Capnography

By
DR BY
DR CHERYL S RAJURYL S RAJU
 HISTORY
• 1943- LUFT- principleof capnography
• CO2 absorb a particular wavelength of IR rays which
can be used to detect the concentration.

• RAMWELL- started ETCO2 measurement

• HOLLAND (1978)– first country to add CAPNOMETRY

into standard of monitoring in anaesthesia
• INDIA- 1999 Dec 30- “desired Standard of care in
anaesthesia”
 Methods of measurement
• IR spectroscopy
• Raman spectroscopy
• Mass spectroscopy
• Photoacoustic spectroscopy
• Chemical caloriemetric analysis
 IR spectroscopy
• CO2 absorbs 4.3mm wavelength of IR light
• When light passes through a gasseous mixture
containing CO2,it absorbs the particular
wavelength
• According to Beer- Lamberts law-
Concentration directly propoiytional to
absorbance
 Photoacoustic spectroscopy
• It uses same principle as IR spectroscopy
• Instead of visual methods it uses acoustic
methods to detect the concentration of gases
 RAMAN spectroscopy
• High intensity Monochromatic argon laser
beam
• Gas sample is aspirated into analysing
chamber
• Raman scattering
• Raman signals---- spectrum
• Analysing the spectrum the [co2] is detected.
 MASS SPECTROSCOPY
• Measures mass to charge ratio
• Plots into a spectrum
• Concentration is calculated from the spectrum
• Expressed- volume %
• Disadvantages- expensive
• bulky
 Chemical caloriemetric
• Chemically treated foam is placed in a plastic
case and is attached to ETT elbow adapter
• Disadvantage- no waveform
• Used in difficult airways to rule out
esophageal intubation
 Physiology
• 1phase of expiration- 02 + N2O + Anaesthesia mixture
• 2 phase- Alveolar CO2 + Dead space air
• 3 phase- Alveolar CO2
• 0/4 phase- beginning of inspiration
Picture from [Link]
 Graph depends
• Cellular Metabolism
– Hypermetabolism(fever, MH, thyrotoxicosis),
– Hypometabolism- hypothermia
• Circulation and pulmonary perfusion
– cardiac arrest,
– hypotension,
– pulmonary embolism of clot or air,
• Ventillatory function
– Hypoventillation /hyperventilation
– V/Q mismatch (bronchospasm, COPD)
• Anaesthetic machine functions
– CO2 rebreathing (bad valves in circle system), exhausted CO2 absorbent,
– ventilator disconnect
Sidestream capnography Mainstream capnography
 ADVANTAGES
SIDE STREAM MAIN STREAM
• Sensor does not get damaged or • Live detection of CO2
discarded.
• No gas removed from the
• Heavy sensor does not pull on the
ETT. circuit
• Easier to clean and discard tubing • No complexity of the circuit
• Can be used in spontaneously
breathing patients
• Sampling port can be used for
bronchodilator therapy
 Disadvantages
Side stream Main stream
• CO2 flight time • Add weight to the breathing unit
• Sample unit Leaks ,failure of • Increases dcead space
pump, obstruction of sampling • Sensor may get disslodged
tube
• Complicated circuit- aspirated gas
have to be rerouted.
• Fresh gas dilution can occur
ETCO2
 Abnormalities of capnogram
• Phase 1 elevation - Rebreathing
• Phase 2
• prolongation-Airway obstruction
• Increased Alpha angle-airway obstruction
• Phase 3
• increased slope- Airway obstruction
• Cleft- curare cleft
• Phase 0- increased Beta angle- rebreathing
Increased EtCO2 Decreased EtCO2
• Hypermetabolic states • Hypometabolic states
– Fever,seizures, • Decreased pul. Perfusion
– hyperthyroidism – Shock
– Malignant hyperthermia – Cardiac arrest
• Tourniquet release – Pul. Embolism
• Co2 insufflation
• Hyperventilation
• Hypoventilation
• Exercise • Apnoea
• Technical errors • Errors
– Exhausted Absorber – Accidental extubation
– Inadequate fresh gas flow – Leaks and disconnections
Charcteristics of capnogram
[Link]
[Link]
[Link] –RR- 12- 16
[Link] – Normal sine wave pattern
5.EtCO2 value- 35-45 mm Hg
 V/Q mismatch (bronchospasm, COPD):

