What Is Capnography?

Capnography is the sensing of exhaled CO2. Carbon dioxide is produced in the body as a by-product of metabolism and is eliminated by exhaling. By measuring exhaled CO2, many types of pulmonary assessments can be made.

Use of Capnography During Intubation

Carbon dioxide is eliminated from the lungs, but not from the stomach or esophagus (unless a carbonated beverage has been consumed). It is easy to determine when a tube, such as an endotracheal or nasogastric tube, has been placed in the trachea. When tracheal placement occurs, a capnogram shows exhaled CO2.
Capnogram after successful placement of endotracheal tube

CO2 Monitoring
By Tom Ahrens,
RN, DNS, CCRN, CS

Applications of Capnography
Detecting esophageal placement of endotracheal tubes during intubation. Detecting tracheal placement of nasogastric tubes. Disconnection of the patient from mechanical ventilation. Predicting survival in cardiopulmonay resuscitation. Avoiding ABG analysis in selected clinical sitiuations. Detecting changes in dead space (eg, pulmonary emboli). Identifying end-expiration on hemodynamic waves. Identifying alveolar emptying (eg, effectiveness of bronchodilator therapy). Identifying attempts to breathe while paralyzed.

If esophageal placement occurs, a flat line occurs or no CO2 is detected.

Flat line indicating the endotracheal tube is not in the trachea or the patient has become disconnected from the ventilator

Characteristics of a Normal Capnogram

PETCO2 (or end-expiration) Beginning of inspiration

Slow rise in CO2 with plateau at end-expiration

Detecting Disconnection from Mechanical Ventilation

Capnography is the fastest way to determine if a patient has become disconnected from the ventilator Capnography, . unlike ventilator alarms, monitors the patient. Immediately upon disconnection from the ventilator the waveform on the , capnogram disappears and goes flat.

A supplement to CRITICAL CARE NURSE

Agilent #5968-9027E Printed in USA 2/00

Expiration

Detecting Changes in Pulmonary Dead Space

Normally, the PETCO2 level correlates closely with PaCO2. The PETCO2 is usually 1 to 5 mm Hg lower than the PaCO2. The difference between the PaCO2 and PETCO2 is called the PaCO2-PETCO2 gradient.
Q 5 L/min VE 5 L/min PETCO2 40

Avoiding Unnecessary Arterial Blood Gas Testing

When the PaCO2-PETCO2 gradient is normal, the PaCO2 can be estimated from the PETCO2. It is important to note the gradient when results of ABG analysis are obtained. When using PETCO2 to estimate PaCO2, it is helpful to simultaneously measure expired ventilation (E). If the E and PETCO2 remain constant, then the PaCO2-PETCO2 gradient is unlikely to have changed. If the E has changed, it is probably unwise to estimate PaCO2 from the PETCO2.

Predicting Survival in Cardiopulmonary Arrest

Exhaled CO2, specifically PETCO2, is a noninvasive indicator of cardiac output. The lower the cardiac output, the lower the PETCO2. If PETCO2 is less than 10 mm Hg after 20 minutes of cardiopulmonary resuscitation, the code is almost always unsuccessful.
Capnogram during cardiopulmonary arrest showing a PETCO2 of 8 mm Hg

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CO 2 Pw
Pa C

Normally, if the PaCO2 increases, so will the PETCO2. The relationship between the PaCO2 and PETCO2 is lost when the pulmonary dead space increases.
C Pa O2

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Pulmonary Capillaries

When a condition such as pulmonary embolism (PE) occurs, blood flow to a part of the lung is decreased.
Q 5 L/min VE 5 L/min PETCO2

VE

Embolism

Two patients with shortness of breath and a potential diagnosis of pulmonary emboli
Patient 1 PaCO2 PETCO2 Interpretation 36 mm Hg 32 mm Hg No significant PE. Normal PaCO2-PETCO2 gradient. Patient 2 39 mm Hg 21 mm Hg PE should be considered. Widened PaCO2-PETCO2 gradient.

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O 2

Alveoli

Recognizing Spontaneous Breathing Attempts in a Patient Who Is Paralyzed

In a patient who is paralyzed, one of the first indications of incomplete paralysis is movement of the diaphragm, which can be detected by noting a dip in the capnogram waveform.
Dip in the exhaled capnogram wave indicating a spontaneous breathing attempt

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40 PaCO2 40

The higher the PETCO2, the more effective the resuscitation efforts.
Capnogram during cardiopulmonary arrest showing a PETCO2 of 21 mm Hg

Pa C

O 2

20

C Pa

O2

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Exhaled air from the poorly perfused part of the lung contains a very small amount of CO2. This reduced CO2 level is detected by capnography.

5 Q
VE 5
C Pa O2

End-Expiration in Hemodynamic Waveforms

By locating the PETCO2 level, end-expiration is often easily identified through the use of capnography.

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Recognizing the Adequacy of Alveolar Emptying

PaCO2 40

Abnormal capnogram waveform showing ineffective bronchodilator therapy.

End-expiration indicated by waves in the circle

Decrease in PETCO2 indicates where to locate end-expiration