https://lifeinthefastlane.com/ccc/a-a-gradient/

A-a gradient

OVERVIEW

• calculated as PAO2 – PaO2
• PAO2 is the ‘ideal’ compartment alveolar PO2 determined from the alveolar gas equation
• PAO2 = PiO2 – PaCO2/0.8
• A normal A–a gradient for a young adult non-smoker breathing air, is between 5–10 mmHg.
• However, the A–a gradient increases with age (see limitations)

CLASSIFICATION OF HYPOXIA BASED ON A-a GRADIENT

Normal A-a gradient

1. Alveolar hypoventilation (elevated PACO2)
2. Low PiO2 (FiO2 < 0.21 or barometric pressure < 760mmHg)

Raised A-a gradient

1. Diffusion defect (rare)
2. V/Q mismatch
3. Right-to-Left shunt (intrapulmonary or cardiac)
4. Increased O2 extraction (CaO2-CvO2)

LIMITATIONS

• Gradient varies with age and FiO2:

FiO2 0.21 – 7 mmHg in young, 14 mmHg in elderly
FiO2 1.0 – 31 mmHg in young, 56 mmHg in elderly

•  For every decade a person has lived, their A–a gradient is expected to increase by 1 mmHg – a conservative estimate of normal A–a gradient is < [age in years/4] + 4.
• an exaggerated FiO2 dependence in intrapulmonary shunt (PAO2 vs PAO2/PaO2 difference diagram with regard to increasing percentage of shunt) and even more so in V/Q mismatch.