AACN Clinical Issues
Volume 14, Number 2, pp. 123-132
Capnography Application in
Acute and Critical Care
Tom Ahrens, DNS, RN, CCRN, CS; Carrie Sona, MSN, RN, CCRN, CS
■ The use of capnography has expanded
over recent years. Currently, capnography
is used in a variety of acute care settings.
This article describes what capnography
is and how it is used. The normal and
abnormal capnogram or waveforms are
described to assist in identifying various
clinical situations. The multiplicity of
clinical indications include detection of
pulmonary embolism as well as
malpositioned endotracheal/tracheal,
gastric, and small bowel tubes.
Capnography also provides clinicians
with information regarding expiratory
breathing patterns and assists in
perfusion assessments such as those for
cardiopulmonary resuscitation. Finally,
case studies are provided to help the
reader apply the concepts of
capnography to a variety of acute care
settings. (KEYWORDS: capnography,
capnogram, end-tidal carbon dioxide
[ETCO2], cardiopulmonary resuscitation)
Capnography is one of the most rapidly
growing areas for patient care monitoring in
acute and critical care. Fueled by support
such as the American Heart Association’s
recommendation for its use in confirming
endotracheal tube placement, the growth of
capnography application is encouraging.1
The web site www.capnography.com is de-
voted to education on the use of capnogra-
123
© 2003, AACN
phy. Although capnography is a rapidly
growing parameter, increased clinical use
could improve patient care and patient
safety. The purpose of this article is to high-
light use and improve understanding of
capnography by clinicians in both acute and
critical care.

What Is Capnography?
Capnography is the measurement of exhaled
carbon dioxide (CO2). Carbon dioxide can
be measured by chemical reactions (usually
referred to as colorimetry) or with actual
measurement of CO2 molecules. For acute
and critical care application, the best method
probably is the measurement of CO2 mole-
cules. The actual measurement of CO2 al-
lows for an analysis of the exhaled CO2
waveform and provides a numeric value of
exhaled CO2. These parameters are not avail-
able through colorimetry.
Measurement of the actual CO2 waveforms
is performed through one of four methods:
infrared spectrography, Raman spectrography,
mass spectrography, or photoacoustic spec-
trography, an infrared analysis. The most
common method used is infrared spectrogra-
phy. This technique involves the use of an in-
▪▪▪▪▪▪▪▪▪▪
From the Barnes Jewish Hospital, St. Louis, Mo.
Reprint requests to Tom Ahrens, DNS, RN, CCRN,
CS, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital
Plaza, St. Louis, MO 63110 (e-mail: TsA51@aol.com).
124  AHRENS AND SONA
frared light shown through a filter that allows
infrared light in the 4.3 ␮m wavelength to
pass into a chamber containing exhaled air
with CO2 present. By measuring the amount
of light that passes through the chamber and
how much is absorbed by the CO2, a quantifi-
able amount of CO2 can be measured.2 This
technique is best performed if the measure-
ment occurs immediately upon inspiration
and exhalation. In a patient on a ventilator,
the measurement should take place within
the endotracheal tube. On a nonintubated pa-
tient, the measurement should take place
near the mouth or nares (Figure 1).
The sampling of exhaled air can be mea-
sured immediately (mainstream analysis), or
the air can be drawn through a sampling
tube to an analyzer distant from the patient
(sidestream analysis). Each technique has
Figure 2. Mainstream analyzer.
AACN Clinical Issues
Figure 1. Nonintubated patient
sampling of PetCO2.
advantages and disadvantages. The advan-
tage of the mainstream analysis is that it im-
mediately samples the exhaled CO2 and pro-
vides real-time information (Figure 2). It also
is less affected by factors, such as water va-
por, that interfere with the measurement of
CO2. The major disadvantage of the main-
stream analysis is that the weight of the ana-
lyzer rests on the patient’s ventilator tubing.
This can be uncomfortable, or it can pull on
the endotracheal tube. In addition, main-
stream analysis can be used only on intu-
bated patients.
