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Capnography

Research · July 2015

DOI: 10.13140/RG.2.1.4701.5523

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 Capnography
Marzieh Beigom Khezri

Department of Anesthesiology, Medical School, Qazvin University of Medical Science, Qazvin,

Iran. E-mail: mkhezri@qums.ac.ir

Objective learning : The purpose of this educational activity is to provide an overview of

capnography monitoring. This activity includes a review of capnography, including key terms;
description of the physiology surrounding its application; a discussion of normal end tidal CO2
values, as well as a review of normal and abnormal waveforms. The activity will

• Describe capnography
• Summarize normal respiratory physiology
• Review the differences between oxygenation and ventilation
• Identify basic capnography waveforms
• Applications of capnography

Introduction:

The primary goal of anesthesiologists is to prevent hypoxia, and capnography helps to identify
situations that can lead to hypoxia if uncorrected. Moreover, it also helps in the swift differential
diagnosis of hypoxia before hypoxia can lead to irreversible brain damage.

capnography constitutes an important non-invasive technique that can monitor C02 production,
pulmonary perfusion and alveolar ventilation as well as respiratory patterns. The measurement of
C02 in the expired air directly indicates changes in the elimination of C02 from the lungs.
Indirectly, it indicates changes in the production of C02 at the tissue level and in the delivery of
C02 to thhe lungs by th
he circulatorry system.

Click heere to show animation

Capnograaphs usually y work on thee principle thhat CO2 absoorbs infra-reed radiation. A beam of
infra-red light is passsed across thhe gas samplle to fall on a sensor. Thee presence of
o CO2 in thee gas
leads to a reduction in
i the amounnt of light fallling on the sensor, whicch changes thhe voltage inn a
circuit. The
T analysis is rapid and accurate, buut the presennce of nitrouss oxide in thhe gas mix
changes the
t infra-red d absorption via the phennomenon of collision brooadening.1 Click
C here to shhow

Animaation
Applications of capnography:

Endotracheal intubation

When CO2 is absent as measured by above devices, it means either the endotracheal tube
is in a wrong position (esophageal) or there is an absent/ decreased presentation of CO2 to
the lungs as in a cardiac arrest. When cardiac output increases (e.g. After resuscitation),
PEtCO2 provides information about adequacy of ventilation and circulation. 2

ETCO2 can also be used to assist in difficult intubations of spontaneously breathing

patients.
Paramedics can attach the capnography filter to the ET tube prior to intubation and, in
cases where it is difficult to visualize the cords, use the monitor to assist placement. This
includes cases of nasal tracheal intubation.
Paramedics should document their use of continuous ETCO2 monitoring and attach wave
form strips to their PCRs. Print a strip on intubation, periodically during care and
transport, and then just prior to moving the patient from your stretcher to the hospital
table and then immediately after transfer. This will timestamp and document your tube as
good. Capnography can also be used for combitubes and LMAs.

Role in CPR:
White R.D. et al .3 used EtCO2 measurement in out-of hospital cardiac arrest. They concluded
that capnography can detect the presence of pulmonary blood flow even in the absence of major
pulses (pseudo-electromechanical dissociation- EMD) and also can rapidly indicate changes in
pulmonarry blood flow
w (cardiac output) causeed be alteratiions in cardiiac rhythm.

Click heree to show anim

mation

Data suggests that PE EtCO2 also correlated

c wiith coronaryy perfusion pressure
p P) .4 It is also
(CPP
known too correlate with
w cerebral perfusion prressure and blood
b flow during
d CPR,5 but not witth
neurologgic outcome. This correlation betweeen perfusionn pressure annd ETCO2 is likely to be
secondarry to the relaationship of PETCO
P 2 and
d cardiac outtput.

