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VCO2 & Metabolic Monitoring

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Edited by PMLS Upstream Marketing
 VCO2 Monitoring

• What is VCO2 monitoring and Volumetric Capnography?

• What is Deadspace?

• Benefit

• Mindray VCO2 and Deadspace monitoring method

What is Volumetric CO2?

• Traditional CO2 monitoring is time-based capnography. Volumetric Capnography (also known as single
breath CO2 test) combines the CO2 concentration and volume to help the doctor know the carbon
dioxide metabolism.

• EtCO2 can not fully assess the patient’s CO2 elimination. The patients, who have the same end tidal CO2
values, one patient exhales 50 ml/min MVCO2 (CO2 minute production), one patient exhales 300
ml/min MVCO2, they have the different CO2 elimination.
VCO2 measurement EtCO2 measurement
• Volumetric Capnography • Capnogram
EtCO2 • Volume of exhaled CO2 • Concentration of end tidal CO2
EtCO2
35mmHg
35mmHg • CO2 elimination • EtCO2
• Deadspace • Capnogram
CO2 50ml CO2 300ml • Alveolar ventilator • Respiratory Rate
• Physiologic VD/VT
Volumetric Capnography

• Volumetric Capnography is derived

from time synchronized flow waveform
and CO2 waveform.

• Volumetric Capnography is a useful

RM flow
tool to help doctors to determine why
EtCO2 dropped. For example, if
ventilation hasn’t changed, but a
sudden and large drop in EtCO2 usually
indicates a change in perfusion.

Mainstream CO2
Volumetric Capnography

The Volume Capnography shows the curve from start exhalation to end
exhalation. Typical VCO2 has III stages:

• Stage I is the base line which stands for the gas without CO2 in the
airway.

• Stage II goes up as S style. With breathing, the proportion of the gas in

the alveolar is increasing, so the CO2 concentration increased as well.

• Stage III is a plateau. Stands for complete gas with high CO2
concentration in the alveolar. The pressure of CO2 in the end of the stage
is EtCO2.
stage composition slope （ S = dc/dv ）
Ⅰ gas in the airway SI=0, stands for the airway dead space.
Ⅱ combine gas Smaller SII means less CO2 in unit breath volume and bigger
anatomical dead space
Ⅲ gas in the alveolar Bigger SIII means more CO2 in unit breath volume and the gas
distribution in the alveolar is nonuniform.
Volumetric Capnography
• In the same respiratory rate and EtCO2 value, the different VCO2 values result different CO2 elimination.

EtCO2 = 32 mmHg EtCO2 = 32 mmHg EtCO2 = 32 mmHg

TVe = 600 ml TVe = 800 ml TVe = 1000 ml
MVCO2 = 50 ml/min MVCO2 = 200 ml/min MVCO2 = 300 ml/min
What is Deadspace?

• In physiology, dead space is the volume of air which is inhaled that does not take
part in the gas exchange. In other words, not all the air in each breath is available
for the exchange of oxygen and carbon dioxide.

• There are two types of dead space: anatomic deadspace and alveolar deadspace.

• Anatomic deadspace is the portion of the airways. No gas exchange is possible in

Anatomic deadspace/
these spaces.
Airway deadspace
• Alveolar deadspace is sum of the volumes of those alveoli which have little or no
blood flowing through their adjacent pulmonary capillaries, i.e., alveoli that are
ventilated but not perfused, and where, as a result, no gas exchange can occur.
Alveolar deadspace is negligible in healthy individuals, but can increase
dramatically in some lung diseases due to ventilation-perfusion mismatch. Alveolar deadspace
What is Deadspace?
• For this patient, there is no change in airway deadspace, and EtCO2. There is no change in total tidal volume.
• According to ∆ CO2, we can know this patient’s alveolar deadspace has increased.
PaCO2
PaCO2 = 45 mmHg
= 38 mmHg
EtCO2 EtCO2
= 35 mmHg = 35 mmHg

EtCO2 = 33 mmHg

Note: Because the alveoli deadspace does not take part in gas exchange, so the CO2 concentration
is diluted by the N2 and O2. (In the air, N2 ≈ 78%, O2 ≈ 21%, CO2 ≈ 0.03%, others ≈ 0.939%)
Benefit of VCO2 monitoring

• Evaluate the adequacy of ventilation and determine the ventilator setting.

• Determine the effects of ventilator changes before the first ABG (artery blood gas analysis) is drawn. Reduces the
requirement for repeated ABG.

• Helps in weaning and extubation.

• Change in VCO2 in weaning trials indicates the work of breathing.