The sidestream analyzer has the advan-
tage of being lightweight. It also can be used
on both intubated and nonintubated patients
(Figure 3). The major disadvantage of this
technique is its likelihood of becoming ob-
structed by water because the sampling tube
Figure 3. Sidestream analyzer.
Vol. 14, No. 2 May 2003 CAPNOGRAPHY APPLICATION  125

Figure 4. Normal capnogram.

has a very small internal diameter. It also pro-
vides a waveform slightly delayed by a few
milliseconds. Advances in sidestream tech-
nology have reduced some of the problems
previously seen, such as obstructions in the
tubing.3 The choice for mainstream or side-
stream analysis depends on the clinical appli-
cation. Both techniques, however, work well
as long as their limitations are understood.

Capnography Waveforms and
Values
When CO2 is measured as the patient
breathes, a characteristic waveform is created
(Figure 4). The components of the waveform
have different meanings. Figure 5 provides a
description of the capnogram waveform.4
The presence of a capnogram wave indi-
cates that the sensor is detecting CO2 from the
lungs. The presence of a waveform is as im-
portant as a CO2 value reading. For example,
if the waveform shows a climbing phase III,
then there may be obstruction in the way of
reaching the alveolar plateau phase, a condi-
tion common in reactive airways (eg, asthma)
(Figure 6). Any condition that alters the rela-
tion of ventilation to lung perfusion can
change the slope and value of phase III. For
example, a condition that decreases blood
flow to the lungs (eg, pulmonary emboli or
cardiac arrest) while breathing is maintained
will create an effective increase in physiologic
dead space. This can change either the angle
or the value of phase III (Figure 7).
In addition, the absence of a waveform or
the presence of a steady CO2 value indicates
a loss of effective breathing (Figure 8). This
may occur with a misplaced endotracheal
tube or correct placement of nasogastric
tubes, which would be in the stomach
where CO2 is not detected.

Figure 5. Capnogram Waveform Phases. Phase 0: Inspiration. Phase I: Early expiration. This represents the
anatomic dead-space of ventilation that is either absent or has small amounts of CO2 present. Phase II: Expira-
tory phase, in which CO2 is being emptied from initial gas exchanging parts of the lung. This level is slightly re-
duced due to mixing with the airways, which has small amounts or absence of CO2. Phase III: Alveolar emptying
phase, noted by a sudden increase and stabilization in the CO2 wave. The point of the sudden change is often
called the alpha angle. A sharp drop in CO2 values marks the point where Phase III ends and Phase 0 begins.
The beta angle is the angle between Phase III and Phase 0. The end of Phase III is also called the end-tidal CO2
value (PetCO2).
126  AHRENS AND SONA
Figure 6. Obstructive ventilatory pattern.
The extrapolated end-tidal CO2 tension
(PetCO2) value is one of the most useful
aspects of capnography. This value, un-
der normal ventilation-perfusion relations,
closely matches that for the partial pressure
of CO2 in arterial gas (PaCO2). If the PetCO2
level falls, one of two conditions normally
exist. Either PaCO2 has fallen because of in-
creased alveolar ventilation or perfusion to
the lung has dropped relative to ventilation
because of pulmonary emboli, decreased
cardiac output, chronic obstructive pul-
monary disease, or some other cause.
If the PetCO2 level is rising, alveolar venti-
lation is possibly reduced, and the arterial
CO2 levels may be climbing. This is a serious
situation that needs to be addressed quickly
to protect the adequacy of ventilation.

Clinical
Applications of
Capnography
Assessment of Endotracheal or
Tracheal Tube Placement
Capnography is a valuable tool for identify-
ing tube placement as an esophageal or air-
Figure 7. Altered phase 3.
