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Capnography Reference Handbook

About This Handbook

This handbook has been prepared by Respironics as a reference for Health Care Professionals
who are interested in capnography. It is divided into the following three sections:

The clinical need for capnography based on the physiology and patho-physiology
of respiration.

Technical aspects of capnography.

Examples and clinical interpretations of CO2 waveforms.

We hope that this reference can enhance the utility of capnography in the clinical setting.

Contents
Physiologic Aspects and the Need for Capnography
Respiration
Capnography Depicts Respiration
Factors Affecting Capnographic Readings
Dead Space
Ventilation-Perfusion Relationships
Normal End-Tidal and Arterial CO2 Values
Arterial to End-Tidal CO2 Gradient
Display of CO2 Data
Capnography vs. Capnometry
Capnography is More than ETCO2
Quantitative vs. Qualitative ETCO2
ETCO2 Trend Graph and Histogram

Technical Aspects of Capnography

CO2 Measurement Techniques
Infrared (IR) Absorption
Solid State vs. Chopper Wheel
Mainstream vs. Sidestream
Colorimetric CO2 Detectors

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Capnogram Examples and Interpretations

Normal Capnogram
Increasing ETCO2 Level
Decreasing ETCO2 Level
Rebreathing
Obstruction in Breathing Circuit or Airway
Muscle Relaxants (curare cleft)
Endotracheal Tube in the Esophagus
Inadequate Seal Around Endotracheal Tube
Faulty Ventilator Circuit Valve
Cardiogenic Oscillations

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Glossary of Terms

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Physiologic Aspects and the Need for Capnography

Respiration
The Big Picture:
The respiratory process consists of three main events:

Cellular Metabolism of food into energy

O2 consumption and CO2 production.

Transport of O2 and CO2 between cells and pulmonary

capillaries, and diffusion from/into alveoli.

Ventilation between alveoli and atmosphere.

Capnography Depicts Respiration

Because all three components of respiration (metabolism, transport, and ventilation) are involved
in the appearance of CO2 in exhaled gas, capnography gives an excellent picture of the
respiratory process.

Note: Of course, oxygenation is a major part of respiration and therefore must also be monitored in order to
complete the picture. This can be accomplished through pulse oximetry, which is not covered in this handbook.
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Factors Affecting Capnographic Readings

The factors which can affect capnographic readings can be classified as follows:
Physiologic
Factors which can affect CO2 production include substrate metabolism,
drug therapy, and core temperature.
Factors affecting CO2 transport
include cardiac output and
pulmonary perfusion.
Factors which can affect ventilation
include obstructive and restrictive
diseases, and breath rate.
Ventilation-perfusion ratios
(described on page 11) can also
affect capnographic readings.

Equipment
Ventilator settings
and malfunctions,
tubing obstructions,
disconnections, and
leaks can all affect
capnographic readings.
Sampling method and
site, sample rate (if sidestream), as well as monitor
(capnograph) malfunctions
can affect capnographic
readings.

Physiologic Factors Affecting ETCO2 Levels

Increase in ETCO2

Decrease in ETCO2

Increased muscular activity (shivering)

Decreased muscular activity

(muscle relaxants)

Malignant hyperthermia

Hypothermia
Increased cardiac output
(during resuscitation)

Decreased cardiac output

Pulmonary embolism

Bicarbonate infusion
Tourniquet release
Effective drug therapy
for bronchospasm
Decreased minute ventilation
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Bronchospasm
Increased minute ventilation

Equipment Related Factors Affecting ETCO2 Levels

Increase in ETCO2

Decrease in ETCO2

Malfunctioning exhalation valve

Circuit leak or partial obstruction

Decreased minute ventilations settings

Increased minute ventilation settings

Poor sampling technique

Dead Space
Dead space refers to ventilated areas which do not participate in gas exchange. Total, or physiologic
dead space, refers to the sum of the three components of dead space as described below:
TOTAL (PHYSIOLOGIC) DEAD SPACE =

Anatomic dead space refers to

the dead space caused by anatomical structures, i.e., the airways
leading to the alveoli. These areas
are not associated with pulmonary
perfusion and therefore do not
participate in gas exchange.

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Alveolar dead space refers

to ventilated areas which are
designed for gas exchange,
i.e. alveoli, but do not actually
participate. This can be caused by
lack of perfusion, e.g., pulmonary
embolism, or blockage of gas
exchange, e.g. cystic fibrosis.

