CAPNOGRAPHY & PULSE

OXIMETRY

Aritra Goswami
Dept. Of Anesthesiology, Pain & Critical Care
RG Kar Medical College and
Hospital
CAPNOGRAPHY
CAPNOMETRY
Measurement and quantification of the inhaled or
exhaled CO2 concentrations at the airway opening.

CAPNOGRAPHY
Graphic display of CO2 measurement as a function
of time or volume.

CAPNOGRAPH
A device that records and displays exhaled CO2
concentrations, usually as a function of time.

CAPNOGRAM
Refers to the graphic display that the capnograph
generates.
 HISTORY

• Jan Baptist Van Helmont & John Tyndall in the 19th

century - measurement of gas volumes.

• John Scott Haldane- measurement of CO2 in a

mixture of gasses in 1905.

• German Scientist Karl Luft- modern capnography in

1943, using infrared light device known as URAS.
(Ultra Rod Absorption Schreiber)

• Modern capnography first put into clinical practice

in Netherlands, by Dr. Zden Kalenda & Dr. Bob
Smalhout
OBJECTIVES OF CAPNOGRAPHY

CAPNOGRAPHY

VENTILATION PERFUSION
METABOLISM
How effectively, CO2 Transport of CO2 How effectively,
CO2
is eliminated by the across the body is produced by
Lungs. tissues. cellular
metabolism.
 WORKING PRINCIPLE

CO2 MEASUREMENT

MASS SPECTRO- RAMAN SPECTRO- CHEMICAL INFRARED

METRY METRY COLORIMETRY

SPECTROMETRY
-Charge Mass -Change in pH - Non dispersive
Ratio causing change in infrared
absorption
colour. - M/C used in
-M/C used in pre hospital setting.
hospital setting.
 INFRARED SPECTROMETRY
• A beam of infrared light is passed through a gas
sample, and the resulting intensity of the transmitted
light is measured by a photodetector.

• The difference in the intensity of incident and

transmitted infrared light is used to calculate the
concentration of CO2,

• PRINCIPLE: CO2 selectively absorbs infrared light at

a wavelength of about 4.26 micometer. The amount of
light absorbed is directly proportional to the
concentration of CO2 in the gas sample.
INFRARED SPECTROMETRY DESIGN
INFRARED LIGHT SOURCE

ROTATING CHOPPER DISC(60rps)

GAS SAMPLE REFERENCE CELL

BLOCKER

PHOTODETECTOR
Circuit

DISPLAY
 TYPES OF CAPNOMETERS
• SIDESTREAM(diverting):The CO2 sensors are
physically located away from the airway gases to be
measured. M/C used in clinical practice.

• MAINSTREAM(non diverting): The sample cell is

placed directly into the patient’s breathing circuit.
Thus, the inspiratory or expiratory gases pass directly
through the infrared light path.
 SIDESTREAM CAPNOMETER

• Gas sample is aspirated via a pump/compressor from

the breathing circuit into the CO2 sensor located away
from the airway.
 SIDESTREAM CAPNOMETER
• Typical tubing length for this aspiration may be 6 feet,
and gas withdrawal rates may vary from 30 to 500
mL/minute.

• Aspirated gas passes through various filters before

being presented to the CO2 sensor.

• Transport delay: time required for the aspirated gas

to reach the CO2 sensor. It corresponds to the rate at
which gas is sampled and the washout of the
analyzing chamber.
 SIDESTREAM CAPNOMETER
• Rise time: defined as the time required for the
analyzer to respond to a sudden change in CO2
concentration, or time interval required for the analyzer
output to change from 10% to 70% of its final value.

• Commercially available capnometers have rise times

ranging from 10 to 400 msec.

• Depends on the rotation of the chopper wheel, the rate

of gas aspiration, the volume of aspiration tubing,
dynamic responses of the infra red light source and
other circuitry.
SIDESTREAM CAPNOMETER
 SIDESTREAM CAPNOMETER
ADVANTAGES:
• Lighter, easy to use.
• Can be used with patient in any position.
• Lesser chance of contamination with other gasses.
• No change in dead space.

DISADVANTAGES:
• Aspiration tube frequently obstructed with water vapor/
secretions.
• Water vapor can alter the EtCO2 reading.
• Transport delay.
 MAINSTREAM CAPNOMETER

• The sample cell is placed directly into the patient’s

breathing circuit.
MAINSTREAM CAPNOMETER
 MAINSTREAM CAPNOMETER
ADVANTAGES:
• No transport delay.
• Recordings are “real time”.
• No variation due to changes in barometric
pressure/humidity.
• Preferred in pediatrics/ neonates.

