Time to Throw Away Your Stethoscope?

Capnography: Evidence-Based Patient Monitoring Technology

j Alexander Johnson, RN, MSN, ACNP-BC, CCNS, CCRN; Donna Schweitzer, RN, MSN, CCNS, CCRN; and Thomas Ahrens, RN, PhD, CCRN, CS, FAAN
ABSTRACT: The stethoscope has provided valuable patient assessment information since its invention in 1816. However, there are limitations to the information that the stethoscope can provide that can be indirectly harmful to the patient. We listen to breath sounds to assess presence and quality of air movement. However, this information provides the clinician little information regarding the patients ventilation-perfusion relationship. When we rely on our stethoscope without realizing its limitations, patients may indirectly be put in danger. The combination of the stethoscope with additional technologies for assessment can exponentially benet the safety and care of our patients. The specic technology being discussed in this article is capnograpy. Capnography is a highly evidence-based method for patient monitoring of ventilation, pulmonary deadspace, and blood ow. Although the supporting literature for capnography is fairly clear, the science does not receive the widespread utilization it deserves. The applications of capnography are diverse, including, but not limited to conrming placement of advanced airways and nasogastric tubes, diagnosing pulmonary embolus, and identifying low cardiac output and hypoventilation. The increased accuracy and efciency in patient monitoring would likely improve patient outcomes and help avoid costs in any acute care area. (J Radiol Nurs 2011;30:25-34.) KEYWORDS: Capnography; Exhaled carbon dioxide; CO2 monitoring; Ventilation.

INTRODUCTIONdA CASE STUDY A 55-year-old male patient intubated for severe pneumonia is being transferred from the intensive care unit (ICU) to the radiology department for a computed

Alexander Johnson, RN, MSN, ACNP-BC, CCNS, CCRN, is from Advocate BroMenn Medical Center in Normal, IL; Donna Schweitzer, RN, MSN, CCNS, CCRN, is from Advocate BroMenn Medical Center in Normal, IL; Thomas Ahrens, RN, PhD, CCRN, CS, FAAN, is from Barnes-Jewish Hospital in St. Louis, MO. No grant support or nancial assistance was in any way received in association with this article.This article has not been previously presented. Corresponding author: Alexander Johnson, Advocate BroMenn Medical Center, 1423 Chadwick Drive, Normal, IL 61761. E-mail: apjccrn@hotmail.com 1546-0843/$36.00 Copyright 2011 by the Association for Radiologic & Imaging Nursing. doi: 10.1016/j.jradnu.2010.12.003

