CAPNOGRAPHY

Capnography is the continuous monitoring of instantaneous CO2 concentration in respired gases during the
respiratory cycle. Capnography provides information about CO2 production, pulmonary perfusion, alveolar
ventilation, respiratory patterns, and elimination of CO2 from the anesthesia circuit and ventilator. It serves as
an adjuvant in the differential diagnosis of hypoxia in determining the etiology so that corrective measures can
be implemented before irreversible brain damage.

Luft 1943 developed it from knowledge that co2 is absorbs infrared radiation of particular wavelength. 1978
Holland – first country to adopt capnography as standard monitoring in anesthesia.

Capnography monitors various components of patient and anesthesia circuit/equipment as well as the critical
connection between the two

TERMINOLOGY

Capnography: display of instanteneous CO2 conc. Vs time (time capnogran) or expired volume (volume
capnogram)

Capnograph: Machine that generates waveform.

• Capnogram: Actual waveform

 Capnometry: Measurment & numerical display. Normal range is 35-45mm Hg

 Capnometer: Device that performs the measurement & display readings
 Breath to breath waveform needs to be displayed for continuous monitoring

TECHNOLOGY

Physical Methods of Carbon dioxide Measurement

1. Infra Red Spectrography
2. Molecular Correlation Spectrography (Microstream technology)
3. Mass Spectrography
4. Raman Spectrography
5. Photoacoustic Spectrography

Infrared Analysis
Infrared analysis is by far the most common technology in use today. Infrared (IR) analyzers are based on the
principle that gases with two or more dissimilar atoms in the molecule(nitrous oxide, CO2, and the halogenated
agents) have specific and unique infrared light absorption spectra. Since the amount of infrared light absorbed
is proportional to the concentration of the absorbing molecules, the concentration can be determined by
comparing the infrared light absorbance in the sample with that of a known standard.

2 general types of infrared technology available today:

A)blackbody radiation technology

Blackbody Radiation Technology The most commonly used infrared technology utilizes a heated element
calleda blackbody emitter as the source of infrared light. This produces a broad infrared spectrum. The optical
detectors must be calibrated to recognize only infrared radiation that is modulated at a certain frequency by
using a spinning chopper wheel.

B) microstream radiation technology.

Microstream Technology Microstream technology utilizes laser-based technology to generate infrared
emission that precisely matches the absorption spectrum of CO2 .

Raman Spectrography
Raman Spectrography uses the principle of "Raman Scattering" for CO2 measurement. The gas sample is
aspirated into an analyzing chamber, where the sample is illuminated by a high intensity monochromatic argon
laser beam. The light is absorbed by molecules which are then excited to unstable vibrational or rotational
energy states (Raman scattering). The Raman scattering signals (Raman light) are of low intensity and are
measured at right angles to the laser beam

Mass Spectrography

The mass spectrograph separates molecules on the basis of mass to charge ratios. A gas sample is aspirated
into a high vacuum chamber (10-5 mmHg) where an electron beam ionizes and fragments the components of
the sample. The ions are accelerated by an electric field into a final chamber, which has a magnetic field,
perpendicular to the path of the ionized gas stream. In the magnetic field the particles follow a path wherein
the radius of curvature is proportional to the charge:mass ratio. A detector plate allows for determination of
the components of the gas and for the concentration of each component. Mass spectrometers are quite
expensive and too bulky to use at the bedside and are rarely used presently

Photoacoustic Spectrography

Photoacoustic gas measurement (e.g., Bruel-Kjaer gas monitor)is based on the same principles as conventional
IR-based gas analyzers: the ability of CO2 and N20 and anaesthetic agents to absorb IR light. However, they
differ in measurement techniques. While Infra-red spectrography uses optical methods, PAS uses an acoustic
technique. When an IR energy is applied to a gas, the gas will expand and lead to an increase in pressure. If the
applied energy is delivered in pulses the gas expansion would be also pulsatile, resulting in pressure
fluctuations. If the pulsation frequency lies within the audible range, an acoustic signal is produced and is
detected by a microphone. Potential advantages of PAS over IR spectrometry are higher accuracy, better
reliability, less need of preventive maintenance, and less frequent need for calibration.
colorimetric
A chemical (colorimetric) detector consists of a pH-sensitive indicator enclosed in a housing.When the
indicator is exposed to carbonic acid that is formed as a product of the reaction between CO2 and water it
becomes more acidic and changes color. During inspiration, the color returns to its resting state unless it is
used with a breathing system that allows rebreathing (purple in room temprature to yellow)
The inlet and outlet ports are 15 mm, so the device can be placed between patient and the breathing system or
resuscitation bag.
HYGROSCOPIC HYDROPHOBIC

