Use of Expired CO2

Monitoring in the ICU

Dennis Bing, RRT

© 2008 db
CO2: what is it?

Expired gas:
• 78% N2
• ~ 16% O2
• ~ 5% CO2
• 1% inert gases

© 2008 db
 CO2?
No. It is VD

CO2?
No. It is VD

CO2?
Yes. It is VA
(but has some VD)

VT = VDanat + VDphysio + VA © 2008 db

 Expired CO2 Monitoring terminology

PvCO2 = mmHg
~ 46 mmHg

PACO2 = mmHg
~ 40 mmHg
PaCO2

PaCO2 = mmHg Why is PaCO2 > PACO2?

~ 42 mmHg

© 2008 db
 Expired CO2 Monitoring terminology

CO2 detector
presence only

capnograph/ capnogram
a picture

capnometry
a number

© 2008 db
How to monitor CO2: Infrared (IR) Spectrometry

CO2 CO
2

CO2 CO2 CO2

CO2 CO2

© 2008 db
Monitoring CO2 with Assisted Ventilation: Sidestream method

• vacuum pump draws expired

sample into sensing chamber

• signal delay due to sample line

length
• moisture sensitive

• sampling flow creates error in

VT measurement
• can actually reduce VT in
small patients
Courtesy of Bhavani Shankar Kodali MD • it “sucks”

© 2008 db
Monitoring CO2 with Assisted Ventilation: Mainstream method

• compact sensor placed in- line

• rapid response

• does not change volume

delivery or measurement

• less moisture sensitive

• new solid- state technology

is light weight and not hot
Courtesy of Bhavani Shankar Kodali MD

© 2008 db
Monitoring CO2 with Assisted Ventilation: Mainstream method

© 2008 db
 Top 10 Reasons for Monitoring Expired CO2

1: confirm/ monitor endotracheal intubation

accidental extubation: 3 - 14% in ICUs, 27% in burn units

2: assess adequacy of ventilation

standard of care during anesthesia
(Standards for Basic Anesthetic Monitoring, ASA 2004)
“desirable” for monitoring adult ICU MV patients
(Guidelines for ICU Design, SCCM, 1995)
“required” for Level I & II Pediatric ICU MV patients
(Guidelines and Levels of Care for PICUs, SCCM, 1998)

© 2008 db
Top 10 Reasons for Monitoring Expired CO2

3: assess/ monitor airway obstruction

Normal capnogram shape capnogram shape of bronchspasm

Slope of capnogram correlates with FEV1

in asthma and COPD pts
You et al. Eur Resp J (7) 1994

© 2008 db
Top 10 Reasons for Monitoring Expired CO2

4: “conscious sedation” monitoring

Airway obstruction/ O2 desaturation events
reported as high as 50% in adults
Bailey, et al. Anesthesiology (73),1990
and reported as high as 23% in children
Croswell, et al. Pediatr Dent (17),1995
“recommended” for adult with parental CS
(American Dental Association, 2003)
“required” for children in “deep” sedation
(American Academy of Pediatric Dentistry, 1998)
“encouraged” for pediatric CS
(American Academy of Pediatrics, 1992)

© 2008 db
Top 10 Reasons for Monitoring Expired CO2
5: confirm enteric tube placement
Queen’s University Teaching Hospital, London, UK
• 100 enteric tubes placed
• 11 accidentally placed in airway
• all identified by capnography
Kindopp et al, Can J Anesth (48) 2001

University of Virginia
• 217 patients studied
• 22 enteric tubes accidentally placed in airway
• all identified by capnography
Truwit et al, Am J Resp Crit Care Med (165) 2002
© 2008 db
 Top 10 Reasons for Monitoring Expired CO2

6: assess efficacy & prognosis of CPR

An ETCO2 of < 10 mmHg at 20 minutes

of CPR accurately predicts failure
(multiple studies)

90 pts, 97.3% Sensitivity, 100% Specificity, p <0.0001

Wayne et al. Ann Emerg Med (25) 1995

150 pts, 100% Sensitivity, 100% Specificity , p <0.0001

Levine et al. New Eng J Med (337) 1997

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Top 10 Reasons for Monitoring Expired CO2

7: monitor pulmonary perfusion

If ventilation is constant and stable,
then ETCO2 is a monitor of PBF

8: Non-invasive Cardiac Output

measurement
Novametrix NICO™ partial CO2
rebreathing Fick Qc

© 2008 db
 9: detect possible pulmonary embolism
Alveolar/ deadspace fraction = (PaCO2 – ETCO2) / PaCO2
It’s just the % difference between PaCO2 and ETCO2

An alveolar/ deadspace fraction of ≥ 0.20

(particularly a rapid change) can accurately
detect Pulmonary Embolism

170 pts, 88.5% Sensitivity, 100% Specificity, (with D-diner)

Klein et al. Acad Emerg Med (4) 1997

© 2008 db
10: manage mechanically assisted ventilation
Mostly CO2
Some CO2
CO2 plateau
45
No CO2 PETCO2
PECO2
0
I II III

insp

Flow
exp

CO2 over Time

© 2008 db
 10: manage mechanically assisted ventilation
VD VA

45
150 mL 600 mL
PECO2

Start of expiration
0

VT 750mL
VD / VT = 0.20
CO2 over Volume

© 2008 db
 Monitoring CO2: Ventilator management

The deadspace/ Tidal Volume ratio (VD / VT)

Normal VD / VT ≤ 0.20

If VD / VT ≤ 0.50, then expect good

PaCO2 - ETCO2 correlation (within 5 mmHg)

If VD / VT > 0.60, then expect poor

PaCO2 - ETCO2 correlation

A VD / VT > 0.60 is a good predictor of

weaning & extubation failure, esp. pediatric pts.
Hubble, et al, Crit Care Med (28) 2000

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 Monitoring CO2 with Assisted Ventilation: Capnometry

Post- op MV IBW = 75 kg

VT set = 750 mL VT set = 850 mL

f set = 12 bpm f set = 12 bpm

PET CO2 = 58 mmHg PET CO2 = 48 mmHg

VA = 600 mL VA = 680 mL

VD = 150 mL VD = 170 mL

VD / VT = .20 VD / VT = .20

© 2008 db
 Monitoring CO2 with Assisted Ventilation: Capnometry

Post- op MV IBW = 75 kg

VT set = 750 mL VT set = 850 mL

f set = 12 bpm f set = 12 bpm

PET CO2 = 58 mmHg PET CO2 = 56 mmHg

VA = 600 mL VA = 620 mL
VD = 150 mL VD = 230 mL

VD / VT = .20 VD/ VT = .27

© 2008 db
 Monitoring CO2: Time- based Capnogram

45

PECO2 7
0

insp

Flow
exp

Rebreathing? Gas trapping?

© 2008 db
Monitoring CO2: Time- based Capnogram

45

PECO2 7
0

insp

Flow
exp

Rebreathing? Gas trapping?

© 2008 db
Further study opportunities

www.capnography.com

Capnography: Clinical Aspects

Edited by J. S. Gravenstein
Michael B. Jaffe
David A. Paulus

© 2008 db