56
Članek prispel / Received
16. 9. 2020
Članek sprejet / Accepted
2. 4. 2021
Abstract
Purpose: The diagnosis of acute respi-
ratory failure (ARF) is based on arteri-
al blood gas analysis (ABGA), which is 
associated with patient discomfort and 
requires an additional vascular punc-
ture. Our aim was to compare ABGA 
with peripheral venous blood gas analysis 
(PVBGA) and pulse oximetry in adult 
patients with dyspnea and/or suspected 
ARF.
Methods: We included 102 patients 
(56 males) in a prospective study perfor-
med in a medical emergency department 
from March–May 2019. Patients with 
overt signs of circulatory shock or severe 
respiratory failure were not included. 
Izvleček
Namen: Diagnoza akutne dihalne 
odpovedi temelji na plinski analizi ar-
terijske krvi (ABGA, iz ang. Arterial 
Blood Gases Analysis). Odvzem krvi 
za PAAK je neprijeten, ob odvzemu pa 
lahko nastanejo zapleti. Naš cilj je bil 
primerjati rezultate ABGA s plinsko 
analizo periferne venske krvi (PVBGA, 
iz ang. Peripheral Venous Blood Gases 
Analysis) in pulzno oksimetrijo pri od-
raslih bolnikih z dispnejo in/ali sumom 
na akutno dihalno odpoved.
Metode: Opravili smo prospektivno raz-
iskavo, v katero smo vključili 102 bolni-
ka (od tega 56 moških). Raziskavo smo 
opravili v obdobju od marca do maja 
Ključne besede: 
Akutna dihalna odpoved, dispneja, 
plinska analiza arterijske krvi, 
hiperkapnija, pulzna oksimetrija.
Key words: 
acute respiratory failure; dyspnea; 
arterial blood gas analysis; 
hypercapnia, pulse oximetry
Plinska analiza periferne venske krvi in 
pulzna oksimetrija za oceno akutne dihalne 
odpovedi v urgentni ambulanti
Use of Peripheral Venous Blood Gas Analysis 
and Oximetry to Assess Respiratory Failure 
in the Emergency Department
Avtor / Author Jerneja Golub1, Mario Gorenjak2, Eva Žuran Pilinger1, Amadeus 
Lešnik1, Andrej Markota1,3,4
Ustanova / Institute 1Univerzitetni klinični center Maribor, Internistična nujna pomoč, Maribor; 2Univerza v 
Mariboru, Medicinska fakulteta, Center za humano molekularno genetiko in farmagenomiko, 
Maribor, Slovenija;  3Univerzitetni klinični center Maribor, Oddelek za intenzivno interno 
medicino, Maribor, Slovenija;  4Univerza v Mariboru, Medicinska fakulteta, Katedra za interno 
medicine, Maribor, Slovenija; 
1University Medical Centre Maribor, Medical Emergency Department, Maribor; 
2University of Maribor, Faculty of Medicine, Centre for Human Molecular Genetics and 
Pharmacogenomics, Maribor, Slovenia;  3University Medical Centre Maribor, Medical 
Intensive Care Unit, Maribor, Slovenia;   4University of Maribor, Faculty of Medicine, Chair 
of Internal Medicine, Maribor, Slovenia;  
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INTRODUCTION
The gold standard for the diagnosis of acute 
respiratory failure (ARF) is based on the results of 
arterial blood gas analysis [ABGA] (1). The blood for 
ABGA is usually obtained by radial artery puncture or 
from an indwelling arterial catheter. Both procedures 
are associated with patient discomfort, and rarely, 
significant complications (2). In addition to patient 
comfort, the benefits of assessing respiratory or 
metabolic status using peripheral venous blood 
include more streamlined diagnostic procedures 
because all blood can be obtained from a peripheral 
venous cannula (3-6). Several studies (7-13) have been 
conducted involving patients with different respiratory 
and metabolic diseases who did not require a high 
fraction of inspired oxygen and were not in circulatory 
failure, in which differences were reported, as 
follows: 0.02–0.04 units lower pH and approximately 
1 kPa higher pCO
2
 in venous blood (statistically 
significant); and insignificant differences between 
oxygen saturation, as measured by ABGA compared 
to noninvasive oximetry. Rang et al. (13) conducted 
a survey among emergency physicians regarding the 
above differences, which revealed that the differences 
were considered too large for interchangeability of 
results; however, adding correction factors to venous 
values could allow for interpretation of the results.