DISADVANTAGES:
• Heavy. Can dislodge the ETT.
• Increases dead space.
• Difficult to use in lateral/semi lateral/prone positions.
• Minor facial burns reported with older models.
• Contamination with other gasses. (N2O, inhalation
 TYPES OF CAPNOGRAM
CAPNOGRAM

TIME CAPNOGRAM VOLUME CAPNOGRAM

• M/C used. - display CO2 conc/ pp v/s
• Displays both inspiratory exhaled volume.
and expiratory phases. - Only expiratory phase
• Divided into 4 phases - More sensitive
• 2 angles- alpha & beta - Can measure VCO2 and
expired CO2 mass.
- Also measure contribution
from anatomic and alveolar
dead space.
 TIME CAPNOGRAM

• Phase I,II & III reflect the expiratory phase.

• Phase 0/IV occurs in inspiration.
 TIME CAPNOGRAM: PHASE1

• Phase 1 contains
air from the
anatomical dead
space.

• No CO2 is present.

• This part of the

curve is flat and
lies on the
baseline.
 TIME CAPNOGRAM: PHASE II

• Phase II consists
of a steep
upstroke.

• It occurs as a
result of alveolar
washout and
recruitment,
containing a
mixture of dead
space and alveolar
space gas.
 TIME CAPNOGRAM: PHASE III

• Phase III k/a

alveolar plateau
phase, contains
exhaled air from the
alveoli

• In patients with
normal ventilation, it
is flat with a gentle
upward slope.

• The highest point of

the slope represents
the EtC02.
 TIME CAPNOGRAM: PHASE 0

• Phase 0 occurs
during inspiration.

• Exhaled CO2
levels fall rapidly

• This part of the

curve is a steep
downward slope.
TIME CAPNOGRAM: PHASE IV

• Phase IV is
sometimes seen as
a upward elevation
at the end of phase
III.

• Results from the

closure of lung units
with relatively low
Pco2 and allows for
regions of higher
CO2 to contribute a
greater proportion of
the exhaled gas to
be sampled.
 CAPNOGRAM ANGLES

• ALPHA ANGLE:
- Angle between
phase II and III.
- Normal: 100-110 deg
- in airway
obstruction.

• BETA ANGLE:
- Angle between
phase III & phase 0.
- Normal: 90-100 deg.
- in rebreathing.
 END TIDAL CO2

• The peak partial pressure of CO2 during exhalation, or

the highest level of expired CO2 reached during
exhalation is k/a the End Tidal CO2 or EtCO2.

• It is the value at the terminal end of phase III of the

capnogram.

• Normal value: 35-45 mmHg.

• EtCO2 depends on alveolar ventillation, CO2 production

and pulmonary blood flow.
 IMPORTANCE OF EtCO2

• Helps in identifying correct placement of ETT or LMA.

• Determines the adequacy of ventillation, and integrity of

breathing circuit.

• Also used to estimate the adequacy of cardiac output.

• Effectiveness of resuscitation and prognosis of cardiac

arrest.

• Titrating EtCO2 can affect the ICP, in cases of TBI.

 CAUSES OF EtCO2

↑ CO2 Production ↓ Alveolar Ventilation

• Increased BMR - hypoventilation
• Fever - respiratory center
• Sepsis depression
• Malignant hyper - partial muscular paralysis
thermia - neuromuscular disease
• Thyrotoxicosis - high spinal
• Increased CO - COPD
• Bicarbonate
administration. Equipment Malfunction
- rebreathing
- exhausted CO2 absorber
- leak in ventilator circuit
- faulty ins/exp valve
 CAUSES OF EtCO2

↓ CO2 Production Equipment

Malfunction
• Hypothermia - ventilator disconnect
• Pulmonary hypoperfusion - esophageal intubation
• Cardiac arrest - complete airway obstruction
• Pulmonary embolism - poor sampling
• Haemorrhage - leak in ETT cuff
• Hypotension

↑ Alveolar Ventilation
• hyperventillation
 CAPNOGRAPH WAVEFORMS

Decreasing EtCO2:
• Progressive decline in the amplitude of alveolar plateau
 CAPNOGRAPH WAVEFORMS

Increasing EtCO2:
• Progressive incline in the amplitude of alveolar plateau
 CAPNOGRAPH WAVEFORMS

Normal capnogram during spontaneous breathing

 CAPNOGRAPH WAVEFORMS

Esophageal intubation
• Progressive decrease in the amplitude of the
waveform, finally resulting in a complete absence.
 CAPNOGRAPH WAVEFORMS