tomography (CT) scan of the chest. The patient is being escorted by an ICU nurse and respiratory therapist, supporting ventilation via bag-valve mask. During transfer from the bed to the CT table, the patient becomes agitated, attempts to sit up, and pulls his endotracheal tube. As the ICU nurse administers sedation, the respiratory therapist assists in restraining the patient. No endotracheal tube displacement seems obvious, and distant breath sounds can be auscultated. Approximately 15 min later, during the CT scan, ventricular brillation is noted on the patient monitor and the resuscitation team is called. The response team immediately attaches a capnography monitor to the endotracheal tube and notes the absence of a capnogram (e.g., at line). The emergency room (ER) physician removes the endotracheal tube and inserts a new one. Moments after insertion of the new tube, a strong capnography waveform is noted, a positive nding to
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conrm that the tube is in the trachea. The staff used the resources immediately available to them to avoid the tube dislodgement that caused the patients arrest. However, use of capnography to provide ongoing conrmation of tube position before the arrhythmia event could have aided staff in identifying the tube malposition earlier, thus helping this patient avoid unnecessary risk of hypoxic brain injury or even death. PHYSIOLOGY OF CARBON DIOXIDE (CO2) PRODUCTION Capnography is the measurement of CO2 being exhaled with each breath. CO2 is a by-product of cellular metabolism, brought to the lungs by the venous circulation and exhaled. The measurement of exhaled CO2 can give insight into what is going on inside the body. It is also an indirect measurement of the CO2 level present in the bloodstream. In other words, the amount of exhaled CO2 measured is a function of both CO2 production and elimination. Respiration is a two-phase process. The rst phase is oxygenation or the intake of oxygenated air into the lungs where the oxygen moves from the alveoli into the capillary blood ow. The blood then transports the oxygen to the tissues where it will be used in cellular metabolism. During cellular metabolism, CO2 is produced and must be transported by the blood to the lungs to be exhaled. On reaching the lungs, CO2 diffuses into the alveoli as oxygen is moving from the alveoli into the bloodstream. This exchange of gases is the second phase of respiration, called ventilation (Eisenbacher & Heard, 2005). When CO2 levels in the blood are abnormal, either high or low, adverse effects including death can occur. Traditionally, a patients respiratory assessment is supplemented with the use of a pulse oximeter to monitor the percent saturation of oxyhemoglobin in the blood. Although pulse oximetry measures the ability of the lungs to oxygenate the blood, it does not display information regarding respiratory rate, depth, apnea, or CO2 levels. The caregiver is alerted to a possible respiratoy failure when the oxygen level desaturates or drops below the prescribed low limit (usually 90e95%). The use of supplemental oxygen can prevent desaturation during hypoventilation and can mask deteriorations in the patients respiratory status (Fu, Downs, Schweiger, Miguel, & Smith, 2004). This is a reason why oxygen desaturation is considered a late sign of respiratory compromise in hypoventilating patients. Capnography monitors expired CO2 levels and produces a waveform for each respiration, which reveals respiratory rate and depth, the presence of apnea, and efciency of ventilation or gas exchange (Eisenbacher & Heard, 2005; Hutchison & Rodriguez, 2008). The addition of
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capnography can detect early signs of hypoventilation that pulse oximetry cannot detect. HOW IS EXHALED CO2 MEASURED? CO2 can be measured via chemical reaction (referred to as colorimetry) or with measurement of actual CO2 molecules. Measurement of CO2 molecules is probably the best method in acute and critical care (Ahrens & Sona, 2003). Actual CO2 molecule measurement allows clinicians to observe a waveform and numeric CO2 value. Colorimetry does not produce a waveform. The CO2 molecule measurement is most frequently obtained when exhaled air passes through a sensor that contains a beam of light (infrared absorption spectrophotometry) and can be performed by using either sidestream or mainstream sampling (Ahrens, 1998; Schallom & Ahrens, 2001; Figure 1). Sidestream sampling analysis is performed by using a length of tubing to aspirate exhaled air to a monitor where the analyzing sensor is located (air passes through the sensor and the CO2 level is assessed). The CO2 value is then displayed on the screen of the monitor. Often a nasal cannulatype device is used to capture the exhaled air to be analyzed. However, clinicians must be careful in determining correct cannula positioning as malpositioned cannulas may result in inaccurate CO2 readings (Figure 2). Air can also be aspirated from the circuit of a mechanical ventilator but this is not the preferred method for measuring CO2 for mechanically ventilated patients. Mainstream sampling analysis is preferred for CO2 measurement in intubated patients and is performed by placing a sensor device into the end of the endotracheal tube or tting a sensor to a facemask with nonintubated patients. As the patient exhales, the air passes through the inline sensor, the CO2 value is assessed and the information is transported via a cable to a display monitor. Advances in mainstream technology have made it less bulky, lighter, dryer (less condensation), and more durable thereby limiting many of the disadvantages in using mainstream capnography (Evans, Lavorata, & Lord, 2008; Kodali, 2010). THE CAPNOGRAM The amount of circulating CO2 is inuenced mainly by oxygenation, ventilation, and blood ow. Therefore, measuring the amount of CO2 exhaled with each breath enhances clinicians ability to treat and triage patients. Capnography is the measurement of the partial pressure of exhaled CO2 converted to a waveform and a numerical reading. Although the numerical reading is important, the waveform, or capnogram, characteristics can also reveal diagnostic information about
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Figure 1. Two techniques for measurement of exhaled carbon dioxide (A) mainstream and (B) sidestream.

