Capnography

Presenter : Dr. Yashas T S

Mentors : Dr. Sreenivasa Babu
Dr. Amar Simha
 Capnography is continuous, non invasive measurement and
graphical display of EtCO2 concentration v/s time or volume during
a respiratory cycle.
CO2 transport and monitoring

Changes in respired CO2 reflects alterations in metabolism,

circulation, respiration or the breathing system.
Metabolism
• Monitoring CO2 elimination → indication of metabolic rate

• ↑ or ↓ in etCO2 is a reliable indicator off metabolism only in

mechanically ventilated patients

• For spontaneously breathing patients – etCO2 might not ↑ with

↑metabolism because of compensatory hyperventilation
Metabolic causes of ↑ CO2 excretion (↑etCO2)

• ↑ Temperature, Malignant hyperthermia

• Shivering
• Convulsions
• Excessive catecholamine production / administration
• Blood / Bicarbonate administration
• Release of an arterial clamp or torniquet
• Parenteral hyperalimentation
Other causes for ↑ EtCO2 :
o ↑ exhaled CO2 can result from CO2 used to inflate
• Peritoneal cavity during Laparoscopy
• Pleural cavity during Thoracoscopy
• Joint during arthroscopy
• ↑ visualisation for endoscopic vein harvest

o ↓ CO2 elimination–
• ↓ Production - ↑muscle relaxation, ↓ Temperature
• Hypoventilation
• Rebreathing
• CO2 absorber exhaustion
Circulation
• CO2 reflects CO and Pulmonary blood flow
• (As gas – venous system – R heart – Pumped to Lungs by RV)

• ↓ EtCO2 is seen with ↓CO if ventilation

is constant and viceversa
• ↓ blood flow to lungs – Hypovolemia, Pulmonary emboli (thrombus, fat, amniotic
fluid, tumor), Aortic aneurysm, surgical manipulations

• During CPR, exhaled CO2 is a better guide than ECG, Pulse or BP

Capnometer is not susceptible to mechanical artifacts that are associated
with chest compressions, and chest compressions do not have to be
interrupted to assess circulation
Respiration
• CO2 monitoring give info about rate, frequency and depth of
respiration
• Used to evaluate patient’s ability to breathe spontaneously, detect
bronchospasm, altered ventilation parameters as well as effect of
bronchodilator treatment
EtCO2
Partial pressure of CO2 at end of exhaled breath, which is
expressed as a percentage of CO2 or mmHg

Normal values – 5-6% / 35-45mmHg

EtCo2 is reflection of alveolar CO2 in normal lungs

Use of Capnography comes with understanding relationship b/w
arterial, alveolar and EtCO2

EtCO2 provides a clinical estimate of arterial CO2 (PaCO2) when:

• Ventilation and Perfusion are appropriately matched
• Co2 is easily diffusible through the alveolar capillary membrane
• No sampling errors occur during measurement
• The difference b/w EtCO2 (alveolar) and PaCO2 (arterial) is referred to
as the (a-Et)PCO2 (CO2 gradient)
Normal – 2-5 mmHg

• Conditions that alter the V/Q ratio, volume and/or distribution of PBF
affects CO2 gradient
History
• Developed by Karl Luft in 1943 and introduced to clinical practice in
early 1950s
• Rapid IR CO2 analysis – Collier
• Value of end tidal sample established by – Ramwell
• In 1978, Holland was first country to adopt capnography as a standard
of monitoring during anaesthesia
• In 1990s, according to an ASA study – 93% of avoidable anaesthesia related
incidents could have been prevented with use of capnography in
conjunction with pulse oximetry

• 1998 – ASA Committee on standards of care → Mandatory that all patients

receiving GA be continuously monitored for EtCO2

• 1999 – ISA designated capnography as desirable standard in it’s

“Anaesthesia monitoring standards”

