Respiratory acidosis is a disturbance in acid-base balance where the decrease of ventilation increases carbon dioxide concentration and decreases the blood’s pH (acidosis). Acute respiratory acidosis is a sudden failure of ventilation from a neuromuscular or central nervous system disease.
This is considered as a medical emergency because carbon dioxide builds up quickly before the kidneys can compensate and return to a state of balance.
While chronic respiratory acidosis is caused by a prolonged state of hypoxia and hypercapnia, secondary to chronic obstructive pulmonary disease. This results in a stable condition where the kidneys increase body chemicals to restore the acid-base balance.
Signs and Symptoms of Respiratory Acidosis
The clinical presentation of respiratory acidosis varies based on severity and its underlying cause such as:
- shortness of breath
- sweating, warm, and flushed skin
- headache and sleepiness due to obstructive sleep apnea (osa)
- anxiety or restlessness
- blurring of vision
- peripheral cyanosis due to hypoxemia
- lethargy or fatigue
- personality changes due to acid levels in the brain
- confusion or delirium
- myoclonic jerks, blunted deep tendon reflexes, muscle twitching or tremors
- seizures due to prolonged hypoventilation
- stupor or coma due to high levels of carbon dioxide in the brain
- confusion or memory loss
- delirium or carbon dioxide narcosis
- impaired gait or coordination
- arrhythmias or heart failure due to the low ph in the blood
- increased intracranial pressure (ICP) and papilledema due to cerebral vasodilation caused by hypercapnia
Causes of Respiratory Acidosis
Respiratory acidosis may be caused by a variety of different causes such as:
- COPD. Diseases of the lungs such as severe asthma, emphysema, and chronic bronchitis cause airway obstruction and may gradually develop into respiratory failure.
- Chest wall disorders. Limits the lung functioning and breathing such as scoliosis, status post thoracoplasty, flail chest, ankylosing spondylitis, pectus excavatum, or carinatum.
- Lung diseases. This causes scarring and thickening of lung tissues such as pulmonary fibrosis, interstitial lung disease, and laryngeal or tracheal stenosis.
- CNS depression. Narcotics and benzodiazepines can cause breathing suppression.
- Neurologic disorders. Encephalitis, brain stem diseases, or trauma due to sudden failure of ventilation.
- Neuromuscular diseases. This affects the signal to the lungs to inflate or deflate such as Amyotrophic Lateral Sclerosis (ALS), Guillain-Barre syndrome, myasthenia gravis, muscular dystrophy, diaphragm dysfunction, and paralysis.
- Obstructive sleep apnea (OSA). A disorder that causes repetitive collapse of the upper airways while sleeping.
- Dead space ventilation. A mismatch between ventilation and perfusion such as pneumonia, pulmonary edema, and pneumothorax.
- Obesity-hypoventilation syndrome. Restricts the lungs from expanding.
- Hypermetabolic states. This can cause an elevation of carbon dioxide levels such as overfeeding, sepsis, thyroid crisis, and malignant hyperthermia.
- Bronchoscopy-guided percutaneous dilation tracheostomy. This reduces minute ventilation which causes acute respiratory acidosis.
- Lung-protective mechanical ventilation. Patients with acute respiratory distress syndrome (ARDS) require paralytic agents and heavy sedation.
- Administration of bicarbonate. Use in dialysis treatment to buffer acidosis, however, this may cause an elevated partial arterial pressure of carbon dioxide (PaCO2) levels leading to acute respiratory acidosis.
Risk Factors to Respiratory Acidosis
Some factors that increase the risk of developing respiratory acidosis are:
- Asthma. Asthma is a common illness among all age groups and the risk of respiratory acidosis increases with exacerbation. Hypoxemia compromises heart-lung interaction and perfusion with an increased workload.
- Surgery. Patients undergoing surgery tend to develop carbon dioxide retention especially if adequate ventilation is not maintained. General anesthesia increased arterial carbon dioxide tension resulting in respiratory acidosis. Additionally, rebreathing after being under general anesthesia can lead to an increase inspired carbon dioxide.
- End-stage COPD. Respiratory acidosis is commonly observed in patients with COPD in the advanced phase, worsening the prognosis and fatality rate. Patients with end-stage COPD are prone to carbon dioxide retention even during oxygen therapy.
