e s

l
Capnography
id
e S
p l
a m
S
CPD Ventilasi Mekanis
Keseminatan Intensive Care
2017

Physiology of CO2
• Concentration of CO e s
d
in alveoli is determined

i
2

l
by:

S
Perfusion (Q)

e
Ventilation (V)

p l
• Varies indirectly with ventilation
a m
• Increase Ventilation
• Decrease Ventilation
Decrease CO2 in Alveoli

S
Increase CO2 in Alveol
• Varies directly with perfusion
• Decrease Perfusion Decrease CO2 in Alveoli
• Increase Perfusion Increase CO2 in Alveoli
2
 Definition
• Capnography is the noninvasive continuous e s
l id
measurement of the concentration or partial

S
pressure of carbon dioxide in respiratory gas

e
during breathing
•
p l
Carbondioxide waveforms are plotted against
time or expired volume
•
a m
Time capnography is most commonly used now
•
S
Capnography, like ECG, is a diagnostic
monitoring modality because changes in the
shape of the waveform are diagnostic of
disease conditions
3

Definition

e s
d
• Capnography refers to the graphic display of the
l i
concentration or partial pressure of exhaled and

S
inhaled carbon dioxide plotted against time

e
• Capnometry refers to the measurement and
• PaCO 2 l
numerical display of carbon dioxide concentrations

p
denotes the partial pressure of carbon

m
dioxide in arterial blood.

a
• End-tidal carbon dioxide (ETCO ) is the
S
2
percentage concentration, or partial pressure, of
carbon dioxide at the end of exhalation.
• Normally 5% of atmospheric pressure, or approximately
38 mm Hg at sea level

4
 Why Capnography?

e s
•
id
Indirect monitor and helps in the differential diagnosis of

l
hypoxia ➞ earlier measures before hypoxia results in an

S
irreversible brain damage.

•
le
Provides information about CO2 production, pulmonary

p
perfusion, alveolar ventilation, respiratory patterns, and
elimination of CO2 from the anesthesia circuit and

m
ventilator ➞ early detection of adverse respiratory events.

•
• S a
Capnography and pulse oximetry ➞ prevention of 93% of
avoidable anesthesia mishaps (ASA closed claim study)
Capnography ➞ facilitates better detection of potentially
life-threatening problems than clinical judgment alone

5 http://www.capnography.com/new/index.php?option=com_content&view=article&id=48&Itemid=986

Airway
O2 O2 O2

Transport 160 torr

s
104 torr

id e Breathing

Sl
e
Hb Pulse oximetry

p l 100 torr

Circulation

a m
50 torr

S 1-10 torr

Mitochondrial Respiratory Chain

 CO2 O2

Transport

e s
Capnography

d
CO2

i
elimination

Sl
p le Circulation
CO2
transport

m
Hb

S a CO2 CO2
production

Mitochondrial Respiratory Chain

Pulse oximetry vs capnography

e s
d
Pulse oximetry Capnography

be used for metabolisme

Sl i
• Reflects oxygenation to • Reflects ventilation to get
rid of CO2 as the waste
• Measures oxygen
le
product of metabolism

p
saturation • Measures carbon dioxide
• exchange

m
Change lags when pt is
•
a
hypoventilating or apneic Ventilation problems can

S
• Used in combination with be detected immediately
capnography ➞ Better • Should be used in
insight of patient’s conjunction with pulse ox
respiratory (dys)function
8
 Physics of Capnography

e s
• Infra-red Spectrography
l id
S
• Molecular Correlation Spectrography
e
p l
• Raman Spectrography
m
• Mass Spectrography
a
S
• Photoacoustic Spectrography
• Chemical colorimetric analysis (disposable)
9

Infra Red  Spectrography

e s
l id
e S
p l
a m
S
10
 Factors Affecting IR Spectrography

e s
• Atmospheric Pressure
l id
• Nitrous oxide
e S
• Oxygen
p l
• Water Vapor
a m
S
• Inhalational Agents
• Response Time
11

Types of Capnographs
• Main-stream Capnographs e s
• Side-stream Capnographs
l id
e S
l
IR Source

p
CO2 CO2 CO2

m
IR Detector

a
ETT ETT

S
Sampling catheter
Sensor

Display
Sensor &
Display

Main-stream Side-stream
12
 Main-stream Capnographs

e s
d
Advantages Disadvantages

i
• •
l
No sampling tube Traction on the endotracheal
•
S
No obstruction tube. (newer - lighter)
• Not affected due to pressure • Long electrical cord (lightweight)

le •
drop Facial burns have been reported
• (eliminated with newer sensors)

p
Not affected due to changes in
water vapor pressure • Sensor windows may clog with

m
• No pollution secretions. Can be replaced or

a
• No deformity of capnograms
S
due to non dispersion of gases
• No delay in recording
• Suitable for neonates and
children
cleaned easily
•
Difficult to use in unusual patient
positioning
• Disposable newer versions
eliminating sterilization problem