Cardiogenic oscillations:
• Occurs at the end of exhalation.
• d/t differential emptying of different lung regions.
• More prominent in tachycardia.
 CAPNOGRAPH WAVEFORMS

Faulty inspiratory valve resulting in a slower

downslope:
• Increase in beta angle.
• D/t rebreathing of the CO2 in the inspiratory limb.
 CAPNOGRAPH WAVEFORMS

Faulty inspiratory valve:

• Notch in the inspiratory limb
• Rise in the baseline d/t rebreathing.
 CAPNOGRAPH WAVEFORMS

Rebreathing of CO2:
• May occur with faulty expiratory valve, exhausted
CO2 absorber.
• Capnograph fails to touch baseline
• imCO2
 CAPNOGRAPH WAVEFORMS

Curare notch:
• Clefts seen in phase III
• Spontaneous breathing effort in mechanically
ventillated patients.
 CAPNOGRAPH WAVEFORMS

Airway Obstruction:
• upslope of phase III
• Bronchospasm d/t any cause
• Partially obstructed ETT/breathing circuit.
 CAPNOGRAPH WAVEFORMS

Single Lung Transplant:

• 2 peaks in phase III
• Sequential emptying of 2 heterogenous lung
compartments
 CAPNOGRAPH WAVEFORMS

Leak in sidestream sample line:

• Double plateau in phase III
• Early portion of phase III is abnormally low because
of dilution of exhaled gas with ambient air
• The sharp in CO2 at the end of phase III reflects a
diminished leak resulting from circuit pressure.
 CAPNOGRAPH WAVEFORMS

Ruptured or leaking endotracheal tube cuff:

• Sudden shortening of phase III during controlled
mechanical ventillation.
 STANDARD CAPNOGRAPH

• Margin of error must be <12% or 4mmHg(0.53

Kpa), of the actual reading. (whichever is greater).

• Any interference caused by commonly used

inhalational agents, ethanol, acetone, methane,
helium, tetrafluoroethane, & dichlorodifluoroethane
must be disclosed by the manufacturer.

• Appropriate alarms for high and low exhaled CO2.

CHECKING THE CAPNOGRAPH

• Manual cleaning of the gas sample cell, aspiration

tubes.

• Regular calibration by the manufacturer.

• Blowing into the aspiration tube to see the

waveform.
PULSE OXIMETRY
 DEFINITIONS

OXIMETER
• Device that uses light absorbance measurements
to determine the concentration of various species
of Hb.

PULSE OXIMETER
• Oximeters using light absorbance to determine the
oxygen saturation in pulsatile arterial blood.

OXYGEN SATURATION
• Refers to the fraction of oxygen saturated
hemoglobin relative to the total hemoglobin,
expressed as %age.
 DEFINITIONS

FRACTIONAL Hb SATURATION(O2Hb%)

O2Hb% = HbO2 x 100

HbO2 + Hb + metHb + COHb

FUNCTIONAL Hb SATURATION(SaO2)

SaO2 = HbO2 x 100

HbO2 + Hb

• COHb & metHB are k/a “dyshemoglobins” and are present in

negligible amounts in blood.
 HISTORY

• Glen Milikan an American physiologist, coined the

term “Oximeter” in 1940.

• Mathees k/a father of oximetry, 1st described the

concept in 1932.

• Hertzman introduced the concept of photoelectric

finger plethysmography in 1937.

• In 1975, concept of modern pulse oximetry was

introduced in Japan by Takuo Aoyagi
 WHY IS SaO2 IMPORTANT

• The primary roles of the cardiorespiratory system

are the uptake and delivery of O2 to the body.

• Delivery of O2 (DO2) = CAO2 x Cardiac Output

• CAO2 = (1.34 × SaO2 × Hb) + 0.0031 × PaO2

• Hence, SaO2 is a major determinant of O2 content

and consequently Do2.

• Low SaO2 is the “1st warning sign” of arterial

hypoxemia.
FACTORS DETERMINIG SaO2
 WORKING PRINCIPLE

OXIMETRY

SPECTROPHOTOMETRY BEER LAMBERT LAW

- Absorption of light at a certain - Conc. of a solute in a
wavelength by atoms of solution can found out
optically active molecules. by calculating the
differe-
nce between the intensity
of incident and transmitted
light.
I =Ie
trans in -DCε
 WORKING PRINCIPLE

• Substances have a specific pattern of absorbing

light at a specific wavelength k/a their “extinction
coefficient”.