+
Mechanical dead space refers
to external artificial airways
which add to the total dead
space, as when a patient is
being mechanically ventilated.
Mechanical dead space is an
extension of anatomic dead space.

Ventilation-Perfusion Relationships
The ventilation-perfusion ratio (V/Q) describes the relationship between air flow in the alveoli and
blood flow in the pulmonary capillaries. If ventilation is perfectly matched to perfusion, then V/Q
is 1. Both ventilation and perfusion are unevenly distributed throughout the normal lung. However,
the normal overall V/Q is 0.8.

Dead space ventilation

occurs under conditions
in which alveoli are
ventilated but not
perfused, such as:

Shunt perfusion occurs

under conditions in which
alveoli are perfused but
not ventilated, such as:

Mucus plugging

ET tube in mainstream
bronchus

Atelectasis

Ventilation-Perfusion Spectrum

Pulmonary embolism

Hypovolemia

Cardiac arrest

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Normal Arterial and End-Tidal CO2 Values

Arterial CO2 (PaCO2)

End-Tidal CO2 (ETCO2)

from Arterial Blood Gas sample (ABG)

from Capnograph

Normal PaCO2 values:

Normal ETCO2 values:

35-45 mmHg

30-43 mmHg
4.0-5.7 kPa
4.0-5.6%
Note: Numbers shown correspond to sea level.

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Arterial to End-Tidal CO2 Gradient

Under normal physiologic conditions, the difference between arterial PCO2 (from ABG) and alveolar
PCO2 (ETCO2 from capnograph) is 2-5 mmHg. This difference is termed the PaCO2 PETCO2
gradient or the a-ADCO2 and can be increased by:

COPD (causing incomplete alveolar emptying).

ARDS (causing a ventilation-perfusion mismatch).

A leak in the sampling system or around the ET tube.

With both healthy and diseased lungs, ETCO2 can be used to detect trends in PaCO2, alert the
clinician to changes in a patients condition, and reduce the required number of ABGs.
With healthy lungs and normal airway conditions, end-tidal CO2 provides a
reasonable estimate of arterial CO2 (within 2-5 mmHg).

With diseased/injured lungs, there is an increased arterial to end-tidal CO2

gradient due to ventilation-perfusion mismatch. Related changes in the patients
condition will be reflected in a widening or narrowing of the gradient, conveying
the V/Q imbalance and therefore the pathophysiological state of the lungs.
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Display of CO2 Data

CO2 data can be displayed in a variety of formats, such as numerics, waveforms, bar graphs, etc.
The next few pages briefly describe:

Capnography vs. Capnometry

Definitions
Capnography is more than ETCO2

Display Formats for End-Tidal CO2

Quantitative vs. Qualitative
ETCO2 Trend Graph and Histogram

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Capnography vs. Capnometry

Definitions
Often times little or no distinction is made between the terms capnography and capnometry.
Below is a brief explanation:

Capnography refers to the comprehensive

measurement and display of CO2 including
end-tidal, inspired, and the capnogram (real-time
CO2 waveform). A capnograph is a device which
measures CO2 and displays a waveform.

Capnometry refers to the measurement and

display of CO2 in numeric form only. A capnometer
is a device which performs such a function, displaying
end-tidal and sometimes inspired CO2.

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Capnography is More than ETCO2

As previously noted, capnography is comprised of CO2 measurement and display of the capnogram.
The capnograph enhances the clinical application of ECO2 monitoring.

Value of the Capnogram

The capnogram is an extremely valuable clinical tool which can be used in a plethora of applications,
including but by no means limited to:

Validation of reported end-tidal CO2 values

Assessment of patient airway integrity

Assessment of ventilator, breathing circuit, and gas sampling integrity

Verification of proper endotracheal tube placement

Viewing a numerical value for ETCO2 without its associated capnogram is like viewing the heart rate
value from an electrocardiogram without the waveform. End-Tidal CO2 monitors that offer both a
measurement of ETCO2 and a waveform enhance the clincal application of ETCO2 monitoring.
The waveform validates the ETCO2 numerical value.
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Quantitative vs. Qualitative ETCO2

The format for reported end-tidal CO2 can be classified as quantitative (an actual numeric value) or
qualitative (low, medium, high):

