Respiratory Monitoring

Dr Arthur Chun-Wing LAU

Associate Consultant
Department of Intensive Care
PYNEH
28 Sep 2007
 Gas exchange

 Pulse oximetry
 Capnometry
 Continuous blood gas analysis
 Transcutaneous monitoring (PTCO2
and PTCCO2)
 Question

Which patient is more hypoxemic, and why?

Patient pH PaCO2 PaO2 SaO2 Hb

A 7.48 34 85 95 7

B 7.32 74 55 85 15

 Answer: A (Patient A, with the higher PaO2 but the

lower hemoglobin content, is more hypoxemic)

• Patient A: Arterial oxygen content = 7 x 1.36 x .95 +

0.0031 x 85 = 9.3 ml O2/dl
• Patient B: Arterial oxygen content = 15 x 1.36 x .85 +
0.0031 x 55 = 17.5 ml O2/dl
 Arterial oxygen content
 CaO2 = Total oxygen content in the arterial
blood in ml O2/dL (N: 18 – 21)

 (Hgb x 1.36 x Oxygen bound to Hb

• SpO2: measured by pulse
SaO2) oximeter
• SaO2: calculated from PaO2

 + (0.0031 x Oxygen dissolved in plasma

• negligible amount
PaO2) • Measured by electrode
 Question
 Which of the following situation(s) would be
expected to lower PaO2?
1. anemia
2. CO poisoning
3. Abnormal hemoglobin that holds oxygen with half the
affinity of normal hemoglobin
4. Abnormal hemoglobin that holds oxygen with twice
the affinity of normal hemoglobin
5. lung disease with intra-pulmonary shunting.

 Answer: only 5
• 1 affects only content, not oxygen saturation or PO2.
• 2 through 4 affect only oxygen saturation and content,
not PO2
 Important

• Neither the quantity nor quality of

hemoglobin should affect the amount of
dissolved oxygen, and hence should not
affect the PaO2.
• PaO2 is not a function of hemoglobin
content or of its characteristics, but only of
the alveolar PO2 and the lung architecture
(alveolar-capillary interface).
 How to measure oxygen saturation
1. Calculated from pO2: as in most automated blood gas analyzers (Clark electrodes)
1. calculated from the measured parameters pO2 and pH, on the basis of standard
oxygen-dissociation curves
2. Assumption: there is an otherwise normal hemoglobin dissociation curve, also
provided that nothing else is binding to the Hb except O2
2. Differential spectrophotometry: as in oximeter
3. Tonometry
1. process of exposing a liquid to an ambient gas phase in such a way that each
gas in the gaseous phase partitions to an equilibrium between the liquid and gas
phases.
2. For QC samples, checking linearity of electrodes, or for various hemoglobin
studies.
4. Transcutaneous monitors
1. rely on the oxygen content of capillary blood
2. measured by heating skin locally to dilate capillaries
3. agrees well with arterial blood pO2 when tissue perfusion is adequate, but not in
states of hypoperfusion
Pulse Oximetry
 What is oxygen saturation %
 Numerator
• oxygenated Hemoglobin
• carboxyhemoglobin (usu not present)
• methemoglobin (usu not present)
 Denominator
• total oxygenated and deoxygenated
hemoglobin
 Based on two physical principles
1. Photoplethysmography: “pulse”
 to distinguish pulsatile arterial blood
from venous blood
2. Spectrophotometry: “oximeter”
 to distinguish oxyhemoglobin (oxyHb)
and deoxyhemoglobin (deoxyHb)
Typical pulse oximeter sensing
configuration on a finger

Probes for fingers and ear lobes are commonly used

Two light-emitting diodes
Emit light of the following
wavelengths
1. 660 nm (red)
• Absorbed more by
dexoyHb
2. 940 nm (infrared)
• Absorbed more by
oxyHb
 Ratio of absorbencies
is calibrated against
direct measurements
of arterial oxygen
saturation (SaO2)
 Numeric value of the
red-to-infrared ratio
(R/IR) is converted to
SpO2
 Bias +/- precision of SpO2 varies with
levels of actual SaO2
SaO2 Bias Precision
 Accuracy varies widely (difference (SD)
)
because of different
algorithms employed

 Prudent to assume that SpO2 >=90 1.7% 1.2%

is over-estimating SaO2, and %
to take some action whenever
SpO2 falls below 93%
<90% 5.1%% 2.7%

Jubran & Tobin. Chest 1990

van Oostrom JH and Melker RJ. Anesth Analg 2004;98:1354 –8
 Question
 Carbon monoxide (>= 1 answers)
• a) shifts the oxygen dissociation curve to the
left
b) lowers the PaO2
c) lowers the arterial oxygen content
d) is elevated in the blood of cigarette smokers

Correct responses are a, c and d.

