Capnography

Moderator: Presenter:

DR. JYOTSANA KUBREY DR.PRAVIN KANOJE

DEFINATION:

-Capnography is defined as continuous monitoring of

instantaneous CO2 concentration and graphic
display(waveform) in respired gas.

-Capnogram is the tracings of waveforms obtained on the

monitor.

-Capnograph is the machine that generates the waveform.

-Capnometer is the device that performs the measurement

and displays the readings in numerical form.
Principles:
Three methods available:-

1.Infrared analysis: Quantitative

– Blackbody radiation technology
– Microstream technology.

2. Chemical colorimetric analysis: Semiquantitative

– Hygroscopic
– Hydrophobic.

3.Mass spectroscopy.
INFRARED ANALYSIS :

Introduction:-
-Most common technology.
-Used most commonly with side stream sampling.

 Principle:-
-Gases with 2 or more dissimilar atoms in a molecule
have specific IR light absorption spectra (e.g: CO2,N2O).
-Amount of IR absorbed proportional to concentration of
absorbing molecules.
-Concentration determined by comparing IR light
absorbance in sample with known standard.
 Based on the location of IR sensor,
there are two types of capnographs

 Sidestream

 Mainstream
Sidestream:-
• 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• The gas that is withdrawn from the patients often contains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) or low

(<400 ml/min). The optimal gas flow is considered to be 50-200
ml/min 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.

• 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
cannula.
Advantages:-

• Allows for unobstructive sampling near patient

• Calibration usually automatic
• Patient interface is light
• Sampling port can be used to administer bronchodilators.

Disadvantages:-

Prone to gas leak, sample tube obstruction and

moisture problems
• Hypoventilation if sampling rate > fresh gas flow
rate
• Error if sampling rate > expiratory flow rate: Causes
inspired gas to be sampled
Sources of error:-
• Water vapor condensation in sample tubing
• Liquids and particulate matter entering cell
• Delayed response time
• Multiple sites for damage/gas leakage
• CO2 can diffuse out of sample tube
• Longer tubing increases chances of error.
Mainstream:-
-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.
Mainstream:
 The sample chamber is positioned within the patient's
gas stream near the patient's end of the breathing
system.
 heavier and more cumbersome
 there is no delay in the rise and fall times of gas
composition changes.
 no gas is lost from the attachment.
 no mixing occurs along the capillary tube before
analysis.
 there are fewer problems with water vapour
condensation.
Advantage:

• Allows for analysis of multiple gases

• Very accurate and stable
• Avoids sampling system
• No delay in response time
• Reduces sample tubing dead space.

Disadvantages :

• Large and bulky

• Adds more dead space in pediatric patients
• Can cause kinking of ETT due to weight
• Requires frequent calibration
• Prone to soiling with mucus/saliva due to proximity
to patient
• Leak/circuit disconnection can occur
• Can measure only O2 and N2O
• Difficult to use in intubated patients.
1. Blackbody Radiation Technology:

• Most commonly used

• Heated element called blackbody emitter is source of IR

• Filter present to block radiation which is outside the desired

range

• Analyzer selects appropriate IR wave length to maximize

absorption by selected gas

• Sensor detects transmitted IR light and converts it to electrical

signals

• Electrical signal amplified and concentration is displayed.

2. Microstream Technology:
• Laser based technology to generate IR light
• Uses smaller sample cell and low flow rates (50 ml/ min)
• IR light precisely matches absorption spectrum of CO2
• Emitted electrons excite nitrogen molecules
• These molecules collide with CO2 molecules and excite them
• IR light of signature wavelength of CO2 emitted as excited CO2
molecules drop back to ground state
• Amplitude of signal depends on amount of IR radiation absorbed which
is proportional to CO2 concentration.

Advantages
• Rapid response time
• Require low sample flow
• Not affected by pressure of other gases
• Small sample cell required which is useful in:
– Small patient
– High respiratory rates
– Low flow applications
– Nonintubated patient.

Disadvantages
• Continuous withdrawal of gas from RS (if used with side stream)
• Propensity to leak/occlude
• Sensitive to water accumulation.
 CHEMICAL COLORIMETRIC ANALYSIS
Principles:
• Consists of a pH sensitive indicator enclosed in a housing.
• When indicator is exposed to carbonic acid (formed by reaction CO2 and H2O), it becomes acidic.

Technologies:

Hygroscopic:-
• Can detect CO2 concentration in range 0.25–0.6%.
• Minimum CO2 concentration to produce color change is 0.54%.
• Life span of detector depends on humidity of expired gas.
• Reduced humidity prolongs detectors life.
• Color changes are:
– Purple: Low CO2 (< 0.5% or < 2.3 mm Hg).
– Biege: Moderate CO2 (0.5–2% or 3.7–7.6 mm Hg).
– Yellow: High CO2 (> 2% or > 15.2 mm Hg).
– Changes color back to purple after removal of CO2.
Hydrophobic:-
• Color changes from blue to green to yellow as CO2
concentration increases
• Faster response time
• Less affected by humidity
• Performs better at higher respiratory rate.
Advantages:

• Cheaper, easy to use, disposable

• Small in size, portable
• Useful in remote site resuscitative evaluation
• Not affected by N2O or anesthetic vapor
• Require no other equipment.

