CAPNOGRAPHY
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)
TECHNOLOGY
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.
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. It may take several breaths before conclusions can be
1. The device is easy to use. drawn about the tracheal tube location to avoid errors
2. Its performance is not affected by nitrous oxide or caused by false-positive results, as discussed below.
anesthetic vapors. It is usually recommended to wait six breaths before
3. Its small size, portability, and lack of need for a power making a determination.
source allow it to be used in locations where use of a 2. False-negative results may be seen with very low tidal
CO2 monitor is not possible. volumes and low end-tidal CO2 concentrations, such
4. The cost is low compared with other methods of CO2 as in cases of compromised lung perfusion.
analysis. During cardiopulmonar y resuscitation, a positive test
5. Studies show the device to be accurate in diagnosing indicates that the tracheal tube is in the airway, but
esophageal intubation a negative result (suggesting esophageal placement)
6. The device can serve to evaluate resuscitation or as requires an alternate method of confirming tracheal
a prognostic indicator of successful short-term tube position. If there is little or no circulation to the
resuscitation after the tracheal tube has been correctly lung, CO2 will not be available for the detector to verify
positioned correct tracheal tube placement. Failure to inflate the
7. It offers minimal resistance to flow. tracheal tube cuff may cause equivocal color change
8. It is always ready for use, does not require cleaning, 3. Drugs instilled in the trachea or gastric contents can
and minimizes the risk of transmission of infection. cause irreversible damage to the device
9. Carbon monoxide does not interfere with the 4. False-positive results can occur if there is CO2 in
chemical CO2 detectors 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:
. 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 CO2 sensor is housed external to the breathing
circuit and endotracheal tube circuit
• No gas removed from circuit • Gas is constantly aspirated from circuit via a 6
• Increase in mechanical dead space feet sampling tube into the unit containing CO2
• Earlier sensors were heavy and might have sensor
caused kinking or disconnection of circuit. • Minimal dead space
Modern sensors are lightweight and small • Light weight adapter
• Sensor may be damaged or lost • Sampling line may clog
• Waveform in real time • Waveform is delayed (1–4 seconds) due to
• Difficult to adapt to nonintubated patients. transportation of gases from the patient’s airway
Modifications are made to this type to enable to the unit containing the sensor
connection to the oxygen mask or mimic • Easily adapted to nonintubated patients
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% ventilated areas which do not participate in gas
exchange. Total, or physiologic dead space, refers to the sum of the
three components of dead space as described below
. Alveolar dead space refers Mechanical dead space refers
TOTAL (PHYSIOLOGIC) to external artificial airways
DEAD SPACE to ventilated areas which are which add to the total dead
Anatomic dead space refers to designed for gas exchange, space, as when a patient is
the dead space caused by i.e. alveoli, but do not actually being mechanically ventilated.
anatomical participate. This can be caused Mechanical dead space is an
structures, i.e., the airways by extension of anatomic dead
leading to the alveoli. These lack of perfusion, e.g., space
areas pulmonary
are not associated with embolism, or blockage of gas
pulmonary exchange, e.g. cystic fibrosis.
perfusion and therefore do not
participate in ga s exchange
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
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