Carbon monoxide does not lower the PaO2
CO poisoning

> 200x affinity for Hb than O2

 Carboxyhemoglobin
• COHb absorption spectrum is at 940nm
(IR), i.e. similar to that of oxyHb
• Therefore, read by the oximeter as if it were
oxyHb (does not affect the reading)

• For example
 SpO2 95% can represent true SaO2 of

85% +10% COHb

 Question
 Blood gas checked in room air: PaO2 is
77 mm Hg (10.3 kPa)
 Below are three values for arterial
oxygen saturation from this patient:
1. 95%, calculated from PaO2 value
2. 98%, from pulse oximeter
3. 85%, from co-oximeter
 Question:
• Which value is the most reliable?
This patient actually had 10% carboxy-hemoglobin and 2%
methemoglobin
 Answer
 Co-oximeter directly
measure oxyhemoglobin,
carboxyhemoglobin and
methemoglobin, using
four wavelengths of light

•Calculated SaO2 is only

reliable if nothing else but
oxygen is binding to
hemoglobin, which you
can't know from just the
PaO2.
 Methemoglobinemia
 MetHb depresses the SpO2 reading non-linearly
• Absorbs R light (660 nm) similar to that by deoxyHb
• Absorbs IR light (940 nm) to a greater extent than of
both oxyHb and deoxyHb

 Net result: MetHb causes the SpO2 to migrate

toward 85%, further increases in [metHb] do not
lower the SpO2 any further

 For example:
• True high SaO2 (>85%) condition: MetHb results in a falsely low
SpO2
• True low SaO2 (<85%) condition: MetHb results in a falsely high
SpO2
 Etiology
 Fe within Hb is oxidized from
the ferrous (Fe2+) state to
the ferric (Fe3+) state
 Effects:

• formation of methemoglobin
• inability to transport oxygen
and carbon dioxide
• brownish discoloration of the
blood
 Causes of MetHb
 Acquired:
• Exposure to Nitrites, Aniline dyes, Silver nitrate,
Nitroprusside, Antimalarials;
• Local anesthetics (Benzocaine, prilocaine, and lidocaine,
particularly when applied to mucosa, such as during
bronchoscopy, or after repeated cutaneous exposure to
eutectic mixture of lidocaine-prilocaine (EMLA(R) cream)
over a short period of time;
• Nitric and nitrous oxides;
• Vegetables (eg, spinach, beets, carrots) inadequately
cooked or contaminated with bacteria
 Hereditary: deficiency of NADH cytochrome b5
reductase or NADPH-flavin reductase or the
presence of hemoglobin M.
The patient had been wrongly given sodium nitrite instead of the herbal NatriiSulfas
(chiefly NaPO4) as a laxative for clearing heat and decreasing edema.
Low perfusion-resistant pulse oximeter

 Masimo Signal Extraction Technology

(Masimo SET)
• a unique method of measuring signals
accurately and reliably in the presence
of patient motion and low perfusion
• employs 5 parallel processing engines
Radical Signal Extraction Technology
(SET) pulse oximeter, Masimo Corp. (Irvine,
CA)
Rad-57 portable pulse CO-oximeter,
manufactured and entered by Masimo Corp.
(Irvine, CA).

• The Rad-57 is the world’s first

pulse CO-oximeter.
• Masimo Rainbow SET®
technology analyzes 7+
wavelengths of light to
accurately measure
carboxyhemoglobin (SpCO®)
and methemoglobin (SpMet™)
percent levels in the blood
noninvasively and continuously
Rainbow technology uses 7+ wavelengths of light to continuously and
noninvasively measure carboxyhemoglobin (SpCO®) and methemoglobin
(SpMet™)

Perfusion Index (PI) with trending capability indicates arterial pulse signal
strength and may be used as a diagnostic tool during low perfusion.

Pleth Variability Index (PVI): captures vital thoracic pressure changes that may
compromise normal cardiac function affecting systemic circulation
Accurate on cyanotic patients.