alveolar ventilation and perfusion (Ahrens & Sona, 2003; Eisenbacher & Heard, 2005). For example, there are distinct phases of the waveform that correlate with phases of the respiratory cycle. The initial air that is exhaled contains little to no CO2 and the waveform is at (baseline). As the air from the bronchial tree, which contains an increasing level of CO2, begins to be exhaled, the waveform begins to incline (Figure 3). Toward the end of the exhalation, the air from the alveoli, which has the highest concentration of CO2, is exhaled and the waveform reaches its peak. At the end of exhalation, inspiration begins, the CO2 levels fall, and the waveform begins to decline back to baseline (Ahrens, Wiejera, & Ray, 1999). The height, length, frequency, and shape of the waveform are representative of the quality of the respiration. For example, a shallow respiration will be shorter in height, apnea will have a longer baseline reading, diminishing respiratory depth will produce a progressively shorter or attened wave pattern, and reactive airways commonly produce a shark n-shaped waveform (e.g., asthma; Figure 4). However, any condition that changes the

relationship of ventilation to lung perfusion can change wave conguration (Ahrens & Sona, 2003). The numerical readout represents the partial pressure of end-tidal CO2 (PetCO2) at the end of expiration. A respiratory rate is often available as a numeric reading also, reecting the number of capnograms (respirations) occurring within a set timeframe. The PetCO2 reading has a variety of applications in the care of a person undergoing medical treatments (Table 1). PetCO2 can be useful in assessing endotracheal tube placement and displacement, effectiveness or harmfulness of ventilator adjustments such as positive end expiratory pressure and tidal volumes, weaning of the ventilator, effectiveness of cardiopulmonary resuscitation (CPR), rate and depth of respiration during sedation, and the return of spontaneous circulation during CPR. Alterations or improvements in oxygenation, ventilation, or blood ow will be reected in the PetCO2 reading. It can assist with diagnosing a pulmonary embolism and assessing the amount of lung involved with pneumonia or acute lung injury. These applications will be discussed later in this article.

Figure 2. Nasal cannula carbon dioxide (CO2) sampling techniques; (A) correctly positioned cannula and (B) malpositioned cannulas may result in inaccurate CO2 readings. VOLUME 30 ISSUE 1 27

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Figure 3. Waveform characteristics of the capnogram. 1 to 2dEarly expiration (gas contains small amounts of carbon dioxide [CO2]). 2 to 3dExpiratory phase (an increased amount of CO2 is present from gas-exchanging areas of the lung, however, CO2 is reduced because of mixing from areas that do not participate in gas exchange). 3 to 0dAlveolar emptying phase, characterized by a sudden increase and plateau of the CO2 wave. The sharp drop identies the point where phase 3 ends and phase 0 begins. 0 to 1dInspiration (no CO2 detected via capnography).

TREATING ABNORMAL CAPNOGRAPHY LEVELS The most important question clinicians should ask themselves regarding interpretation of capnography values is, Is my patient safe? However, interpretation using predetermined CO2 reference ranges, 35 to 45 mmHg for example, may mislead the clinician into deciding what is normal for that patient. Therefore, before answering that question, an understanding of that patients baseline is helpful. Acute changes from baseline values obtained after capnogram acquisition are more likely to require treatment. Treatment may not be necessary if the PetCO2 level is chronically abnormal. However, sometimes it is difcult to discern whether or not an abnormal PetCO2 level is new or chronic. If the PetCO2 level changes during capnography use, then the clinician can be sure the change is new. However, if the PetCO2 level is abnormal when capnography is initially applied, two ways exist to evaluate whether it is new or chronic. THE ABNORMAL PETCO2 LEVELdIS IT NEW OR CHRONIC? Treating elevated PetCO2 levels Elevations in PetCO2 may constitute a medical emergency or may be normal for certain patients. To determine if an elevated PetCO2 level is acute or chronic,