AACN Clinical Issues
way placement. Capnography has become
the standard method for verifying safe
placement of endotracheal tubes.5 When a
capnography unit is placed in line with a
tube positioned in the airway, CO2 can be
measured as it is exhaled from the lungs. If
the tube is placed in the esophagus or
stomach, CO2 is not detected because no
CO2 is produced in the upper gastrointesti-
nal tract. A rare, but possible, limitation to
this is the recent ingestion of carbonated
beverages. This can alter the results of the
colorimeters, which require colors to de-
note the presence of CO2. This is less likely
to be a problem with monitors, which pro-
vide a waveform and numeric result for the
level of CO2 present.
Anesthesia departments as well as many
emergency departments and intensive care
units have portable handheld units as stan-
dard equipment for intubations performed
outside the operating room. Although it is
optimal to visualize endotracheal tubes pass-
ing through cords during intubation, CO2 de-
tectors confirm that the tube is not mis-
placed into the esophagus.
Capnography use in intensive care units,
emergency departments, recovery rooms, and
long-term ventilator facilities also has proved
to be invaluable for the early identification of
a dislodged tube. This is particularly impor-
tant in busy areas where patients may be
awake or agitated, and limited patient visual-
ization can lead to tube loss. In addition,
capnography offers the most rapid alarm for a
ventilator disconnection by immediately
showing a flat line. In support of this claim, a
recent sentinel event report by the Joint Com-
mission on Accreditation of Healthcare Orga-
nizations reviewed 23 ventilator-associated
deaths and injuries.6 The review of these
cases found that 65% of the deaths or injuries
Vol. 14, No. 2 May 2003
Figure 8. Loss of effective ven-
tilation.
were related to malfunction or misuse of the
ventilator alarm, that 52% were related to ven-
tilator tubing disconnect, and that 26% were
related to a disconnected tracheal or endotra-
cheal tube. In some instances, ventilator
alarms were not heard because of environ-
mental noise or because they were buried in
patient linens. The use of capnography as an
additional tool to alert caregivers to early loss
of airway or ventilator circuit disconnection is
an asset for patient safety.
Assessment of Gastric or
Small Bowel Tube Placement
Researchers currently are investigating the
use of capnography for assistance in iden-
tifying the placement of orally or nasally
placed gastric and small bowel tubes.7,8
Inadvertent placement of gastric tubes
into the trachea or lung can lead to com-
plications such as aspiration, pneumonia,
acute respiratory distress syndrome, and
pneumothorax. If a gastric tube is placed
correctly in the esophagus, CO2 will not
be present. Initial low levels of CO2 can
be seen while the tube moves through the
oropharynx, but will decrease to zero af-
ter this point. Capnography may negate
the need for an abdominal radiograph to
show the tip position before use of the
tube for medications or enteral nutrition
because it offers immediate assurance that
the tube is not in the airway. This applica-
tion of capnography has proved to be use-
ful with nasogastric tubes, but limitations
exist with small bowel tubes. These tubes
have a smaller diameter and can become
clogged with the lubricant used for inser-
tion (Figure 9).
Assessment of Blood Flow
In patients with normal ventilation-perfusion
ratios, PetCO2 has proved to be a reliable
and noninvasive way to measure alveolar
and arterial CO2, particularly if pulmonary
blood flow is normal.9-14 Because of its abil-
CAPNOGRAPHY APPLICATION  127
ity to be influenced by reduction in blood
flow if alveolar ventilation is maintained,
capnography can also provide helpful infor-
mation about systemic blood flow. In situa-
tions where systemic blood flow is de-
creased, pulmonary blood flow also is
decreased. This decrease in alveolar blood
flow while alveolar ventilation is unchanged
produces a decreased amount of CO2 added
to the exhaled air. The result is a decrease in
PetCO2 values. In cardiac arrest, there is vir-
tually no blood flow, which corresponds to
an absent or very low PetCO2 reading. De-
creased PetCO2 also correlates with a de-
crease in blood pressure significant enough
to decrease cardiac output with a compen-
satory mechanism of increased heart rate.15
Decreased cardiac output and blood pres-
sure also lead to a decrease in urine output
because perfusion to the kidney also will be
decreased.
