Capnography

TERMINOLOGY

CAPNOMETRY- Measurement and display of expired CO2 on a digital or analog monitor. CAPNOMETER- Device that performs the measurement and displays the readings in numerical forms CAPNOGRAPHY- A graphical display of instantaneous CO2 concentration versus time or expired volume during a respiratory cycle CAPNOGRAM- Actual waveform

ASA GUIDELINES

Standard for every patient receiving general anaesthesia. Continual monitoring for expired co2 For verification of positioning of endotracheal tube or laryngeal mask airway

Standard requirements of a capnometer (U.S. standard)

1. The CO2 reading shall be within a range of 12%of actual value or 4mm of Hg whichever is greater over the full range of capnometer. 2. The manufacture must disclose any interference caused by ethanol, acetone, methane, helium, tetrafluoroethane, as well as commonly used halogenated anaesthetic agents.

3. The capnometer must have a high CO2 alarm for both inspired and exhaled co2. High CO2 alarm must be of medium priority 4. An alarm for low exhaled CO2 is required. Low CO2 alarm shall be medium priority 5. Must disclose the quantitative effects of barometric pressure on capnometer performance in instruction for use.

Methods of CO2 measurement

PHYSICAL METHODS
( a) Infra red spectrography (b) Molecular correlation spectrography working on microstream technology (c) Mass spectrography (d) Raman spectrography ( e) Photo acoustic spectrography

CHEMICAL METHODS
(a) ph sensitive also k/a the colorimetric method

It is the most common technology in use. Gases that have two or more dissimilar atoms in the molecule have a specific and unique absorption spectrum of IR light CO2 absorbs infra red light at 4.3 micrometer

INFRA RED SPECTROGRAPHY

Amount of light absorbed is proportional to conc.

INTERFERENCE
1. 2. 3. 4. 5.

Halogenated anaesthetic agents do not absorb infra red light at the wavelength used for CO2 Atmospheric pressure can also influence readings Water vapour can occlude tubing and or sampling chamber. Response time also affects the analyzing process N20 absorbs while oxygen does not absorb infra red light

Effect of N2O

N2O causes broadening of band

COLORIMETRIC METHOD

Consists of ph sensitive chemical indicator, which when exposed to CO2, becomes more acidic & changes color Is portable & used mainly to confirm successful tracheal intubation Minimum of 6 breaths should be performed Paediatric version also available

Assesment of CO2 from color change

PURPLE: <0.5% GREEN: 0.5%-2% YELLOW: >2%

RESPONSE TIME

It consists of (a) transit time (b) rise time

Transit time : is the time to move from point

of sampling to point of measurement.

Rise time : is the time to change in response

to steep changes in co2. Response time can be reduced by a) use of more powerful amplifiers b) minimizing volume of sampling chamber and tubes. c) use of relatively high flow rates.

Effect of slow analyzer on response time

1.

Underestimation of co2 due to dispersion of gases at longer transit time.

2.

Abnormal waveforms , reduce slope of phase 2 at longer rise time.

TYPES OF CAPNOMETER

MAIN STREAM CAPNOMETER SIDESTREAM CAPNOMETER

MAINSTREAM CAPNOMETER

MAINSTREAM CAPNOMETRY (NONDIVERTING)

Placed between breathing system & pt. Gas passes through a chamber (cuvette) with 2 sapphire windows transparent to IR light The sensor which houses both the light source & the detector, fits over the cuvette

ADVANTAGES

Fast response time

Better fidelity No need of scavenging or to increase the fresh gas flow Sample contamination with fresh gas flow is less likely Standard gas is not required for calibration Fewer disposable items

DISADVANTAGES

Traction on airway device and may cause kinking of ETT Increases dead space Leaks , disconnections and circuit obstructions can occur Condensed water or secretions on the cuvette interfere with light transmission Sensor may get dislodge from cuvette Measures only C02 and O2 Must be cleaned and disinfected between uses