• The differences in the extinction coefficients of

oxyHb and reduced Hb is maximum at wavelengths
of 940nm & 660nm respectively.

• 660nm (Red): absorption of reduced Hb is greater.

• 940nm (Infrared): absorption of oxyHb is greater.

WORKING PRINCIPLE
 WORKING PRINCIPLE

• Light absorption by tissue can be divided into a

pulsatile component(AC), & a nonpulsatile
component(DC).
 WORKING PRINCIPLE

• Pulse oximeters flashes the Red and Infrared light,

through the tissue, several hundred times per
second.

• This rapid sampling rate, allows for recognition of a

“peak” and a “trough” in each pulse wave.

• At the peak, all the components of tissue are

illuminated. (AC+DC).

• At the trough, only the nonpulsatile portion(DC) is

illuminated.
 WORKING PRINCIPLE

• The pulse oximeter, then computes a ratio (R) of

AC and DC light absorption at two different
wavelengths.

R = AC660/DC660
AC940/DC940

• This ratio (R) is then empirically related to O2

saturation based on a calibration curve, that is
inbuilt in each pulse oximeter.
 TYPES OF PULSE OXIMETRY
TRANSMISSION TYPE
• M/c used in clinical practice
• LED and photodetector
present on opposite side of the
tissue.
• Usual site: finger tip
REFLECTANCE TYPE
• Used in labs, for quantification
of different Hb types.
• LED and photodetector
present on the same side of
the tissue.
• Usual site: forehead
COMPONENTS OF A PULSE OXIMETER
COMPONENTS OF A PULSE OXIMETER

OXIMETER PROBE
• Consist of a sensor and a transducer, and is in direct
contact with the skin.

• Consist of an LED, that emits monochromatic light at 2

different wavelengths, alternatively.

• Reusable/ non reusable.

• Available in different sizes.

COMPONENTS OF A PULSE OXIMETER

• May be rigid/ self adhesive or wrap around(less

interference with motion).

• Common sites of probe placement:

- finger tip
- toes
- ear lobe
- tongue
- nose
- forehead
- cheek
- esophagus
COMPONENTS OF A PULSE OXIMETER

CONNECTING CORD
• Connects the probe to the oximeter console

OXIMETER CONSOLE
• Consist of a photodiode, that converts the light
impulses into electrical impulse.

• The electrical impulses are the processed and

amplified.

• The final result is matched with an inbuilt algorithm

to determine the SaO2.
COMPONENTS OF A PULSE OXIMETER

LCD DISPLAY
• Displays the numerical value of the SaO2 along
with its graphical representation (Plethysmograph)

ALARMS
• Variable pitch audio alarm for low SaO2 and pulse
rate.

• ASA standard for basic anesthetic monitoring

requires all pulse oximeters to be equipped with
“Variable Pitch Pulse Tone Alarms”
STANDARD PULSE OXIMETER

• The international standard for pulse oximeter

manufacture, ISO 80601-2-61-2011, requires an
accuracy of up to a 4% error over a range of SaO2
from 70% to100%.

• There should be minimal interference with ambient

lighting.

• Variable pitch pulse tone alarms for low SaO2.

 SOURCES OF ERROR

MOTION
• Movement causes venous pulsations, which may be
mistakenly taken up by the pulse oximeter sensor.

• Motion artifacts cause erroneously low SpO2

reading.

HYPOTENSION
• Hypoperfusion leads to a reduction in the amplitude
of the pulsatile component of the waveform, thus
giving rise to lower readings.

• SBP< 80mmHg cause significantly low reading.

 SOURCES OF ERROR

ANEMIA
• With normal SaO2, anemia has little effect on
SpO2.

• In the presence of hypoxia, SpO2 readings

underestimate SaO2 in anemic patients.

DYES
• Methylene blue, Indigo carmine, Isosulfan Blue and
indocyanine green also artificially decrease SpO2
 SOURCES OF ERROR

CO POISONING
• The absorption of light at 660 nm by COHb is
similar to that of O2Hb.

• Whereas at 940 nm, COHb absorbs virtually no

light.

• Thus, in a patient with carbon monoxide poisoning,

the SpO2 is falsely elevated.
 SOURCES OF ERROR

METHHEMOGLOBINEMIA
• MetHb absorbs a significant amount of light at both
660 and 940 nm.

• As a result, in its presence, the ratio of light

absorption R is approx 1.

• An R value of 1 represents the presence of equal

concentrations of O2Hb and deO2Hb and
corresponds to an SpO2 of 85%.