Quantitative ETCO2 values are currently associated with electronic

devices and usually can be displayed in units of mmHg, %, or kPa.
Although not absolutely necessary for some applications, i.e., verification
of proper ET tube placement, quantitative ETCO2 is needed in order to
take advantage of most of the major benefits of CO2 measurements.
Qualitative CO2 measurements are associated with a range of ETCO2
rather than the actual number. Electronic devices usually present this as
a bar graph, while colorimetric devices are presented in a percentage
range grouped by color. If the ranges are numeric as is usually the case,
e.g., <5, 5-10, >20 mmHg, it is said to be semiquantitative. These devices
are termed CO2 detectors, and their applications are typically
limited to ET tube verification.

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ETCO2 Trend Graph and Histogram

The trend graph and histogram of ETCO2 are convenient ways to clearly review patient data which
has been stored in memory. They are especially useful for:

Reviewing effectiveness of interventions, e.g., drug therapy or changes in ventilator settings

Noting significant events from periods when the patient was not continuously supervised

Keeping records of patient data for future reference

An ETCO2 trend graph is shown for a onehour time period. Note the transient rise in
ETCO2, indicating possible administration of a
bicarbonate bolus or release of a tourniquet.

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An ETCO2 histogram is shown for an eight

hour time period. This format shows a statistical
distribution of ETCO2 values recorded during
the time period.

Technical Aspects of Capnography

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CO2 Measurement Techniques

Various configurations and measurement techniques are currently available in devices which
measure CO2, some of which are briefly described below:

Infrared (IR) absorption

Principle
Solid State vs. Chopper Wheel
Mainstream vs. Sidestream Sampling

Colorimetric Detectors
Principle

Other techniques not included in this discussion are mass spectrometry, Raman scattering,
and gas chromatography.
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Infrared (IR) Absorption

The infrared absorption technique for monitoring CO2 has endured and evolved in the clinical setting
for over two decades, and remains the most popular and versatile technique today.

Principle
The principle is based on the fact that CO2 molecules absorb infrared light energy of specific
wavelengths, with the amount of energy absorbed being directly related to the CO2 concentration.
When an IR light beam is passed through a gas sample containing CO2, the electronic signal from
a photodetector (which measures the remaining light energy), can be obtained. This signal is then
compared to the energy of the IR source, and calibrated to accurately reflect CO2 concentration in
the sample. To calibrate, the photodetectors response to a known concentration of CO2 is stored
in the monitors memory.

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Infrared (IR) Absorption (cont.)

Solid State vs. Chopper Wheel
Since the intensity of the IR light source must be known for a CO2 measurement to be made,
some method must be employed to obtain a signal which makes that correlation. This can be done
with or without moving parts:
Solid state CO2 sensors use a beam splitter to simultaneously
measure the IR light at two wavelengths: one which is absorbed by
CO2 (data) and one which is not (reference). Also, the IR light source
is electronically pulsed (rather than interrupting the IR beam with a
chopper wheel) in order to eliminate effects of changes in electronic
components. The major advantage of solid state electronics is durability.
CO2 sensors which are not solid state employ a spinning disk
known as a chopper wheel, which can periodically switch among the
following to be measured by the photodetector:
The gas sample to be measured (data)
The sample plus a sealed gas cell with a known CO2
concentration (reference)
No light at all
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Due to the moving parts, this type of arrangement tends to be fragile.

Infrared (IR) Absorption (cont.)

Mainstream vs. Sidestream Sampling
Mainstream and sidestream sampling refer to the two basic configurations of CO2 monitors,
regarding the position of the actual measurement device (often referred to as the IR bench)
relative to the source of the gas being sampled:

CAPNOSTAT Mainstream CO2 sensors are placed at the airway

of an intubated patient, allowing the inspired and expired gas to
pass directly across the IR light path. State-of-the-art technology
allows this configuration to be durable, small, and lightweight, and
virtually hassle-free. The major advantages of mainstream sensors
are fast response time and elimination of water traps.
LoFlo Sidestream CO2 sensors are located away from the airway,
requiring a gas sample to be continuously aspirated from the
breathing circuit and transported to the sensor by means of a
pump. This type of system is needed for non-intubated patients.

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Colorimetric CO2 Detectors

Principle
Colorimetric CO2 detectors rely on a modified form of litmus paper, which changes color relative to
the hydrogen ion concentration (pH) present.