The aim of our study was to compare the pCO
2
, pO
2
, 
pH, and HCO
3
 values between ABGA and peripheral 
venous blood gas analysis (PVBGA), and oxygen 
saturation between ABGA (SaO
2
) and pulse oximetry 
(SpO
2
) in adult patients with dyspnea and/or ARF. In 
addition, we tested a simple method of approximating 
the arterial pCO
2
 and pO
2
. 
2019 na Internistični nujni pomoči. 
Bolnikov z izraženo hudo dihalno odpo-
vedjo ali cirkulatorno odpovedjo nismo 
vključevali. 
Rezultati: Ugotovili smo signifikan-
tne pozitivne korelacije med rezultati 
ABGA in PVBGA (za pH ρ = 0,590, 
za HCO
3
 ρ = 0,901 in za pCO
2
 ρ = 
0,740) ter nesignifikantne razlike med 
saturacijo kisika v ABGA in oksimetriji 
(95 % proti 94 %; p = 0,49). Ko smo 
od venskega pCO
2
 odšteli 1 kPa in ven-
skemu pO2 dodali 4 kPa, ni bilo več 
statistično pomembnih razlik med peri-
fernimi venskimi in arterijskimi pCO
2
 
in pO2 (4,8 v primerjavi s 4,7 kPa; p 
= 0,26 in 9,5 v primerjavi s 8,9 kPa; p 
= 0,21). 
Zaklju~ek: Z upoštevanjem rezultatov 
PVBGA in oksimetrije bi lahko pridobi-
li dovolj podatkov za sprejemanje klinič-
nih odločitev pri izbrani skupini bolni-
kov z dispnejo in/ali dihalno odpovedjo.
Results: We showed significant posi-
tive correlations between ABGA and 
PVBGA results (for pH, ρ=0.590; 
for HCO
3
, ρ=0.901; and for pCO
2
, 
ρ=0.740), and insignificant differences 
between oxygen saturation based on 
ABGA and pulse oximetry (95% vs. 
94%; p=0.49). When we subtracted 1 
kPa from the venous pCO
2
 and added 
4 kPa to the venous pO
2
, there were no 
statistically significant differences betwe-
en peripheral venous and arterial pCO
2 
and pO
2
 (4.8 vs. 4.7 kPa, p=0.26 and 
9.5 vs. 8.9 kPa, p=0.21, respectively).
Conclusion: The combination of 
PVBGA and pulse oximetry provided 
sufficient data to make clinical decisions 
in a select group of patients with dyspnea 
and/or ARF. 
Naslov za dopisovanje /  
Correspondence
Andrej Markota
Univerzitetni klinični center Maribor, 
Internistična nujna pomoč, Ljubljanska 
5, 2000 Maribor
E-pošta: andrej.markota@ukc-mb.si
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MATERIALS AND METHODS
We conducted a prospective observational study with 
data collection from March–May 2019 in a medical 
emergency department of a university hospital with 
approximately 100,000 patient visits/year. The aim 
was to compare the pCO
2
, pO
2
, pH, and HCO3 
values between ABGA and PVBGA and to compare 
SaO
2
 with SpO
2
 in adult patients with dyspnea and/or 
suspected ARF. We hypothesized the following: pCO
2 
is 1 kPa lower in ABGA compared to PVBGA; there 
is no difference in pH and HCO
3 
between ABGA and 
PVBGA; and there is no difference between SaO
2
 
and SpO
2
. 
Institutional Ethics Committee approval was obtained 
(No. 22/19) and patient/surrogate consent was 
obtained. We included adult patients (age > 18 years) 
with dyspnea and/or suspected ARF (hypoxemic 
or hypercapnic) in whom the attending physician 
decided to obtain blood for ABGA. The exclusion 
criteria were body mass index (BMI) < 18 kg/m2 and 
> 45 kg/m2, pregnancy, inability to obtain informed 
consent, patients in profound circulatory shock or 
severe respiratory failure in whom lifesaving procedures 
were required, patients in whom any changes in 
oxygen substitution therapy were made between blood 
withdrawals for ABGA and PVBGA, and patients in 
whom peripheral venous or arterial access could not be 
obtained. 