rst obtain an arterial blood gas (ABG). Second, ask yourself, Is this patient safe? This question can be answered by analyzing the ABG pH level. If the pH is below normal, the patient is in danger because of hypoventilation (e.g., underbreathing). Necessary next steps must involve maneuvers to open the airway and/or support breathing. If the pH is normal, the patient is safe from the dangers of hypoventilation. Chronic elevations in PetCO2 are common in chronic lung disease, such as chronic obstructive pulmonary disease. Over time, patients with chronic lung disease retain bicarbonate, allowing compensation for elevation in CO2 to occur to keep the pH normal. Any sudden or developing elevations in PetCO2 require treatment to support respirations. Increases to greater than 50 or 10 mmHg above baseline necessitate quick intervention or validation with an ABG. For example, if the patient is receiving procedural sedation, decrease the sedation and provide ventilatory support until the PetCO2 begins to normalize. Strategies to decrease PetCO2 include airway maneuvers, reversal of sedative or narcotic agents, initiation of Bipap (bi-level positive airway pressure), or intubation with mechanical ventilation. If an ABG is unobtainable and the patient has no history of lung disease, assume an elevation in PetCO2 is new while supporting the airway and breathing as best as possible. Treatment should be aimed toward returning the PetCO2 back to normal (40 mmHg or less). Table 1. Summary of common indications for capnography monitoring
Monitoring alveolar-emptying patterns (e.g., asthma) Patients receiving conscious sedation Avoiding esophageal intubation during advanced airway (endotracheal tube) placement Avoiding airway intubation during naso/orogastric tube placement Prognosis and quality of cardiopulmonary resuscitations (i.e., bloodow monitoring) Reducing arterial blood gas use and radiologic costs Detecting pulmonary deadspace (pulmonary embolus, low cardiac output states) Use in weaning from or detecting disconnection from mechanical ventilator

Figure 4. Characteristic shark n-shaped waveform seen in patients with reactive airways (e.g., asthma). 28

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Case study: A 59-year-old female is undergoing a colonoscopy. During most of the procedure, the vital signs (heart rate, respiratory rate, blood pressure, and pulse oximetry) remain consistent, while the PetCO2 increases. The assessment of respiration quality is subjective and cannot indicate the quality of the gas exchange. Toward the end of the procedure, the patient is found to be unresponsive with vital signs that have only slightly changed (Table 2). In this example, the elevating PetCO2 should have allowed caregivers to identify the hypoventilation earlier (20 min into the procedure) and perform interventions to increase quality of respirations. Unfortunately, late signs were the alerting factor, recognized at 30 min into the procedure (e.g., unresponsiveness and decreased SaO2) and reversal agents must be given to rescue the patient. Treating low PetCO2 levels The two main causes of low PetCO2 include overbreathing, or hyperventilation, and decreased cardiac output. Causes of overbreathing include pain, fear, anxiety, or overbreathing from the mechanical ventilator. Goals of care should include adjustments to ventilator settings and/or treating the underlying cause, such as analgesics or removal of anxiety-provoking stimuli. When PetCO2 decreases quickly (greater than 10 mmHg) and breathing has not changed, suspect a low cardiac output state such as bleeding, heart failure, or hypovolemia. Stroke volume and cardiac output should be measured if possible. However, pulmonary emboli may also manifest itself via a decreased PetCO2 level. In this case, ABG analysis can help differentiate the reason for the low PetCO2 value. If the partial pressure of arterial CO2 (PaCO2) on the ABG is normal, this could suggest a sudden loss of cardiac output or chronic lung disease (see Capnography and the Assessment of Blood Flow). Measurement of the cardiac output, if possible, can aid in identifying the underlying cause of the low PetCO2 reading. Emergent situations Capnography aids clinicians in emergency situations by helping to identify hypoventilation or loss of cardiac output. Elevation in PetCO2 (e.g., greater than 50 mmHg or increase of 10 mmHg above baseline) should alert clinicians to conrm whether or not the Table 2. Procedural sedation
Time 0917 0927 0937 0942 0947 Nursing documentation 4 mg Versed and 100 mcg Fentanyl, procedure begins patient restful, procedure in progress patient restless, Versed 2 mg, Fentanyl 50 mcg given patient resting, procedure in progress reversal agents given for unresponsiveness BP