• VCO2 can assist the evaluation of some diseases:

• Bronchial asthma
• Acute Lung Injury, ALI
• Acute Respiratory Distress Syndrome, ARDS
• Pulmonary Embolism, PE
• Cystic Fibrosis, CF
• Chronic Obstructive Pulmonary Disease, COPD
Mindray VCO2 and Deadspace monitoring method

• For mechanically ventilated patients.

• Simultaneously monitoring via Mainstream CO2 and RM modules
• EtCO2/FiCO2, awRR
• RM parameters
• VCO2(Volumetric Capnography) New
Mainstream CO2
• Deadspace parameters New

RM
VCO2 and more parameters
Volumetric CO2 parameters Ventilation parameters Deadspace parameters

VCO2 (ml): CO2 production for Vtalv (ml): Alveolar tidal Vdaw (ml): Airway deadspace Anatomic
one breach volume Vdaw/Vt (%): Airway deadspace dead
to space
MVCO2 (ml/min): CO2 minute MValv (L/min): Alveolar minute tidal volume ratio
production volume Vdalv (ml): Alveolar deadspace
FeCO2 (%vol): Mixed expired Vdalv/Vt (%): Alveolar deadspaceAlveolar
dead space
CO2 concentration to tidal volume radio
SlopeCO2 (%vol/L): Slope of Vdphy (ml): Physiologic deadspace
the alveolar plateau Vd/Vt (%): Deadspace to tidal
Total
volume ratio dead space

Note: To measure the values of Vdalv, Vdalv/Vt, Vdphy, Vd/Vt, need input PaCO2 value manually. (PaCO2 could be from arterial
blood gas analysis)
VCO2

MVCO2 and MValv trend

Vtalv and MVtalv display in Vol

Switch RM loop and VCO2 display
parameter area
 Metabolic Monitoring

• What is Metabolic monitoring?

• Benefit

• Measuring Methods

• Mindray Metabolic monitoring method

What is Metabolic monitoring

• Metabolic monitoring is the measurement of respiratory gas exchange for energy metabolism. Clinical applications
vary from assessment of energy requirements and response to nutrition in malnutrition and obesity to
comprehensive analysis of ventilation and oxygen transport in intensive care patients with complex respiratory and
hemodynamic problems.

• Early in the 20th century, Benedict and Atwater demonstrated that heat production in humans could be determined
indirectly by measuring respiratory gas exchange and computing the corresponding heat production from the
energy content of nutrients. These measurements was correlated by calorimetry.

• Calorimetry is measuring changes in state variables of a body for the purpose of deriving the heat transfer
associated with changes of its state due for example to chemical reactions, physical changes, or phase transitions
under specified constraints. There are two type calorimetries: direct calorimetry and indirect calorimetry.
Benefit of Metabolic monitoring

• Follows changes in patient metabolic status

• Hypermatabolism caused by injuries or septic reactions is easily detected.

• Provides clear treatment indications

• Helps to define sufficient oxygen delivery.

• Guidance for ventilator settings.

• Helps in weaning and extubation

• Change in VCO2 in weaning trials indicates the work of breathing.

Benefit of Metabolic monitoring

• Metabolic monitoring can help to evaluate the nutrition balance of the critical patient.
• Most patients in ICU are unable to tolerate normal diet, many of them a re malnourished on
admission, since catabolism of critical illness causes malnutrition which closely associated with poor
outcomes. But often, the energy needed is underestimated since stress, acute illness, surgery or
trauma produce major changes in the metabolic milieu of the body.
• Consequences of malnutrition: increased morbidity and mortality; prolonged length of stay in ICU;
impaired tissue function and wound healing; defective muscle function; reduced respiratory and
cardiac function; immune-suppression, increased risk of infection.
• Overnutrition leads to the burden of the corresponding organs, such as the kidney, and also, may
affect the metabolic balance (for ex: blood-glucose level) and hence affect the recovery of the
patients.
Measuring Methods

• Direct Calorimetry
• Direct measure the total heat of patient unit time to the outside environment.

• Hard to operate.

• Harris-Benedict Formulas
• Calculate the total heat according to person’s weight, height, and age.

• The formulas are not suitable for intensive patient. And not a continual measurement.

• Indirect Calorimetry
• Use the respiratory monitoring to get the gas exchange

• Non-invasive, continuous, and more accurate than estimation formula.

