Capnography
Clinical insights
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Introduction
EtCO2 monitoring can be invaluable when assessing cardiopulmonary status
particularly when a patient is receiving oxygen therapy as this may mask the
presence of respiratory compromise
(SpO2 may remain normal while ventilation is compromised).
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Objectives
•Understand the role of capnography in therapeutic interventions
•Identify types of CO2 monitoring
•Identify indications for capnography measurement
•Identify factors affecting the results of EtCO2 measurements
•Discuss the role of volumetric CO2 in guiding therapy
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General Principles of CO2 Measurement
•Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in respiratory gases
(typically expressed in mmHg).
•EtCO2 is frequently used to assess a patients’ gas exchange and help guide therapy (often used for trending between
ABGs)
•Capnography allows for the early detection of respiratory compromise and is non-invasive
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General Principles of CO2 Measurement
Factors contributing to gas exchange:
•Ventilation
•Perfusion
•Diffusion
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General Principles of CO2 Measurement
How can using capnography assist the Clinician in making therapeutic
decisions?
• The normal lung has varying degrees of ventilation/perfusion matching because of the uneven distribution
of ventilation and blood flow (caused by anatomical dead space and gravity)
• Capnography allows the Clinician to rapidly identify changes in ventilation and perfusion
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General Principles of CO2 Measurement
Monitoring capnography allows the clinician to guide their therapeutic interventions:
• Identify efficacy of bag-mask ventilation and ensure appropriate MV
• Assess cardiopulmonary resuscitation efforts (evaluate efficacy of chest compressions and
identify ROSC)
• Tailor ventilator settings as per patients’ metabolic state and assess effects of ventilator
setting changes
• Identify patient response to prone positioning
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General Principles of CO2 Measurement
Monitoring capnography allows the clinician to guide their therapeutic interventions:
• Rapidly identify ventilatory compromise
• Identify metabolic issues such as Malignant Hyperthermia during Anesthesia
• Assess effectiveness of recruitment maneuvers
• Guide thrombolytic therapy in pulmonary embolism
• Identify other respiratory problems such as bronchospasm
• Transport – identify accidental extubation
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Examples of factors affecting V/Q ratio
Dead space ↑:
• Addition of equipment between patient’s mouth and Y-piece
• Hyperinflation or over-distension of the lungs (causes collapse of pulmonary vessels and therefore decreases
perfusion)
• Any process that causes vasoconstriction or blockage of blood flow within the pulmonary capillary bed (pulmonary
embolus, pulmonary hypertension)
• Anatomical abnormality
Shunt ↑:
• Atelectasis (collapse of lung tissue)
• Pulmonary edema
• Airway obstruction (mucus plugging, bronchospasm, tumors)
• Endobronchial intubation
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General Principles of CO2 Measurement
Mainstream
• Analysed at the patient wye
• Additional weight on circuit/ETT (although
units now are much smaller/lighter)
• Generally for intubated patients only
• Real time analysis
• More susceptible to condensation and
secretions
General Principles of CO2 Measurement
Sidestream
• Gas samples are drawn from the ventilator
circuit and analysed
• Delay in values due to distance the sample has
to “travel” before being analysed
• Patient does not have to be intubated
• ~100-200 ml/min sampling rate
• Infrared Spectroscopy: Sample gas is fed
through an optical measurement bench and
filtered at different wavelengths
A Normal Capnograph
A rapid rise in A plateau
CO2 after the towards the
pause end of
absence of exhalation
obstructive processes
exhalation is
affecting gas flow
complete (zero or
minimal gas flow)
prior to the next
inspiration
A brief pause
at the ETCO2 value
beginning of stable approx. 2-5
expiration mmHg less than PaCO2
large airway gas (no “PaCO2-ETCO2 Gradient”
CO2)
Result: ETCO2 2-5 mmHg less than PaCO2
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PaCO2 - ETCO2 Gradient: What does it tell us?
PaCO2 - ETCO2 Gradient
• In healthy lungs normal gradient
Arterial PaCO2 is 2 – 5 mmHg
• Gradient increases with V/Q
mismatching
• An acute decrease in ETCO2
may indicate a decrease in
pulmonary perfusion
• A large gradient could also be
caused by incomplete exhalation
or airway obstruction
ETCO2 • Equipment error
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So Why the Difference Between PaCO2 and ETCO2?
1. Arteriovenous Admixture
2. Mixing of gases
3. V/Q
Why is my EtCO2 so much lower than PaCO2?
PaCO2 = 50
Normal V/Q Scenario
EtCO2 = 46
PACO2 = 48
PACO2 = 44
PaCO2-ETCO2 Gradient = 4
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Why is my EtCO2 so much lower than PaCO2?