Disadvantages:

• May be several breaths before conclusion is drawn

• Wait for six breaths with colorimetric methods
MASS SPECTROMETRY

• Gas withdrawn continuously through capillary lines

• Sample directed into mass spectrometer

• Sample is ionized and then exposed to magnetic

field in a vacuum chamber

• Ionized molecules separated by mass–charge ratio

• Collectors in vacuum chamber determine concentration

of each gas component.
Normal capnograph :
Types of Capnogram:

• Time capnogram:- The graphical display of co2

concentration versus time produces a time capnogram and is
most commonly used in clinical settings.
• Volume capnogram:-In volume capnogram co2
concentration is plotted against the expired volume and it has
similar characteristics. However, there is no inspiratory
component in volume capnogram.

cc
Description:

• Height depends on ETCO2 concentration

• Frequency depends on respiratory rate

• Rhythm shows regularity of breathing

• Normal shape is Top Hat/Sine Wave

• Baseline is normally zero (EA).

Phases of Capnograph
Phase I: EA
• Inspiratory Baseline
• Usually is zero
• Reflects inspired gas devoid of CO2
.
Phase II: BC
• Expiratory upstroke
• Rapid S-shaped upswing
• Represents transition gas from anatomical dead space
• Prolonged in:
– Partial endotracheal tube obstruction
– COPD, bronchospasm
– Upper airway obstruction.
Phase III: CD
• Plateau phase
• Represents gas coming from alveoli
• End of phase III at point D is End tidal point.
Phase IV: DE
• Inspiratory downstroke
• Represents patient inhalation
• CO2 levels abruptly falls to zero.
Angles of Capnograph:

α Angle:-
• Take off/elevation angle
• Angle between phase II and phase III
• Normally between 100–110°
• Decreased in obstructive lung diseases
• Increased in:
– Airway obstruction
– PEEP.
β Angle:-
• Angle between phase III and descending limb of
capnogram
• Normally around 90 degree
• Decreased in airway obstruction and PEEP
• Increased in rebreathing.
- Comparison of PetCO2 with PaCO2 is necessary to
distinguish these two conditions.
and when a patient tries to breathe during
mechanical ventilation. The cleft is seen in
the last third of the plateau.
Cardiogenic oscillations:-
-Cardiogenic oscillations appear as small, regular, toothlike humps at
the end of the expiratory phase.

-They may be single or multiple, and the heights may vary

considerably. They are believed to be due to the heart beating against
the lungs.

-A number of factors contribute to the appearance of cardiogenic

oscillations, including negative intrathoracic pressure, a low respiratory
rate, diminution in the vital capacity:heart size ratio, a low
inspiratory:expiratory ratio, low tidal volumes, and muscular relaxation.

-Cardiogenic oscillations are the rule rather than the exception in

pediatric patients because of the relative size of the infant's heart and
thorax.
-The waveform shows a prolonged plateau and a
slanting inspiratory downstroke.
-The inspiratory phase is shortened, and the
baseline may or may not reach zero, depending
on the fresh gas flow.
-Similar pattern may be seen with suction
applied to a chest tube.
Irregular plateau and/or baseline may result from
displacement of the tracheal tube into the upper larynx or
lower pharynx with intermittent ventilation of the stomach
and lungs or from pressure on the chest, which causes
small volumes of gas to move in and out of the lungs.
-A plateau of long duration is followed by a peak of brief
duration. The height of the plateau is inversely proportional to
the size of the leak.
-The brief peak is caused by the next inspiration, when
positive pressure transiently pushes undiluted end-tidal gas
through the sampling line.
-Contamination of expired sample by fresh
gas or ambient air may be caused by
placing the sampling site too near the fresh
gas inlet, a leak, or too high a sampling flow
rate.

-A large leak is indicated by the progressive

decrease in the plateau.
Here, the contamination is of lesser
magnitude and a dropoff occurs at the end
of the plateau.
-The causes of a sudden drop of end-tidal CO2 to a
low but nonzero value include a poorly fitting
tracheal
tube or mask, a leak or partial disconnection in the
breathing system, and a partial obstruction of a
tracheal tube.
Elevated ETCO2 with Normal
Waveform
• Hypoventilation
• Hyperthermia
• Malignant hyperthermia
• Sepsis
• Hyperthyroidism
• Pain, anxiety, shivering
• Increased skeletal muscle tone, convulsion
• Sodium bicarbonate injection
• Reperfusion:
– Tourniquet release
– Aortic cross clamp release.
• During laparoscopic surgery with CO2.
Decreased ETCO2 with Normal
Waveform
• Hyperventilation
• Hypothermia, shock
• Hypothyroidism
• Increased depth of anesthesia, use of muscle relaxants
• Increase anatomical dead space
• Pulmonary embolism
• Surgeries on heart lung and dissecting aneurysm
• Wedging of PA catheter
• Leakage in sample line.
Zero ETCO2 with Absent
Waveform
• Disconnection
• Apnea
• Ventilator malfunction
• Blockage of sample line

Elevated ETCO2 with Elevated

Baseline
• Rebreathing
• Exhausted absorbent, bypassed
absorbent
• Malfunction of nonrebreathing valve
• Inadequate fresh gas flow rates,
misassembly
• Problem with inner tubing in Bain circuit
• Increased apparatus dead space.
Elevated ETCO2 with Abnormal
Waveform

• Prolonged expiratory upstroke

• Upper airway obstruction

• COPD

• Bronchospasm.
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