1.

End tidal carbon dioxide

analysis
2.Transcutaneous and carbon
dioxide monitors

Introduction
Capnometry refers to the measurement
and quantification of inhaled or exhaled
CO2 concentrations at the airway
opening.
Capnography, however, refers not only
to the method of CO2 measurement, but
also to its graphic display as a function
of time or volume.

PHYSIOLOGY OF
CAPNOMETRY

Oxygenation and Ventilation

Ventilation
(capnography)

O2

Oxygenation
(oximetry)

Cellular
Metabolism
CO2

Oxygenation and Ventilation

Oxygenation
Oxygen for
metabolism
SpO2 measures
% of O2 in RBC
Reflects change in
oxygenation within
5 minutes

Ventilation
Carbon dioxide
from metabolism
EtCO2 measures
exhaled CO2 at
point of exit
Reflects change in
ventilation within
10 seconds

CO2 transport

End-tidal CO2 (EtCO2)

Reflects changes in
Ventilation - movement of air in and
out of the lungs
Diffusion - exchange of gases
between the air-filled alveoli and the
pulmonary circulation
Perfusion - circulation of blood

End-tidal CO2 (EtCO2)

Pulmonary Blood Flow
Ventilation

Right
Ventricle

Artery

Vein

Oxygen

CO2

O2
O2

Perfusion

Left
Atrium

End-tidal CO2 (EtCO2)

Monitors changes in
Ventilation - asthma, COPD, airway
edema, foreign body, stroke
Diffusion - pulmonary edema,
alveolar damage, CO poisoning,
smoke inhalation
Perfusion - shock, pulmonary
embolus, cardiac arrest,
severe dysrhythmias

PRINCIPLES OF
CAPNOGRAPHY

BEER-LAMBERT LAW

Types of sensors

Solid state CO2 sensors

Chopper wheel CO2 sensor

Sidestream vs Mainstream
Capnometry
Sidestream/ Diverging
CO2 sensor located away from the
airway gases to be measured.
Incorporate a pump or
compressor.
Tubing length- 6 ft
Gas withdrawal rate 30500ml/min
Lost gas volume needs to be
considered in closed circuit
anesthesia.
Gases must pass through various
water traps and filters.
Transport delay time
Associated RISE TIME

Mainstream/ Nondiverting
Sample cell placed directly in
the patients breathing circuit.
Inspiratory and expiratory gases
pass directly through the IR path
Increase in dead space and is
heavy
Sample cell heated to 40
degrees to minimize
condensation.
Increased risk of facial burns.
Requires daily calibration.
No delay time
RISE TIME is faster

Types of capnometers

Interpretation of TIME

CAPNOGRAPHY
WAVEFORMS

Capnographic Waveform
Normal waveform of one respiratory
cycle
Similar to ECG
Height shows amount of CO2
Length depicts time

Capnographic Waveform
Waveforms on screen and printout
may differ in duration
On-screen capnography waveform is
condensed to provide adequate
information the in 4-second view.

Capnographic Waveform
Capnograph detects only CO2
from ventilation
No CO2 present during inspiration
Baseline is normally zero
C

E
Baseline

Capnogram Phase I
Dead Space Ventilation
Beginning of exhalation
No CO2 present
Air from trachea,
posterior pharynx,
mouth and nose
No gas exchange
occurs there
Called dead space

Deadspac
e

Capnogram Phase I
Baseline

Baseline

Beginning of exhalation

Capnogram Phase II
Ascending Phase
CO2 from the alveoli
begins to reach the
upper airway and mix
with the dead space air
Causes a rapid rise in the
amount of CO2

CO2 now present and

detected in exhaled air
Alveoli

Capnogram Phase II
Ascending Phase

C
Ascending Phase
Early Exhalation

II

CO2 present and increasing in exhaled air

Capnogram Phase III

Alveolar Plateau
CO2 rich alveolar
gas now constitutes
the majority of the
exhaled air
Uniform
concentration of
CO2 from alveoli to
nose/mouth

