The Journal of Emergency Medicine, Vol. 53, No. 6, pp.

829–842, 2017
Published by Elsevier Inc.
0736-4679/$ - see front matter

[Link]

Clinical
Reviews in Emergency Medicine

CAPNOGRAPHY IN THE EMERGENCY DEPARTMENT: A REVIEW OF USES,

WAVEFORMS, AND LIMITATIONS

Brit Long, MD,* Alex Koyfman, MD,† and Michael A. Vivirito, RN, CEN‡
*Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas, †Department of Emergency Medicine,
The University of Texas Southwestern Medical Center, Dallas, Texas, and ‡Department of Emergency Medicine, Joint Base Elmendorf-
Richardson Medical Center, Joint Base Elmendorf-Richardson, Alaska
Reprint Address: Brit Long, MD, Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam
Houston, TX 78234

, Abstract—Background: Capnography has many uses in trauma, and respiratory conditions. It should only be used in
the emergency department (ED) and critical care setting, conjunction with other patient factors and clinical asses-
most commonly cardiac arrest and procedural sedation. sment. Published by Elsevier Inc.
Objective of the Review: This review evaluates several indi-
cations concerning capnography beyond cardiac arrest and , Keywords—capnography; capnometer; carbon dioxide;
procedural sedation in the ED, as well as limitations and end-tidal; monitoring; resuscitation; waveform
specific waveforms. Discussion: Capnography includes the
noninvasive measurement of CO2, providing information
INTRODUCTION
on ventilation, perfusion, and metabolism in intubated and
spontaneously breathing patients. Since the 1990s, capnog-
raphy has been utilized extensively for cardiac arrest and Breathing consists of oxygenation and ventilation.
procedural sedation. Qualitative capnography includes a Oxygenation can be assessed with pulse oximetry, while
colorimetric device, changing color on the amount of CO2 capnography provides information on ventilation (effec-
present. Quantitative capnography provides a numeric tiveness of carbon dioxide [CO2] elimination), perfusion
value (end-tidal CO2), and capnography most commonly (CO2 transportation in vasculature), and metabolism
includes a waveform as a function of time. Conditions in (production of CO2 via cellular metabolism) (1–8).
which capnography is informative include cardiac arrest, Capnography includes the noninvasive measurement of
procedural sedation, mechanically ventilated patients, and CO2 partial pressure during the breathing cycle. Capnogra-
patients with metabolic acidemia. Patients with seizure, phy and capnometry are often used interchangeably, though
trauma, and respiratory conditions, such as pulmonary
they are distinct entities. Capnography is a comprehensive
embolism and obstructive airway disease, can benefit from
measurement and display of CO2, including end-tidal and
capnography, but further study is needed. Limitations
include use of capnography in conditions with mixed patho- inspired CO2 as a number and waveform. A capnometer dis-
physiology, patients with low tidal volumes, and equipment plays a numeric value for CO2 on a monitor. The CO2 wave-
malfunction. Capnography should be used in conjunction form is most commonly displayed as a function of time,
with clinical assessment. Conclusions: Capnography demon- though critical care uses include graphs with the waveform
strates benefit in cardiac arrest, procedural sedation, me- as a function of volume (1–8). One of the first studies
chanically ventilated patients, and patients with metabolic utilizing exhaled CO2 was conducted in the 1970s (9). Since
acidemia. Further study is required in patients with seizure, the 1990s, capnography has been used for an increasing

RECEIVED: 21 July 2017;

ACCEPTED: 11 August 2017

829
830 B. Long et al.

number of conditions, procedures, and monitoring (1–4,8). Table 1. Capnography Phases