A prior power analysis showed that approximately 50 
patients would be needed to detect a 1 kPa higher pCO
2 
in PVBGA compared to ABGA with 80% power and 
an alpha of 0.05. To increase the accuracy of the study 
we planned to include approximately 100 patients. 
Measurements 
The collected variables were pCO
2
 pO
2
, pH, and 
HCO
3
 (ABGA and PVBGA), SpO
2
, and SaO
2
. In 
addition to the study data, we also collected basic 
demographic data, data on therapy with oxygen 
and bronchodilators, and data required for an 
Acute Physiology and Chronic Health Evaluation 
(APACHE) II score calculation (7).
Study intervention 
Our standard procedure for treatment of patients 
with dyspnoea and/or suspected ARF was to obtain 
peripheral venous access as soon as possible, usually in 
the right cubital region. Blood for ABGA was usually 
withdrawn from the right radial artery (2,3). 
In this study the attending physician requested the 
withdrawal of blood for ABGA based on a clinical 
indication. Blood for PVBGA was withdrawn from a 
peripheral venous catheter as soon as possible after 
radial artery puncture (maximally within 5 min). 
If a tourniquet was used during the insertion of 
the peripheral venous catheter, the tourniquet was 
removed at least 5 min before blood was withdrawn 
for PVBGA. If possible, the right cubital region and 
right radial artery were used for access to peripheral 
venous and arterial blood. No changes in oxygen 
substitution therapy were permitted 5 min before 
blood for study purposes was withdrawn. Blood for 
ABGA and PVBGA was sent to a central laboratory 
(ABL800 FLEX; Radiometer, Brønshøj, Denmark). 
We used fingertip oximetry measurements for SpO
2 
(PM-60; Mindray Bio-Medical Electronics Co., 
Shenzen, China). When results were available, clinical 
decisions were made based on the ABGA results; the 
PVBGA results were only used for study purposes.
Data analysis 
Statistical analyses were performed using SPSS IBM 
Statistics 24.0 (IBM Inc., Armonk, NY, USA), R (R 
Core Team 2019, https://www.R-project.org/), and 
GPower 3.1.9.2 software. [source?] Data were first tested 
for normality of distribution using the Kolmogorov-
Smirnov test of normality. The statistical differences 
between two categorical dichotomous variables were 
determined using Fisher’s exact test. A comparison 
of continuous variables across two groups was carried 
out using the Mann-Whitney U-test. The correlation 
between two continuous variables was determined 
using Spearman's rank correlation. Generalized 
linear models (GLMs) were fitted to confirm linear 
relationships between arterial (dependent variable) 
and venous parameters adjusted for age, sex, chronic 
obstructive pulmonary disease (COPD), and clinical 
signs of congestive heart failure. Statistical power 
was calculated post hoc for each comparison of the 
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variables using the Wilcoxon-Mann-Whitney test and 
a point biserial correlation model.
RESULTS 
Baseline characteristics 
A total of 102 patients (56 males and 46 females; 
mean age, 70±16 years) were enrolled. During the 
study period, nine additional patients were eligible 
for inclusion, but were not included; five patients 
were not included because blood for PVBGA was not 
obtained, two patients because the blood sample was 
hemolyzed, one patient because a BMI<18 kg/m2, 
and one because oxygen therapy was changed between 
the withdrawal of blood for ABGA and PVBGA. 
The characteristics of the study patients are 
summarized in Table 1. In our study population, 65% 
of patients were admitted to the hospital, 44% received 
oxygen therapy, and 39% received bronchodilator 
therapy. Of the patients, 25% had been previously 
diagnosed with COPD, 37% of patients had clinical 
signs of congestive heart failure on presentation to the 
emergency department, and 24% of patients had been 
previously diagnosed with congestive heart failure. 
The mean arterial blood pressure on admission was 
101 ± 17 mmHg and the mean heart rate 85 ± 19 
bpm. The body temperature was > 37.0°C in 16% of 
patients.  The median serum lactate concentration 
in ABGA samples was 1.5 ±. 0.8 mmol/L. None of 
the patients required vasoactive or inotropic support 
with norepinephrine, dopamine, or dobutamine. The 
APACHE II score was 11.4 ± 5.2 points. 