The hygroscopic CO2 detector contains hygroscopic filter A hydrophobic indicator in a colorimetric
paper that is impregnated with a colorless base and an device shows a color change from blue to green to
indicator that changes color as a function of pH. yellow when exposed to CO2.Liquid water may
The filter paper is visible through a clear window. The cause the device to not function properly. If the device
color chart on the dome was designed to be read under is allowed to dry, it will recover its activity. It has a
fluorescent light.purple or mauve (A) color indicates a faster response time, performs better at high
low CO2 (< 0.5%) level. A beige (B) color indicates a respiratory frequencies,
moderate level (0.5% to 2%). A yellow color (C) and is less affected by humidity than the hygroscopic
indicates a high level (> 2%) The mean minimum model
concentration of CO2 needed to produce a color change
is 0.54%, with a range from 0.25%to 0.60%.The
hygroscopic CO2 detector’s useful life may last from a
few minutes to several hours, depending on the humidity
of the gas being monitored.Reducing the relative
humidity of exhaled gases by using an HME to trap
moisture before it reaches the device prolongs the
detector’s useful life.

Uses
 A chemical CO2 detector is useful for confirming successful tracheal intubation when a capnometer is
not available.
 It is useful for intubations that are performed out of the hospital, in the emergency department, or on
the
 wards .
 It can be used to determine the position of the Combitube.
 It can be used during an intubation in a hyperbaric chamber.
 A manual resuscitator may have a built-in colorimetric CO2 detector.Because it is disposable, it may be
especially useful to confirm tracheal intubation in patients with respiratory diseases such as severe
acute respiratory syndrome (SARS)
 Advantages Disadvantages

1. The device is easy to use.
2. Its performance is not affected by nitrous oxide or
anesthetic vapors.
3. Its small size, portability, and lack of need for a power
source allow it to be used in locations where use of a
CO2 monitor is not possible.
4. The cost is low compared with other methods of CO2
analysis.
5. Studies show the device to be accurate in diagnosing
esophageal intubation
6. The device can serve to evaluate resuscitation or as
a prognostic indicator of successful short-term
resuscitation after the tracheal tube has been correctly
positioned
7. It offers minimal resistance to flow.
8. It is always ready for use, does not require cleaning,
and minimizes the risk of transmission of infection.
9. Carbon monoxide does not interfere with the
chemical CO2 detectors
1. It may take several breaths before conclusions can be
drawn about the tracheal tube location to avoid errors
caused by false-positive results, as discussed below.
It is usually recommended to wait six breaths before
making a determination.
2. False-negative results may be seen with very low tidal
volumes and low end-tidal CO2 concentrations, such
as in cases of compromised lung perfusion.
During cardiopulmonar y resuscitation, a positive test
indicates that the tracheal tube is in the airway, but
a negative result (suggesting esophageal placement)
requires an alternate method of confirming tracheal
tube position. If there is little or no circulation to the
lung, CO2 will not be available for the detector to verify
correct tracheal tube placement. Failure to inflate the
tracheal tube cuff may cause equivocal color change
3. Drugs instilled in the trachea or gastric contents can
cause irreversible damage to the device
4. False-positive results can occur if there is CO2 in
the stomach (from ingested carbonated beverages or
antacids or mask ventilation). The display
may initially turn color and only slowly revert to its
original color.
5. Difficulty in distinguishing color changes has been
reported. It may be difficult to determine whether
a subtle color change is due to the patient’s low endtidal
CO2 or a misplaced tracheal tube.
6. There is no alarm or CO2 waveform.
7. This device may not be cost effective for routine use
when compared with use of a capnometer . Its
cost-effectiveness may be greater with a small number
of applications .
8. Airflow obstruction from a manufacturing defect has
been reported .
9. This device is semiquantitative and cannot give accurate
measurement of CO2. For this reason, its application
is limited to tracheal tube position verification.