• SHARK FIN APPEARANCE

• Alveoli emptying early have less CO2.
Alveoli emptying late have more CO2.
“Curare cleft”: muscle relaxant is wearing off and patient takes
a weak breath during exhalation, temporarily decreasing
sampled CO2 concentration.
“Cardiogenic oscillations”: Cardiac activity moves tracheal gas
column enough to vary the sampled CO2 concentration.
Camel hump
endobronchial intubation
lateral decubitus position
extrinsic lung compression
Faulty ventilator
Oesophageal intubation
 Absent capnogram
• No CO2 production (death).
• Cardiac arrest (no CO2 transport to lungs despite ongoing metabolism).
• No ventilation (Apnoea)
• Airway-circuit disconnect, ETT dislodgementesophageal intubation, upper
airway obstruction.
• Capnograph dysfunction: sampling tube disconnect, loose or blocked
filter, etc.
 Rapid decrease in ETCO2 implies rapid decrease in pulmonary
perfusion and rapid increase in alveolar dead space, possibly due
to:

– Hypotension (hemorrhage, pump failure,

anaphylaxis, etc.)

– Clot or gas embolus

– Cardiac arrest
– Dead space increase
Alveolar dead space consists of the volume of the alveoli which are not
currently participating in gas exchange. These unperfused alveoli empty at
the same time as the alveoli which are participating in gas exchange and
the gas inside them dilutes the CO2 in expired gas and decreases ETCO2.

[Link]/.../section4/4ch3/s4ch3_15.htm
 Anatomic and alveolar dead space
• Anatomic dead space gas comes out before
alveolar CO2.

• Alveolar dead space gas comes out at the same

time as CO2 from perfused alveoli.

• Alveolar dead space gas dilutes CO2 from perfused

alveoli. This is why PaCO2 > ETCO2.
 Why does increased alveolar dead
space reduce the ETCO2?

• The gas in alveolar dead space does not have

CO2 in it.

• Therefore, alveolar dead space gas dilutes the

CO2 coming from the perfused alveoli.

• This dilution of expired CO2 during the “alveolar

plateau” is the key idea.
 ETCO2 = ETCO2 = 20
40 mm Hg mm Hg
With no With 50%
alveolar alveolar 20
40
dead space dead space
([Link]
hypotension)
40
20
Alveolar dead
space gas
(with no CO2)
dilutes other
alveolar gas.
0
40
40 40
0 46
46 46
Hemorrhage abruptly reduces pulmonary perfusion and
increases alveolar dead space, abruptly reducing ETCO2.
Hemorrhage is a common cause of rapid decrease in ETCO2.
Thromboembolus abruptly reduces pulmonary perfusion and
increases alveolar dead space, abruptly reducing ETCO2.
Air embolus abruptly reduces pulmonary perfusion and
increases alveolar dead space, abruptly reducing ETCO2.
 Uses of Capnogram
• Estimate PaCO2
• Adequacy of spontaneous respiration
• Integrity of anaesthetic apparatus
• To determine the correct ventilatory needs during controlled ventilation
• Accidental esophageal intubation
• Tracheal intubation during awake fibro-optic bronchoscopy
• Wearing of muscle relaxant
• Blind nasal intubation
• To detect Pulmonary embolism.
• To detect Malignant Hyperthermia
 Cardio-Pulmonary resuscitation
• High quality CPR- EtCO2 -10-20 mmHg
• Achievement of ROSC- significant increase in
EtCO2
• Failed CPR- failure to achieve EtCO2 more
than 10 mm Hg after 20 mtsof Chest
compressions.
• Difficult airway algorhithm- EtCO2 is used to
confirm secured airway
 Volume capnography
• CO2 colume when plotted against expired gas
volume during a respiratory cycle
• Only plots expiratory segment
• Volume of CO2 per total expired volume is
measured
• V/q status better represented.
• Bulky instruments so not extensively used.
The End