• In a patient with methemoglobinemia, the SpO2 is

80% to 85% irrespective of the SaO2
 SOURCES OF ERROR

NAIL POLISH
• Black, dark blue & purple cause significantly low
SpO2

• Other skin and nail pigments like Henna can lower

Sp02 readings.

DIATHERMY
• Electrical interference can cause false readings of
Sp02.

• More with bipolar than unipolar.

 SOURCES OF ERROR

DIFFERENT Hb TYPES
• Hb Bassett, Hb Rothschild, and Hb Canabiere,
have a reduced affinity for O2, hence their
presence lowers Sp02.

• Hb Lansing, Hb Bonn, and Hb Hammersmith, have

altered absorption spectra, and can also give
falsely low reading.

• HbS, HbF, HbH, Sulfhemoglobin have no effect on

SpO2
SOURCES OF ERROR
 METHODS TO REDUCE ERROR
• Checking the pulse oximeter before use.
• Minimising patient movement/shivering.
• Maintain SBP> 80mmHg
• Warming the cool extremities with warm water,
radiant warmers.
• Digital nerve block.
• Application of vasodilating creams/ointment.
• Trying an alternative probe site.
• Choose appropriate probe size.
• Minimising ambient lighting.
LIMITATIONS OF PULSE OXIMETRY
• SpO2 is just an estimate of SaO2. Hence, it does
not provide information about actual tissue
oxygenation.

• SpO2 is a measurement of functional and not

fractional SaO2, so the presence of other forms of
Hb can affect its reading.

• Because of the nonlinearity of the O2-Hb

dissociation curve, at high saturations "hyperoxia”
cannot be easily detected by SpO2
LIMITATIONS OF PULSE OXIMETRY
• Conversely, at low saturations such as at high
altitude, small changes in PaO2 can produce large
changes in SpO2.

• SpO2 accuracy is reduced at values lower than

70% to 75%. (d/t variations in individual O2-Hb
dissociation curves)

• Pulse oximetry does not provide information about

acid-base status.
LIMITATIONS OF PULSE OXIMETRY

Optical Shunting
• If an inappropriate size of probe has been used, or
in case of probe malposition, some of the light from
the LED illuminates the venous blood in addition to
the pulsatile arterial blood.

• The pulse oximeter in this case cannot accurately

differentiate between the arterial and venous blood.

• Can lead to falsely low SpO2 reading.

LIMITATIONS OF PULSE OXIMETRY
• Patient actors like patient movement, nail polish,
tattoos etc affect the SpO2 reading.

• SpO2 reading can be confounded by environmental

factors like ambient lighting, cold OT temperatures.

• D/t individual variation in the manufacturer

algorithms of SpO2, using a probe and a console of
different machine may give false values.
 APPLIED USES OF PULSE
OXIMETRY
• Monitoring oxygenation during transport.

• Monitoring intravascular volume:

pulse oximeter can also be used as a
“photoplethysmograph”, since the absorption of
light is proportional to the amount of blood between
the transmitter and detector.

• Predict fluid responsiveness:

Variations in the amplitude of the pulse oximetry
plethysmographic waveform (ΔPOP)
 APPLIED USES OF PULSE
OXIMETRY
• Pleth Variability Index(PVI) can be used to
quantify (ΔPOP) and guide fluid therapy in critically
ill patients.

• Monitorig peripheral circulation in patients of

trauma/RTA.

• Plethysmograph tracing can also suggest presence

of arrythmias/dysrythmias.

• Reflectance pulse oximeter probes can be used to

determine fetal oxygenation in utero.
 ASA BASIC MONITORING STANDARDS
(Approved by the ASA House of Delegates on October 21, 1986, last amended on October
20, 2010, and last affirmed on October 28, 2015)
 TAKE HOME MESSAGE
• Capnography and pulse oximetry are part of ASA
basic monitoring standard.
• Both are base on Beer-Lambert Law
• Capnography denotes ventilation, perfusion and
cellular metabolism, wheras pulse oximetry shows
the O2 saturation
• Capnographs maybe sidestream or mainstream.
• EtCO2 values is derived from the highest peak in
the capnograph wave.
• Capnography is useful in mechanically ventillated
patients to know the correct placement of ETT.
• Integrity of breathing circuits, and patency of ETT
can be known with a capnograph
 TAKE HOME MESSAGE
• Pulse oximeters use light at 660 and 940 nm to
determine the O2 saturation.
• Pulse oximetry can be reflectance or transmission
type.
• Common sources of error include motion,
hypoperfusion, nail varnish.
• Prognostic value in c/o trauma, CPR and in
critically ill.
• Can also be used for GDFT.
THANK YOU