- Smoking. This can cause a variety of lung diseases leading to respiratory acidosis. Smoking and exposure to secondhand smoke are strongly related to the development of COPD.
- Obesity. Hypoventilation syndrome usually results from morbid obesity due to structural and functional impairment. Obese individuals have decreased chest wall expansion causing restrictive lung function. This also causes sleep-related breathing alterations due to decreased alveolar ventilation.
- Opioids. These drugs can cause hypoventilation and respiratory acidosis when abused or overdose reaching toxicity levels. Opioid-induced respiratory depression (OIRD) causes an increase in carbon dioxide in the brain leading to respiratory failure.
Complications of Respiratory Acidosis
Respiratory acidosis may lead to the following complications:
- Poor organ function. Respiratory acidosis can damage the kidneys and lungs when these organs cannot compensate for the excess acid accumulating in the blood and body. The kidneys and lungs play a major role in maintaining pH balance in the body and even a small damage can cause significant effects on other vital organs.
- Respiratory failure. This can happen when the respiratory system fails in one or both of its gas exchange functions such as when there is a build-up of carbon dioxide in the blood, and dangerously low levels of oxygen making it difficult to breathe on your own. Increased carbon dioxide can cause hypoxemia due to alveolar hypoventilation or decreased respiratory drive. Respiratory failure also causes lactic acidosis which impairs ventilation and tissue oxygenation.
- Shock. Severe acidemia causes vasodilation due to smooth muscle hyperpolarization leading to hypotension. Respiratory acidosis decreases vascular resistance and hemodynamic stability leading to refractory shock and death.
- Neurologic complications. High levels of carbon dioxide reduce the amount of oxygen that reaches the brain causing impaired cognitive function or even brain damage. The combination of hypoxia and hypercapnia causes cerebral vasodilation increasing intracranial pressure.
- Cardiovascular complications. Respiratory acidosis increases work demand on the heart causing diminished cardiac contractility and perfusion. Acidosis usually results in arrhythmia and ischemia due to reduced left ventricle contractility causing the heart to compensate by increasing the heart rate and cardiac output.
Diagnosis of Respiratory Acidosis
Respiratory acidosis typically presents with difficulty of breathing or unconsciousness and should require urgent evaluation such as:
- Blood test. A series of blood tests must be done to measure the level of acidosis.
- Arterial Blood Gas (ABG). This test measures the acidity as well as the balance between oxygen and carbon dioxide in the blood.
- Serum bicarbonate testing. This test is usually done with ABG to measure the level of carbon dioxide in the blood.
- Basic metabolic panel. It measures eight different substances in the blood to determine blood sugar levels, electrolyte imbalances levels, and kidney function.
- Medical history. A complete medical history including the past and present health conditions can be helpful in the diagnosis.
- Physical exam. A complete physical exam will be done focusing on the heart and lungs to check for blockage and circulation.
- Imaging test. These tests will determine the abnormality in the musculoskeletal or central nervous system.
- Chest X-ray. This can determine muscular or skeletal issues that can cause acidosis.
- CT scan or MRI. These tests are considered if the cause is due to an abnormality in the brain or musculoskeletal system.
- Pulmonary function test. Measure lungs functioning.
- Spirometry. A spirometer is used to measure the volume of inspired and expired air.
- Lung volume test. Taking deep breaths in an airtight booth, the air breathed in will affect the air pressure inside the booth to determine the amount of air the lungs can hold.
- Gas diffusion test. Inhaling a safe amount of carbon dioxide to measure the effectiveness of lung function while passing into the bloodstream.
- Exercise test. This test measures lung function upon exertion. The patient will run on a treadmill or use a stationary bike while being hooked on a monitor to check the heart rate, blood pressure, and blood oxygen levels.
Treatment for Respiratory Acidosis
Treatment for respiratory acidosis will depend on the underlying condition and should focus on airway stabilization, including the following methods:
- Medications. This is used to relieve signs and symptoms.
- Bronchodilators. Relaxes the muscles that control breathing and expand the airways, especially for patients with COPD.
- Diuretics. Used to eliminate excess fluid reducing pulmonary and cardiac workload.
- Antibiotics. Control infection and prevent sepsis.