Thermal burns
Pressure injury

CLINICAL IMPLICATIONS
HEAVY hence must be supported HEATED hence direct contact avoided RESPONSE TIME IS FASTER since no gas is subtracted. CALIBRATION must be done at least once a day SECRETION or CONDENSED WATER may interfere with light transmission and interpretation

SIDESTREAM CAPNOMETER

SIDESTREAM CAPNOMETRY (DIVERTING)

Sampling flow rate varies from 50 to 500 ml/min. If sampling flow exceeds expired gas flows contamination from fresh gas flow will occur

CO2 FLIGHT TIME- Delay in

gas detection depends onSampling dead space Sampling rate

Water traps or filters may be required to protect the measuring chamber

ADVANTAGES

Calibration and zeroing are usually automatic Added dead space is minimal Potential for cross contamination between patients is low Sampling port can be used to administer bronchodilators Can be used when monitor must be remote from the patient (MRI) Several gases can be measured simultaneously

DISADVANTAGES

Leaks, sampling tube obstruction, failure of aspiratory pump . Aspirated gas must be either scavenged or returned to the breathing system. Increased delay time. Supply of calibration gas must be available. Deformation of wave form fresh gas dilution. More variable difference between arterial and end tidal CO2 levels.

CAPNO-TIPS

Positioning of monitor higher than the patient. Position sampling tube upwards Use filters Regular calibration if required should be done by using standard gases In monitors equipped with automated calibration anaesthesist can check by expiring into detecting device.

DUAL CAPNOGRAPHY
IN THIS, CO2 IS SAMPLED FROM BOTH LUMENS OF DLT

CIRCUIT OF CO2

APPLICATIONS OF CAPNOGRAPHY

APPLICATION OF CAPNOGRAPHY

End-tidal to arterial CO2 gradient

Normal PaCO2 ranges from 35-45 mm of Hg.(7-10 cm of H2O )

Normally EtCO2 is 2-5 mm less than arterial CO2.

When gas exchange is impaired, PEtCO2 decreases relative to PaCO2, so the PaCO2- PEtCO2 increases

INCREASED ANATOMIC DEAD SPACE shallow breathing

INCREASED PHYSIOLOGICAL DEAD SPACE COPD low CO Pulmonary embolism Excessive lung inflation eg PEEP

ALTERED CO2 PRODUCTION

Waveform EtCO2 iCO2 Gradient

Abs of CO2 from peritoneal cavity Soda bicarb Pain, anxiety, shivering Inc ms tone
Convulsions Hyperthermia

Normal
Normal Normal Normal Normal Normal

0
0 0 0 0 0

Normal
Normal Normal Normal Normal Normal

ALTERED CO2 PRODUCTION

Waveform EtCO2 iCO2 Gradient

Hypothermia
Inc. anaesthesia depth Use of ms. relaxants Release of tourniquet

Normal
Normal May see curare cleft Normal

0
0 0 0

Normal
Normal Normal Normal

ALTERATIONS D/T CIRCULATORY CHANGES

Waveform EtCO2 iCO2 Gradient

Dec CO2 Normal transport to lungs Dec CO2 Normal through lungs Rt Lt shunt Normal Increased pt dead space Normal

Normal

Elevated

0
0

Elevated
Elevated

ALTERATIONS WITH RESPIRATORY PROBLEMS

Waveform Absent
Absent EtCO2 iCO2 Gradient 0 0

Disconnection Apneic pt

Hyperventilation Hypoventilation
Upper airway obs Rebreathing

Normal Normal
Abnormal Baseline elevated

0 0
0

Normal Normal
Elevated Normal

Esophageal int.