TYPES OF CAPNOGRAMS:

SIDE STREAM/DIVERTING TYPE: In side-stream capnography, the

CO2 sensor is located in the main unit
itself (away from the airway) and a tiny
pump aspirates gas samples from the
patient's airway through a 6 foot long
capillary tube into the main unit. The
sampling tube is connected to a T-piece
inserted at the endotracheal tube or
anesthesia mask connector

. The gas that is withdrawn from the patients often contains anesthetic gases and so the exhausted gas
from the capnograph should be routed to a gas scavenger or returned to the patient breathing system.
The sampling flow rate may be high (>400 ml.min-1) or low (<400 ml.min-1). The optimal gas flow is
considered to be 50-200 ml.min-1 which ensures that the capnographs are reliable in both children and
adults. The side-stream capnographs have a unique advantage: they allows monitoring of non-intubated
subjects, as sampling of the expiratory gases can be obtained from the nasal cavity using nasal adaptors.
Further, gases can also be sampled from the nasal cavity during the administration of oxygen using a
 simple modification of the standard nasal cannulae. This feature enables monitoring of expired CO2 in
subjects receiving simultaneous oxygen administration using nasal cannulae.
To avoid water or particulate contamination in the monitor, traps (which must be emptied periodically), flters
and hydrophobic membranes (which must be changed periodically), and special tubing (which allows water to
diffuse through its walls)
Water droplets and secretions from the breathing system can enter the sampling tube and increase resistance
in the tubing, affecting the accuracy
Most diverting capnometers are accurate at those respiratory rates that are normally encountered in clinical
practice (20 to 40 breaths per minute). At higher respiratory rates, accuracy is lower.

Main-stream capnographs:
In the mainstream capnograph, a sample cell or cuvette (airway adapter) is inserted directly in the airway
between the breathing circuit and the endotracheal tube. A lightweight infrared sensor is then attached to the
airway adapter. The sensor emits infrared light through the adapter windows to a photodetector typically
located on the other side of the airway adapter. The light which reaches the photodetector is used to measure
ETCO2. Mainstream technology eliminates the need for gas sampling and scavenging as the measurement is
made directly in the airway. This sampling technique results in crisper waveforms which reflect real-time
ETCO2 in the patient airway.
To prevent condensation of water vapor, which if not
compensated for can cause falsely high CO2 readings,
the mainstream sensor is heated to slightly above
body temperature. This heating process helps keep
the windows of the airway adapter clear so the sensor
can tolerate high moisture environments. New
mainstream sensors use circuitry, which limits the
power delivered so the sensor never reaches a
temperature high enough to cause even redness of the
mainstream sidestream
skin eliminating the concern of patient burns.

CO2 sensor is inserted between the breathing
circuit and endotracheal tube
• No gas removed from circuit
• Increase in mechanical dead space
• Earlier sensors were heavy and might have
caused kinking or disconnection of circuit.
Modern sensors are lightweight and small
• Sensor may be damaged or lost
• Waveform in real time
• Difficult to adapt to nonintubated patients.
Modifications are made to this type to enable
connection to the oxygen mask or mimic
sidestream sensors by aspirating the sample
via sampling line to the mainstream sensor
plugged to the side of the display unit
Normal and arteral PCO2
35-45mmhg in PaC02
Normal ETCO2 values:
30-43 mmHg
4.0-5.7 kPa
Dead space refers to 4.0-5.6%
exchange. Total, or
three components of dead space as described below
CO2 sensor is housed external to the breathing
circuit
• Gas is constantly aspirated from circuit via a 6
feet sampling tube into the unit containing CO2
sensor
• Minimal dead space
• Light weight adapter
• Sampling line may clog
• Waveform is delayed (1–4 seconds) due to
transportation of gases from the patient’s airway
to the unit containing the sensor
• Easily adapted to nonintubated patients
ventilated areas which do not participate in gas
physiologic dead space, refers to the sum of the
 . Alveolar dead space refers
TOTAL (PHYSIOLOGIC)
DEAD SPACE
Anatomic dead space refers to
the dead space caused by
anatomical
structures, i.e., the airways
leading to the alveoli. These
areas
are not associated with
pulmonary
perfusion and therefore do not
participate in ga s exchange
to ventilated areas which are
designed for gas exchange,
i.e. alveoli, but do not actually
participate. This can be caused
by
lack of perfusion, e.g.,
pulmonary
embolism, or blockage of gas
exchange, e.g. cystic fibrosis.
Mechanical dead space refers
to external artificial airways
which add to the total dead
space, as when a patient is
being mechanically ventilated.
Mechanical dead space is an
extension of anatomic dead
space

Volume and time capnograms:

There is no inspiratory segment in a volume capnogram

The expiratory segment is divided into three phases. Phase III of a volume capnogram is a better
representation of V/Q status of lung than the phase III of time capnogram
A typical time capnogram can be considered as two segments and two angles;an inspiratory segment and an
expiratory segment, and alpha and beta angles
The expiratory segment of a time capnogram is divided into three phases: I, II, III.
Phase I
Represents the CO2-free gas from the airways (anatomical and apparatus dead space).

