
Do Chest X-ray | |||||||||||||||||||||||||
Treatment
- Respiratory alkalosis is not self-limiting.
- Correction of the primary disorder of the respiratory alkalosis is needed
Shown below is an algorithm summarizing the treatment of Respiratory Alkalosis:
If patient comes with Anxiety or hyperventilation syndromes | Treatment options ❑Rebreathing into a paper or plastic bag ❑mild sedation ❑Reassurance | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient is Hypoxic | Treatment options ❑Give O2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Respiratory Alkalosis | Salicylates overdose | Treatment options ❑Urinary alkalinization ❑Forced diuresis ❑Dialysis | |||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has Hyperthyroidism | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has Asthma | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has Pneumonia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has Pulmonary oedema | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has Pulmonary embolism | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
If patient has history of going to high altitude, climbing | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mechanical ventilation | Treatment options ❑Reduce Ventilatory rate and tidal volume | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Patient may experience faster and deeper breathing, physician should provide reassurance and empathy which can help to get patient's breathing under control.[5]
- Physician should look for the underlying cause and it's severity.
- A patient who suffers from regular respiratory can seek help from a therapist and can learn breathing exercises, meditation, and regular exercise.[5]
Don'ts
- Patient should not hesitate to seek help from professionals in case of recurrence of respiratory alkalosis.
References
- ↑ "Respiratory Alkalosis - StatPearls - NCBI Bookshelf".
- ↑ Hopkins E, Sanvictores T, Sharma S. PMID 29939584. Missing or empty
|title=
(help) - ↑ Hasan, Ashfaq (2009). "Respiratory Alkalosis": 207–212. doi:10.1007/978-1-84800-334-7_9.
- ↑ Reddi, Alluru S. (2018). "Respiratory Alkalosis": 441–448. doi:10.1007/978-3-319-60167-0_33.
- ↑ 5.0 5.1 "Respiratory Alkalosis: Symptoms, Treatments, and Prevention".