- Corticosteroids. Treat inflammatory diseases that cause respiratory acidosis.
- Inotropes. This is used to improve heart function by increasing oxygen flow and lowering the acid levels in the blood. Treatment for acidosis caused by heart problems.
- Sodium bicarbonate. This can only be used as a treatment for severe bronchospasm which is unresponsive to beta-agonists as it may cause paradoxical acidosis in the CNS.
- Non-invasive positive-pressure ventilation. Used in acute respiratory acidosis to avoid the need for intubation or mechanical ventilation.
- Continuous positive airway pressure (CPAP) or bilevel (BiPAP) therapy. The machine assists the lungs to expel carbon dioxide through pressurized air via a face mask.
- Oxygen therapy. Use to prevent long-standing hypoxemia such as patients with COPD. However, this must be used with caution because it may worsen hypercapnia.
- Endotracheal intubation. ET intubation can be used to have direct access to the lungs for maximum oxygen intake and carbon dioxide expulsion. This is also used for patients with severe hypercapnia such as patients with OHS and neuromuscular disorders.
- Mechanical ventilation. A mechanical ventilator assists in breathing for patients with severe respiratory acidosis. This should be used with caution because rapid correction of hypercapnia by mechanical ventilation may cause alkalemia.
- Detoxification. This treatment should be used for acidosis caused by alcohol or drug overdose, however, in severe cases hemodialysis may be used. Naloxone can counteract the effect of opioids.
- Hemodialysis. This type of dialysis treatment is used to remove wastes and excess acid from the blood in cases of severe kidney problems or kidney failure.
Respiratory Acidosis Nursing Diagnosis
Respiratory Acidosis Nursing Care Plan 1
Nursing Diagnosis: Impaired Gas Exchange related to altered oxygen supply secondary to respiratory acidosis as evidenced by wheezing and abnormal breathing pattern.
Desired Outcomes:
- The patient will display a normal breathing pattern within 2 hours of nursing intervention.
- The patient will maintain an adequate breathing pattern without wheezing and use of accessory muscles.
| Respiratory Acidosis Nursing Interventions | Rationale |
| Assess the patient’s breathing pattern including the rate and depth. Document and monitor every hour taking note of the patient’s lung sound via auscultation, oxygen saturation, use of accessory muscles, pursed lip breathing, or difficulty speaking. | Assessment and monitoring of breath sounds detect bronchospasm early. |
| Assess the patient’s skin and mucous membrane. | To determine peripheral cyanosis and adequate tissue perfusion, as this may be a sign of hypoxemia. |
| Assess the patient’s level of consciousness, mental status, and sleep and wake cycle. | Respiratory acidosis may cause confusion, restlessness, and coma. Hypersomnolence or early sleepiness may indicate hypoxemia. |
| Check and monitor arterial blood gas values. Monitor vital signs and cardiac rhythm frequently. | Arterial blood gases are an accurate test to check for oxygen and carbon dioxide level in the blood. Cardiac rhythm should be monitored frequently because acidosis may cause arrhythmias. |
| Assist the patient in a semi or high-Fowler’s position or elevate the head of the bed. | This position promotes maximum lung expansion relieving pressure on the lungs. |
| Encourage deep breathing as tolerated. | Deep breathing should be done properly to be effective and prevent lung collapse. |
| Provide supplemental oxygen or nebulization as ordered. | Nebulization can be useful in improving wheezing from bronchospasm. Low flow humidified oxygen should be used to improve breathing. |
| Provide a safe and quiet environment for rest. | Adequate rest is needed, and noises may prevent relaxation and sleep. |
Respiratory Acidosis Nursing Care Plan 2
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory acidosis secondary to chronic obstructive pulmonary disease as evidenced by oxygen saturation of 85% and dyspnea.
Desired Outcomes:
- The patient will be able to maintain an adequate oxygen level to 95% after 2 hours of nursing intervention.