Main results 
Arterial and venous parameters were first assessed for 
statistically significant differences (Fig. 1). The median 
pH in ABGA samples was significantly different from 
the pH in PVBGA samples (7.43 vs.7.39; p=2.03×10-
10). Statistically significant differences were also 
detected between the median HCO3 in ABGA and 
PVBGA samples (23.8 vs. 25.7 mmol/L; p=7.30×10-
5), and between the median arterial pCO2 and venous 
pCO2 (4.8 vs. 5.7 kPa; p=1.27×10-10). There was a 
statistically significant difference between the median 
Figure 1. Comparison of arterial and venous pa-
rameters. A: pH; B: HCO3; C: pCO2; D: SpO2. 
Data are presented as the median, interquartile 
range, and minimum-to-maximum. P values were 
assessed using the Mann-Whitney U-test. Power 
was calculated using the Wilcoxon-Mann-Whit-
ney test. *P < 0.05.
Figure 2. Correlations between arterial and ve-
nous parameters. A: pH; B: HCO3; C: pCO2; 
D: SpO2. Correlations were determined using a 
Spearman rank correlation. Power was calculated 
using a point biserial correlation model and R2 co-
efficients of determination.
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pO2 in ABGA and PVBGA samples (9.5 vs. 4.9 kPa; 
p<0.0001). 
Oxygen saturation was compared between SaO
2 
and SpO
2
. Comparison of SpO
2
 did not show any 
statistically significant differences between the median 
SaO
2
 and SpO
2
 (95% vs. 94%; p=0.49).
The correlations between ABGA and PVBGA and 
between SaO
2
 and SpO
2
 were assessed. There was 
a strong positive statistically significant correlation 
between ABGA/SaO
2
 and PVBGA/SpO
2
 parameters 
for pH (ρ=0.590), HCO3 (ρ=0.901), pCO
2
 (ρ=0.740), 
and SpO
2
 (ρ=0.645; Fig. 2).
We further assessed pCO
2
 after subtracting 1 
kPa from the venous pCO
2
 variable as a “rule of 
thumb” to approximate the arterial pCO
2
. With 
the aforementioned application, the statistically 
significant difference was no longer observed between 
the arterial and venous pCO
2
 with a median of 4.8 
kPa and 4.7 kPa (p=0.26), respectively (Fig. 3).
We also assessed pO
2
 with the addition of 4 kPa 
to the venous pO
2
 variable as a “rule of thumb” to 
approximate the arterial pO
2
. The aforementioned 
statistically significant difference was no longer 
evident (9.5 vs. 8.9 kPa; p=0.21). 
Table 2. Characteristics of included patients
Number of 
patients (n=102) %
Sex
Male 56 55
Female 46 45
Age groups
18–40 7 0.7
41–65 24 23.6
66–79 41 40.2
≥ 80 30 29.4
Cause of dyspnea/ ARF
Pneumonia 25 23.6
Other respiratory tract 
infections 12 11.3
AECOPD 13 12.3
Acute asthma 
exacerbation 6 5.7
Heart failure 25 23.6
Sarcoidosis 1 0.9
Chemical pneumonitis 1 0.9
Pulmonary embolism 3 2.8
Pleural effusion 2 1.9
Other causes (cardiac, 
psychologic) 24 22.6
COPD (stable disease or 
AECOPD) 26 25
Hospital admission
Yes 66 64.7
No 36 35.3
Body temperature
< 37°C 111.86 84.3
37°C–37.5°C 10 9.8
≥ 37.6°C 6 5.6
Respiratory rate
≥ 20 breaths/minute 10 9.8
Figure 3. Subtraction of 7.5 mmHg from venous 
pCO2. Vein*: venous data with subtraction. Data 
are presented as the median, interquartile range, 
and minimum-to-maximum. P values were as-
sessed using the Mann-Whitney U-test. Power 
was calculated using the Wilcoxon-Mann-Whit-
ney test.*P < 0.05.
