CAPNOGRAPHY

Lecturer[; warfaa Tuesday, January 7, 2025

Definitions
 Capnography – A graphical display of CO2 concentration over time or expired
volume.
 Capnogram – CO2 waveform either plotted against a volume (CO2
expirogram) or against time (time capnogram).
 PACO2 – Partial pressure of carbon dioxide in the alveoli.
 PaCO2 – Partial pressure of carbon dioxide in arterial blood.
 PETCO2 – Partial pressure of carbon dioxide at the end of expiration.
 P(a-ET)CO2 – The difference between PaCO2 and PETCO2 .
Sometimes called the “CO2 -diff”, or “CO2 gradient”.
 PVCO2 – Partial pressure of carbon dioxide in venous blood.
 The respiratory cycle consists of two components; a- inspiration and b-expiration.
 To understand capnography we MUST understand that “Oxygenation” and
“Ventilation” are two entirely different mechanisms, but they both rely on the
respiratory cycle.
 Oxygenation relies on the inspiratory phase and refers to the amount
of oxygen (O2) available and utilized.
 Ventilation relies on the expiratory phase and refers to the amount of
carbon dioxide (CO2) produced during the metabolic cycle of the cells,
and exhaled from the body.
 Oxygenation and ventilation are BOTH needed, in proper proportion, to
sustain an adequate and safe quality of life.
Determination of Oxygenation Status:
 Invasively an arterial blood gas (ABG) can be obtained
which measures, among other things, the PaO2 (Partial
Pressure of Oxygen dissolved in the blood plasma of
arterial blood).
 Non-Invasively a pulse oxymetry can be obtained which
measures the amount of oxygen that is bound to the
hemoglobin
Determination of Ventilation Status:
 Invasively the same arterial blood gas (ABG) sample that
measures the PaO2 also measures the PaCO2 (Partial
Pressure of carbon dioxide dissolved in blood plasma of
arterial blood).
 Non-Invasively the PETCO2 (Partial pressure of carbon
dioxide in exhaled gas) can be measured. This is measured
breath by breath at the end of the expiratory phase of
respiration.
CO2 production
 Production of carbon dioxide is a result of cellular metabolism.
 During normal aerobic cellular metabolism carbon dioxide is produced
when we burn glucose and oxygen to produce energy in the form of
adenosine triphosphate (ATP).
 The exhaust, or waste products, of aerobic cellular metabolism are
mostly water (H2O) and carbon dioxide (CO2).
 The excess water is eventually transported to the kidneys where it is
converted to urine, which leaves the body during urination.
 The carbon dioxide is transported to the lungs where it diffuses across
the
alveolar capillary membrane and leaves the body during the expiratory
phase of respiration
 Methods of Monitoring
 The most common methods used for detecting and measuring carbon dioxide
in exhaled gas are:
 Chemical colorimetric analysis – Most commonly used in the pre-hospital
setting
 Infrared Spectrography – Most commonly used in the hospital setting
 Molecular Correlation Spectrography (Micro stream technology)
 Other methods used are:
Raman Spectrography
Mass Spectrography
Photo-acoustic Spectrography
 Advantages of CO2 Monitors:
 Provides a measured concentration of
carbon dioxide present in the gas sample.
 Provides a breath by breath waveform
and measurement that can be used to
help determine your patients airway
and gas exchange condition.
 Can detect, measure, and monitor
very small amounts of CO2 in exhaled
gas (less than 1%).
 Can accurately measure CO2 during CPR.
 CO2 monitors can be used continuously.
 Disadvantages of CO2 Monitors:
• Takes longer to show results after
endotracheal intubation.
• Sensors can be bulky or heavy on the end of
the ET tube.
• Sample tubing or electrical line attached to
the ET tube can increase risk of unplanned
extubation, creating a sudden unexpected
airway emergency.
• Most units require some maintenance
and supplies (batteries, airway adapters,
etc…).
• It is expensive
 Chemical colorimetric analysis
Chemical colorimetric analysis uses a pH-sensitive
chemical indicator inside a device that is placed
between an endotracheal circuit. tube and a
breathing
• This indicator changes color breath by breath. It
turns yellow when it’s exposed to a carbon
dioxide concentration of 4% or greater, and
purple when it’s exposed to room air that
contains almost no carbon dioxide.
• These devices are good for quick determination of
the presence of CO2 but are not sensitive to low
concentrations of CO2, as is the case during
CPR or other low cardiac output situations
 Advantages of Colorimetric Devices:
 Very portable devices can easily be stored
until needed.
 Quick and easy to use.
 Good for quick determination of ET tube
placement immediately following
endotracheal intubation.
 Very light weight, putting little to
no stress on the end of the ET tube
 Disadvantages of Colorimetric Devices:
 Colorimetric devices are for short term use only
(< 30 min). When they become too wet from
water vapor in exhaled gas they will stop
functioning.
 These devices do not measure carbon dioxide.
They only respond to the presence of carbon
dioxide in the sample.
 In the event of an esophageal intubation a
colorimetric CO2 detection device will show a
false positive for carbon dioxide if the patient has
consumed carbonated beverages just prior to
intubation.
Volume Capnogram
 Carbon dioxide concentration when plotted against expired volume
during a respiratory cycle is termed as ‘Volume Capnogram’.
 Unlike the ‘Time Capnogram’ it has only an expiratory segment and no
inspiratory segment.
 Volume capnography has several advantages over time capnography.
1 - the volume of CO2 exhaled per breath can be measured.
2 - significant changes in the morphology of the expired wave form
can be detected in the volume capnogram (e.g. secondary to
PEEP) that are not seen in the traditional time capnogram
 The Capnogram
 Phase-I is the onset of expiration which
contains only deadspace gas of the upper
airway.