Capnogram Phase III

Alveolar Plateau
Alveolar Plateau

III
A

CO2 exhalation wave plateaus

Capnogram Phase III

End-Tidal

End of exhalation contains the

highest concentration of CO2
The end-tidal CO2
The number seen on your monitor

Normal EtCO2 is 35-45mmHg

Capnogram Phase III

End-Tidal

End-tidal

End of the the wave of exhalation

Capnogram Phase IV
Descending Phase
Inhalation begins
Oxygen fills airway
CO2 level quickly
drops to zero

Alveoli

Capnogram Phase IV
Descending Phase

IV

Descending Phase
Inhalation

Inspiratory downstroke returns to baseline

Capnography Waveform
Normal Waveform

45
0

Normal range is 35-45mm Hg

(5% vol)

a-A Gradient
arterial to Alveolar Difference for CO2
Ventilation

Right
Ventricle

Alveolus

Artery

EtCO2
PaCO2

Perfusion

Vein

Left
Atrium

End-tidal CO2 (EtCO2)

Normal a-A gradient
2-5mmHg difference between the EtCO2
and PaCO2 in a patient with healthy
lungs

Factors Affecting ETCO2 Levels

Hyperventilation
RR

: EtCO2
Normal

45
0
Hyperventilation

45
0

Waveform:
Regular Shape, Plateau Below Normal
Indicates CO2 deficiency
Hyperventilation
Decreased pulmonary perfusion
Hypothermia
Decreased metabolism

Interventions
Adjust ventilation rate
Evaluate for adequate sedation
Evaluate anxiety
Conserve body heat

Hypoventilation
RR

: EtCO2

Normal

45
0
Hypoventilation

45
0

Waveform:
Regular Shape, Plateau Above Normal
Indicates increase in ETCO2
Hypoventilation
Respiratory depressant drugs
Increased metabolism

Interventions
Adjust ventilation rate
Decrease respiratory depressant drug dosages
Maintain normal body temperature

Bronchospasm Waveform Pattern

Bronchospasm hampers ventilation
Alveoli unevenly filled on inspiration
Empty asynchronously during expiration
Asynchronous air flow on exhalation dilutes
exhaled CO2

Alters the ascending phase and plateau

Slower rise in CO2 concentration
Characteristic pattern for bronchospasm
Shark Fin shape to waveform

Capnography Waveform Patterns

Normal

45
0

Bronchospasm

45
0

Capnography Waveform Patterns

Normal
45
0

Hyperventilation
45
0

Hypoventilation
45
0

Bronchospasm
45

Airway obstruction

Curare Cleft

Cardiogenic oscillations

Esophageal Intubation

Rebreathing of CO2

Patient with single lung transplant

Faulty inspiratory valve

Faulty inspiratory valve

Ruptured/ Leaking ET tube cuff

Leak in side stream sample line

Expiratory valve stuck open

Electrical Noise

VOLUME CAPNOGRAM

Volume Capnogram

Acute Bronchospasm

Changes in pulmonary perfusion

Advantages of volume
capnogram
Allows for estimation of the relative contributions
of anatomic and alveolar components of Vd.
More sensitive than the time capnogram in
detecting subtle changes in dead space that are
caused by alterations in PEEP, pulmonary blood
flow, or ventilation heterogeneity.
Allows for determination of the total mass of CO2
exhaled during a breath and provides for
estimation of V CO2.

USES OF CAPNOGRAPHY

Detect ET Tube
Displacement

Confirm ET
Tube
Placement

Capnography in
Cardiopulmonary Resuscitation

Assess chest compressions

Early detection of ROSC
Objective data for decision to cease resuscitation
Use feedback from EtCO2 to depth/rate/force of
chest compressions during CPR.

In Laparoscopic Surgeries
1.Non invasive monitor of PaCO2 and can be used to adjust ventilation.
2.Detection of accidental intravascular CO2 insufflation.
3.Helps to detect complications of CO2 insufflation like pneumothorax.