Signal IQ® waveform for signal identification and quality indication during
excessive motion and low signal to noise situations.
 Transcutaneous monitoring
 Measures O2 and CO2 diffusing
through the skin
 Mainly used in infants (NICU,
PICU)
 Relis on the oxygen content of
capillary blood
 agrees well with arterial blood
pO2 when tissue perfusion is
adequate, but not in states of
hypoperfusion
 measured by heating skin locally
to dilate capillaries
 The heat emitted by the electrode
may cause areas of redness on
the skin. Hence, the site of
placement of the sensor needs to
be changed regularly.
 Continuous blood gas
monitoring
 A fiber optic sensor with three
sensing elements for monitoring pH,
PCO2, and PO2 plus a thermocouple
for measuring temperature.
 Length: 30 cm; diameter <0.5 mm,
dead space 6/10,000 of a milliliter
 A Y connector on the sensor allows
simultaneous continuous blood
pressure monitoring and enables
intermittent withdrawal of blood
samples and infusions.
 Performance in the clinical setting
was not as satisfactory, especially
for PO2 values. (Ganter M and
Zollinger A. Br J Anaesth 2003)

Diametrics Paratrend 7+ sensor for adults

Capnography
 Capnography
 Measurement of CO2 in expired gas
 Analyzers utilize
• Infrared (employed in most intensive
care units)
• mass or Raman spectra technology
• photoacoustic spectra technology
 Mainstream or sidestream analyzers

 Mainstream analyzer
• sampling window inside the ventilator
circuit for CO2 measurement
 Sidestream analyzer
• aspirates gas from the ventilator circuit,
and the analysis occurs away from the
ventilator circuit
 Mainstream CO2 sensor
 During exhalation, exhaled gas
passes directly over the sensor
 Designed primarily for intubated
patients
 Difficult to use in nonintubated
patients because
1. it requires a mouthpiece or
mask that patients in
respiratory distress find
uncomfortable
2. In addition, when a mask is
used, any supplemental
oxygen must be delivered at
a flow rate of greater than 6
Lpm to ensure the patient
does not rebreathe CO2 that
can accumulate in the mask
at lower oxygen flow rates.
3. extra weight of the sensor
dragging on the
endotracheal tube
 Sidestream
 In sidestream capnography, a sample of exhaled
gas is aspirated from the patient’s airway
interface into the monitor, which houses the
sensor.
 Designed for use in both intubated and
nonintubated patients.
 Prone to obstruction with moisture.
 Microstream technology is a unique low-flow (50
cc/min) system that permits precise
measurement of CO2 levels without problems of
dilution or moisture accumulation.
 Normal capnogram
Expiration:
1. A or phase 1: Carbon dioxide cleared
from the anatomic dead space
2. B or phase 2: dead space and
alveolar carbon dioxide
3. C or phase 3: alveolar plateau
4. D or phase 4: end-tidal carbon
dioxide tension (PETCO2): normal
range of ETCO2 is 35 – 45 mm Hg .

Inspiration
 Inhaled PCO2 is zero (the amount in
inhaled air is negligible)
DISLODGED ETT: Loss of
waveform, Loss of ETCO2
reading

CPR: “Square box”

waveform; baseline CO2 =
0; ETCO2 = 10-15 mm Hg
(possibly higher) with
adequate CPR
Management: Change
rescuers if ETCO2 drops < 10

ROSC: As in CPR, but ETCO2

rises above 10-15 mm Hg
Management: Check for pulse
“ SHARKFIN” (Slanting and prolonged phase 2 and
increased slope of phase 3 ) with/without prolonged
expiration = Bronchospasm (asthma, COPD, allergic rxn)

Esophageal intubation:
Small CO2 spikes

Hypoventilation: low RR, gradually increases ETCO2

values > 45 mmHg with normal base line

RISING BASELINE = Patient is rebreathing CO2:

Rebreathing producing gradual elevation of base line and
ETCO2 values
Management: Check equipment for adequate oxygen
inflow, allow intubated patient more time to exhale
Onset of hyperventilation: results in gradual
lowering of ETCO2 values.