 Phase-II is the upward slope that contains a

mixture of deadspace gas and alveolar gas.
 Phase-III, also called the alveolar
plateau, contains only alveolar gas.

 Phase-0 is the onset of inspiration

.
a. The alpha-angle is the angle
between Phase-II and Phase-
III of the capnogram.
b. An increased alpha angle
indicates expiratory
seen in a prolonged phase as
is often bronchospasm or
partial airway obstruction.
a. The beta-angle is the angle
between Phase-III and Phase-0
of the capnogram.

b. A increased beta angle is

indicative of partial rebreathing
of exhaled carbon dioxide as is
sometimes foreign body seen
with partial airway obstruction or
laryngospasm.
• The presence of Phase-IV
on a capnogram indicates an
unequal emptying between
the left and right lung.
• This can be caused by a
unilateral bronchospasm, or a
partial airway obstruction
within the left or right
bronchial tree
 Indications for Use : capnography
 Endotracheal Intubation: Confirmation of proper ET tube
placement
 Procedural Sedation: Continuous monitoring of respiratory
pattern
 Mechanical Ventilation: Monitoring effects of ventilator setting
changes
 General Anesthesia: Monitoring of pulmonary and cardiac
output status
 Cardio-Pulmonary Resuscitation: Monitoring effectiveness
of chest compressions, and predicting the outcome of CPR
Capnography During Endotracheal Intubation:
 Carbon Dioxide is a waste product of cellular metabolism, and leaves the
body during the expiratory phase of respiration.
 If cardiac output is stable, and the airway is patent, then carbon dioxide is
present in exhaled gas.
 Carbon dioxide is normally NOT present in the stomach.
 Capnography should be initiated immediately after endotracheal
intubation.
 The consistent presence of CO2 after 4 – 5 breaths* indicates a successful
endotracheal intubation.
 The absence of CO2 in the exhaled gas indicates an esophageal
intubation
Capnography During Endotracheal Intubation:
 After an inadvertent esophageal intubation a false-
positive capnographic reading can be caused by:
Resent consumption of carbonated beverages
Exhaled gas entering the stomach during aggressive
bag-valve-mask ventilation
 A significant tracheo-esophageal fistula can cause
exhaled gas to enter the gastrointestinal tract.
Capnography During Procedural Sedation:
 Capnography is a vital sign of ventilation.
 The capnographic waveform DIRECTLY correlates with respiration.
 Changes in respiratory status can be detected instantly when
monitored with the proper use of capnography.
 Changes in respiratory status can go undetected for up to 5 minutes
when being monitored with pulse-oxymetry alone, even if a cardiac
monitor is being used.
 During procedural sedation capnography should be used in
conjunction with pulse-oxymetry.
Capnography During Mechanical Ventilation:
 When a critically ill patient is on mechanical ventilation
oxygenation and ventilation are being continually
monitored.
 Invasively this is done by drawing an arterial blood
sample and running an arterial blood gas (ABG) at
regular intervals, and after changes in ventilator settings.
 Non-Invasively oxygenation is continually monitored with
the use of pulse- oxymetry, and ventilation can be
continually monitored with the use of capnography.
 Capnography can be used as a trending tool and to aid
in determining the effect of changes in mechanical
ventilator settings.
 When used properly capnography can help you manage
your intubated patients with fewer arterial blood samples.
Capnography During General Anesthesia:
 After anesthesia induction capnography is first used to
verify ET tube placement after endotracheal intubation.
 During surgery capnography is used to monitor airway
status, ventilatory status, and pulmonary perfusion status.
 Airway status: The waveform is closely watched for
change in shape, which will alert the anesthesiologist of
anything from bronchospasm to dislodgement of the ET
tube.
 Ventilatory status : During surgery a sudden decrease in PETCO2
can alert the anesthesiologist of changes to ventilation status.
 A sudden decrease in PETCO2 indicates a sudden increase in
alveolar deadspace, leading to the suspicion of an acute
pulmonary thromboembolism or air embolism.
 Perfusion status: A sudden decrease in PETCO2 can also mean an
acute decrease in pulmonary perfusion. Pulmonary perfusion is
directly proportional to PETCO2
 Capnography During Cardio-Pulmonary Resuscitation:

 The benefit of using capnography during cardiopulmonary

resuscitation has been known about for many years, and several
studies have been published supporting its use.
 We already know that if ventilation is consistent then measured
PETCO2 is directly proportional to cardiac output and
pulmonary perfusion status.
 With an intubated patient if manual ventilation is consistent
then PETCO2 can help determine if chest compressions are
effectively circulating blood to the vital organs.
.
 As the person performing chest compressions begins to fatigue
chest compressions will not be as effective and PETCO2 will
begin to decline. MOST people can only perform EFFECTIVE
chest compressions for a maximum of three (3) minutes before
beginning to fatigue.
 Studies show that the initial measured PETCO2 can also be a
predictive indicator of outcome and survivability of CPR.
 If the initial PETCO2 is < 8mmHg then the survivability is less
than 1%.
 If the initial PETCO2 is > 18 then your patient has a 70% greater
 It MUST be understood that outcome is also dependent on the initial cause of
the cardiopulmonary arrest
 Normal values for PETCO2 is 30 – 40 mmHg. This is for the text-book
patient; 35 year old, 6 foot, 165 pound, white male in perfect health.
 In the clinical setting normal PETCO2 is considered to be 3 – 5 mmHg
below the P aCO2 via arterial blood gas measurement.
 This calculated measurement is the P(a-ET)CO2, also called the CO2-diff, or
the CO2 gradient.
 The P (a-ET)CO2 is directly proportional to the amount of dead-space
ventilation (Ventilation that does not participate in gas exchange).
 PETCO2 & Cardiac Output:
 PETCO2 is directly proportional to cardiac output and
pulmonary perfusion.
 If ventilation is consistent then any sudden change in cardiac
output or pulmonary perfusion will result in a sudden change in
PETCO2.
 A sudden increase in cardiac output or pulmonary perfusion will
result in a sudden increase in PETCO2.
 A sudden decrease in cardiac output or pulmonary perfusion will
result in a sudden decrease in PETCO2
 The P(a-ET)CO2:
 There are several conditions or disease states that will
cause an increase in the CO2-diff.
 Pulmonary embolism
 Emphysema
 Low cardiac output states
 Hypovolemia
 Slightly increases with age
 The P(a-ET)CO2:
 Pulmonary Embolism:
Air that is rich in CO2 leaves the
alveoli and gets diluted with
dead-space air that leaves
alveoli with poor perfusion or
no perfusion. The result is a
lower concentration of CO2 in
exhaled air.
 Capnography is a very fast indicator of many problems that
can arise during artificial ventilation.
 In most cases capnography responds much faster than pulse-
oximetry, which can sometimes take 3 – 4 minutes to show a
change in respiratory status.
 The measured ETCO2 alone, while important, is of limited
value. In many cases it is the waveform that tells you a lot
more about the pulmonary and airway status of your patient
Capnography examples and Interpretations
Thank you