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DISCUSSION 
We compared the pH, pCO
2
, and HCO
3
 between 
ABGA and PVBGA, and SaO
2
 with SpO
2
 in patients 
with undifferentiated dyspnea and/or suspected ARF. 
We also tested a simple method of approximation 
of arterial pCO
2
 and pO
2
 from peripheral venous 
blood. The emphasis was on the general patient 
population in the ED setting, and not on critically 
ill patients, who required ABGA and insertion of an 
arterial line.
Use of PVBGA and oximetry for assessment of 
patients with dyspnea and suspected ARF has two 
important advantages over the use of ABGA, as 
follows: increased patient comfort because arterial 
radial puncture is not required; and more streamlined 
and simplified workflow, because all required blood 
samples could be obtained from a peripheral venous 
catheter without the need for additional needle 
puncture.
The correlations between ABGA and PVBGA 
have been described before; however, these studies 
were performed in different settings and patient 
populations. [references?] Thus far, all studies 
have been observational. Gokel et al. [reference #?] 
compared the ABGA and PVBGA results in 121 
patients with metabolic acidosis (uremia and diabetic 
ketoacidosis) and 31 healthy controls. Gokel et al. 
[reference #?] showed a good correlation between 
arterial and venous pH and HCO
3
 in patients with 
metabolic acidosis and healthy subjects, with a 0.05 
unit lower venous pH and 2 mmol/l higher venous 
HCO
3
. This difference remained unchanged in spite 
of a wide range of pH and HCO
3
 concentrations 
reported [pH, approximately 7.15 in the metabolic 
acidosis group and 7.39 in healthy subjects; and 
HCO
3
, approximately 10 mmol/l in the metabolic 
acidosis group and 25 mmol/l in healthy subjects] 
(8). Similarly, Malatesha et al. (9) showed a good 
correlation between arterial and peripheral venous 
pH and HCO
3
 with a venous pH decreased difference 
of 0.02 units and an increased venous HCO
3
 of 2 
mmol/L in a group of 95 mixed medical patients with 
metabolic and respiratory disorders. McCanny et al. 
(10) reported a 0.04 unit lower venous pH and 1.1 
kPa higher venous pCO
2
 in 94 patients with COPD 
and respiratory failure. In a meta-analysis by Bingheng 
et al. (11) in which the ABGA and PVBGA results 
were compared in patients with acute exacerbation of 
COPD (AECOPD), good correlations were observed 
for pCO
2
, pH, and HCO
3
. Bingheng et al. (11) also 
proposed an algorithm for evaluating patients with 
AECOPD based on PVBGA or ABGA (11). A good 
correlation and similar differences between arterial 
and peripheral venous pH and HCO
3
 (0.03 units 
and 1 mmol/L, respectively) were also demonstrated 
in a high altitude setting (12). Zeserson et al. (14) 
also observed a good correlation between ABGA 
and PVBGA in a mixed medical population in the 
emergency department and ICU setting, and between 
SaO
2
 and SpO
2
 (14). None of the studies observed 
a correlation between arterial and venous pO
2
  (10-
12,14).
The results of our study are in agreement with 
previously published studies. We observed an 
approximate 0.04 unit lower pH, an approximate 
0.9 kPa higher pCO
2
, an approximate 2 mmol/L 
higher HCO
3
 in PVBGA compared to ABGA, and 
no difference between SaO
2
 and SpO
2
. Differences 
between ABGA and PVBGA in pH, pCO
2
, and 
HCO
3
 were statistically significant; however, the 
clinical relevance of these differences was minimal 
(8-10,12,14), and all relationships between arterial 
and peripheral venous variables exhibited a strong 
predictive value, i.e., the trend toward lower or 
higher values was consistent. In agreement with other 
studies, we observed a significant difference between 
pO
2
 in ABGA and PVBGA, but when we added 4 
kPa there was no longer a difference, allowing for 
rapid approximation of arterial pO
2
 from PVBGA 
in patients who are not shocked and require a low 
fraction of inspired oxygen (FiO
2
). In accordance 
with other studies, we have also shown that among 
patients not in shock with a low FiO
2
, SpO
2
 served as 
a good substitute for SaO2; however, great care and 
caution should be exercised when approximating 
pCO
2
 and pO
2
 from PVBGA, and the clinical status 
of the patient needs to be taken into account to avoid 
misinterpreting the results.   