Studies in
i animals an nd humans demonstrated
d d that PEtCOO2 decreasess when a largge dose of
6
epinephrine was used d during CPR R. This deccrease in EtCCO2 has beenn attributed tot increase inn
shunt fraaction and alsso due to droop in cardiacc output secoondary to inccreased afterrload by
epinephrine .6 The du uration of deecrease in EttCO2 has nott been quantiified, but cliinically can be
b
7
useful for timing subbsequent epinnephrine dossing . PEtCO O2 can be ussed as a feeddback to optiimize
8
chest commpressions during
d CPR. Monitorinng PEtCO2 during d cardiaac arrest mayy detect
unrecognnized CPR prrovider fatiggue.

End Tid
dal CO2 As
A Predicttor of Resu
uscitation Outcome
End tidall CO2 monito oring can coonfirm the fuutility of resuuscitation as well as foreecast the
likelihood of resuscittation.

"An end--tidal carbonn dioxide levvel of 10 mm mHg or less measured

m 20 minutes after the initiattion
of advancced cardiac life
l support accurately predicts
p deathh in patientss with cardiaac arrest
associateed with electrrical activityy but no pulsse. Cardiopuulmonary ressuscitation may
m reasonabbly
h patients.9
be terminnated in such
 “An ETCO2 value of 16 torr or less successfully discriminated between the survivors and
the non survivors in our study because no patient survived with an ETCO2 less than 16
torr. Our logistic regression model further showed that for every increase of 1 torr in
ETCO2, the odds of surviving increased by 16%.10

Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial
ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg

Other applications:

• ETCO2 waveform analysis can give information of leaks in breathing circuit, airway
obstruction (asthma, COPD).
• Diagnosis of Pulmonary embolism.
• Estimation of PaCO2 in mechanically ventilated patients: End-tidal PCO2 can be used to
estimate arterial PaCO2 in patients with healthy lungs.
• Indirectly measures metabolism and circulation
• Provides an immediate picture of patient condition of ventilation
• Perfusion Warning Sign

Capnography versus Pulse Oximetry

Capnography provides an immediate picture of patient condition. Pulse oximetry is
delayed. Hold your breath. Capnography will show immediate apnea, while pulse
oximetry will show a high saturation for several minutes.

Circulation and Metabolism

While capnography is a direct measurement of ventilation in the lungs, it also indirectly

measures metabolism and circulation. For example, an increased metabolism will
increase the production of carbon dioxide increasing the ETCO2. A decrease in cardiac
output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2.

V/Q Mismatch

If ventilation or perfusion are unstable, a Ventilation/Perfusion (V/Q) mismatch can

occur. This will alter the correlation between PaC02 and PETCO2.This V/Q mismatch can
be caused by blood shunting such as occurs during atelectasis (perfusing unventilated
lung area) or by dead space in the lungs (Ventilating unperfused lung area) such as occurs
with a pulmonary embolisim or hypovolemia.
Time veersus Volu
ume Capn
nographs

 
Time Caapnographs

The mostt commonly used type of capnograph plots PCO2 versus timee. The tracinng is traditionnally
divided into an inspirratory phasee and three (ssometimes foour) expiratoory phases:

Phhase 0: inspirratory phasee

Phhase I: dead space and litttle or no CO
O2
Phhase II: mixtture of alveoolar and deadd space gas
Phhase III: alveeolar plateauu, with the peeak represennting end-exppiratory (endd-tidal) CO2
(P
PETCO2).
Phase IV : Att the terminaal end of the phase III plaateau, a sharrp rise in PCOO2 is sometim
mes
obbserved and is referred too as phase IV V

Cllick here to sh
how animation
A terminal upswing at the end of phase 3, known as phase 4, can occur in pregnant subjects,
obese subjects and low compliance states.