Absent

ALTERATIONS WITH EQUIPMENT

Waveform
Inc app. Dead space Baseline elevated EtCO2 iCO2

Gradient
Normal

Rebreathing
Blockage in sampling line

"
Absent

Normal

Leak in sampling line Abnormal

Too high sampling rate Abnormal

0
0

Increased
Increased

INCREASED PETCO2
OUTPUT
Fever Malignant Hyperthermia Sodium Bicarbonate Tourniquet Release Venous CO2 Embolism

PERFUSION
Inc. cardiac Output

VENTILATION
Hypoventilation

TECH . ERROR
Exhausted Absorber Inadequate Fresh Gas Flow Leaks in Breathing System Faulty Valve

Inc. Blood Pressure Rebreathing Partial Airway Obstruction

DECREASED PETCO2
OUTPUT
Hypothermia

PERFUSION
Dec. Cardiac Output Dec. Blood Pressure Hypovolemia Cardiac Arrest

VENTILATION
Hyperventilation Apnoea Total Airway Obstruction Accidental Tracheal Extubation

TECH. ERRORS
Circuit Disconnection Sampling Tube Leak

Pulm.Embolism

TIME CAPNOGRAPHY

CO2 conc. Plotted versus time

Simple popular and adequate for clinical use Monitors dynamics of inspiration as well as expiration Can be used for non intubated patients , for example pt of high spinal anaesthesia

TIME CAPNOGRAM
PHASE I Inspiration and

phase of expiration during which dead space gas is exhaled PHASE II Rapid upstroke d/t transition between airway & alveolar gas PHASE III Alveolar plateau, constant, slowly upsloping part

1st

Top hat or sine wave pattern

PHASE IV Beginning of inspiration angle- normally 100-110. Airway obstruction leads to a larger angle
angle- normally approx. 90. Increased in rebreathing, prolonged
response time

CHARACTERISTICS OF A CAPNOGRAM

Height depends on EtCO2 Frequency depends on respiratory rate Rhythm determines regularity Baseline should be zero in normal conditions. It is increased in case of rebreathing or if CO2 is deliberately added to inspired gases Shape it helps diagnostically and therapeutically

SPEED OF OSCILLOSCOPE
FAST MOVING waveform observation

SLOW MOVING used for trend observation(overall CO2 changes)

LOW EtCO2(<35mm Hg)

HYPERVENTILATION INCREASE IN DEAD SPACE VENTILATION

PacO2- PetCO2 gradient should be determined to distinguish

ELEVATED EtCO2

HYPOVENTILATION

INCREASED CO2 DELIVERY TO LUNGS

CURARE CLEFT OR NOTCH

Seen during spont. Ventilation Seen in last third of plateau phase and is caused by lack of synchronous action between intercostal muscles and diaphragm It may be also seen in cervical transverse lesions, flail chest, hiccups, and pneumothorax and when a patient tries to breath during mechanical ventilation.

Spontaneous respiratory efforts during mechanical ventilation

Hypoventilation due to maladjusted ventilator Inadequate muscle paralysis Patient waking up

Pressure on patient chest

Ventilator malfunction

The end-tidal co2 may rise slightly because of increasing

RIPPLE EFFECT

Also known as CARDIOGENIC OSCILLATIONS RESULT of to and fro movement of gases due to cardiac pulsations Observed during plateau phase Rate of oscillations matches that of a simultaneously recorded HR Minimized when sampling port moves distal or lung volume is increased by PEEP. Routine in pediatric patients May be absent in a case of emphysema.

Prolonged expiratory upstroke

D/T INCOMPLETE EMPTYING OF LUNGS: Tracheal secretions

Bronchospasm Partially kinked or partially obstructed ETT

Prolonged expiratory upstroke

ALSO CALLED SHARK FIN WAVEFORM DUE TO ITS SHAPE As expiration is progressively prolonged, inspiration may start before expiration is complete, so EtCO2 falls & is no longer a good estimate of PACO2. Squeezing of patients chest may cause EtCO2 to rise towards normal. This SQEEZE PEtCO2 be used as an estimate of alveolar CO2

Biphasic expiratory plateau

When compliance , airway resistance or ventilation perfusion ratio in one lung differ substantially from the other Single lung transplantation Severe kyphoscoliosis

TERMINAL HUMP(Tail up pattern)

Leak in sampling line during PPV will result in upswing at end of phase III Peak of short duration is caused by next inspiration when positive pressure transiently pushes undiluted end tidal gas through sampling line