patient is in immediate danger by checking an ABG. Patients with a low pH and elevated PaCO2 should be treated with prompt airway protection and support of patient ventilation. Because sudden drops in PetCO2 (especially to less than 10 mmHg) occur in patients with decreased cardiac output, stroke volume and cardiac output should be promptly measured. Treatment of the underlying cause aimed at improving blood ow could include, but would not be limited to intravenous uid administration, blood transfusion, inotropes, or vasopressors. Abrupt decreases in PetCO2 may also be observed with sudden increases in pulmonary deadspace, such as pulmonary embolus (PE) (Johanning, Veverka, Bays, Tong, & Schmiege, 1999; Weg, 2000; Yamanuka & Sue, 1987). Suspicion of PE may prompt the clinician to consider anticoagulant therapy, thrombolysis, or thrombectomy (discussed later under Deadspace). The ability of the PetCO2 to correlate with blood ow also has been shown to be a strong mortality predictor in patients with cardiac arrest. PetCO2 levels less than 10 mmHg after 20 min of CPR have been found to be consistent in nonsurvivors (Ahrens, Wiejera, & Ray, 1999; Ahrens et al., 2001; Levine, Wayne, & Miller, 1997). As a result, capnography during resuscitation efforts gives bedside clinicians valuable information regarding quality of CPR, return of spontaneous circulation, and guidance regarding when to stop resuscitation efforts (see also Capnography and Assessment of Blood Flow). PULMONARY ASSESSMENT AND CLINICAL APPLICATIONS Physical assessmentdis it enough? A thorough physical assessment and examination can be pivotal in the care and outcomes of a patient situation (Reilly, 2003). Advantages of a physical assessment include the ability to perform rapidly and with minimal equipment. However, information obtained during a physical assessment may not be enough to identify exactly what the problem may be. Physical examination ndings also tend to change slowly and at times only manifest as late signs of patient decompensation, such as altered mental status, nasal aring,

HR 79 81 80 82 78

RR 16 12 12 12 8

SpO2 99 98 98 94 90

Respiration quality Moderate Moderate Moderate Moderate Shallow

PetCO2 39 43 50 53 62

134/71 131/70 132/73 135/74 129/69

Bp, blood pressure; HR, heart rate; RR, respiratory rate; SpO2, Oxygen saturation measured by pulse oximetry.

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and cyanosis, if present at all. Perhaps most signicantly, physical assessment, including auscultation of breath sounds, does not tell us how well the lungs can oxygenate the blood or eliminate CO2. Capnography can augment the physical assessment with information otherwise undetectable by revealing physical changes that could be harmful to the patient. Respiratory rate For decades, respiratory rate has been taught as a key vital sign. Obtaining a respiratory rate is easy to do and can be performed quickly. However, it is extremely limited in its capacity to tell clinicians about a patients ability to acquire oxygen, eliminate CO2, and inhale or exhale a tidal volume. In other words, physical assessment offers virtually no information regarding alveolar ventilation. For example, patients with increased respiratory rates may have increased, normal, or even decreased CO2 elimination. Evaluating respiratory depth via physical assessment is subjective and risks signicant clinician-to-clinician variability. Consistent evaluation of respiratory depth is misleading as well, because chest wall movement still manifests during upper airway obstruction and laryngospasm. Capnography helps objectify the respiratory and ventilatory assessment. Clinicians can also assess PetCO2 trends. A patient with a respiratory rate of 28 will produce 140 PetCO2 readings in 5 min, providing clinicians with enough information to rapidly determine whether a patients condition is improving, stabilizing, or worsening. Respiratory rate alone may be a warning sign of decompensation in patient status, however, clinical suspicions should be validated with PetCO2 or PaCO2 levels, and perhaps serum pH monitoring. Nevertheless, physical assessment of respiratory rate and depth commonly remain the only physical assessment the bedside clinician has to assess ventilation. Because of these challenges, efforts to enhance monitoring during sedation are part of a national agenda for patient safety (Kohn, Corrigan, & Donaldson, 2000; Poe et al., 2001). In fact, recent literature suggests ventilation assessment using capnography in nonintubated patients undergoing sedation may improve practice by providing an early warning system for impending respiratory compromise and hypoxemia (Cacho et al., 2010; Lightdale et al., 2006; Soto, Fu, Vila, & Miguel, 2004; Vargo, 2000; Vargo et al., 2002). Current practice generally has an increased emphasis on pulse oximetry for all patients receiving sedation, perhaps enabling a false sense of security while increased PetCO2 levels go undetected (DeWitt, 2001; Fu, Downs, Schweiger, Miguel, & Smith, 2004; Hutchison & Rodriguez, 2008; Maddox, Williams, Oglesby, Butler, & Colclasure, 2006). However, pulse oximetry does not measure ventilation and decreased arterial sat30

