Capnography

continuous non-invasive monitoring and

analysis of end-tidal CO2 concentration, during a
respiratory cycle.( I.E. waveforms and numbers)
Capnography
 TERMINOLOGY

End Tidal CO2 (ETCO2 or PetCO2)

the level of (partial pressure of) carbon dioxide released at end of expiration.

Capnograph
the graphical representation of the concentration or partial pressure of expired CO2
during a respiratory cycle in a “waveform” format
38
mmH
g

 Capnogram
a real-time waveform record of the concentration of carbon dioxide in the
respiratory gases

Capnometer – the numeric measurement of CO2.

38
4 Main Uses of Capnography
Severity of asthma
Monitoring head injured patients
Cardiac arrest
Tube confirmation
 INDICATION

- Evaluation of the exhaled CO2, especially end-tidal CO2 levels

- Monitoring severity of pulmonary disease and evaluating the patient’s
response to therapy, especially that intended to do the following:
Improve the VD/VT (deadspace/tidal volume)ratio
Improve the matching of V/Q
Increase coronary blood flow
- Determining that tracheal, rather than esophageal, intubation has taken
place
Continued monitoring of the integrity of the ventilatory circuit, including the
artificial airway
- Evaluation of the efficiency of mechanical ventilatory support (by [PaCO 2
(Partial pressure of CO2 in the alveoli)-PETCO2(Partial pressure of
CO2 at the end of expiration)
- Monitoring adequacy of pulmonary, systemic, and coronary blood flow
- Monitoring inspired CO2 when CO2 gas is being therapeutically
administered
- Graphic evaluation of ventilator-patient interface
- Measurement of the volume of CO2 elimination to assess metabolic rate or
CONTRAINDICATION

There are no absolute contraindications

to Capnography in mechanically
ventilated adults, provided that the data
obtained are evaluated with
consideration given to the patient’s
clinical condition.
LIMITATION

•Critically ill patients often have rapidly changing dead

space and Ventilation/perfision mismatch

•Higher rates and smaller TV can increase the amount of

dead space ventilation

•High mean airway pressures and PEEP(POSITIVE END-

EXPIRATORY PRESSURE) restrict alveolar perfusion,
leading to falsely decreased readings

•Low cardiac output will decrease the reading

Physiology
Factors that affect CO2 levels:
INCREASE IN ETCO2 DECREASE IN ETCO2

Increased muscular activity Decreased muscular activity

Increased cardiac output Decreased cardiac output

(during resuscitation) (during resuscitation)
Effective drug therapy for
Bronchospasm
bronchospasm

Hypoventilation Hyperventilation
EtCO2 – End Tidal CO2

The measurement of exhaled CO2 in the breath

Normal Range | 35-45 mmHg
Normal EtCO2
EtCO2 Values

Normal 35 – 45 mmHg
Hypoventilation > 45 mmHg
Hyperventilation < 35 mmHg

ETCO2 Less Than 35 mmHg = "Hyperventilation/Hypocapnia“

pH Increases (Alkalosis)
ETCO2 Greater Than 45 mmHg = “Hypoventilation/Hypercapnia"
pH Decreases (Acidosis)
Simply put, a number less than 35 means the patient is being ventilated too fast,
and a number higher than 45 means the patient is ventilated too slow and is becoming acidotic.
Normal Waveform
End of
Alveolar
Beginning of exhalation
plateau
exhalation

Beginning of
new breath
End of
inspiration

Clearing of anatomic dead space

Non-Intubated Applications
Bronchospasms: Asthma, chronic obstructive
pulmonary disease, Anaphlyaxis

Hypoventilation: Drugs, Stroke, congestive heart

failure, Post-Ictal

Shock & Circulatory compromise

Hyperventilation Syndrome: Biofeedback

Intubated Applications
Verification of Endotracheal Tube placement

Endotracheal tube surveillance during transport

Control ventilations during increased ICP(increase

intracranial pressure)

Cardiopulmonary resuscitation : compression

efficacy, early signs of return of spontaneous
circulation, survival predictor
Pulse oximetry

