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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
O2
Oxygenation
(oximetry)
Cellular
Metabolism
CO2
Ventilation
Carbon dioxide
from metabolism
EtCO2 measures
exhaled CO2 at
point of exit
Reflects change in
ventilation within
10 seconds
CO2 transport
Right
Ventricle
Artery
Vein
Oxygen
CO2
O2
O2
Perfusion
Left
Atrium
PRINCIPLES OF
CAPNOGRAPHY
BEER-LAMBERT LAW
Types of sensors
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
Capnogram Phase II
Ascending Phase
C
Ascending Phase
Early Exhalation
II
III
A
End-tidal
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
Capnography Waveform
Normal Waveform
45
0
a-A Gradient
arterial to Alveolar Difference for CO2
Ventilation
Right
Ventricle
Alveolus
Artery
EtCO2
PaCO2
Perfusion
Vein
Left
Atrium
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
Normal
45
0
Bronchospasm
45
0
Hyperventilation
45
0
Hypoventilation
45
0
Bronchospasm
45
Airway obstruction
Curare Cleft
Cardiogenic oscillations
Esophageal Intubation
Rebreathing of CO2
Electrical Noise
VOLUME CAPNOGRAM
Volume Capnogram
Acute Bronchospasm
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
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
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
Capnography in
Bronchospastic Conditions
Alveoli
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
Asthma Case
Initial
After therapy
Pathology of COPD
Progressive
Partially reversible
Airways obstructed
Hyperplasia of mucous glands &
smooth muscle
Excess mucous production
Some hyper-responsiveness
Capnography in COPD
Arterial CO2 in COPD
PaCO2 increases as disease progresses
Requires frequent arterial punctures for
ABGs
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
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
References
Understanding anesthesia
equipment, 5th edition Dorsch and
Dorsch
Millers Anesthesia 8th edition
Care fusion capnography handbook
www.capnography.org
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