PhaseII
Consists of a rapid S-shaped upswing on the tracing (due to mixing of dead space gas with alveolar gas).
represents the emptying of connecting airways and the beginning of the emptying of alveoli. As exhalation
continues, gas from alveoli in regions with relatively short conducting airways appears and mixes with dead
space gas from regions with relatively long conducting airways, resulting in an increasing CO2 level
PhaseIII
Consists of an alveolar plateau representing CO2-rich gas from the alveoli. shows the alveolar plateau. Because
of uneven emptying of alveoli, the slope continues to rise gently

α angle : the angle between Phase II and III (100-110⁰)

angle increases as the slope of Phase III increases
β angle: between III and 0 (90⁰), increases during rebreathing
Point D shows the best
approximation of alveolar CO2 (end of
expiration, beginning of inspiration

bronchospasm, or airway
Expiratory valve
obstruction
malfunction

A. Prolonged phase II and steeper phase III suggestive of bronchospasm, or airway obstruction;
B. Expiratory valve malfunction resulting in elevation of the baseline and obtuse down stroke of
inspiratory down stroke. This is due to rebreathing of expiratory gases from the expiratory limb during
inspiration;
C. Inspiratory valve malfunction resulting in rebreathing of expired gases from inspiratory limb during
inspiration;
D. Capnogram with normal phase II but with increased slope of phase III. Observed in pregnant subjects
under general anesthesia. (Normal physiological variant9);
E. Curare cleft: Patient is attempting to breathe during partial muscle paralysis. Surgical movements on the
chest and abdomen can also result in the curare cleft; The cleft is in the last third of the plateau and is caused
by a lack of synchronous action between the intercostal muscles and the diaphragm, most commonly caused by
inadequate muscle relaxant reversal. The depth of cleft propotional to the degree of paralysis.
F. Baseline is elevated as a result of CO2 rebreathing exhausted sodalime
G. Esophageal intubation resulting in the gastric washout of residual CO2 and subsequent CO2 will be
zero;
H. Spontaneously breathing capnograms where phase III is not well delineated;
I. Dual capnogram in one lung transplantation patient of severe skyphosis. The first of peak of phase III
is from the transplanted normal lung, whereas the second peak is from the native disease lung. A leak
around the sidestream sensor port at the monitor can also result in a dual peaked capnogram. This is
because of the dilution of expired PCO2 with atmospheric;
J. Malignant hyperpyrexia where CO2 is raising gradually with zero baseline suggesting increased CO2
production with CO2 absorption by the soda lime;
K. Ripple effect during the expiratory pause showing cardiogenic oscillations. These occur as a result of
to and fro movement of expired gases at the sensor due to motion of the heartbeat;
L. Sudden raise of baseline and the partial pressure of end-tidal carbon dioxide (PetCO2) due to
contamination of the sensor with secretions or water vapor;
M. Intermittent mechanical ventilation (IMV) breaths in the midst of spontaneously breathing patient. A
comparison of the height of spontaneous breaths compared to the mechanical breaths is useful to assess
spontaneous ventilation during the weaning process;
N. Cardiopulmonary resuscitation: Capnogram showing positive waveforms during each compression
suggesting effective cardiac compression generating pulmonary blood;
O. Capnogram showing rebreathing during inspiration. This is normal in rebreathing circuits such as
Mapelson D or Bain circuit

Causes of decrease in etco2 Causes of increase in et co2

Due to decrease in CO2 production Due to increase in CO2 production

– Hypothermia
– Hypothyroidism
– Any other cause of decreased metabolic
rate like general anesthesia
• Due to increase CO2 elimination
– Hyperventilation
• Due to decrease in alveolar delivery of
CO2
– Decrease cardiac output states or
hypoperfusion
– Pulmonary embolism
– Pulmonary edema
– Intrapulmonary or intracardiac shunts
• Due to technical failure
– Sampling tube leak or block
– Disconnection of breathing system
– Malignant hyperthermia
– Thyroid storm or hyperthyroidism
– Malignant neuroleptic syndrome
– Sepsis
– Any other cause of increased metabolic
rate like fever, shivering – Extraneous CO2
—laparoscopic procedures
• Due to decrease in CO2 elimination
– Hypoventilation due to any cause
– Rebreathing
– CO2 absorber exhaustion
• Due to technical failure
– Improper calibration
– Malfunction or contamination of
measuring system