• Today – utility extended to ICUs, EDs, Endoscopic suites and other

procedures
Definitions
• Capnography – continuous non-invasive measurement and graphical
display of EtCO2 concentration v/s time or expired volume during a
respiratory cycle
• Capnograph – Machine that generates the waveform
• Capnogram – Actual waveform
• Capnometry – measurement and numerical display of maximal
inspiratory and expiratory CO2 concentrations in a respiratory cycle
• Capnometer – device that performs measurement and displays the
reading
Standard requirements
• CO2 reading should be within ±12% of actual value or ±4mmHg,
whichever is greater over the full range of capnometer
• Manufacture should disclose any interference caused by ethanol,
acetone, methane, helium, tetrafluroethane, dichlorodifluromethane,
as well as other halogenated anaesthetic gases
• Capnometer should have alarms
• High CO2 alarm for both inspired and exhaled CO2
• Low exhaled CO2 alarm
Physics of CO2 measurement
Methods :
• IR Spectrography
• Molecular correlation Spectrography (microstream)
• Chemical colorimetric analysis
• Photoacoustic Spectrography
• Raman Spectrography
• Mass Spectrography
 Infrared Spectrography

• Most common

• CO2 absorbs light over very low bandwidth =

4.26 µm

Absorption spectrum for CO2 partially overlaps

with other gases (water, N20)
↓
Compensation algorithm – minimize
interference – improve accuracy
Depending upon position of sensor

Mainstream
Sidestream
 Mainstream Sidestream

• CO2 directly measured in • Incorporates a pump /

circuit compressor that aspirates
• No gas is subtracted gases into a sample cell
• Faster response time located at unit’s console
• Measuring chamber must be • Fixed volume of gas
warmed to about 40℃ continuously sampled from
circuit through nylon / Teflon
• Heavy
tubing
• Requires frequent calibration
• Rate : 50-500mL/min
• Prone to soiling with
• O2 masks/nasal cannulas can
saliva/mucus
be adopted to allow CO2
monitoring
• RR can be monitored
adequately
 Mainstream

o- Sensor at patient’s - Secretions and

Advantages

airway humidity block the

o- Fast resposnse sensor
(Crisp waveform) - Facial burns

Disadvantages
o- Short time-lag - Difficult to use with
o- No sample flow to non intubated patients
reduce tidal volume - Cleaning and
sterilization hassle
 Sidestream

o- Easy to connect -Response time is delayed

Advantages

o- Disposable sample line - Sampling tube obstruction

o- Can be used in - Water vapor pressure
nonintubated patients changes affect readings

Disadvantages
o- Easy to use in unsual - Pressure drop along
positions (like prone) sample tube affects CO2
o- No bulky sensors / measurements
heaters at airway - Sample flow may reduce
tidal volume
Basic Physiology of Capnography
CO2 concentration plotted against time or expired volume during a
respiratory cycle

1) Time Capnogram
2) Volume Capnogram (CO2 expirogram)
Time Capnogram
2 segments –
a. Inspiratory : Phase 0
b. Expiratory : Phases I, II, III,
IV (occasional)

2 angles – α,β
Waveform

• Height shows amount of CO2

• Length depicts time
• No CO2 present during inspiration – baseline normally 0
Phase I
Dead space Ventilation

• Beginning of exhalation
• No CO2 present
• Air from mouth, nose, posterior pharynx, trachea
• No gas exchange
Phase II
Ascending phase

• CO2 from alveoli begins to reach

the upper airway and mix with
dead space air
• Causes a rapid rise in the
amount of CO2
• CO2 now present and detected
in exhaled air
Phase III
Alveolar Plateau

• CO2 rich alveolar gas now

constitutes majority of exhaled air
• Uniform concentration of CO2 from
alveoli to nose/mouth
End-tidal CO2
Concentration of CO2
in at the end of exhalation

N : 35-45mmHg
Phase 0
Descending Phase

• Inhalation begins
• O2 fills airway
• CO2 level quickly drops to zero
α Angle β Angle
• Takeoff/elevation angle • N: 90 degrees
• N : 100 – 110 degrees • Angle ↑ : Rebreathing
• Airway obstruction and PEEP • Angle ↓ : Phase III slope ↑
↓
Increased slope
↓
Larger α angle
• Other factors : Capnometer’s Response
time, sweep speed, respiratory cycle time
Volume Capnogram
• FCO2 in exhaled gas v/s Exhaled volume
• Only Expirtory limb
• 3 phases:
Phase I – Anatomical Dead space
Phase II – Transitional
Phase III – Alveolar gas
Total air below horizontal line denotes:
Fraction of CO2 in equilibrium with
arterial blood