The concentration of CO2 vs. time represents the CO2
Segment Phase Explanation
waveform, and changes in this shape can assist physicians
in a variety of conditions, including assessment of disease Inspiration 0 Inspiration begins, with clearing of
severity, cardiac arrest (compression quality, return of CO2
b-angle Located between phase III and
spontaneous circulation, endotracheal tube placement, descending part of inspiration,
prognosis, among others), procedural sedation, and normally 90 degrees
critical illness (1–4,7,8). Expiration I Consists of anatomical dead space
Should not contain CO2
Capnography measures CO2 partial pressure by main- II Rapid rise in CO2 concentration as
stream or side-stream device. Mainstream devices measure the breath reaches upper airway
CO2 directly from the airway, most commonly with the from the alveoli
Mixture of anatomical and alveolar
sensor housed directly in the respiratory circuit, and these dead space
devices are used for intubated and spontaneously breathing III Alveolar plateau
patients. Sidestream devices measure CO2 by sampling CO2 concentration reaches uniform
levels in the airway
exhaled breath through a side port and can be used for Height and slope of the line offers
intubated and spontaneously breathing patients as well important information on the
(2–4,8,10,11). ventilation and perfusion ratios in
the lungs
Qualitative monitors include a colorimetric end-tidal Height related to cardiac output
CO2 (EtCO2) device, which changes color depending on a-angle Located between phase II and III,
amount of CO2 present (8,10,11). This color change normally 100 degrees
occurs due to the pH of carbonic acid that is formed as a
product of the reaction between carbon dioxide and
water. The device is purple for EtCO2 < 3–4 mm Hg
(< 0.5%), tan for 3–15 mm Hg (0.5%–2%), and yellow METHODS
for values > 15 mm Hg (> 2%) (1–4,8,10,11).
Quantitative monitors utilize infrared radiation, as CO2 The authors conducted a literature search of Medline,
absorbs a specific wavelength of radiation, allowing EBSCO, and Google Scholar for search terms including
photodetectors to calculate CO2 concentration in the capnography, capnogram, interpretation, cardiac arrest,
sample (2–4,8–11). procedural sedation, end-tidal, return of spontaneous cir-
A capnogram consists of two primary components, culation, trauma, injury, metabolic acidosis/acidemia,
inspiratory and expiratory, which can be further broken critical illness, pulmonary embolism, seizure, sepsis,
into four different phases (2–4,8–11). This is and obstructive airway disease. Studies were limited to
demonstrated in Table 1, with Figure 1 displaying a those evaluating human subjects in English from 1980
normal waveform. to 2017. The authors agreed on articles to include by
Interpretation requires consideration of three aspects consensus. This review is not a systematic review or
of capnography: the EtCO2 maximum number or plateau, meta-analysis, and study quality was not assessed
the shape of the capnogram, and the difference or gradient formally with a standardized tool.
between EtCO2 and arterial CO2 pressure (6–8,10,11).
Normal ventilation and lung function demonstrate a
rectangular waveform. Factors that affect capnography
include CO2 production, CO2 transport, ventilation, and
ventilation to perfusion ratio changes. Ventilator
settings and malfunctions, disconnections and leaks,
tubing obstruction, sampling method and site, sample
rate, and monitor malfunctions can also affect
capnography readings. The maximum PCO2 at end
expiration is the EtCO2, which varies normally between
35 and 40 mm Hg. The gradient between arterial CO2
and alveolar CO2 is approximately 3–5 mm Hg in
healthy patients, due to the combination of dead space
CO2 and alveolar CO2 (1–5,8,10,11). This gradient Figure 1. Normal capnography waveform. Reprinted from:
functions as a surrogate for assessing ventilation– [Link] with
permission.
perfusion relationship (1–5,8,10,11).
Capnography in the ED 831

DISCUSSION means of confirmation after visual confirmation of tube

placement through the vocal cords.
Capnography possesses a significant number of clinical Monitoring ETT location during patient transport with
applications in the ED, whether for the intubated or quantitative capnography is beneficial to evaluate for
spontaneously breathing patient. This review will assess displacement (40). One observational study of prehospi-
several indications for capnography, limitations, and tal intubations found a 23% rate of misplacement in
future uses. Specific waveforms and capnography patients not undergoing continuous monitoring during
findings will be discussed as well. transport, while no patients in the continuous monitoring
group had an unrecognized misplaced intubation (35).
Verification and Monitoring of Endotracheal Tube During transport of ventilated patients, capnography
Placement should be utilized routinely (39,41,42).

Verification of endotracheal tube (ETT) placement using Cardiac Arrest

EtCO2 is reliable and safe (1–3,7). It may be the most
accurate method for confirming placement, as fogging or EtCO2 was first used to monitor effectiveness of cardiopul-
condensation of the ETT occurs in up to 83% of monary resuscitation in the 1980s in animal models, and the
esophageal intubations (Figure 2) (12). Chest wall move- first study in humans was released in 1989 (2–4,8,39,43,44).
ment may occur with intubation of the esophagus, and The level of EtCO2 reflects cardiopulmonary blood flow,
breath sounds incorrectly identify at least 16% of esopha- and EtCO2 measurement is associated directly with chest
geal intubations (12–14). Unrecognized misplacement of compressions (35–39,43). Advanced Cardiac Life Support
an ETT can be disastrous, which can reach 25% 2015 guidelines recommend quantitative waveform to
(14–27). Quantitative and qualitative verification of tube monitor compressions, as well as return of spontaneous
placement can be conducted after intubation. Qualitative circulation (ROSC) (39). However, capnography is not
markers will turn yellow with proper intubation. These regularly utilized in cardiac arrest, though it has many
markers have demonstrated accuracy in assessing ETT uses in resuscitation of these patients and may improve
placement with sensitivity approaching 100%, and they outcomes (45,46). Positive waveform tracing should be
may be as accurate as quantitative capnography, except present during high-quality compressions, and high-
in states with no perfusion (28–32). quality compressions increase EtCO2 levels
A quantitative capnogram will demonstrate four (39,43,45–47). A level > 20 mm Hg is optimal, and levels
phases with proper intubation (1–4,8,10,11). However, < 10 mm Hg require improved technique or a different
right mainstem bronchus intubation will result in provider to perform compressions (38,39,41–50). A
similar findings on capnography. If the ETT is placed in gradual decrease in EtCO2 suggests compressions are not
the hypopharynx above the vocal cords, the waveform optimal, and a decrease should trigger consideration of
may appear appropriate, but over time will become factors associated with decline (e.g., hemorrhage,
erratic. A flat capnogram indicates misplacement in the pneumothorax, tamponade, myocardial infarction, among
esophagus, though it may also occur in ETT others) (2–4,39,51,52).
obstruction, technical malfunction of the monitor or An abrupt increase in EtCO2 is an early indicator of
tubing, prolonged cardiac arrest, and complete airway ROSC (Figure 3) (36–39,53). A sudden increase to
obstruction distal to the ETT (1–4,8,10,11). Accuracy normal values (30–40 mm Hg) suggests ROSC, and an
in patients with spontaneous circulation is close to
100%, though in cardiac arrest the sensitivity varies
between 60% and 100%, depending on the duration of
arrest and the modality used (10,11,19,33–39). Physical
examination and capnography function as secondary