uration (SaO2) is often a late sign of patient deterioration (American Academy of Pediatrics, Committee on Drugs, 2002; American Society of Anesthesiologists Task Force on Sedation and Analgesia by non-Anesthesiologists, 2002; Greensmith & Aker, 1998; Lightdale et al., 2006). CAPNOGRAPHY AND ASSESSMENT OF BLOOD FLOW The ability of the PetCO2 to measure CO2 production and elimination is predicated on sufcient blood ow through the capillary beds in the lungs. The heart continually supplies the lungs with deoxygenated blood to produce the PetCO2. Simply stated, the heart beats and blood is returned to the lungs where CO2 diffuses over into the airways to be exhaled. When there is a sudden drop in the PetCO2 level without concomitant changes in respiratory rate or tidal volume, this can signify that the PetCO2 dropped because of a decreased cardiac output (e.g., decreased blood ow to the lungs; Ahrens, 1998). Furthermore, sudden drops in the PetCO2 to zero may reect cardiac or respiratory arrest (or disconnection for the mechanical ventilator). Assessment of perfusion Disparity between the PetCO2 and the arterial PaCO2 is expected because of anatomic (normal) deadspace, with the PetCO2 often being slightly lower. Under normal circumstances, this discrepancy is between 1 and 5 mmHg (Ahrens, 2004; Schallom & Ahrens, 2001). Admixture of other gases in the large airways between the alveolar level and PetCO2 sensor account for this gradient. Wider gradients (greater than 5 mmHg) suggest an increased amount of nonperfused alveoli (deadspace). However, sudden drops in PetCO2 (when breathing has not changed) are more commonly associated with drops in pulmonary blood ow (e.g., cardiac output), such as bleeding and heart failure (Ahrens, 1998). Case study: A 73-year-old male following a coronary artery bypass graft and valve replacement complains of acute shortness of breath at 0630 hr. His vital signs show an increase in blood pressure, heart rate, and respirations, and a decrease in pulse oximetry, PetCO2, and PaCO2 (Table 3). This sudden drop in PetCO2 and widening of the PaCO2-PetCO2 gradient suggests an alteration in the alveolar ventilation-perfusion relationship (i.e., increased deadspace), which often manifests as either a PE or decrease in cardiac output. Cardiac output and stroke volume should be measured immediately to determine the underlying cause of the increased gradient. Deadspace Deadspace is an area in the respiratory anatomy that receives inhaled air (ventilation), but no blood ow (perfusion) is available to facilitate the exchange of
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Table 3. Case example

0600 hr BP, 112/68 HR, 92 RR, 14 SpO2, 97% PaCO2, 32 PetCO2, 28 0630 hr BP, 122/76 HR, 110 RR, 22 SpO2, 95% PaCO2, 29 PetCO2, 7

oxygen and CO2. Anatomic deadspace is that portion of the inhaled air that occupies the tracheobronchial tree, never reaching the alveoli to exchange gases. Alveolar deadspace occurs when ventilation of the alveoli occurs but the blood ow to the surrounding alveolar-capillary bed (perfusion) is absent because of physiologic or pathophysiologic conditions (Ahrens, 1998, 2004). Sudden drops in PetCO2 levels can also result from increased deadspace. For example, pulmonary emboli can contribute to decreased oxygenation and low PetCO2 level, despite a compensatory increase in respiratory rate, because clot material (often because of deep vein thrombosis) is blocking blood from reaching the alveolar-capillary interface (Figure 5). In fact, research has suggested the difference between the PetCO2 and PaCO2 is considered to be diagnostic for pulmonary embolism (PE) (Ahrens, Wiejera, & Ray, 1999; Chopin et al., 1990; Drummond, Prutow, & Scheller, 1985; Severinghaus & Stupfel, 1957). Kurt et al. (2010) recently conducted a study suggesting that capnography used in conjunction with certain scoring systems improves diagnostic accuracy for PE. Because these affected alveoli do not participate in gas exchange, the exhaled air from these nonperfused alveoli will have a low CO2 content, resulting in a decreased PetCO2 value. Use associated with ABG interpretation Healthy lungs (with normal ventilation and perfusion) produce a gradient of PetCO2 levels between 1 and 5 mmHg lower than the PaCO2 level (Ahrens, 1998; Ahrens & Sona, 2003; Schallom & Ahrens, 2002). The difference in the PetCO2 and the PaCO2 should be conrmed with ABG testing before assuming that the gradient is normal. This gradient remains constant