Several researchers have been able to
show that a return in PetCO2 corresponds to a
return of spontaneous circulation.16-20
Kalenda19 showed that PetCO2 increases with
the increased strength of chest compressions.
These findings have led to more research
aimed at identifying a level of PetCO2 for a
given time frame that can be used as prog-
nostic information to indicate whether pa-
tients will survive cardiopulmonary arrest.
Levine et al20 studied patients who had car-
diac arrests outside the hospital setting. These
Figure 9. Narrow-diameter small bowel feeding tube.
128  AHRENS AND SONA
authors found that a PetCO2 level lower than
10 after 20 minutes corresponded to 100%
mortality. Similar findings were reported by
Ahrens et al21-22 for an in-hospital setting.
Because of its ability to detect changes in
pulmonary blood while maintaining alveolar
ventilation (dead space ventilation), cap-
nography can be helpful in the diagnosis of
other conditions involving altered pulmonary
blood flow (ie, pulmonary embolism).23-24
Pulmonary embolism diminishes pulmonary
blood flow while not affecting alveolar venti-
lation. An obstructed pulmonary artery leads
to areas of the lung being ventilated but not
perfused. This leads to a decrease of the
PetCO2 level and a widening of the arterial to
end-tidal gradient (PaCO2-PetCO2). Normally,
the PaCO2-PetCO2 gradient is less than 5 mm
Hg. In a study by Chopin et al, the CO2 gradi-
ent considered to be diagnostic for pul-
monary embolism in one study was identi-
fied as 12 ⫾ 6.9 mm Hg, which was correct
as correlated with pulmonary angiogram for
74% of the patients.25 In this study, the pa-
tients with negative results for pulmonary
embolism via pulmonary angiogram had a
CO2 gradient of 1 ⫾ 2.4 mm Hg, which was
correct for 100% of the patients. Other re-
searchers have shown that patients with pul-
monary embolism have PetCO2 values lower
than those without pulmonary embolism.

Assessment of Ventilation
Continuous PetCO2 monitoring offers useful
information in the assessment of arterial CO2,
particularly in patients with normal ventila-
tion-perfusion relations. The relation between
alveolar and arterial CO2 (PaCO2-PetCO2) is
close in healthy patients (eg, less than 5 mm
Hg of difference). For example, if the arterial
CO2 is 35 mm Hg and the PetCO2 is 30, the
CO2 gradient is 5 mm Hg. Exhaled CO2 is al-
most always slightly lower than the PaCO2.
In patients with normal dead space, it is
safe to use PetCO2 as a substitute for
PaCO2.27-33 When the baseline CO2 gradient
is assessed and trends are followed this can
greatly reduce the necessity for an assess-
ment of arterial blood gases using pulse
oximetry and capnography.
The continuous monitoring of PetCO2
with minute ventilation also can be helpful in
AACN Clinical Issues
the assessment of dead space ventilation.
Minute ventilation is the amount of air (mea-
sured in liters/minute) determined by the res-
piratory rate times the tidal volume. The nor-
mal response to increased minute ventilation
is a decrease in PetCO2. Because PaCO2 is
determined by the relation between alveolar
ventilation and CO2 production, a high
minute ventilation in the presence of hyper-
capnia indicates either increased dead space
ventilation or increased CO2 production.34
This information can assist in the determina-
tion of clinically relevant changes such as
pulmonary embolus and decreased perfusion
states when used with an understanding of
the relation between the CO2 gradient and
minute ventilation in the assessment of dead
space ventilation.
Another ventilatory pattern easily identi-
fied with PetCO2 is incomplete neuromuscu-
lar blockade. Patients who have been chem-
ically paralyzed for operative procedures or
who remain chemically paralyzed in the in-
tensive care unit for ventilatory management
can benefit from capnography. When a
chemically paralyzed patient initiates a spon-
taneous breath, which would indicate in-
complete chemical paralysis, a characteristic
cleft (dip) appears in the PetCO2 waveform.