Figure 2. Waveform capnography with esophageal intuba- Figure 3. Waveform capnography with return of sponta-
tion. Reprinted from [Link] neous circulation. Reprinted from [Link]
encyclopedia, with permission. com/new/encyclopedia, with permission.
832 B. Long et al.

increase of at least 10 mm Hg is highly specific for ROSC oximetry, especially with oxygen supplementation
(0.97) (2–4,36–39,54). However, utilizing a specific (67–76). It can also detect upper airway obstruction,
value of EtCO2 is not recommended to definitely define laryngospasm, and bronchospasm, and it can be used as
ROSC, and EtCO2 should be used with other factors in an adjunct in assessing ventilation and different sedation
arrest (55). Compressions are one of the primary compo- strategies (77). Respiratory depression will manifest as
nents of management of cardiac arrest and, unfortunately, abnormally high EtCO2 (67–76). Adverse events,
the literature demonstrates frequent interruptions including respiratory complications, are rare in
(56–58). With return of perfusing rhythm, an increase procedural sedation in the ED, as one recent meta-
in cardiac output results in rapid increase in EtCO2 analysis finds hypoxia occurs in 1.5% of pediatric seda-
(36–39,51,59,60). If a rise in EtCO2 is noted, chest tions (78). Five of 1000 patients receiving sedation
compressions may be stopped while cardiac rhythm is required intervention with bag-valve mask (BVM), oral
assessed. Otherwise compressions should be continued. airway, or positive pressure ventilation. Emesis and
EtCO2 at various time points in cardiopulmonary resus- agitation are the most frequent events, with 55.5 and
citation (CPR) is useful prognostically, as studies have 17.9 events per 1000 patients, respectively (78). The
evaluated levels at 3 min onward, though most evaluate American College of Emergency Physicians provides a
20 min (43–51,61). Values > 20 mm Hg demonstrate a Level B recommendation stating ‘‘Capnography may be
higher chance of obtaining ROSC, and values < 10 mm used as an adjunct to pulse oximetry and clinical assess-
Hg at 20 min demonstrate minimal chance of survival ment to detect hypoventilation and apnea earlier than pulse
(43–51,62). One meta-analysis suggests a level > 25 mm oximetry or clinical assessment alone in patients undergo-
Hg is associated with ROSC, vs. 13.1 mm Hg, and ing procedural sedation and analgesia in the ED’’ (67).
ROSC or mean difference in capnography was not modi- Though capnography possesses potential benefits in
fied by resuscitation guidelines or era in which the studies sedation, several studies suggest it may not reduce
were conducted (63). Similar numbers are supported in patient-centered outcomes (79–83). A 2016 systematic
inpatient pulseless electrical activity arrest for prognosti- review suggests routine EtCO2 during procedural
cation, with increase in capnography possessing an odds sedation would be costly, with > $2 million over a
ratio (OR) of 4.8 (95% confidence interval [CI] 1.2– 5-year period per prevented catastrophic event (80). A
19.2) for ROSC, though likelihood of survival to discharge Cochrane review evaluating capnography in procedural
was not affected by EtCO2 (64). One study assessing prog- sedation evaluated three trials involving 1272 patients
nostic factors in arrest found EtCO2 to have the greatest suggests addition of capnography to standard monitoring
predictive value for ROSC at 5 and 10 min, with sensitivity may not reduce clinically significant adverse events,
0.88 and specificity 0.77 (62). Another study finds EtCO2 though significant heterogeneity and bias are present in
at 20 min < 14 mm Hg is associated with mortality (65). study design and results, and this review included a study
Currently, EtCO2 demonstrates many uses in cardiac ar- that found no change in desaturation with capnography
rest, though utilizing a specific number for cutoff is diffi- use, though airway repositioning occurred more
cult and should not be used in isolation. Capnography frequently (increase by 3.5%) (81,82). Sivilotti et al.
should not used in isolation to determine cause of arrest finds no significant difference in capnography vs. pulse
(52). One review offers a valuable mnemonic for use of oximetry when detecting hypoxia (83).
capnography in arrest, termed PQRST (Table 2) (66). However, multiple studies support capnography’s
utility for monitoring. A study in 2015 by Langhan et al.
Procedural Sedation evaluating pediatric sedation suggests capnography
decreased episodes of hypoventilation and desaturation
One of the most common uses for capnography is patient (84). Miner et al. in 2002 finds capnography detects all
monitoring during procedural sedation. This modality cases of respiratory depression, while standard monitoring
provides an advantage over solely monitoring pulse finds only one-third (72). Burton et al. finds EtCO2 abnor-
oximetry, as it detects hypoventilation earlier than pulse malities are present in 70% of cases before pulse oximetry