whether the PetCO2 increases or decreases in patients with normal lungs. Traditionally, the PetCO2-PaCO2 gradient is not considered to remain constant when the difference is greater than 7 mmHg (e.g., the two values may not correlate). When gradients are conrmed to be consistent, predictability of the PaCO2 results and clinicians can safely gauge PaCO2 levels without ABG acquisitions in certain circumstances. However, recent research suggests that PetCO2 can be used as a PaCO2 surrogate across all levels of deadspace as long as the expected PetCO2-PaCO2 difference is considered (McSwain et al., 2010). Further research may clarify the clinical utility of the abnormal PetCO2 value in the setting of an increased gradient. Ecacy in cardiac arrest Capnographys ability to correlate with cardiac output and blood ow provides an added advantage for providers performing CPR. A case example to illustrate this is that of a 66-year-old male transported to the ER after suffering a prehospital cardiac arrest. He was found down is his house by his wife. CPR has been in progress for greater than 30 min. The PetCO2 level is noted to be 6 mmHg during the resuscitation. Absent or very low values such as this one are common in cardiac arrest because there is essentially no blood ow (Ahrens & Sona, 2003; Schallom & Ahrens, 2002). Research suggests that PetCO2 levels less than 10 mmHg after 20 min of CPR correspond to 100% mortality, even if a spontaneous electrocardiogram rhythm is reestablished (Ahrens, Wiejera, & Ray, 1999, 2001; Levine et al., 1997; Sanders, Kern, Otto, Milander, & Ewy, 1989; Wayne, Levine, & Miller, 1995). This resuscitation effort should be stopped. Conversely, several studies have shown that a rapid increase in PetCO2 level during CPR is associated with a return of spontaneous circulation (Asplin & White, 1995; Cantineau et al., 1996; Grmec & Klemen, 2001; Kalenda, 1978; Levine et al., 1997; Schallom & Ahrens, 2002). Research also suggests that PetCO2 increases with increased strength of chest compressions (Falk, Rackow, & Weil, 1988; Garnett, Ornato, Gonzalez, & Johnson, 1987; Kalenda, 1978; Lambert, Cantineau, & Merckx, 1992; White & Asplin, 1994). As a result, capnography monitoring can detect fatigue in the person performing chest compressions, which may otherwise go unrecognized. In addition, capnography is easy to read and manual chest compressions do not interfere with accuracy (Ahrens & Sona, 2003). Detection of misplaced tubes