In patients with normal lung function, PETCO2 generally underestimates PaCO2 by 1 to 5 mm Hg

because of the presence of a small amount of alveolar dead space. 11 Factors that increase
alveolar dead space will widen this gradient and increase the slope of phase III. During
anesthesia there is often increased alveolar dead space caused by reduced cardiac output and
decreased perfusion of the lung apices. 12

It is therefore not surprising that studies under anesthesia have found the PETCO2-PaCO2 gradient
to be slightly elevated at 5 to 10 mm Hg.13 An extreme example of acutely increased alveolar
dead space is pulmonary embolism. Thus, an abruptly decreased PETCO2 with ventilation held
constant is often indicative of a sudden decrease in cardiac output or pulmonary embolism. Other
common causes of a widened gradient include obstructive lung disease, smoking, and advanced
age. High mixed venous CO2 tension and malignant hyperthermia have also been reported to
cause a negative PaCO2-PETCO2 gradient.14 In such cases, PETCO2 is clearly not an accurate
estimate of PaCO2, and the average alveolar PCO2 obtained from a volume capnograph may be
more indicative of PaCO2.15

volume capnograph
A volume capnograph is obtained by plotting expired PCO2 versus exhaled gas volume, usually
obtained with a spirometer or pneumotachometer. There is no inspiratory phase in a volume
capnograph, and the curve is divided into three expiratory phases.

Capnography has been used to titrate positive end-expiratory pressure (PEEP) settings inasmuch
as narrowing of the PaCO2-PETCO2 gradient suggests reduced alveolar dead space and shunt
fraction as a result of alveolar recruitment and improved V/Q matching. These changes are
often subtle or absent on a time capnograph and may be detectable only with volume
capnography.16 It has been suggested that an incompetent inspiratory valve and rebreathing
during mechanical ventilation may require volume capnography to be detected reliably.17 The
technique may also be better than time capnography for the diagnosis of pulmonary embolism.18  
  

Volume capnograph: single-breath CO2 (SBCO2) curve. The horizontal axis of the graph represents expiratory/inspiratory tidal
volume and is generally divided into three areas: I, the anatomic dead space volume (VDSanat): II, the transitional phase II volume;
and III, the phase III alveolar volume. The sum of these values is the tidal volume. The vertical axis represents the concentration
of CO2. PCO2, partial pressure of carbon dioxide. (From Pilbeam SP, Cairo JM: Mechanical Ventilation: Physiological and
Clinical Applications, 4th ed. St. Louis, Elsevier, 2006.)
Volume capnograph: graph of the percentage of carbon dioxide (%CO2) (y axis) and volume (x axis). A horizontal line drawn at
the top of the curve represents %CO2 in arterial blood. Three distinct regions are established. Area X represents the actual CO2
exhaled in one breath (assuming that no CO2 is rebreathed), area Y is the amount of CO2 that is not eliminated because of
alveolar dead space, and area Z is the amount of CO2 not eliminated because of anatomic dead space. The ratios of these areas are
the same as in the relationship seen in the Bohr equation: (PaCO2 - PECO2)/PaCO2 = (Y + Z)/(X + Y + Z). PECO2, mixed expired
PCO2; VA, alveolar volume; VDS, dead space volume.

ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say
30 mm HG - 43 mm Hg can be considered normal.

Hyperventilation
When a person hyperventilates, their CO2 goes down.Hyperventilation can be caused by
many factors from anxiety to bronchospasm to pulmonary embolus. Other reasons C02
may be low: cardiac arrest, decreased cardiac output, hypotension, cold, severe
pulmonary edema.
Hypoventilation
When a person hypoventilates, their CO2 goes up.Hypoventilation can be caused by
altered mental status such as overdose, sedation, intoxication, postictal states, head
trauma, or stroke, or by a tiring CHF patient. Other reasons CO2 may be high: Increased
cardiac output with increased breathing, fever, sepsis, pain, severe difficulty breathing,
depressed respirations, chronic hypercapnia.

Continuous Wave Form Capnography Versus Colorimetric

Capnography

In colorimetric capnography a filter attached to an ET tube changes color

from purple to yellow when it detects carbon dioxide. This device has
several drawbacks when compared to waveform capnography. It is not
continuous, has no waveform, no number, no alarms, is easily contaminated,
is hard to read in dark, and can give false readings.Paramedics should
 encourage their services to equip them with continuous wave form
capnography.