Table 2. PQRST Mnemonic (66)

P Position of tube Confirmation of endotracheal tube position, which is more reliable than other measures
Q Quality of compressions Provides valuable CPR feedback based on level
R ROSC Sudden increase in value suggests ROSC, decreasing ‘‘hands-off’’ time in CPR
S Strategy for further treatment Values and trends in conjunction with other investigations (ultrasound) may provide assistance in
treatment (e.g., pulmonary embolism and thrombolytics)
T Termination of resuscitation Values and trends over time can be used in association with other measures (values < 10 mm Hg
associated with death)

CPR = cardiopulmonary resuscitation; ROSC = return of spontaneous circulation.

Capnography in the ED 833

is affected, and Vargo et al. finds capnography detects < 25 mm Hg in trauma is associated with decreased
100% of respiratory events, while pulse oximetry detects cardiac output, decreased blood pressure, and mortality
50% (73,75). Anderson et al. evaluated capnography in (84.9%) (91,92). Capnography may also be used in
pediatric procedural sedation, with capnography patients with head trauma and suspected elevated
detecting 100% of apnea cases before pulse oximetry intracranial pressure. High CO2 values cause cerebral
(76). Capnography was 17.6 times more likely to detect vasodilation, and low values are associated with
respiratory depression when compared to standard moni- vasoconstriction. Hypoventilation (elevated CO2) can
toring in one meta-analysis (71). Though capnography cause increased cerebral blood flow and intracranial
can detect respiratory depression and decrease the chance pressure, potentially worsening outcomes (2–4,8,92).
of respiratory events, the literature evaluating improved However, EtCO2 should not be used alone for assessing
patients outcomes with capnography is controversial. ventilation status in ventilated patients with severe
Several studies suggest it may decrease risk of hypoxia. injury, as EtCO2 alone can result in underventilation in
Qadeer et al. evaluated capnography in adult endoscopy > 80% of patients, though another study suggests it can
procedures, finding a reduction by 23% in hypoxia with provide valuable information for severely injured
capnography (69). Deitch et al. evaluated capnography patients and their ventilation status (93,94). Use of
for adults undergoing sedation with propofol, with results EtCO2 should be used in combination with other factors
demonstrating a sensitivity of 1.0 and specificity 0.64 for to evaluate respiratory status in ventilated trauma patients.
detection of hypoxia and an absolute risk reduction of A study conducted in blunt trauma prehospital patients
17% (70). Lightdale et al. found a 13% reduction in who underwent intubation finds EtCO2 to be greater in
hypoxia with capnography use in pediatric endoscopy, survivors (30.8 mm Hg in survivors and 26.3 mm Hg in
and Soto et al. evaluated capnography and anesthesia nonsurvivors) (95). EtCO2 demonstrates a strong inverse
providers, finding capnography detects all cases of apnea relationship with lactate in patients with penetrating
(68,85). A systematic review for procedural sedation trauma, with EtCO2 displaying an OR of 20.4 for
finds capnography decreases hypoxemic episodes, with requiring emergent operation (96). Capnography levels
relative risk 0.71 (95% CI 0.56–0.91) (86). < 30 mm Hg may be associated with increased risk of se-
Currently, waveform capnography offers the ability to vere injury in trauma, though it does not change decision
evaluate ventilation while at the bedside. The literature making when combined with blood pressure, age, or
evaluating waveform capnography varies in outcomes Glasgow Coma Scale (97). A recent study released in
with capnography. However, capnography allows pro- Injury finds capnography levels < 35 mm Hg are associ-
viders a numerical value with waveform, and for physi- ated with mortality and need for blood transfusion (98).
cians working in settings where the individual performs Capnography in trauma requires additional study, but it
the sedation and procedure, or with limited resources holds promise for determining those critically ill if used
and personnel, it offers a layer of monitoring and patient in conjunction with clinical assessment, as well as need
safety. Pulse oximetry, if used alone, can suffer from for transfusion.
response delay (10–90 s in healthy patients), or the time
to detect hypoxemia, and physicians are not accurate in Metabolic Acidemia
detecting hypoventilation (87).
Capnography can reliably assist in the diagnosis of meta-
Other Indications bolic acidemia. A linear correlation is present between
EtCO2 and serum bicarbonate, with studies evaluating
EtCO2 has been studied for other critically ill patients. One this relationship in diabetic ketoacidosis (DKA) and
study that evaluated patients with hypotension in the ED gastroenteritis (1–3,7,99–103). As acidemia worsens,
found EtCO2 correlates with blood pressure, lactate, and bicarbonate decreases, which can result in respiratory
base excess, and mortality rate increases as EtCO2 levels compensation, decreasing EtCO2 (1–3,7). The greater
decrease (with a marker of 28 mm Hg demonstrating a the severity of acidemia, the lower the bicarbonate and
mortality rate of 55%) (88). No patients with levels EtCO2 levels, and these EtCO2 levels correlate with
< 12 mm Hg survived. EtCO2 also correlates with lactate, venous pH and bicarbonate in diagnosis (99,100,104).
serum pH, bicarbonate, and base excess (89,90). This may show promise for diabetic patients when
determining whether ketoacidosis is present (99,100).
Trauma Various levels of EtCO2 have been suggested for DKA
diagnosis. A study by Solmeinpur et al. conducted in
Monitoring EtCO2 can assist in several situations associ- adult patients with diabetes and blood glucose
ated with trauma, including brain injury (2–6,8). EtCO2 > 250 mg/dL finds EtCO2 has a sensitivity of 0.90 and
834 B. Long et al.