Figure 5. Alveolar-capillary unit affected by deadspace. VOLUME 30 ISSUE 1

Capnography assessments have the ability to detect CO2 wherever an endotracheal tube or nasogastric
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tube (NG) is placed to assist with verication of placement. A capnogram visualized after endotracheal intubation conrms that the advanced airway is in the oro/nasopharyngeal area or the trachea. Utilization of CO2 detectors is considered a standard of care in this circumstance according to the American Society of Anesthesiologists and the American Heart Association (Ahrens & Sona, 2003; American Society of Anesthesiologists, 2010; ECC Committee, Subcommittees and Tasks Forces of the American Heart Association, 2005). CO2 detection will rarely, if ever, occur after intubation of the esophagus, such as if the patient recently ingested a carbonated beverage. Lack of a capnogram after intubation usually suggests the endotracheal tube was misplaced into the esophagus. Likewise, capnography can facilitate early identication of a potentially catastrophic tracheal tube dislodgement or ventilator disconnection (Nagler & Krauss, 2008; Warner et al., 2009). An abrupt decrease in PetCO2 suggests a displaced or obstructed tracheal tube. Such events have been cited by the Joint Commission on Accreditation of Healthcare Organizations in sentinel event reports regarding ventilator-associated deaths (The Joint Commission, 2002). Capnography use after NG insertion is a relatively newer, but promising method to help conrm tube placement on insertion. NGs should not detect CO2, therefore, absence of CO2 detection after NG tube insertion usually suggests the tube is correctly placed into the esophagus. Inadvertent placement of gastrointestinal tubes in the airway can lead to complications such as aspiration, pneumonia, and acute respiratory distress syndrome (Ahrens & Sona, 2003). However, this method is not reliable when tube feedings are present. Research regarding this practice is ongoing (Burns, Carpenter, & Truwit, 2001; Kindopp, Drover, & Heyland, 2001). COST/BENEFITS OF CAPNOGRAPHY Costs of capnography Cost of capnography monitoring is essentially from two types of expenditures: 1) the monitor (analyzer) and 2) the disposable portion attached to the patient or ventilator circuit. Cost of a single monitor is variable, and often ranges between $2,000 and $5,000 (Ahrens, 1998; Ahrens, Wiejera, & Ray, 1999). However, the disposable portion costs less than $10 per patient. Although cleaning and replacing disposable portions is required after each patient use, the monitors last for years with little maintenance (Ahrens, 1998; Ahrens, Wiejera, & Ray, 1999). Cost of time required to train staff is negligible. Web-based resources to complement staff education such as www.capnography.com and GE Healthcare, a site for virtual reality patient
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care, are also devoted to education regarding capnography use (GEHealthcare, 2010; Kodali, 2010). Benets of capnography Benets of capnography seem to far outweigh the cost. Capnography can increase patient safety and aid in avoiding complications through identication of respiratory depression during procedural sedation, and misplaced (including displaced) endotracheal and NGs. Avoidance of costs associated with futile resuscitation efforts can also limit excess resource utilization (Ahrens, Wiejera, & Ray, 1999). In addition to the improved efciency in care that results from the use of capnography, factors such as improved airway management and avoidance of hypoventilation contribute to the increased likelihood of lives saved. Although saving lives and patient safety are the primary reasons why capnography should be considered, the early detection and avoidance of complications produce a secondary benet in the reduction of legal liability and is a cost benet that todays healthcare institutions cannot overlook. Chest and abdominal radiographs, and need for ABGs can also be reduced because of capnography use, avoiding further costs and patient discomfort (Ahrens, 1998). Naturally, it is difcult to attribute a cost benet to the added value of being able to more precisely monitor ventilation. No price can truly be placed on the avoidance of a catastrophic patient event because respiratory depression, excess analgesia, or oversedation was avoided with capnography monitoring. Such complications include, but are not limited to aspiration, increased drug use, stafng time, and extended ICU and hospital length of stays (Ahrens, 1998). Deadly ventilator disconnections can also be identied more promptly with the assistance of capnography (Ahrens & Sona, 2003). Savings could potentially be in excess of hundreds of thousands of dollars, depending how widespread capnography implementation is within a given institution. Anesthesia departments, radiology procedure areas, medical-surgical areas, ERs, recovery rooms, long-term ventilator facilities, and ICUs are several examples of settings that may benet. In fact, the Society of Critical Care Medicine has recommended that all ICUs be able to provide capnography monitoring (Task Force on Guidelines, Society of Critical Care Medicine, 1988). SUMMARY The measured amount of CO2 that is being exhaled with each respiration can provide valuable information regarding not only respiration, but also blood ow through the body and location of life saving tubes. It
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is no wonder that capnography has been referred to as an emerging new vital sign (Ahrens & Sona, 2003). However, it still does not have the widespread use it deserves (Ahrens, 2004; Ahrens, Wiejera, & Ray, 1999). Capnography has been used by anesthesiology for many years to help ensure the quality of respirations during surgery. The knowledge of additional uses for capnography coupled with the advancement and ease of monitor use could benet patients in all areas of healthcare. References
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