This can be helpful for postoperative pa-
tients who may need a reversal agent or for
patients that need an additional dose of neu-
romuscular blocker.
Many intensive care unit nurses use the
benefit of capnography to help them inter-
pret hemodynamic information. Hemody-
namic waveforms are most reliable when
read at the end of the patient’s expiratory cy-
cle.22 With the use of PetCO2, end expiration
is easily identified (Figure 10). This makes
bedside interpretation of hemodynamic in-
formation more reliable and accurate.
The benefits of capnography in a variety
of clinical settings and scenarios are shown
in the following examples.

Case Studies
Case 1. Prehospital: Malpositioned
Endotracheal Tube
Emergency medical system workers respond
to a single car motor vehicle crash at 0200
during a snowstorm. The unrestrained driver
Vol. 14, No. 2 May 2003
Figure 10. Identifying end
expiration.
was ejected from her vehicle, and according
to an eyewitness account, was thrown 20 feet
from the vehicle. The emergency medical
technician finds the victim with only shallow,
agonal respiratory effort and unresponsive.
He immediately intubates the patient after se-
curing the cervical spine and transports the
patient via air evacuation to the closest level
1 trauma center. The patient is monitored
with electrocardiography (ECG) and pulse
oximetry. She requires 100% fraction of in-
spired oxygen (FiO2) by bag mask with per-
sistently low O2 saturations in route.
On the patient’s arrival in the emergency
department, an ETCO2 monitor is hooked up.
No waveform or number is visible on the
monitor. The emergency department nurse
auscultates only distant breath sounds. The
tube is removed and replaced with an imme-
diate capnogram detected on the PetCO2
monitor. The tube placement had been
esophageal.
The emergency medical system staff used
the monitoring equipment available to them
en route and confirmed endotracheal tube
placement quickly by hearing distant breath
sounds in a noisy environment in the middle
of a snowstorm. The availability of capnog-
raphy to this crew could have been life sav-
ing for this patient. She received 100% FiO2
via a bag mask en route, but did not have
adequate ventilation because of the tube
malposition. This could have resulted in hy-
poxic brain injury for this patient.
CAPNOGRAPHY APPLICATION  129
Case 2. Emergency Department: Full Arrest
An 80-year-old man is on a stretcher in the
emergency department reporting chest pain
and shortness of breath. He is in the process
of ruling out myocardial ischemia via 12-lead
ECG and cardiac enzymes. A routine my-
ocardial ischemia algorithm is followed, and
the patient is placed on a monitor. Oxygen is
applied via a nasal cannula. An intravenous
line is started and morphine given. Sud-
denly, the ECG monitor alarms and shows
the development of ventricular fibrillation.
Immediate defibrillation at 200 joules is per-
formed, and advanced cardiac life support
protocol is followed. The patient receives
three successive countershocks without con-
version of the rhythm. Cardiopulmonary re-
suscitation (CPR) is initiated. The patient is
intubated, and drug therapies are started.
The capnogram shows a waveform and a
PetCO2 reading of 14 mmHg. With CPR, the
PetCO2 reading increases to 18 mm Hg. Ad-
vanced cardiac life support protocol contin-
ues, and an increase in the PetCO2 to 25 mm
Hg is seen. Cardiopulmonary resuscitation is
stopped. A rhythm is detected on the moni-
tor, and a pulse is palpable.
This example shows how an early sign of
restored spontaneous circulation and im-
proved blood flow was detected with
capnography. Capnography is easy to read
and not interfered with by manual chest
compressions. The increase in the PetCO2
130  AHRENS AND SONA
alerted the clinicians to stop CPR and check
the rhythm and pulse.