- The patient will be able to perform normal activities without the difficulty of breathing.
| Respiratory Acidosis Nursing Interventions | Rationale |
| Assess the patient’s breathing pattern including the rate and depth. Document and monitor every hour taking note of the patient’s lung sound, use of accessory muscles, nasal flaring, and pursed lip breathing. | Monitoring every hour can be helpful in determining fluctuations and progression of symptoms. |
| Assess the patient’s skin and mucous membrane. | To determine peripheral cyanosis and adequate tissue perfusion, as this may be a sign of hypoxemia. |
| Assess the patient’s level of consciousness, mental status, and sleep and wake cycle. | Respiratory acidosis may cause confusion, restlessness, and coma. Hypersomnolence or early sleepiness may indicate hypoxemia. |
| Monitor vital signs including oxygen saturation and cardiac rhythm frequently. | Monitoring of oxygen saturation will determine adequate tissue perfusion. Cardiac rhythm should be monitored frequently because acidosis may cause arrhythmias. |
| Check the arterial blood gases. | Arterial blood gases are an accurate test to check for oxygen and carbon dioxide level in the blood |
| Provide humidified oxygen and nebulization as ordered. | Low flow humidified oxygen should be used to prevent mucosal dryness and improve breathing. Nebulization will promote airway expansion. |
| Assist the patient in a semi or high-Fowler’s position or elevate the head of the bed. | This position promotes maximum lung expansion relieving pressure on the lungs. |
| Encourage deep breathing or pursed lip breathing. | Deep breathing should be done properly by inhaling through the nose and exhaling through the mouth. Pursed lip breathing allows controlled ventilation, and both are effective to prevent lung collapse. |
| Educate the patient about the use of an incentive spirometer. | This will help in the monitoring of the patient’s lung function while promoting lung expansion. |
| Provide a safe and quiet environment for rest. | Adequate rest is needed, and noises may prevent relaxation and sleep. |
| Referral to respiratory therapist upon consent. | Professional RT can provide interventions that can greatly help the patient’s condition improve. |
Respiratory Acidosis Nursing Care Plan 3
Nursing Diagnosis: Fatigue related to respiratory acidosis secondary to asthma in exacerbation as evidenced by reports of tiredness and having no energy.
Desired Outcomes:
- The patient will be able to verbalize increased feeling of energy.
- The patient will be able to engage in activities of daily living without feeling exhausted.
| Respiratory Acidosis Nursing Interventions | Rationale |
| Assess the patient’s fatigue by describing the characteristics and perceptions about fatigue. | This will help the nurse plan and identify the nature and factors that cause the fatigue. |
| Assess the patient’s past medical history and review the chief complaint. | Past and present illnesses may contribute to the patient’s fatigue. Identifying these will help the nurse plan appropriate care for the patient. |
| Assess the patient’s medications and possible reasons for fatigue. | Some activities can cause overexertion and fatigue. Certain medications may also cause fatigue as side effects. |
| Assist the patient with passive and active range of motion exercises of both extremities. | Facilitates adequate tissue perfusion, maintains muscle tone, preserves joint mobility, and prevents muscle atrophy from disuse. |
| Encourage the patient to participate in the planning of his/her care. | This will determine the patient’s capacity to perform planned activities. |
| Encourage the patient to perform activities during the most energetic hours of the day. | This will facilitate the completion of the task given. |
| Provide adequate rest periods in between activities and a quiet environment to rest. | Allows a restful sleep and reduces anxiety. |
| Encourage gradual resumption of regular activities of daily living. | Gradual resumption of activity will prevent the sudden feeling of exhaustion. |
| Encourage the patient to have a regular schedule of activities. | This will help the patient establish a regular routine. |
| Educate the patient about energy-conserving techniques such as time management, scheduling activities, and delegating tasks to significant others. | This helps the patient conserve energy and prevent exhaustion. |
Respiratory Acidosis Nursing Care Plan 4
Nursing Diagnosis: Nausea related to respiratory acidosis secondary to hypermetabolic disorder as evidenced by gagging and verbal report of nausea.
Desired Outcomes:
- The patient will be able to report diminished gagging and resolution of nausea.
- The patient will be able to perform interventions to relieve nausea.
Respiratory Acidosis Nursing Care Plan 5
Nursing Diagnosis: Acute Confusion related to hypoxemia secondary to respiratory acidosis as evidenced by fluctuation in cognition and restlessness.
Desired Outcomes:
- The patient will be able to regain orientation to the current situation.
- The patient will be able to demonstrate techniques to prevent the recurrence of acute confusion.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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