specificity of 0.90 for ruling out DKA with a capnography mortality (114,115). More study is required at this time
value of 24.5 mmHg (100). Fearon and Steele, in pediat- for capnography use in sepsis.
ric patients with DKA, finds a level of 29 mm Hg to have a
sensitivity of 0.83 with specificity of 1.0 for diagnosis Pulmonary Embolism
(101). A study conducted in adults suggests capnography
levels of < 25 mm Hg and > 36 mm Hg to respectively Pulmonary embolism (PE) can be a challenging diagnosis.
have a specificity of 0.838 for metabolic acidemia and Evaluation in the ED relies on clinical gestalt or risk strat-
sensitivity of 0.98 for excluding metabolic acidemia ification, with the most common diagnostic modality CT
(99). A second study suggests this level of 36 mm Hg of the pulmonary vasculature (116). This test is reasonably
can rule out DKA with a sensitivity of 1.0, while a level sensitive and specific for PE diagnosis. Capnography may
< 20 mm Hg has a specificity of 1.0 (105). Fearon and have a role in evaluation for PE, as PE decreases perfusion
Steele report a sensitivity of 0.83 for a cutoff of 29 torr of a specific segment of the lung, while ventilation usually
(a separate measurement for EtCO2), with a specificity remains normal. PE increases alveolar dead space, lowers
of 1.0 (101). In pediatric patients, Gilhotra et al. found the expired CO2, and increases the PaCO2 and EtCO2
a 1.0 sensitivity and 0.86 specificity for capnography of gradient (117–119). Several studies have demonstrated
> 30 mm Hg for excluding DKA (102). Capnography PE increases the physiologic dead space fraction and
can evaluate for ketoacidosis and acidemia, though arterial EtCO2 difference (117–121). PE may flatten the
more study is required for specific levels. slope of phase III (Figure 4) (117–120).
Pooled sensitivity of capnography for PE in a meta-
Sepsis analysis is 0.80, with specificity of 0.49 and area under
the summary receiver operating characteristic curve of
Sepsis is a common disease managed in the ED, and emer- 0.84 (121). Authors suggest capnography may be used to
gency physicians often utilize laboratory markers to supple- rule out PE in low-risk patients, as pretest probability of
ment clinical assessment, such as lactate (106–109). 10% and negative capnography would lead to post-test
Literature suggests capnography has potential to be used probability of 3% (121). Authors discuss the use of this
similarly to lactate for prognostication and resuscitation in test in patients with positive D-dimer testing but low
sepsis. EtCO2 demonstrates an inverse relationship with clinical suspicion of PE, as positive D-dimer testing and
lactate levels (110–112). Increased lactate levels are low suspicion of PE is associated with 6%–23% chance
associated with increased mortality and decreased EtCO2 of PE (122–125). When combined with Wells score of 4
levels (110–112). One study of 183 patients with or less, EtCO2 $36 mm Hg demonstrates a negative
suspected sepsis finds EtCO2 < 25 mm Hg occurs in 78% predictive value (NPV) of 0.976 (125). Another study finds
of patients, with higher mortality in 11% of patients with a level of 32 mm Hg possesses a sensitivity 1.0 and NPVof
EtCO2 < 25 mm Hg (112). Another study finds EtCO2 1.0, and authors suggest combination with D-dimer and
levels < 35 mm Hg may correlate with increased lactate
(> 4 mmol/L) and Sequential Organ Failure Assessment
(SOFA) score > 2 in sepsis, though the sensitivity and
area under the curve (AUC) of capnography for predicting
these findings is not reliable (sensitivity 0.73 for SOFA and
sensitivity 0.60 for lactate) (90). However, a recent study
finds no statistically significant relationship of capnography
with lactate levels, but it may be used in triage with other
markers (113). This use as a marker in prehospital response
or triage is supported by a study by Hunter et al, which finds
low EtCO2 < 25 mm Hg is the strongest marker for sepsis
(AUC 0.99, 95% CI 0.99–1.00), severe sepsis (AUC 0.80,
95% CI 0.73–0.86), and mortality (AUC 0.70, 95% CI
0.57–0.83) among all prehospital variables, which include
systemic inflammatory response syndrome criteria (112).
Studies also suggest capnography is predictive for mor-
tality in sepsis (112,114,115). Per study results for patients
with sepsis, EtCO2 is associated with serum bicarbonate,
lactate, and anion gap, and levels are significantly lower Figure 4. Waveform capnography in pulmonary embolism
with increased gradient and decreased EtCO2. Reprinted
in those patients who suffer mortality. In these studies, from [Link] with
levels < 31 mm Hg demonstrate a 0.93 sensitivity for permission.
Capnography in the ED 835