13

Side-stream Capnographs

e s
d
Advantages Disadvantages

i
• •
l
Easy to connect Delay in recording due to
•
S
No problems with sterilization movement of gases from the ET
to the unit
• Can be used in awake, non-

e
•
l
intubated patients Sampling tube obstruction
• • Water vapor pressure changes

p
Easy to use in unusual positions
such as in prone position affect CO2 concentrations
•
m
• Can be used in collaboration Pressure drop along the

a
with simultaneous oxygen sampling tube affects CO2

S
administration via a nasal prong measurements
• Deformity of capnograms in
children due to dispersion of
gases in sampling tubes

14
 Capnography
• Quantitative: measure the
e s
precise ETCO2 either as a

l id Quantitative Capnography

S
number or a number plus a
waveform
•
le
Qualitative: measure a range in

p
which the ETCO2 falls (eg, 0 to

m
10 mm Hg, 35 mm Hg) as Qulitative Capnography

a
opposed to a precise value (eg,

S
38 mm Hg)
• Colorimetric ETCO2 detector
• Its primary use is for verification of
endotracheal tube placement and
position
15

Time Capnogram Volume Capnogram

e s
l id
e S
p l
a m
S
Kodali BS. Anesthesiology 2013; 118:192-201
 New Technology In Capnography

e s
• Non invasive measurement / monitoring of

l id
S
cardiac output
• Based on Fick’s principle
le
• Computed on breath-by-breath measurements of
CO2 elimination
p
•
m
Cardiac output is proportional to the change in CO2

a
elimination divided by the change in end tidal CO2

• S
resulting from a brief rebreathing period
The results are controversial when the lungs are
diseased

17

Capnogram phases

s
I E ETCO2
mmHg

e
III

l id
S
IV II IV

IV. Inspiration starts.

CO2 becomes zero

p le I
time

m
inspiration expiration
begin (dead space)

a
inspiration
end III. Alveolar plateau,

S
After inspiration, O2 in the lung is CO2 reach the sensor
replaced by CO2. However, CO2 does
not enter the dead space, which
therefore still has O2.

I. Expiration begins.
II . The expiration continues.
Dead space exhaled,no CO2
Mixing of alveolar gas with
the capnograph trace in early
dead space. The continues
expiration remains at the base
till the end of expiration.
line.
18
 Time Capnogram

e s
id
PaCO2 • The slope of the of the phase III

l
represents the V/Q status of the

S
3-5 mmHg (physiologic dead space)
III lung
ETCO2
•

e
The angle between phase II &
mmHg

l
α β
phase III is called α angle

p
II IV • Normal: around 1000
• Increased in bronchoconstriction

m
• Height of the alveolar plateau is

a
I related to the ratio of cardiac

S
time output to alveolar ventilation.

• For a given alveolar ventilation the height of the plateau increases or

decreases with abrupt change in cardiac output.
• The angle between phase III & IV is β angle .
• Generally it is 900
• Increases in the presence of rebreathing
19

PCO2 changes

e s
d
Increase on PCO2 Decrease on PCO2
• •
l i
Decreased ventilation Increased respiratory rate

S
• Decreased respiratory rate • Increased tidal volume

e
• Decreased tidal volume • Decreased CO2 production
•
l •
Increased cardiac output Hypothermia

• Increased CO2 production

•
m p
Shivering, fever, hypercatabolism
• Decreased CO: decreased
blood vol more dead space

a
• Malignant hyperthermia • Pulmonary Embolism or

S
blockage of gas exchange

Adjust the ventilation Adjust the ventilation

Decrease resp. depressant drugs Evaluate the need of sedation
Assess pain management Body warming
20
Body cooling
 ETCO2 value
• Normal: 35 - 45 mmHg e s
l
• Deadspace ventilation: decreasedid
• Shunt: normal/increased
e S
p l
a m
S
Deadspace ventilation Shunted perfusion
21

Indications of ET CO2 Monitoring

e s
i
• Validation of proper ET placement
l d
S
• Detection and monitoring of respiratory
e
l
function
•
•
Hypoventilation

m p
Obstructive sleep apnea
•
• S a
Procedural sedation
Adjustment of parameter settings in
mechanically ventilated patients

22
 Where can it be used?

e s
• Intensive Care Units
l id
S
• Post Anesthesia Care Units
e
p l
• Emergency departments and ambulances
m
• Endoscopy suites
a
S
• Sleep laboratories
• Cardiac catheterization laboratories
23

Capnography waveforms

e s
id
45

Sl Normal

e
0

45

p l
m
Hyperventilation

a
0

S
45

0 Hypoventilation

24
 The "straight line" wave

e s
l id
e S
• Possible reasons:
•
•
p l
An unconnected/disconnected capnograph room air (CO2 nearly 0)

m
Respiratory arrest (apnea). In this case pulse oximeter wave is still present
•

a
Total obstruction:
•

S
Total lungs obstruction: e.g. severe bronchospasm
• Total airway obstruction: e.g. tracheal tube obstruction
• Total obstruction of capnograph sampling tubing