•Oxygen Saturation
• Reflects Oxygenation
• SpO2(oxygen saturation) changes lag when patient is
hypoventilating or apneic
• Should be used with Capnography

Capnography

• Carbon Dioxide
• Reflects Ventilation
• Hypoventilation/Apnea detected immediately
• Should be used with pulse Oximetry
Types of CO2 Monitors

 Colorimetric Monitors

 Infrared Monitors
Mainstream
Sidestream
Colorimetric

-Disposable detector
-Color changes in the presence of CO2
-This occurs when CO2 is exhaled, causing the pH to
decrease changing the disc from purple
to tan.
Infrared Monitoring

 Uses a variety of different monitoring technology.

 Measures the percentage of CO2 that is present through the

third phases of expiration cycle. Based on CO2 diffusion from
pulmonary arterial blood carried to the pulmonary capillary
beds of the alveoli – where gas exchange occurs.

 Dependent upon adequate circulation and pulmonary

perfusion.
Infrared Monitoring Technology

Mainstream
 Sensor located
directly in pt.’s
breathing circuit
 Used primarily on
intubated patients.
 Sensor has a longer
warm up time before
gas sample is
analyzed
Infrared Monitoring Technology

Sidestream
 Sample is removed
from pt.’s airway and
delivered to a distant
sensor.
 Can be used on
nonintubated
patients.
Min. sample volume
100cc – 150cc
Normal Waveforms
Normal

Square box waveform

ETCO2 35-45 mm Hg
Management: Monitor Patient
 Hypoventilation
Prolonged waveform
ETCO2 >45 mm Hg
Management: Assist ventilations or intubate as needed

Hyperventilation

Shortened waveform
ETCO2 < 35 mm Hg
Management: If conscious gives biofeedback. If ventilating, give slow
ventilations.
 ROSC (Return of Spontaneous Circulation)

During CPR sudden increase of ETCO2 above 10-15 mm Hg

Management: Check for pulse
Obstructive airway

Shark fin waveform

With or without prolonged expiratory phase
Can be seen before actual attack
Indicative of Bronchospasm( asthma, COPD, allergic reaction)
Patient breathing around ETT

Angled, sloping down stroke on the waveform

In adults may mean ruptured cuff or tube too small
In pediatrics tube too small
Management: Assess patient, Oxygenate, ventilate and possible re-
intubation
Esophageal Tube

•Absence of waveform
•Absence of ETCO2
•Management: Re-Intubate
CPR

Square box waveform

ETCO2 10-15 mm Hg (possibly higher) with adequate CPR
Management: Change Rescuers if ETCO2 falls below 10 mm Hg
Rebreathing

A capnogram that does not touch the baseline is indicative of a patient who
is rebreathing CO2 through insufficient inspiratory or expiratory flow
Patient is re-breathing CO2
Management: Check equipment for adequate oxygen flow
If patient is intubated allow more time to
The Head Injured Patient
Carbon dioxide dilates the cerebral blood vessels,
increasing the volume of blood in the intracranial vault and
therefore increasing ICP
Recognizing the head
injured patient and
titrating their CO2
levels to the 30-35
mmHg range can help
relieve the untoward
effects of ICP
The Head Injured Patient
Titration IS NOT hyperventilation. Intubating a head
injured patient and using capnography gives a means to
closely monitor CO2 levels.

Keep them between 30 and 35 mmHg

Titrate EtCO2
EtCO2 and Cardiac Arrest
The capnograph of an intubated cardiac arrest
patient is a direct correlation to cardiac output

Increase in CO2 during CPR can be an

early indicator of ROSC
Termination of Resuscitation
End tidal Carbon dioxide measurements during a
resuscitation give you an accurate indicator of
survivability for patients under CPR

Non-survivors <10 mmHg

Survivors >30 mmHg
(to discharge)
Endotracheal Tube Verification
Verification of proper tube placement
References
EGAN’S FUNDAMENTAL OF RESPIRATORY CARE 10 TH EDITION
www.acphd.org/media/86883/capnography
www.mecriticalcare.net/lectures.php?cat_id&download_id=83