In two observational studies conducted in a 
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population of patients (not in shock) in an ICU setting 
by Middleton et al. [reference #?] and Hassanloei et 
al., [reference#?] a similar 0.02–0.03 unit decreased 
venous pH difference was also apparent between 
ABGA and central venous BGA. Middleton et al. 
[reference #?] and Hassanloei et al., [reference#?] also 
observed significant correlations in pH, pCO
2
, and 
HCO3 between ABGA and central venous BGA, 
implying that among patients in whom delivery and 
utilization of oxygen in peripheral tissues was not 
impaired, changes in pH, pCO
2
, and HCO
3 
could be 
determined by blood sampling from the venous side 
of the circulation (15,16).
The veno-arterial difference in pH, pCO
2
, and 
HCO
3
 are influenced by local and systemic factors, 
which need to be taken into account before results 
are interpreted. First, hypoperfusion due to the 
use of a tourniquet for peripheral venous catheter 
insertion can be associated with local ischaemia and 
changes in metabolism that can affect pH, pCO
2
, 
and HCO
3
 levels (17). Second, systemic changes in 
oxygen metabolism among patients in shock have 
profound effects on venous pH, pCO
2
, and HCO
3
, 
which prevent interpretation with an aim to evaluate 
ventilation, and enable interpretation of central 
venous-arterial changes with an aim to assess the 
adequacy of the circulation, both in patients with 
septic (18) and cardiogenic shock (19). 
A number of studies have shown that SpO
2
 in 
combination with clinical presentation in patients 
who are not in shock and did not require vasopressors 
and a high fraction of inspired oxygen was a good 
parameter of oxygenation (12,14,20-24), and SpO2 
was commonly used to screen for hypoxemia 
(12,20,23-27). 
A number of factors can shift the oxygen dissociation 
curve affecting the relationship between arterial pO
2
 
and SaO
2
, potentially leading to a false-normal SpO
2
, 
such as profound pyrexia, alkalosis, hypercarbia, 
anemia, dyshemoglobinemia, and carbon monoxide 
poisoning or methemoglobinaemia, which must be 
taken into consideration (21).
None of the patients that were included to the 
current study initially received palliative treatment 
or were admitted with “do not resuscitate” orders; 
however, a combination of PVBGA and oximetry 
could be beneficial for some patients in this group, 
in whom preservation of the quality of life takes 
advantage over more invasive procedures (28).
A limitation of our study was that it was a single 
center observational study. Also, the results of our 
study should not be generalized to the critically ill 
population, who often have to wait for admission 
to an ICU from the emergency department (29-
31). However, patients in whom a “noninvasive” 
approach (PVBGA and oximetry) should not be used 
can be defined as patients in shock (with elevated 
lactate levels or require vasopressors) or patients who 
require a FiO2 > 60% (15,18,26,27). Approximately 
5% of patients presenting with dyspnea as the 
main complaint in the emergency department were 
admitted to the ICU due to severe ARF or shock, 
which made the pool of  non-critically ill patients 
that might benefit from a “noninvasive” approach in 
terms of patient comfort and streamlined workflow 
considerable (32,33). 
CONCLUSION 
In our population of patients not in shock who did 
not require a FiO2>60% and presented with dyspnea 
and/or suspected ARF, the pH, pCO
2
, and HCO3 
on PVBGA correlated well with the pH, pCO
2
, and 
HCO
3
 on ABGA, with constant differences of 0.04 
units, 0.9 kPa, and 2 mmol/L, respectively. The 
SpO
2
 correlated well with SaO
2
. Simple subtraction 
of 1 kPa from peripheral venous pCO
2
 and addition 
of 4 kPa to peripheral venous pO
2
 might be used 
as a “rule of thumb” to approximate the arterial 
pCO
2
 and pO
2
. The combination of PVBGA and 
SpO
2
 measured by oximetry could provide sufficient 
information on which to make clinical decisions 
regarding ventilation, oxygenation, and acid-base 
status for patients not in shock and with a low FiO
2
. 
A prospective interventional study is warranted to 
determine whether some patients with ARF can be 
treated based on the results of PVBGA and SpO
2
.  
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