• If patient is intubated and pulmonary ventilation is consistent with bagging,

ETCO2 will directly reflect cardiac output
• Cardiac arrest : no circulation no CO2 to the lungs

25

Sloping expiratory trace

e s
id
mmHg

l
40

e S
l
time

•
p
Some possible reasons:
•
m
Partial obstruction of lungs:

a
• bronchospasm

S
• chronic obstructive pulmonary disease (COPD)
• Partial obstruction of artificial airway:
• tracheal tube secretions/foreign body
• kinking

26
 Re-Breathing

e s
mmHg

l id
S
40

p le time

a m
• Malfunction of CO absorber system
2

• Faulty expiratory valve

S
• Inadequate inspiratory flow
• Breath stacking
27

"Relaxant Notches"

e s
45

l id
e S
l
0

p
• Wear of neuromuscular blockade. The pt takes a
m
a
small breath

S
• Give additional dose of muscle relaxant

28
 "Cardiac Notches"

s
(cardiac oscillations)

id e
Sl
p le
a m
• The disturbance caused by the cardiac oscillations
S
may be seen as a series of notches in the waveform.

29

Esophageal Intubation

e s
l id
e S
•
p l
If the tracheal tube is in the esophagus, there will be

m
no or little CO2

•
S a
Flat trace or a rapidly descending series of curves.

30
 Other issues

e s
l id
• DKA: Patients with DKA hyperventilate to lessen their
acidosis ➞ ↓ ETCO2

e S
l
• Pulmonary Embolus: Pulmonary embolism ➞ ↑ dead
p
space in the lungs (ventilated non perfused alveoli)
decreasing the alveoli available to offload carbon

•
a m
dioxide ➞ ↓ ETCO2

S
Hyperthermia : ↑ Metabolism ➞ ↑ ETCO2. Malignant
hyperthermia can be detected early ➞ Managed
early

31

Capnography in ICU

e s
id
1. Capnography should be used for intubation of all critically ill

l
patients irrespective of location.

S
2. Continuous capnography should be used in all ICU patients with

e
tracheal tubes (including tracheostomy) who are intubated and

l
ventilator-dependent. Cost and technical difficulties may be

p
practical impediments to the rapid introduction of routine
capnography. However, these need not prevent its implementation.

m
3. Where capnography is not used, the reason should be

a
documented in the chart.

S
4. Training of all clinical staff who work in ICU should include
interpretation of capnography. Teaching should focus on
identification of airway obstruction or displacement. In addition,
recognition of the abnormal (but not flat) capnograph trace during
CPR should be emphasized

32 Cook TM, et al. British Journal of Anaesthesia 2011;106(5):632-42

 Capnography in Emergency Unit

e s
l id
S
1. Capnography should be used for all intubations
in the ED

p le
2. Capnography should be used for all
anesthetized patients in ED

a m
3. Capnography should be used for intubated

S
patients during transfers from the ED to other
departments.

33 Cook TM, et al. British Journal of Anaesthesia 2011;106(5):632-42

ETCO2 in Cardiac Arrest

e s
d
• The ETCO provides an estimate of the alveolar

i
2

l
CO2 tension and reflects the combined effects of:
• CO2 production,

e S
l
• CO2 transport (to the lungs)

p
• CO2 elimination

• ETCO 2

a m
> 10 mmHg reasonable compression
•
S
ETCO2 > 15 mmHg
• Sudden jump P ETCO2
> 30 mmHg sudden
improvement in perfusion (ROSC)
continue the CPR

34 Gazmuri R, Kube E. Crit Care 2003,7:411-412

 Capnogram trend in CA
• A - Initial ETCO2 reading = zero.

e s
d
The patient in a full

l i
cardiorespiratory arrest. Chest
compression started

S
• B - Intubated. Waveform is seen

e
• C - ETCO2 goes back down to

l
zero. Unexpected extubation

p
• D - Successful reintubation.
ETCO2 ∽ 10 mmHg

m
• E - Gradual increase to an

a
ETCO2 15 - 20 mm Hg (CPR

S
efficient)
• F - ROSC (sudden rise to an ETCO2 value > 40). Capnography may predict RESC
before a pulse is felt!
• G - Return to normal ETCO2 (∽ 35 - 45) after ROSC
• H - Sudden drop of ETCO2 CPR restarted

35 ACLS Pocket Brain

Summary

e s
• ETCO
l id
is a great tool to help monitor breath to
2

S
breath the ventilatory status of the patients

p le
• Can help recognize ventilatory problems before
the patient has signs of attacks ➞ prevent

m
mishaps

S
injured patient a
• Can help to control the increase in ICP in head
• Can help to identify ROSC in cardiac arrest
36
 Thank you for your kind attention

e s
l id
e S
p l
a m
S
37