and heart failure, and EtCO2 can correlate with arterial

CO2 levels within 5 mm Hg in > 80% of patients with
dyspnea (1–3,7,130,131). Assessment of EtCO2 and
clinical respiratory status provides important information
concerning patient clinical status (131–134).
Bronchospasm and obstruction will demonstrate an
appearance resembling a sharkfin on capnography
(Figure 5), with a steep phase III (1–3,134,135).
Exacerbation of obstructive airway disease may result in
a small decrease in EtCO2 levels as the patient tries to
compensate (136,137). If the patient decompensates and
the exacerbation worsens, EtCO2 will increase due to
ineffective ventilation (7,135–137). A study conducted in
Figure 5. Waveform capnography with obstructive airway
disease. Reprinted from [Link] prehospital patients with asthma or COPD exacerbation
new/encyclopedia, with permission. suggests both high levels (> 50 mm Hg) and low levels
(< 28 mm Hg) on capnography are associated with
greater rates of intubation, critical care admission, and
clinical probability (126). Capnography in this setting mortality (138). Asthma exacerbation will result in differ-
could lower further testing, but this requires study, specif- ences in phase III and a-angle with treatment including
ically targeting optimal EtCO2 values. A study in 2010 b-agonists, suggesting capnography can be used in associ-
demonstrates sensitivity approaching 0.70, specificity ation with clinical assessment to evaluate for response
0.61, and NPV 0.478 for measurement of alveolar dead (139). In pediatric asthma, EtCO2 may function to deter-
space measurement, while a second study in 2015 suggests mine need for admission, though this should only be
a value of 26.5 mm Hg possesses sensitivity 0.78, speci- used as an adjunct to clinical assessment. More study is
ficity 0.676, and NPV 0.70 (127,128). A study in 2016 required assessing ability to predict severity, though
evaluating EtCO2 and alveolar dead space fraction EtCO2 may improve with treatment (138,140,141).
suggests EtCO2 possesses an AUC for EtCO2 19 mm Hg A similar use in COPD patients exists, as EtCO2 can be
of 0.751, with sensitivity 0.838, though authors express monitored during ED evaluation, functioning as an adjunct
concern for using this test alone (129). Use of capnography to clinical assessment (142). Capnography may hold
for PE requires further study, focusing on the level of promise in differentiating COPD and congestive heart
EtCO2 and potential combination of EtCO2 with other failure exacerbation by evaluating duration of exhalation,
assessments, such as D-dimer or Well’s score. slope of end-exhalation EtCO2, and duration of maximum
EtCO2, though this requires further study (143). In heart
Other Respiratory Conditions failure, EtCO2 may assist in prognostication, which was
associated with New York Heart Association class and
Capnography can be used in respiratory conditions such as left ventricular ejection fraction (144). As discussed with
asthma, chronic obstructive pulmonary disease (COPD), other conditions, EtCO2 should not be used in isolation

Table 3. Conditions with Changes in End-Tidal CO2 (2–8)

Etiology of Abnormality EtCO2 Decrease EtCO2 Increase

Metabolic Hypothermia Malignant hyperthermia

Metabolic acidosis/acidemia Neuroleptic malignant syndrome
Thyroid storm
Recovery from anesthesia
Respiratory Pulmonary edema Hypoventilation
Intrapulmonary shunt Severe COPD
Hyperventilation Severe asthma
Circulatory Anesthesia induction Release of tourniquet
PE Laparoscopy with CO2 insufflation
Hypovolemia/hemorrhagic shock Treatment of acidosis/acidemia
Cardiogenic shock
Intracardiac shunt
Technical Equipment/tubing disconnection CO2 absorber dysfunction
Block/kink in tubing Monitor contamination

COPD = chronic obstructive pulmonary disorder; EtCO2 = end-tidal CO2; PE = pulmonary embolism.
836 B. Long et al.