Colorimetric CO2 detectors actually measure the

pH of the carbonic acid that is formed as a product of
the reaction between carbon dioxide and water (present
as vapor in exhaled breath). Exhaled and inhaled gas is
allowed to pass across the surface of the paper and the
clinician can then match the color to the color ranges
printed on the device. It is usually recommended to wait
six breaths before making a determination.

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Capnogram Examples and Interpretations

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Normal Capnogram

CO2 (mmHg)

Real Time

Trend

The normal capnogram is a waveform which represents the varying CO2 level throughout
the breath cycle.

Waveform Characteristics:

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A-B

Baseline

End-Tidal Concentration

B-C

Expiratory Upstroke

D-E

Inspiration

C-D

Expiratory Plateau

Increasing ETCO2 Level

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

An increase in the level of ETCO2 from previous levels.

Possible Causes:

Decrease in respiratory rate (hypoventilation)

Increase in metabolic rate

Decrease in tidal volume (hypoventilation)

Rapid rise in body temperature

(malignant hyperthermia)
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Decreasing ETCO2 Level

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

An decrease in the level of ETCO2 from previous levels.

Possible Causes:

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Increase in respiratory rate (hyperventilation)

Decrease in metabolic rate

Increase in tidal volume (hyperventilation)

Fall in body temperature

Rebreathing
Normal Capnogram

CO2 (mmHg)

Real Time

Trend

Elevation of the baseline indicates rebreathing (may also show a corresponding increase in ETCO2).
Possible Causes:

Faulty expiratory valve

Partial rebreathing circuits

Inadequate inspiratory flow

Insufficient expiratory time

Malfunction of a CO2 absorber system

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Obstruction in Breathing Circuit or Airway

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

Obstructed expiratory gas flow is noted as a change in the slope of the ascending limb of the
capnogram (the expiratory plateau may be absent).
Possible Causes:

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Obstruction in the expiratory limb of the

breathing circuit
Presence of a foreign body in the upper airway

Partially kinked or occluded artificial airway

Bronchospasm

Muscle Relaxants (curare cleft)

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

Clefts are seen in the plateau portion of the capnogram. They appear when the action of the muscle
relaxant begins to subside and spontaneous ventilation returns.
Characteristics:

Depth of the cleft is inversely proportional to the degree of drug activity

Position is fairly constant on the same patient but not necessarily present with every breath
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Endotracheal Tube in the Esophagus

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

Waveform Evaluation:
A normal capnogram is the best available evidence that the ET tube is correctly positioned and that
proper ventilation is occurring. When the ET tube is placed in the esophagus, either no CO2 is
sensed or only small transient waveforms are present.

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Inadequate Seal Around Endotracheal Tube

Normal Capnogram

CO2 (mmHg)

Real Time

Trend

The downward slope of the plateau blends in with the descending limb.
Possible Causes:

A leaky or deflated endotracheal or tracheostomy cuff

An artificial airway that is too small for the patient

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Faulty Ventilator Exhalation Valve

Normal Capnogram

CO2 (mmHg)

Real Time

Waveform Evaluation:

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Baseline elevated

Abnormal descending limb of capnogram

Allows patient to rebreathe exhaled gas

Trend

Cardiogenic Oscillations

CO2 (mmHg)

Real Time

Cardiogenic oscillations appear during the final phase of the alveolar plateau and during the
descending limb. They are caused by the heart beating against the lungs.
Characteristics:

Rhythmic and synchronized to heart rate

May be observed in pediatric patients who are mechanically ventilated at low respiratory rates
with prolonged expiratory times

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Glossary of Terms
Capnography
Measurement and graphic as well as numeric display of carbon dioxide.
Capnometry
Measurement and numeric display of carbon dioxide.
Dead Space
Area of the lungs and airways (including artificial) that do not participate in gas exchange.
End-Tidal CO2 (ETCO2)
Peak concentration of carbon dioxide occurring at the end of expiration.
Pulmonary Perfusion
Blood flow through the lungs (pulmonary capillaries).
Shunt Perfusion
Areas of the lung that are perfused with blood but not ventilated.
Substrate Metabolism
Oxidation of carbohydrate, lipid, and protein for energy.
Ventilation-Perfusion Ratio (V/Q)
Ratio of ventilation (air flow) to perfusion (blood flow).
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Notes

Notes

Notes

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