ETCO2

MODERATOR : DR S. ARUNA KUMARI ( ASSOCIATE PROFESSOR) DEPT OF ANAESTHESIA

PRESENTOR : R JAYALAKSHMI ( 1ST YEAR PG RESIDENT)
CONTENTS

• INTRODUCTION
• PRINCIPLES OF CAPNOGRAPHY
• TYPES OF CAPNOGRAPHS
• CAPNOGRAPHIC WAVEFORMS
• CLINICAL SIGNIFICANCE OF CAPNOMETRY
• VARIOUS CAPNOGRAPHIC WAVES
INTRODUCTION

• CAPNOMETRY is the measurement and numeric representation of co2

concentration during inspiration and expiration , and a capnometer is the
device that performs the measurement and displays the reading in numerical
form.

• CAPNOGRAPHY is the recording of CO2 concentration versus time , and

CAPNOGRAPH is the machine that generates the waveform .

• The CAPNOGRAM is the actual waveform.

CAPNOMETER

SPECIFICATIONS:
• The CO2 reading shall be within plus or minus 12 % of the actual value
or plus or minus 4mmHg (0.53kPa) , whichever is greater , over the full
range of the capnometer .
• The Capnometer must have a high co2 alarm for both inspired and
exhaled CO2
• An alarm for low exhaled Co2 is required .
PRINCIPLES OF CAPNOGRAPHY

Variety of techniques can be used for co2 measurement .

• Infra red absorption spectrometry (Most widely used method)
• Mass spectrometry
• Raman scattering
• Photo acoustic measurement .

The absorption of light is governed by governed by BEER LAMBERET LAW ie

absorption is proportional to concentration of absorbing gas in the sample
chamber.
• Co2 is the polyatomic gas that absorbs infra red radiation of a specific
wavelength .
ie Co2 shows strong absorption in far IR light at 4.3micrometer which lies
a way beyond the visible wavelength .
TYPES OF CAPNOGRAPHS

SIDE STREAM MAIN STREAM

• Co2 sensor located between ET • Sensor is located in the main
tube and breathing circuit unit and connected to a T piece
( Housed external to the adapter located between ET
breathing circuit) tube and breathing circuit.
TYPES OF CAPNOGRAPHS –CONT….

SIDE STREAM MAINSTREAM

• The gas sample is continuously
• A cuvette containing a Co2
aspirated
sensor with IR source and
from the circuit via 6feet sampling
detector is inserted between the
tube
breathing circuit and ET tube
• It then passes through the measuring
unit containing co2 sensor
and therefore Co2 measurement
takes place within the breathing
• The Co2 concentration is determined by
comparing the IR light absorption in the circuit.
sample cell with a chamber free of co2
TYPES OF CAPNOGRAPHS - CONT…

SIDE STREAM -ADVANTAGE MAIN STREAM -ADVANTAGE

• It allows monitoring of spontaneously • Faster response time
breathing non intubated patient ( as
• No gas being removed from
sampling of expired gas can be
obtained from facemask or nasal cavity breathing circuit
• No need for sampling pumps

SIDE STREAM -DISADVANTAGE MAIN STREAM - DISADVANTAGE

• Delay in recording due to movement of • Relatively heavy measuring adapter
gases from the ET to unit. with electrical cord ( causing et tube
kink)
TYPES OF CAPNOGRAPHS - CONT…..

SIDE STREAM DISADVANTAGE MAIN STREAM DISADVANTAGE

• Sampling tube obstruction • Added dead space
• Water vapour pressure changes • Expense for the repair of
affect co2 concentration. damage ( Newer generation are
lighter and smaller)
CAPNOGRAPHIC WAVEFORMS

• Co2 is produced in tissues through metabolism

• Carried via blood –enters circulation
• Lungs ---Exchange of gas occurs
• Expired out ,
CAPNOGRAM PHASE 1- DEAD SPACE
VENTILATION
• Beginning of exhalation
• No CO2 present
• Air from trachea , posterior pharynx , mouth and nose enters – No gas
exchange occurs there so it is called Dead space ventilation .
• INSPIRATION- O2 + N2O + Volatile anesthetics
No Co2 during inspiration , Baseline is normally zero
CAPNOGRAM PHASE II – ASCENDING PHASE

• CO2 from the alveoli begins to reach the upper airway and mix with
dead space air
- causes a rapid rise in the amount of CO2 .
• CO2 now present and detected in exhaled air .
CAPNOGRAM PHASE III – ALVEOLAR PLATEAU

• CO2 rich alveolar gas now constitutes the majority of exhaled air
• Uniform concentration of CO2 from alveoli to nose/mouth .
• The Co2 concentration at the end of plateau is referred as END TIDAL co2
(PETCO2)
• It is the best reflection of alveolar co2 (PACO2)
• Normally Arterial co2 ie,,Paco2 –PETCO2 = 5mmhg due to dead space.
• The phase 3 slope is increased by ventilation perfusion abnormalities in the
lung( COPD) as well as external factors such as kinked tracheal tube .
CAPNOGRAM PHASE III –CONT…..