Case 3. Intensive Care Unit: Pulmonary
Embolism
A 50-year-old woman with end-stage cervi-
cal cancer is admitted to the intensive care
unit with respiratory distress. She has no ad-
vanced directive or durable power of attor-
ney. She is not alert. Her pulse oximetry
reading shows 88% saturation, and she is
tachypneic, with a respiratory rate of 40. Im-
mediate intubation is performed. Capnogra-
phy shows a waveform and a PetCO2 of 18,
with an immediate increase in the patient’s
pulse oximetry to 93%. She is placed on a
ventilator, with persistently low PetCO2 read-
ings ranging from 18 to 22 mm Hg. Arterial
blood gas analysis is performed after intuba-
tion, with a PaCO2 result of 40. Because the
large CO2 gradient of 22 suggests a pul-
monary embolism, bilateral lower extremity
Dopplers and a portable ventilation-perfu-
sion scan are ordered. The Dopplers show a
large superficial femoral vein thrombosis.
The ventilation-perfusion scan shows a large
perfusion defect, and heparin therapy is
started for pulmonary embolism.
The use of capnography helped to iden-
tify the large CO2 gradient and to move the
case toward early anticoagulation therapy.
Case 4. Postanesthesia Recovery Room:
Massive Exsanguination
A 68-year-old man is in the recovery room
after open repair of a 10-cm infrarenal ab-
dominal aortic aneurysm. He remains se-
dated and mechanically ventilated. The
postanesthesia recovery staff is obtaining
postoperative laboratory work, a chest radi-
ograph, and an ECG. The patient’s blood
pressure via arterial line was 140/90 initially,
but currently is 80 systolic. His PetCO2 on
admission was 35 mm Hg, and now is 20. A
fluid bolus is given while the clinicians await
the results of the complete blood count.
The patient’s hypotension persists, and
the PetCO2 level continues to decrease. The
nurse knows the patient is sedated and not
overbreathing the set ventilator rate of 10.
She pulls back the sheets to examine the pa-
tient and notices mottled feet and a dis-
AACN Clinical Issues
tended abdomen. The surgeon is notified,
and immediate rapid transfusion is initiated
with a stat return to the operating room suite
for repair of an anastomotic leak.
In this case, the low PetCO2 value warned
of the reduced blood flow, consistent with
other clinical symptoms.
Case 5. Outpatient Surgery Center:
Oversedation
A 57-year-old man is admitted to a local out-
patient surgery center for arthroscopic knee
surgery. He is very fearful and requests gen-
eral anesthesia with the use of a laryngeal
mask airway and a local anesthetic during
the case. The nurse anesthetist (CRNA) has
no difficulty inserting the tube, and a capno-
gram with a reading of 36 mm Hg is immedi-
ately present on the portable capnography
unit. The CRNA, wanting to ensure that the
patient is pain free throughout the proce-
dure, administers 200 mcg of fentanyl and 50
mg of propofol. The patient is being venti-
lated at a rate of 14 via ambu bag, but has
shallow spontaneous efforts, with a PetCO2
reading of 36 mm Hg. The CRNA stops bag-
ging to administer additional anxiolytic, and
the PetCO2 reading climbs to 50 mm Hg. The
CRNA notes that the patient is not breathing
spontaneously and resumes ventilation. The
PetCO2 decreases to 40 mm Hg. The CRNA
holds the administration of more analgesics
and anxiolytics until the patient resumes
spontaneous ventilatory efforts.
In this case, the PetCO2 was a clear warn-
ing of inadequate ventilation.

Summary
Capnography is one of the emerging new vi-
tal signs in acute and critical care. There are
at least 10 uses of capnography in clinical
settings, ranging from confirmation of tra-
cheal and esophageal tube placement to as-
sessment of blood flow. Expansion of
capnography use beyond the operating
room and intensive care units will continue,
particularly as the need for ventilation as-
sessment grows in outpatient settings. The
noninvasive nature of capnography serves
only to make its appeal greater. Capnogra-
phy likely will expand to every area of
Vol. 14, No. 2 May 2003
healthcare that requires monitoring of venti-
lation and blood flow, making it one of the
most important new technologies in patient
monitoring.
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