Table 4. Waveform Interpretation and Etiologies (2–8)

Waveform Potential Conditions

Sudden decrease in EtCO2 to 0 (Figure 6) Complete obstruction of the airway or endotracheal tube, apnea,
defective CO2 analyzer, complete disconnection of the
ventilator circuit, or defective ventilator
Sudden decrease in CO2 that does not reach 0 Leakage in the respiratory system, calibration error, obstruction
Exponential decrease in CO2, or ‘‘washout curve’’ within 1 min Circulatory arrest, embolism, sudden decrease in blood pressure,
or sudden severe hyperventilation
Gradually decreasing EtCO2 levels Increase in respiratory rate or tidal volume (hyperventilation),
decrease in metabolic rate or CO2 production, or fall in body
temperature
If gradual taper to 0 mm Hg occurs with decreased waveform,
esophageal intubation is likely
Sudden increase in EtCO2 (Figure 3) Injection of sodium bicarbonate, sudden release of tourniquet, or
sudden increase in blood pressure (ROSC or use of a
vasopressor)
Gradually increasing EtCO2 plateau levels Decreased respiratory rate or tidal volume (hypoventilation),
increase in metabolic rate or production in CO2, and increase in
body temperature (such as malignant hyperthermia, excited
delirium, among others)
Elevation of the plateau and baseline Faulty expiratory valve of the circuit, inadequate respiratory flow,
malfunction of the CO2 absorber system, and insufficient
expiratory time
May be seen with hyperpyrexia (malignant hyperthermia)
Elevation in baseline Rebreathing, including faulty expiratory valve of the circuit,
inadequate respiratory flow, malfunction of the CO2 absorber
system, and insufficient expiratory time
Change in slope of the ascending limb (Figure 5) Obstruction in the expiratory limb of the breathing circuit, foreign
body in the airway, bronchospasm, and partially kinked or
occluded artificial airway
High EtCO2 with normal rate Low minute volume with normal rate or rapidly rising body
temperature
High EtCO2 with low rate Respiratory depression without compensation such as high
intracranial pressure, respiratory depression medications, low
respiratory rate, and minute volume
Low EtCO2 with normal rate Circulatory dysfunction (shock), low body temperature, high
minute volume on ventilator, compensation for metabolic
acidosis
Low EtCO2 with low rate Low body temperature, damage to central nervous system
(central neurogenic hyperventilation)
Low EtCO2 with fast rate Ventilator with high rate and high minute volume, patients in pain,
compensation for metabolic acidosis or hypoxia, severe shock
Curare pattern (decrease in middle of plateau with return to Cervical lesion, muscle paralysis with lack of coordination
normal) between intercostal muscles and diaphragm, patient fighting
ventilator
Cardiogenic oscillations Heart beating against lungs (small tidal volume with low
respiratory rate, end of long expiration)

EtCO2 = end-tidal CO2; ROSC = return of spontaneous circulation.

to predict need for admission or prognostication; rather, Fluid Responsiveness

the entire clinical picture must be considered (145).
Fluid rehydration is often a cornerstone of critically ill
Seizures patients, though patients in shock may fail to respond
to fluids (2,3,147–149). Fluid administration can be
EtCO2 can provide an assessment of the ventilatory status harmful in several circumstances, and evaluating fluid
of a patient who is seizing or in a post-ictal state (2,3,7). responsiveness to guide fluid rehydration can assist
Capnography can predict respiratory failure, and one (150,151). Passive leg raise provides a reliable means of
study of pediatric patients actively seizing found assessing fluid response, but it depends on several factors,
capnography detects hypoventilation more reliably than including other monitors or echocardiogram to assess
pulse oximetry (which missed 5 patients who had pulse response (147–149). EtCO2 provides an important
oximetry > 97% and EtCO2 > 70 torr) (146). These patients assessment in mechanically ventilated patients. If
required assist with BVM and intubation. Twenty other pa- responsive to fluids, patients will demonstrate an increase
tients with EtCO2 > 52 torr required BVM support (146). by at least 5% in EtCO2 (147–149). This increase in
Capnography in the ED 837

