AA Gradient Calculator

Any medical student, physician, or patient will find this AA gradient calculator useful if they are interested in finding the source of hypoxemia.

Once you have the individual levels of each arterial blood gas, take a moment and use this tool to learn more about A A gradient, V Q mismatch, and the causes of oxygenation shifts (check out the oxygenation index calculator). In the article below, you can also find the hypoxemia definition and hypoxia vs. hypoxemia explanations.

AA gradient, short for alveolar-arterial gradient, serves as a method of differentiation between the causes of hypoxemia in a patient. The hypoxemia definition is quite straightforward: it's low levels of oxygen in the blood. Technically, what we calculate is a difference between the alveolar concentration of oxygen and the arterial concentration of oxygen (check also blood pH calculator).

The origin of hypoxemia might be either:

• extrapulmonary (outside the lungs):
  • hypoventilation; and
  • low FiO2 (fraction of inspired oxygen, estimated with PF ratio calculator).
• intrapulmonary (inside the lungs):
  • ventilation-perfusion imbalance (V Q mismatch), present in patients with pneumonia, asthma, or COPD (chronic obstructive pulmonary disease); and
  • intrapulmonary or cardiac shunt.

Among the extrapulmonary causes of hypoxemia, there is hypoventilation. It may present due to e.g., depression of the central nervous system (due to, e.g., opioid overdose), some neuromuscular diseases, scoliosis, or other chest deformities. It means that the oxygen concentration in both the alveoli and the blood is low. Therefore, the AA gradient remains within acceptable limits.

Let's move on to intrapulmonary causes of hypoxemia: cardiac/intrapulmonary shunt and V Q mismatch. The most common example is a patient with pneumonia. The pathophysiology involves an obstruction in the alveoli, which leads to a decrease in the amount of oxygen diffused into the blood. Yet, it doesn't influence the patient's ability to breathe and ventilate. As a result, these patients have a normal oxygen concentration in their alveoli but a decreased concentration in their arterial blood. A patient with pneumonia would probably have an increased AA gradient due to a pronounced difference between their alveolar and arterial oxygen concentrations.

Hypoxia and hypoxemia definitions might be confusing. It's crucial to realize that they represent different states and conditions of the human body.

• Hypoxemia is a state where the partial pressure of oxygen in the blood is decreased. We can measure its levels indirectly, by pulse oximetry, and directly, by drawing blood from either an artery or a vein. The most reliable source of a person's oxygen levels is arterial blood, e.g., from the radial artery.

• Hypoxia is defined as a diminished level of tissue oxygenation.

These two terms aren't synonyms, and they do not always happen at the same time. If a patient can still compensate with increased hemoglobin (check hemoconcentration with our hematocrit hemoglobin ratio calculator) or cardiac output, they might have hypoxemia but not hypoxia.

Hypoxia without hypoxemia is a less common occurrence and is sometimes seen in people who have been poisoned with cyanide. In this case, cyanide blocks the tissue's ability to use oxygen while the oxygen levels in the blood remain normal, thereby causing hypoxia without hypoxemia.

Now that you know the difference between hypoxia vs hypoxemia, the possible causes of hypoxemia, and what AA gradient is used for, let's move on to its formula:

AA gradient = PAO₂ - PaO₂

where:

• PaO₂ is the arterial partial pressure of oxygen, measured from an artery; and

• PAO₂ is the partial pressure of alveolar oxygen, which we can also calculate as:

PAO₂ = [FiO₂ * (P_atm - PH₂0) - PaCO₂ / 8]

where:

• PH₂O is the partial pressure of water;
• FiO₂ is the fraction of inspired oxygen;
• P_atm is the atmospheric pressure; and
• PaCO₂ is the partial pressure of carbon dioxide in the alveoli.

At standard pressure, one can suppose that the fraction of inspired oxygen is FiO₂ = 0.21, or 21%, the atmospheric pressure at sea level is P_atmis atmospheric pressure = 760 mmHg, and, if we assume 100% humidity in the alveoli, PH₂O = 47 mmHg.

In this AA gradient calculator, we also provide you with an acceptable AA gradient that depends on the patient's age. The formula is simple:

AA gradient for age = age/4 + 4

Let's take a moment to work on an example. Laura is a medical doctor working at a hospital. One day a patient with a history of shunting comes to the ER (Emergency Room), and she quickly needs to assess his hypoxemia with an AA gradient calculator.

He's 57, breathes regular air, and from his arterial blood gases it seems that his PaCO₂ = 45 mmHg while PaO₂ = 70 mmHg. Both values are slightly out of the healthy range.

AA gradient = [0.21 * (760 mmHg - 45 mmHg) - 45 mmHg / 8] - 70 mmHg

AA gradient = 23.8 mmHg

The expected AA gradient for age differs from the calculated one:

AA gradient for age = 57/4 + 4

AA gradient for age = 18.3 mmHg

The results suggest an increased AA gradient. Therefore, the probable causes of hypoxemia are V Q mismatch and a cardiac or intrapulmonary shunt.