Measuring Methods: Direct Calorimetry

Method: let the patient stay in a special test

room. And collect the total heat outside in a
certain period of time, then convert the total
heat into the metabolic rate in a unit time.
Measuring Methods - Harris -Benedict Formulas

• BEE - Basal energy expenditure

• BEE (male) = (66.47 + 13.75Weight + 5.0Height – 6.76Age)kcal/24h

• BEE(female) = (65.10 + 9.56Weight + 1.85Height – 4.68Age)kcal/24h

• BSA – Body surface area

• BSA (m2) = 0.0061Height + 0.0128Weight – 0.1529

• BMR – Basal metabolic rate

• BMR = BEE/BSA

• These formulas are used for health people. While patients, especially intensive patients, they have an abnormal
metabolism. For example, fever brings hypermatabolism. Body temperature rises 1 °C, energy consumption increases
by 10 to 15%. In ICU, approximately 50% patients are in a state of excessive nutritional or nutritional deficiencies.
Measuring Methods - Indirect Calorimetry
• There are two different techniques have been developed: the closed circuit and the open circuit.
• In closed circuit, the subject breaths from a closed gas mixture, which can be either pure oxygen or an air-
oxygen mixture. CO2 and water from the expiratory gases are removed and the same gas is used for
subsequent inspirations. Oxygen is added to this circuit so that the original oxygen content is maintained.

• In open circuit, the expired gases are collected, the volume or flow of gas measured, and the inspiratory and
expiratory concentrations of oxygen and carbon dioxide analyzed.

• The open circuit vs. the closed circuit: the open circuit technique just needs a simple breathe circuit, and is
insensitivity to changes in lung volume.
Metabolic Monitoring

• The open circuit technique.

• For mechanically ventilated patients.
• Simultaneously monitoring via Sidestream
OR
CO2+O2/AG+O2 and RM modules
 EtCO2/FiCO2, awRR AG Sidestream CO2
+O2(paramagnetic ) +O2(paramagnetic )
 RM parameters
 VCO2 New
 Metabolic parameters New

RM
How to connect the sensors?

• Must keep the RM sensor connecting interface

upward. To Sidestream CO2+O2 module
• Recommend keep the Sidestream sample line To RM module
connecting interface upward to avoid secretion To Ventilator
blocking the line.
• To get the accurate respiratory parameters
values, the RM sensor shall locate near the
patient.

To Patient
Metabolic Parameters

Volumetric CO2 and O2 parameters Metabolic parameters

VCO2 (ml) : CO2 production for one breath RQ: Respiratory quotient
VO2 (ml): O2 comsumption for one breath EE (kCal/day): Energy expenditure
MVCO2 (ml/min): CO2 minute production
MVO2 (ml/min): O2 minute production
Metabolic Parameters: RQ

• As an important clinical index in nutrition, Respiratory Quotient (RQ) is often used to assess the types of
substrates that produce energy, such as carbohydrates, protein, fat, etc. RQ reflects the ratio of each
substrate used at the cellular level.

• RQ = MVCO2/MVO2 Name of the substance RQ

Carbohydrates 1
Proteins 0.8-0.9
Fat 0.7
Malic Acid 1.3
Metabolic Parameters: EE

• Energy expenditure is the total energy cost of maintaining constant conditions in the body, i.e. homeostasis (basal
metabolism, BMR) plus the energy cost of physical activities.

• Below is some substrates caloric values.

Metabolic Parameters: RQ & EE

• The stoichiometric equations for chemical reactions connected with buring of particular substrates define the RQ and
energy release of the reaction. For example, the oxidation of glucose yields the following reaction:

C6H12O6 + 6 O2 -> 6 H2O + 6 CO2 + 673 kcal

RQ = VCO2/VO2 = 6 VolumeCO2/ 6 VolumeO2 = 1.0

6 moles of oxygen is 6 x 22.4 liters (STPD) = 134.4 liters (STPD)

EE = 5.01kcal/liter x 134.4 liters = 673 kcal (the caloric value of O2 is 5.01kcal/liter)

or

1 mole of glucose weights 180 g, the oxidation of 1g of glucose requires 0.746 L of O2 and produces 0.746 L of CO2 and
3.74 kcal of energe, so

EE = 3.74 kcal/g x 180 g = 673 kcal

Metabolic Parameters: VCO2 & VO2

• Oxygen consumption

• Amount of inspired O2 minus the amount of expired O2 O2

CO2
• MVO2 = MVinsp x FiO2 - MVexp x EtO2 Flow
Volume
• Carbon dioxide production

• Amount of expired CO2 minus the amount of inspired CO2

• MVCO2 = MVexp x EtCO2 - MVinsp x FiCO2

Synchrozation of
concentrations
and flow VO2
VCO2
Compensation of
signal
deformations
Medical minds think alike

Thank you