Poor V/Q Scenario: PaCO2 = 50
EtCO2 = 20 PACO2 = 40
PACO2 = 0
PaCO2-ETCO2 Gradient = 30
What will affect the CO2 Content in Exhaled Gas?
• CO2 production in the cells
• CO2 transport
• CO2 elimination in the lungs
Physiological states affecting CO2 values
Increases CO2 Decreases CO2
•Fever •Pulmonary embolism
•Sepsis •Cardiac arrest
•Malignant hyperthermia •Hypothermia
•Bicarbonate bolus •Hyperventilation
•Increased cardiac output •Hypometabolic state
•ROSC •Hypotension
•COPD •Decreased cardiac output
•Esophageal intubation
Interpreting the Waveform
Normal
Abnormal
PaCO2
}ETCO
2
Plateau
}
ETCO2
Rise
Return to “0”
Normal range: 35-45 mmHg
Waveform Interpretation
Falling ETCO2 Readings Rising ETCO2 Readings
1. Hyperventilation 1. Hypoventilation
2. Pulmonary embolism 2. Fever
3. Shock 3. Increased metabolic rate
4. Blood loss 4. Improving V/Q
5. Ventilator Changes 5. Sedation ( LOC)
Waveform Interpretation
Upsloping (No expiratory plateau) Rising Baseline
1. Obstructive disease 1. Rebreathing (exhalation valve
a. Asthma or soda lime)
b. COPD 2. (mechanical) deadspace
2. Partial Airway Obstruction 3. Incomplete exhalation (air-
1. Kinked ETT trapping)
2. Mucous Plug
Waveform Interpretation
Low End Tidal Measurements High End Tidal Measurements
1. Hyperventilation 1. Hypoventilation
2. Hypometabolic State ( CO2 2. Hypermetabolic State
production)
3. Hypothermia 3. Hyperthermia
4. Hypothyroidism 4. Hyperthyroidism
5. Perfusion issue
6. CO2 transport issue
Waveform Interpretation
Loss of Plateau Oscillations
1. Increased expiratory 1. Cardiac oscillations (more common
in Ped/Neonatal patients)
resistance
2. TEXP too short
3. Obstructive airway
disease with rapid RR
End Tidal CO2 vs. Volumetric CO2 Measurement
End Tidal CO2 Volumetric CO2 (V’CO2)
• Time Based • ETCO2 +
• Value obtained at end-expiration • CO2 Elimination
• Capnogram • Volume of CO2 exhaled
• Respiratory Rate • Deadspace
• Vd/Vt
• Alveolar Ventilation
Volumetric CO2 on the V500
Volume – CO2 Loop
CO2 (elimination) = CO2 concentration X flow X time
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CO2 Elimination (V’CO2)
- Volume of CO2 expelled from the lungs over a minute
- Normal ~ 200ml/min
- Provides continuous information regarding ventilation and perfusion
- Provides immediate indication of changes in gas exchange with changes in ventilator settings
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Clinical Example: CO2 Removal Challenge
ΔP 36 cmH2O
PaCO2 = 68
PaCO2 - ETCO2 gradient = 24
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Decrease RR and ΔP set, Increased PEEP
Decreased ΔP from 36 to 26 (Pinsp & PEEP)
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Decreased ΔP
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Result of decreasing RR but increasing PEEP
PaCO2-ETCO2
Gradient = 24
PaCO2 = 68
PaCO2-ETCO2
Gradient = 10
PaCO2 = 60
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CO2 Monitoring Summary
• EtCO2 is extrapolated from the highest point on the Capnogram
• If ETCO2 not correlating, consider volumetric monitoring to track effects of ventilator changes
• May not correlate with PaCO2 in the following clinical situations:
1. Increase V/Q mismatch
2. Air-trapping --→ incomplete exhalation
Remember! Moisture in the cuvette will affect accuracy
− Keep cuvette at an angle
− When using an HME, place cuvette between wye and HME
− If moisture is an issue, consider keeping 2 cuvettes at bedside and rotate
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CO2 monitoring summary
Capnography is a useful monitoring tool that can provide the clinician with vital information
regarding patient cardiopulmonary status.
• PEEP Titration: If V’CO2 increases = PEEP increase or decrease has improved V/Q.
• Tidal Volume/MV: Should see an increase in V’CO2 with increase in Tidal Volume or
MV. If not, may indicate air trapping or overdistension = ineffective ventilation.
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Many thanks
Seana Martin, Marketing Manager Clinical Education
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