Sustained hyperventilation: high RR;

shortened waveform; baseline ETCO2 = 0;
ETCO2 < 35 mm Hg

PATIENT BREATHING AROUND ET TUBE:

angled, sloping downstroke on waveform
Adult: Broken cuff or tube is too small
Pediatric: tube is too small
 Common indications
 INTUBATED APPLICATIONS:
• Verification of ETT placement
• ETT surveillance during transport
• CPR: compression efficacy, early sign of ROSC,
survival predictor
 NON-INTUBATED APPLICATIONS:
• Bronchospasm: asthma, COPD, anaphylaxis
• Hypoventilation: drugs, stroke, CHF, post-ictal
• Shock & circulatory compromise
• Hyperventilation syndrome: biofeedback
monitor
 Estimation of PaCO2
 In health: PetCO2<= PACO2 <= PaCO2
• In healthy subjects, PaCO2 - PetCO2 is 1 to 5 mmHg
• Correlation coefficients between PetCO2 and PaCO2 are
0.69 to 0.92
 In patients with lung disease and ventilation-perfusion (V-
Q) imbalance
• PaCO2 - PetCO2 is much higher because of increased
physiologic dead space
 Once the difference between the two values is established,
and providing the patient remains clinically stable, the
PetCO2 may be followed in lieu of the PaCO2.
 Limitations
 Composition of the respiratory gas mixture
• High concentrations of either or both oxygen or nitrous oxide
may affect the capnogram
• When a gas that the mass spectrometer cannot detect (such as
helium) is present, the reported values of CO2 are incorrectly
elevated in proportion to the concentration of helium present.
 High breathing frequencies
• exceed the response capabilities of the capnograph.
 The presence of Freon (used as a propellant in metered dose
inhalers)
• artificially increase the CO2 reading of mass spectrometers (ie,
to show an apparent increase in [CO2])
• A similar effect has not yet been demonstrated with Raman or
infrared spectrometers.
 Contamination of the monitor or sampling system by secretions or
condensate, a sample tube of excessive length, a sampling rate
that is too high, or obstruction of the sampling chamber can lead to
unreliable results.
 Respiratory
Neuromuscular function
 Airway Occlusion Pressure
 Breathing Pattern

 Maximal Inspiratory Airway Pressure

(MIP)
Maximal Expiratory Pressure (MEP)

Transdiaphragmatic pressure
 Airway Occlusion Pressure
 = Negative pressure generated 0.1 sec following onset of
inspiration against an briefly and surreptitiously occluded
airway
 Measured by inserting a shutter in the ventilator's inspiratory
line as near as possible to the patient, and recording airway
pressure tracing at the Y piece by maintaining occlusion only
for the first 200 to 300ms of inspiration
 Why first 100 ms?
• chosen because a normal subject requires at least 150 ms to
sense the occlusion and react against it
P0.1 measurement
 Properties
 Unaffected by properties of the respiratory system
 Does not require scaling to patient size
 Normal values: 1 cmH2O
 A measure of neural respiratory drive (central drive)
• P0.1 is maintained following curare-induced muscular
weakness
• However, may be reduced in the presence of severe
inspiratory muscle weakness when capability to produce
pressure is profoundly impaired (consider the P0.1/MIP
ratio in such case)
 Uses
 Predicts weaning failure
• “High” levels of P0.1 (i.e. more negative
than – 4 to -6 cmH2O) are associated
with increased respiratory effort and
indicate an inability to breath
independently with success
• lower values of P0.1 are associated with
effective weaning.
 closely correlated with the work of
breathing
 Eight patients recovering
from acute respiratory
failure of various causes

P0.1 changed significantly

with lower PSV levels when
contraction of the SCM
muscles occurred

P0.1 did not change

significantly with high
levels of PSV

Perrigault PO, Thorax 1999;54:119–

123
Variations in (A) occlusion pressure (P0.1 ), (B)
respiratory frequency (f), and (C) tidal
volume (VT) with contraction of the
sternocleidomastoid (SCM) muscle.

SCM- = the lowest PSV level for each patient

without SCM activity
SCM+ = the first PSV level at which SCM
activity occurred.

1. P0.1 was the only parameter significantly

modified when SCM muscle activity was
present. Horizontal lines indicate mean
values.

2. VT, Ti, and f did not change significantly at

low levels of PSV10 to PSV5

3. When no activity of these muscles was

detected the P0.1 values were always lower
than 2.9 cm H2O

Perrigault PO, Thorax 1999;54:119–

123
 Breathing Pattern
 Tidal volume, Respiratory
frequency, Ti, Ttot, rib cage and
abdominal motion
 Measured by
• Wright spirometer (VT, f)
• Respiratory inductive
plethysmography (RIP)
Wright spirometer
 Respiratory inductive
plethysmography (RIP)
 The commercially available
RIP device, Respitrace
(Ambulatory Monitoring)
1. rib cage sensor bands
2. abdominal sensor bands
3. the oscillator
4. the signal demodulator