CONTAMINATION BY FRESH GAS OR AMBIENT AIR

By placing sampling site too near the fresh gas inlet Too high a sampling rate

A large leak is indicated by progressive decrease in plateau

Elevated baseline with normal waveform

Incompetent expiratory valve or exhausted absorbent Insufficient gas flow Rebreathing under drapes

Fresh co2 gas supply

Sudden Decrease of EtCO2

IMMINENT DISASTER

Oesophageal intubation Complete airway disconnection Ventilator malfunction

Sudden drop but not to zero

Partially obstructed tube Leak in breathing circuit

Partial disconnection in breathing circuit Poorly fitting tracheal tube or mask

Exponential decrease in EtCO2

IMMINENT DISASTER

Hypotension Massive blood loss Circulatory arrest

Pulmonary embolism Obstruction of a major blood vessel

Needs immediate diagnostic action

1.Auscultate the precordium 2.Check BP 3.Check SPO2 heart sounds+ decreased BP Check for occult or obvious bld loss cardiac arrest

vena cava obstruction by re retractor/ packs PULMONARY EMBOLISM ( consider the type of surgery)

PULMONARY EMBOLUS

Sudden increase in CO2

Release of tourniquet Unclamping of a major vessel may result in sudden increase in end -tidal CO2 that gradually return to normal.

ROLE OF CAPNOGRAPHY IN CPR

END-TIDAL CO2 is a better guide to the presence of circulation than ECG , pulse or BP during resuscitation It is not susceptible to mechanical artifacts so that chest compression do not have to be interrupted to assess circulation.

An increase in EtCO2 during CPR IS PREDICTIVE OF A SUCCESSFUL OUTCOME. When EtCO2 does not rise above 10 mm hg after 15 to 20 min of CPR, the resuscitative effort is unlikely to be successful. CAPNOGRAPHY can also point to the fatigue of the rescuer if EtCO2 fall slowly after increasing or fails to rise from a constant value.

Role of Capnography in CPR

First capnogram shows typical square waveform

Capnogram at bottom shows return of spontaneous circulation

EtCO2 IN LAPROSCOPY

EtCO2
INCREASED No
Endobronchial intubation Subcutaneous emphysema Capnothorax Yes

DECREASED

Pneumothorax Massive CO2 embolism

Volume Capnography

Co2 conc.'s Exhaled volume Area under the curve can be integrated to obtain volume of expired Co2 per breath Phase 3 better representation of v/q mismatch than phase 3 of time Capnography Dead space can be partitioned

Note that there is no inspiratory segment

VOLUME CAPNOGRAPHY

Bohrs equation (Enghoffs mod)

Vd = PaCO2-PeCO2 Vt PaCO2

Recent advances in Capnography

MICROSTREAM TECHNOLOGY for side stream sensor
(a) low aspiration flow rates 50 ml/min. (b) minimizes dispersion of gas in sampling tubes. (c) new external sampling cell which is attached to patient interface rather than housed inside the monitors eliminating the need of gas samples to be pulled up.

MAINSTREAM SENSORS
are now available in small light weight and less heating types.

Transcutaneous Capnography

Probe is placed on earlobe. Non invasive. Measures co2 from underlying arterioles. The skin beneath the electrode is heated up to 40C by the probe to promote diffusion of CO2 by promoting dilatation of surface arterioles More reliable than EtCO2 for monitoring arterial PCo2 in patients with abnormal pulmonary exchange Found to be more accurate in evaluating co2 levels during (a) one lung ventilation (b)obese (c) neurosurgical procedures and in older children

+DESATURATION +INCREASED AIRWAY PRESSURE +REDUCED AIR ENTRY

Yours presumptive diagnosis is

+increased airway pressure +reduced air entry in a laproscopic procedure

Yours presumptive diagnosis is

IDENTIFY THE PICTURE

IDENTIFY THE GRAPH

IDENTIFY THE TYPE OF CAPNOGRAPH