3 Areas –
X : Volume of CO2 exhaled over a tidal breath
Can be used to compute CO2
production (VCO2) and mixed expired CO2
fraction using Bohr equation
Y : Represents wasted ventilation
due to alveolar dead space

Z : Represents wasted ventilation

due to anatomical dead space

Y+Z : Total physiological dead space

 - Volume of exhaled CO2 can be
Advantages measured
- Significant change in morphology
of expired waveform can be
detected
- Dead space can be partitioned
into components of interest
- CO2 gradient determination
• Height
• Frequency
• Rhythm Waveform
• Baseline
• Shape

Analysis

EtCO2 Trend
 Indicates rising ETCO2

Probable causes – Hypoventilation, ↓ tidal volume,

↑metabolic rate, hyperthermia, laparoscopic
infiltration

Interventions:
• Adjust Ventilatory settings
• ↓ respiratory depressant drug dosages
• Normalise body temperature
 Indicates falling ETCO2

Probable causes –
↓ Production - ↓ metabolic rate, hypothermia,
hypothyroidism
↑ Elimination - Hyperventilation
↓ Alveolar CO2 delivery - Hypoperfusion,
Pulmonary embolism
Artifact -Tube leak
Malfunction of measuring system

Interventions:
• Adjust Ventilatory settings
• Evaluate for adequate sedation
• Evaluate Anxiety
• Conserve body heat
Exponential ↓ in EtCO2:
• Sudden hypotension owing to massive blood loss
• Obstruction of major blood vessel
• Circulatory arrest
• Pulmonary embolism – air, clot, thrombus, marrow
 Indicates - Slower rise in CO2
↑ upslope of Phase III, Wide α angle

 Impression – Bronchospasm

“Shark Fin” Shape

Other causes:
• Kinking/occlusion of artificial airway
• Foreign body
• Obstruction in expiratory limb of breathing
circuit
Sudden loss of waveform:
• Dislodged airway (oesophageal) / Airway disconnection
• Apnea
• Airway obstruction
• Ventilatory malfunction
• Cardiac arrest
 Esophageal intubation

 EtCO2 - Surest sign of Intubation

 Impression – Rebreathing

 Faulty expiratory valve

 Inadequate inspiratory flow
 Insufficient expiratory flow
 Inadequate seal around ET tube

 Leaky/deflated cuff
 Small ET tube
 Curare cleft
Appears when muscle relaxants’ action begins to subside

 Surgical manipulation of abdomen

 Cardiogenic Oscillations

due to movement of gas in airway as

a result of heart beating against the lungs
“Saw tooth appearance”
 Inspiratory Valve malfunction

 Prolonged plateau
 Slanting inspiratory downstroke (↑ β angle)
 Shortened inspiratory phase
 Intermittent spontaneous breaths
Short alveolar plateau
 Exhausted Soda lime
 Gradual elevation of baseline and height of capnogram
 CPR
ROSC
↓
↑ in EtCO2
↓
Drastic improvement in blood flow

High quality CPR – EtCo2: 10-20 mmHg

Uses:
Evaluate effectiveness of compressions
Identification of ROSC
 Phase 4
Leak in sampling line during
positive pressure ventilation results
in upswing at the end of Phase III

- Also seen in obese and pregnant

patients (less FRC and compliance)
Bifid Capnogram

Severe kyphoscoliosis
Following single lung transplant
Small Air embolus with resolution
Sudden increase of CO2 followed by resolution

 Release of torniquet / unclamping of major vessel

 Inj Sodabicarb
(a-ET)PCO2 - V/Q heterogenicity, particularly - Low tidal volume, low
with high V/Q regions frequency ventilation
- Pulmonary hypoperfusion - Pregnant woman
- Pulmonary emboli - Infants and children
- Cardiac arrest
- High rate, Low tidal volume
respiration
- Emphysema

(a-ET)PCO2
- Old age
- General anaesthesia
 Clinical Applications
• Confirming ET tube placement
Surest sign
False positive- carbonated drinks, aggressive BMV, TEF
Determine position of double lumen tube – blind nasal intubation
• Procedural Sedation : in conjunction with pulse oximetry
• Patients with head injury – raised ICT
• Pediatric patients with Pulmonary hypertension
• Monitoring dead space → Reflects changes in CO and PBF
• ICU setting : choose best PEEP; & assess weaning from MV
• CPR – determine ROSC
THANK YOU