Optimize Ventilation
Use capnography to titrate EtCO2
levels
in patients sensitive to fluctuations
Patients with suspected increased
intracranial pressure (ICP)
Head trauma
Stroke
Brain tumors
Brain infections

Optimize Ventilation
High CO2 levels induce
cerebral vasodilatation
Positive: Increases CBF to
counter cerebral hypoxia
CO2
Negative: Increased CBF,
increases ICP and may increase
brain edema

Hypoventilation retains CO2

which increases levels

Optimize Ventilation
Low CO2 levels lead to cerebral
vasoconstriction
Positive: EtCO2 of 25-30mmHG
causes a mild cerebral
vasoconstriction which may
decrease ICP
Negative: Decreased ICP but
may cause or increase in
cerebral hypoxia

Hyperventilation decreases
CO2 levels

CO2

The Non-intubated Patient Capnography Applications

Identify and monitor bronchospasm

Asthma
COPD

Assess and monitor

Hypoventilation states
Hyperventilation
Low-perfusion states

Capnography in
Bronchospastic Conditions

Air trapped due to

irregularities in airways
Uneven emptying of
alveolar gas
Dilutes exhaled CO2

Alveoli

Slower rise in CO2

concentration during
exhalation

Capnography in
Bronchospastic Diseases
Uneven emptying of
alveolar gas alters
emptying on exhalation A
Produces changes in
ascending phase (II)
with loss of the sharp
upslope
Alters alveolar plateau
(III) producing a shark fin

II

III

Capnography in Bronchospastic Conditions

Asthma Case

Initial

After therapy

Capnography in Bronchospastic Conditions

Pathology of COPD
Progressive
Partially reversible
Airways obstructed
Hyperplasia of mucous glands &
smooth muscle
Excess mucous production
Some hyper-responsiveness

Capnography in Bronchospastic Conditions

Capnography in COPD
Arterial CO2 in COPD
PaCO2 increases as disease progresses
Requires frequent arterial punctures for
ABGs

Correlating capnograph to patient

status
Ascending phase and plateau are
altered by uneven emptying of gases

Capnography in
Hypoventilation States
Altered mental status

Sedation
Alcohol intoxication
Drug Ingestion
Stroke
CNS infections
Head injury

Abnormal breathing
CO2 retention
EtCO2 >50mmHg

Capnography Applications
on Non-intubated Patients
New applications now being
reported
Pulmonary emboli
CHF
DKA

A rt e ry

O xy g e n

O2

V e in

PULMONARY EMBOLUS

TRANSCUTANEOUS AND
CARBON DIOXIDE
MONITORS

 Transcutaneous measurements of PO2 (Ptco2) and

Pco2 (Ptcco2) are monitoring methods that aim to
provide noninvasive estimates of arterial O2 and CO2,
or at least trends associated with these variables.
Transcutaneous monitoring can be applied when
expired gas sampling is limited.
The measurements are based on the diffusion of O2
and CO2 through the skin.
Used successfully in neonates and infants

 Applied when expired gas sampling is limited

Measurements are based on the diffusion of
CO2 and O2 through the skin.
Warming is used to facilitate gas diffusion.
Such an increase in temperature promotes
increased O2 and CO2 partial pressure at skin
surface.
Ptco2 is usually lower than PaO2, and Ptcco2
is higher than Paco2.

 A transducer using a pH electrode to

measure the Pco2 (StowSeveringhaus electrode) is used.
A change in pH is proportional to the
logarithm of the Pco2 change. For CO2
monitors
A temperature correction factor is
used to estimate Paco2 from Ptcco2.

Uses of Ptcco2
1. Assess the efficacy of mechanical
ventilation in respiratory failure.
2. Laparoscopic surgery with prolonged
pneumoperitoneum.
3. Deep sedation for ambulatory
hysteroscopy in healthy patient.
4. Weaning from mechanical
ventilation after off pump CABG.

Uses of Ptco2
Detect hyperoxia in neonates
Adults:
1. Wound management
2. peripheral vascular disease
3. hyperbaric medicine.

Limitations

Poor cutaneous blood flow

Frequent calibration
Slow response time
Skin burns with prolonged application

References
Understanding anesthesia
equipment, 5th edition Dorsch and
Dorsch
Millers Anesthesia 8th edition
Care fusion capnography handbook
www.capnography.org

THE END

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