• The angle between Phase II and phase III is called the alpha . ( take off ,
elevation )angle
• Normally it is between 100 to 110 degrees .
• It is increased in obstructive lung disease.
CAPNOGRAM PHASE III – CONT…..

• The slope of Phase III depends on the ventilation perfusion status of the
lung .
• Airway obstruction and PEEP cause an increased slope and a larger
alpha angle .
• Other factors that affects the angle are the response time, sweep
speed and respiratory cycle time of capnometer.
CAPNOGRAM PHASE III- CONT…..

• The angle between the end of Phase III and the descending limb of
capnogram is called the beta angle . Normally it is app 90 deg.
• The angle increases with rebreathing, prolonged response time
compared with respiratory cycle time particularly in children .
• The angle will be decreased if the phase III slope is increased.
CAPNOGRAM PHASE IV – DESCENDING PHASE

• Inhalation begins
• Oxygen fills airway
• CO2 level quickly drops to zero .
CAPNOGRAPHY WAVEFORM
CLINICAL SIGNIFICANCE OF CAPNOMETRY

• Carbondioxide is produced in body tissues , conveyed by circulatory

system to lungs , excreted by the lungs and removed by the breathing
system .
• Changes in respired CO2 may reflect alterations in
• Metabolism
• Circulation
• Respiration
• Breathing system
METABOLIC CHANGES

INCREASE IN END TIDAL CO2 DECREASE IN END TIDAL CO2

a) Absorption of CO2 from Peritoneal cavity a) Hypothermia
b) Pain , anxiety ,shivering b) Increased depth of
anaesthesia
c) Increased muscle tone (as from muscle c) Use of muscle relaxants
relaxant reversal)
d) Convulsions
e) Hyperthermia
CIRCULATORY CHANGES

DECREASED ETCO2
a) Decreased transport of CO2 to the lungs (impaired peripheral
circulation )
b) Decreased transport of CO2 to the lungs ( Pulmonary embolus, either
air or thrombus , surgical manipulation)
c) Increased patient dead space.
RESPIRATORY CHANGES

INCREASED ETCO2 DECREASED ETCO2

a) Hypoventilation a) Hyperventilation
b) Upper airway obstruction
c) Rebreathing
EQUIPMENT

INCREASED ETCO2 DECREASED ETCO2

a) Increased apparatus dead space a) Leakage in sampling
line
b) Rebreathing with circle system b) Inadequate seal
around tracheal tube
Mapleson
c) Obstruction to expiration in
breathing system
OTHER USES

• A diverting capnometer can be used to localize the leak sites in CO2

insufflation equipment , diagnose a tracheoesophageal or broncho
esophageal fistula, guide blind intubation , determine when the tip of
exchange catheter is positioned in the trachea during cricothyrotomy
or percutaneous dilatational tracheostomy .
• Carbondioxide analysis may be used to assess enteric tube position . If
tube is in the trachea , CO2 will be detected at the free end . If CO2 is
not detected , the tube is likely in gastrointestinal tract.
CORRELATION BETWEEN ARTERIAL AND END
TIDAL CO2 LEVEL

A ) DURING HIGH FREQUENCY VENTILATION :

• Here Petco2 is the poor index of PaCO2 , in order to measure the end
tidal CO2 the high frequency ventilation should be interrupted to
impose a few slow breaths.
CORRELATION BETWEEN ARTERIAL AND END
TIDAL CO2- CONT…..
B) DISTURBANCE IN VENTILATION PERFUSION MISMATCHING
When there is ventilation perfusion mismatching , the relationship between
end tidal and arterial co2 tension is disturbed. Clinical condition that can alter
the volume and distribution of pulmonary blood flow include
• Pulmonary embolism
• Pulmonary artery occlusion
• Reduced cardiac output
• Hypovolemia
CORRELATION BETWEEN ARTERIAL AND END
TIDAL CO2 - CONT….
C) The end tidal to arterial CO2 gradient increases as venous admixture (
right to left shunt) occurs . This can be caused by
• Atelectasis
• Bronchial intubation or certain heart condition
• This effect is less dramatic than that caused by an increase in dead
space , but when the venous admixture is large ( as in cyanotic
congenital heart disease) its contribution can be considerable .
CORRELATION BETWEEN ARTERIAL AND END
TIDAL CO2 - CONT…..
• Patient with pulmonary disease have an uneven distribution of
ventilation and to lesser extent blood flow . This leads to an increased
gradient .
• Since PEEP may decrease the gradient , the arterial to end tidal co2
gradient can be a useful tool for optimizing PEEP .
• Changes in body position , such as the lateral or prone position , may
cause an increase in the Paco2 /Petco2 gradient .
CAPNOMETER PROBLEM

• If there is leak or break in the sampling line or its connections , air will
be added to the sample and the end tidal co2 , reading will be lower
than the actual value
• A partially obstructed sampling catheter can cause the capnogram to
be dampened and lead to both falsely high inspired and falsely low end
tidal co2 values .
• An occluded sampling or exhaust line can result in no co2 being
detected . An internal leak in the analyzer can result in artifactually
high values .
CAPNOMETER PROBLEM - CONT….