• For accurate volumetric measurements using RIP, it is assumed that the

cross-sectional area within the rib cage and the abdomen coil,
respectively, reflects all of the changes occuring within the respective
lung compartment, and further that the lung volume change is the sum of
the volume changes of the two compartments.
• Under optimal situations lung volume can be approximated with an
error less than 10%, less accurate in lateral decubitus and obesity
 Breathing patterns parameters
 f/VT ratio = rapid shallow breathing index
• Measured during the first minute after
transition to spontaneous T-piece breathing
• >100 breaths/min/L suggests that a trial of
weaning is unlikely to be successful
 VT/Ti
• Reflection of central respiratory drive
• In patients who failed a weaning trial, VT/Ti
increased significantly from the start to the
end of the trial
Table 2   Variation in breathing pattern and occlusion pressure
(P0.1) with different levels of pressure support (PS) ventilation

Perrigault PO, Thorax 1999;54:119–

123
Maximal Inspiratory Airway Pressure
 Defined as the most negative pressure
generated during a maximal inspiratory
against an occluded airway (for 15 – 20
secs)
 Evaluation of inspiratory muscle strength
 Usually measured after a forced expiration
to residual volume (some suggest FRC, in
order to mimic spontaneous ventilation)
 Normal values: -100cmH2O
 Uses
 to assess weaning feasibility
• more negative than -30cm H2O predicts
weaning success
• less negative than -20 cm H2O predicts
weaning failure
• should always be considered in conjunction
with other variables
• used in conjunction with P0.1 measurement
(P0.1/MIP) for increasing the specificity and
sensitivity
 to evaluate the respiratory effects of
neuromuscular disease
 Limitations
 Difficult to obtain in uncooperative
patients
 Not very reliable in predicting
weaning success
Maximal expiratory pressure (MEP)
 Seldom evaluated
 Important in patients with inc MV or
airflow obstruction in whom
expiration is an active process
 Performed from TLC
 Normal 150 cmH2O
 Transdiaphragmatic pressure
 Pdi = Pg – Pes
 Having the patient make a maximal
inspiratory effort from FRC against
an occluded airway
 Intersubject variability
 Pdi < 25cmH20 suggests severe
diaphragmatic weakness
SERVO-i ventilator with NAVA (neurally
adjusted ventilatory assist)
• On Sep 25, 2006, MAQUET Critical Care announced the launch of NAVA
(Neurally Adjusted Ventilatory Assist) at the 19th Annual Congress of the
European Society of Intensive Care Medicine.
NAVA
• NAVA senses activity in the
diaphragm and responds by
providing the requested level
of ventilatory assist.
• The Edi signal is obtained
by an electrode array
mounted close to the distal
tip of the Edi catheter.
•This catheter can also serve
as a conventional nasogastric
feeding tube.
 Benefits
1. Improved synchrony and patient comfort
 In NAVA the ventilator is cycled-on as soon as neural inspiration starts.
Moreover, the level of assistance provided during inspiration is determined by
the patient’s own respiratory center demand. The same applies for the cycling-
off phase - the ventilator cycles off inspiration the instant it is alerted to the
onset of neural expiration. By utilizing the Edi signal, maintenance of synchrony
between the patient and the ventilator is improved.
2. Lung protection
 With NAVA the patient's own respiratory demands determine the level of
assistance. NAVA gives the opportunity to avoid over or under assistance of the
patient.
3. Unique monitoring capability
 The Edi signal is a new unique parameter in mechanical ventilation. It can be
used as a diagnostic tool to monitor the electrical activity of the diaphragm
(Edi). The Edi curve and its associated value can thus be used as a powerful
monitoring tool in all ventilation modes, providing information on Respiratory
Drive, Volume requirements and the effect of the ventilatory settings, and to
gain indications for sedation and weaning.
4. Decision support for unloading and extubation
 The Edi signal can be used as an indicator to set the support level from the
ventilator, and to optimize unloading. As the patient’s condition improves, Edi
amplitude decreases, resulting in reduction in ventilator-delivered pressure. This
pressure drop is an indicator to consider weaning and extubation.
Breathing workload
Work of breathing
Pressure-Time Product
Tension-time Index
Oxygen consumption/Energy cost of
breathing

Respiratory Mechanics
 Primary measurements
• Pao, Pes, Flow, auto-PEEP)
 Derived measurements
• Static compliance, Dynamic compliance,
Pressure-volume curves, Resistance

Also refer to lecture on “Waveform

analysis on Mechanical Ventilation”
Thank you