6. ETCO2 in Asthma, COPD, and CHF

End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the severity of
Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce a characteristic
“shark fin” wave form, as the patient has to struggle to exhale, creating a sloping “B-C”
upstroke. The shape is caused by uneven alveolar emptying.

Multiple studies have confirmed the sloping shape correlates to bronchospasm and
obstructive lung disease.

Changing Asthma Values

Asthma values change with severity. With a mild asthma, the CO2 will drop (below 35)
as the patient hyperventilates to compensate. As the asthma worsens, the C02 levels will
rise to normal. When the asthma becomes severe, and the patient is tiring and has little air
movement, the C02 numbers will rise to dangerous levels (above 60).

Successful treatment will lessen or eliminate the shark fin shape and return the ETCO2 to
normal range.

Hypoxic Drive
Capnography will show the hypoxic drive in COPD "retainers." ETCO2 readings will steadily
rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it has
been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography will
also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers
without worry that they will hypoventilate.

CHF: Cardiac Asthma

It has been suggested that in wheezing patients with CHF (because the alveoli are still, for the
most part, emptying equally), the wave form should be upright. This can help assist your clinical
judgement when attempting to differentiate between obstructive airway wheezing such as COPD
and the "cardiac asthma" of CHF.

7. Ventilating Head Injured Patients

Capnography can help paramedics avoid hyperventilation in intubated head injured patients.

Recent evidence suggests hyperventilation leads to ischemia almost immediately.current models

of both ischemic and TBI suggest an immediate period during which the brain is especially
vulnerable to secondary insults. This underscores the importance of avoiding hyperventilation in
the prehospital environment.19 Hyperventilation decreases intracranial pressure by decreasing
intracranial blood flow. The decreased cerebral blood flow may result in cerebral ischemia.

In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with
ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than those
without ETCO2 monitoring (13.4%). Patients in both groups with severe hyperventilation had
significantly higher mortality (56%) than those without (30%). 20A target value of 35 mmHg is
recommended.

8. Perfusion Warning Sign

End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a sudden
drop in cardiac output will show a drop in ETCO2 numbers that may be regardless of any change
in breathing. This has implications for trauma patients, cardiac patients – any patient at risk for
shock.

In the study cited below, 5 pigs had hemorrhagic shock induced by bleeding, 5 pigs had septic
shock induced by infusion of e-coli, and 6 pigs had cardiogenic shock induced by repeated
episodes of v-fib. The pigs' cardiac output was continuously measured as well as their PETCO2.

“Cardiac output and PEtCO2 were highly related in diverse experimental models of circulatory
shock in which cardiac output was reduced by >40 % of baseline values. Measurement of PEtC02
is a noninvasive alternative for continuous assessment of cardiac output during low flow
circulatory shock states of diverse causes.21
A patient with low cardiac output caused by cardiogenic shock or hypovolemia resulting from
hemorrhage won’t carry as much CO2 per minute back to the lungs to be exhaled. This patient’s
ETC02 will be reduced. It doesn’t necessarily mean the patient is hyperventilating or that their
arterial CO2 level will be reduced. Reduced perfusion to the lungs alone causes this phenomenon.
The patient’s lung function may be perfectly normal.22

9. Other Issues:

Diabetic Ketoacidosis

Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation causes their
PaC02 to go down.

“End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If
confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical
assessment, may help discriminate between patients with and without DKA, respectively. 23

Pulmonary Embolus
Pulmonary embolus will cause an increase in the dead space in the lungs decreasing the alveoli
available to offload carbon dioxide. The ETCO2 will go down.