• Other problems that may result in an inaccurate Petco2 reading include

,
• Increased sampling tube resistance
• Changes in atmospheric pressure
• Improper calibration
• Drift, Signal noise , Selectivity .
• Pressure effects from sampling system or patient environment
• Water vapor and foreign substances.
CAPNOMETER PROBLEM - CONT….

• With some analyzers , air is used for zeroing . If co2 containing gas
enters the zeroing sample , there will be falsely low co2 readings with a
normal looking waveform .
VARIOUS CAPNOGRAPHIC WAVES

1) The waveform illustrated shows a normal configuration but the plateau

is well below the normal co2 values .
• This indicates a low tidal value.
• This can occur in Hyperventilation or increase in dead space ventilation
.
2) The waveform is normal but the plateau is higher than normal
• The baseline is zero which indicates that carbondioxide is not present
in the inspired mixture .
• This occurs if co2 production increases such as in malignant
hyperthermia or with Hypoventilation .
• Other causes can be co2 being absorbed during laparoscopy ,
tourniquet release , increased muscle tone , shivering or convulsions.
3) CURARE NOTCH – A curare cleft or notch is sometimes seen during
spontaneous ventilation .
• The cleft is in the last third of plateau and is thought to be 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 the cleft is proportional to the degree of remaining muscle
paralysis.
• The portion of the cleft is fairly constant on the same patient but is not
necessarily present with every breath.
• As muscle relaxant effect is reversed , the curve becomes normal in
shape .
• The notch can also be seen in patient with cervical transverse lesions,
hiccups and pneumothorax.
4) CARDIOGENIC OSCILLATION: These appear as small , regular , tooth like humps
at the end of the expiratory phase .They may be single or multiple and their
heights may vary considerably . They are believed to be due to heart beating
against lungs .
• The number of factors including negative intrathoracic pressure , low respiratory
rate, diminished vital capacity : heart size ratio, low inspiratory : expiratory ratio
, low tidal volumes and muscle relaxation contribute to their appearance .
• In many cases adjusting the flow or tidal volume will remove this pattern from
screen .
• Cardiogenic oscillation are more common in pediatric patient because
of the relative size of infants heart and thorax .
5) INSPIRED CARBONDIOXIDE
6) INCOMPETENT INSPIRATORY UNIDIRECTIONAL VALVE
7) PROLONGED UPSTROKE- The left curve shows a normal waveform .
The three curve shows progressive slanting .
• As expiration is progressively prolonged , inspiration may start before
exhalation is complete so that end tidal co2 reading , but not the actual
end tidal value is decreased .
• This pattern can be caused by obstructed air flow due to a partially
obstructed tracheal tube or obstruction in the patients airways as in
COPD , Bronchospasm or Upper airway obstructions.
8) Return to spontaneous ventilation – The first breath is typically of
small volume. Subsequent breaths show progressively higher peaks with
gradual progression to normal waveform .
9) Sample line leak – A leak in the sampling line during positive pressure
ventilation will result in a plateau of long duration , followed by a peak of
brief duration when the positive pressure transiently pushes undiluted
end tidal gas through the sampling line .
• IF the patient is breathing spontaneously , a terminal hump will be
seen.
• An upswing at the end of Phase III may also be seen in obese and
pregnant patients.
10) Variation between lungs – If compliance , airway resistance or
ventilation perfusion ratio in one lung differ substantially from the other
lung , a biphasic expiratory plateau may be seen . This type of
capnogram has been reported in a patient with severe kyphoscoliosis
and following single lung transplantation .
I1 ) CONTAMINATED GAS SAMPLE- Contamination of expired gas 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
• If the contamination is of lesser magnitude , a drop off occurs at the
end of the plateau.
 12) SUDDEN DROP IN ETCO2
Usually caused by an acute event relating to airway such as
• Extubation
• A complete breathing system disconnection
• Ventilator malfunction
• Esophageal intubation
• A plugged gas sampling tube or totally obstructed tracheal tube.
13) GRADUAL CO2 DROP- Events that can cause an exponential decrease in
end tidal co2 include
• Sudden Hypotension due to massive blood loss
• Obstruction of major blood vessel
• Circulatory arrest with continued pulmonary ventilation
• Pulmonary embolism
• Once the cause of drop is corrected , the end tidal co2 will initially return
to a higher level before it returns to the normal level.
14) SMALL AIR EMBOLISM WITH RESOLUTION- If air enters the vascular
system of the lung it will obstruct a certain portion of the circulation .
• If the embolus is large enough , it will cause the end tidal co2 to
decrease suddenly but not necessarily to zero .
• Often these emboli resolve quickly and the end tidal co2 returns to
normal level.
15) TOURNIQUET RELEASE – Releasing a tourniquet or unclamping of a
major vessel may result in a sudden increase in end tidal co2 level that
gradually returns to normal
•
16) SPONTANEOUS RESPIRATORY EFFORTS DURING MECHANICAL
VENTILATION
17) DISPLACEMENT OF TRACHEAL TUBE INTO UPPER LARYNX
THANK YOU