False-positive CO2 detection can occur in esophageal

intubations if the patient ingested carbonated beverages.
Acidic solution exposure, such as stomach content fluid
or vinegar, can result in qualitative color change
(157–160). Nitrous oxide utilized during sedations or
Figure 6. Apnea. Reprinted from [Link] procedures can interact with infrared light sensors,
com/new/encyclopedia. resulting in falsely elevated EtCO2 levels. False-
negative results may occur with low blood flow states,
EtCO2 demonstrates AUC 0.849, and an increase by at least such as PE or cardiac arrest (2–8).
2 mm Hg is specific (0.96), though sensitivity is 0.60 The device location can impact results. Mainstream
(152,153). This level of 2 mm Hg is suggested by another devices add dead space to the circuit and require time
study that finds OR of 7.3 (95% CI 2.7–20.2) and an to generate heat and avoid condensation. Side-stream
increase by < 2 mm Hg has a NPV of 0.86 (154). EtCO2 devices may result in time delay, are prone to obstruction
may be more reliable than other markers, with an AUC of as they are not in direct line of gas flow, and can be
0.82 in a recent 2016 study evaluating the ability of capnog- inaccurate if low tidal volumes are generated due to
raphy to predict fluid responsiveness, which outperformed entrainment of environmental gases (2,3).
pulse pressure variation, systolic blood pressure, heart
rate, and mean blood pressure in patients undergoing me- Recommendations
chanical ventilation (155). Further study is required to eval-
uate capnography’s ability to predict fluid responsiveness. Capnography has demonstrated utility in cardiac arrest,
critical illness, procedural sedation, DKA, and respiratory
Capnography Interpretation distress, among others. However, specific values for
cutoffs vary in the literature. Trends in capnography, along
Capnography provides important information concerning with clinical assessment, can benefit in evaluating and
patient status. Evaluation of the capnography waveform managing specific situations, including cardiac arrest, pro-
and value can be straightforward, though several intri- cedural sedation, mechanically ventilated patients, and pa-
cacies are present. This section will evaluate several tients with metabolic acidemia or DKA. Further study is
waveforms and potential etiologies of the waveform. required in patients with seizure, trauma, and respiratory
Evaluation of the waveform includes the height, conditions, such as asthma and COPD. Capnography use
frequency, rhythm, baseline, and shape (1–4,7,8). in PE requires further delineation of the specific role it
Table 3 demonstrates conditions that should be consid- plays in evaluation and risk stratification.
ered with decreasing or increasing EtCO2 levels, and
Table 4 discusses several different waveform patterns CONCLUSIONS
and associated conditions. Each of these patterns may
be associated with several conditions, and each condition Capnography possesses many uses in the ED and critical
shown in Table 4 may cause several waveform patterns. care settings in intubated and spontaneously breathing
patients. Quantitative and qualitative capnography are
Capnography Limitations the primary forms of capnography, with quantitative cap-
nography providing a numeric value with waveform,
Capnography is ideal for patients with a specific ventila- which provides information on ventilation, perfusion,
tion, perfusion, or metabolism issue (2–4,8). However, and metabolism. Qualitative capnography changes color
patients with mixed pathophysiology present challenges dependent on amount of CO2 present. Capnography is
for interpretation. For example, a perfusion deficit may informative in cardiac arrest, procedural sedation,
lower EtCO2, while a ventilation deficit may elevate the mechanically ventilated patients, and patients with meta-
value. Interpretation of EtCO2 may be affected by low bolic acidemia. Patients with critical illness, including
tidal volumes, which may drop below the flow rate and seizure, trauma, and respiratory conditions, such as PE
lower the EtCO2 value. This is more commonly seen in and obstructive disease, may benefit from capnography,
younger pediatric patients and neonates. In cardiac but further study is needed. Ultimately, capnography
arrest, EtCO2 is not only dependent on compressions should be used in association with clinical assessment.
but also may be affected by the etiology of arrest
(cardiac, PE, respiratory, among others) (2–7). Other Acknowledgments—The authors thank Bhavani-Shankar Ko-
organ system involvement, including hypotension and dali, MD, of [Link] for providing
low perfusion, can affect EtCO2 levels (156). the figures for this review article. This manuscript did not utilize
838 B. Long et al.

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ARTICLE SUMMARY
1. Why is this topic important?
Capnography can be utilized for many emergency med-
icine and critical care conditions and procedures,
including cardiac arrest and procedural sedation.
2. What does this review attempt to show?
This review evaluates the current literature concerning
capnography, including specific procedures and condi-
tions, waveform patterns, and limitations.
3. What are the key findings?
Capnography includes the noninvasive measurement of
CO2, providing vital information on ventilation, perfu-
sion, and metabolism of emergency department (ED) pa-
tients, intubated and spontaneously breathing. Qualitative
and quantitative capnography can be used, with qualita-
tive capnography providing color change, while quantita-
tive capnography provides a numeric value. Waveform
capnography can be displayed as a function of time,
with specific patterns suggesting certain conditions. Cap-
nography is useful in cardiac arrest, procedural sedation,
mechanically ventilated patients, and patients with meta-
bolic acidemia. Patients with seizure, trauma, and respira-
tory conditions such as pulmonary embolism and
obstructive disease may benefit from capnography. Physi-
cians should be cognizant of several limitations, including
patients with poor ventilation and perfusion.
4. How is patient care impacted?
This review evaluates the current evidence behind cap-
nography utilization in the ED. Capnography possesses
benefits in cardiac arrest, procedural sedation, mechani-
cally ventilated patients, and patients with metabolic
acidosis or diabetic ketoacidosis. Further study is required
in patients with seizure, trauma, and respiratory condi-
tions.