Hyperthermia
Metabolism is on overdrive in fever, which may cause ETCO2 to rise. Observing this
phenomena can be live-saving in patients with malignant hyperthermia, a rare side effect of RSI
(Rapid Sequence Induction).
Trauma

A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent of patients with
ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The median ETCO2 for
survivors was 30.75.24

“Capnography can serve as an effective, rapid assessment and triage tool for critically injured
patients and victims of chemical exposure. It provides the ABCs in less than 15 seconds and
identifies the common complications of chemical terrorism. 25

Anxiety
ETCO2 is being used on an ambulatory basis to teach patients with anxiety disorders as well as
asthmatics how to better control their breathing. Try (it may not always be possible) to get your
anxious patient to focus on the monitor, telling them that as they slow their breathing, their
ETCO2 number will rise, their respiratory rate number will fall and they will feel better.

Anaphylaxis
Some patients who suffer anaphylactic reactions to food they have ingested (nuts, seafood, etc.)
may experience a second attack after initial treatment because the allergens remain in their
stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The wave form may
start to slope before wheezing is noticed.

Accurate Respiratory Rate

Studies have shown that many medical professionals do a poor job of recording a patient's
respiratory rate. Capnography not only provides an accurate respiratory rate, it provides an
accurate trend or respirations.

Different capnograph curves

 Air leak-loose connection between sampling tube and capnogragh

Rebreathing capnogram of Mapleson D circuit, Bain system, Exhausted CO2 absorber

Bronchospasm / COPD / Emphysema/ obstructed endotracheal tube -Slanting and prolonged

phase 2 and increased slope of phase 3
Upward slanting of phase 4. A normal variant in pregnant women during anesthesia.

Unrecognized exhaustion of CO2 absorber resulted in substantial rebreathing and rising ETCO2
values. The closed circuit without functioning absorber mimicked Mapleson D circuit

Contamination of capnometer results in the sudden elevation of base line as well as ETCO2
values
Curare cleft(when a neuromuscular blockade wears off, The patients tackes small spontaneous
respirations in the paralyzed patient).

Resembling curare cleft due to an artifact created by surgeon leaning on the chest, or pushing
against the diaphragm during expiration. Partial disconnect of main stream capnometer.

Dilution of expiratory gases by the forward flow of fresh gases during the later part of expiration
when expiratory flow rate decreases below the forward gas flow rate
Elevation of base line- A classic representation of rebreathing.

Exhausted CO2 absorber

Rebreathing producing gradual elevation of base line and ETCO2 values

Occasionally, there can be a reverse phase 3 slope seen in patients with emphysema. Most like
this may be due to destruction of alveolar capillary system in emphysematous lungs resulting in
the delivery of carbon dioxide to expired gases.
Endobronchial intubation may not result in a characteristic waveform. However, occasionally, it
may be like the one seen in COPD or the above.

A gradual decrease in end tidal carbon dioxide can occur during reduced metabolism,
hypothermia, hyperventilation, small tidal volume ventilation due to inadequate alveolar
sampling, and leaks in the sampling system, decrease in cardiac output .

Lung transplant - Dual capnogram.

Slit sampling tube can result in a pig tail capnogram.

Cardiogenic oscillations - Ripple effect - Seen during low frequency ventilation.

Sampling problems such air or oxygen dilution during nasal or mask sampling of carbon dioxide
in spontaneously breathing patients.
 Expiratory valve malfunction can result in prolonged abnormal phase 2 and phase 0.

Increased CO2 due to hypoventilation, hypermetabolic states and rebreathing.

Inspiratory valve malfunction predominantly results in abnormal phase 0.

For show more detail, Please refer to http://www.capnography.com/find.htm

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9. Levine R, End-tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest,

New England Journal of Medicine, July 1997.

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Combination to Predict Resuscitation Outcomes?, Academic Emergency Medicine, June
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12. Shibutani K, Muraoka M, Shirasaki S, et al: Do changes in end-tidal Pco2

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14. Kwetny I, Finucane BT: Negative arterial to end-tidal carbon dioxide gradient: An
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17. Verschuren F, Heinonen E, Clause D, et al: Volumetric capnography as a bedside

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