American Journal of Emergency Medicine (2010) 28, 460–465

www.elsevier.com/locate/ajem

Original Contribution

The diagnostic role of capnography in pulmonary embolism

Ozlem Kar Kurt MD a,⁎, Sibel Alpar MD a , Tugrul Sipit MD a , Selma Firat Guven MD a ,
Hakan Erturk MD b , Mikail Koray Demirel MD c , Meliha Korkmaz MD c ,
Mutlu Hayran MD d , Bahar Kurt MD e
a
Department of Chest Diseases, Ataturk Chest Disease and Thoracic Surgery Teaching and Research Hospital,
06280 Ankara, Turkey
b
Department of Radiology, Ataturk Chest Disease and Thoracic Surgery Teaching and Research Hospital,
06280 Ankara, Turkey
c
Division of Nuclear Medicine, Ankara Teaching and Research Hospital, 06340 Ankara, Turkey
d
Institute of Oncology, Department of Preventive Oncology, Hacettepe University, Faculty of Medicine, 06100 Ankara, Turkey
e
Department of Chest Diseases, Abant Izzet Baysal University Medical School, 14100 Bolu, Turkey

Received 17 December 2008; revised 24 January 2009; accepted 25 January 2009

Abstract The aim of this study was to evaluate the diagnostic contribution of alveolar dead space
fraction (AVDSf) measured using capnography in patients admitted with suspected pulmonary
embolism (PE). A total of 58 patients who were admitted to our hospital with suspected PE between
October 2006 and January 2008 were included in this study. All patients were assessed using the Wells
clinical score, capnography, computed tomographic pulmonary angiography, D-dimer measurement,
lower-extremity venous Doppler ultrasonography, and V/Q scintigraphy. Forty patients (69%) had PE
based on computed tomographic pulmonary angiography findings. The AVDSf value with the highest
sensitivity and specificity, which was at the same time statistically significant, was 0.09. This value was
consistent with the AVDSf value obtained using receiver operating characteristic analysis. In our study,
the sensitivity of capnography was 70%, with a specificity of 61.1%, positive predictive value of 80%,
and negative predictive value of 47.8%. The use of AVDSf in combination with any of the several
scoring systems that evaluate clinical likelihood of PE and D-dimer levels resulted in higher sensitivity
and specificity rates for the diagnosis of PE.
© 2010 Elsevier Inc. All rights reserved.

1. Introduction by a thrombus originating from the venous system results in a

Pulmonary embolism (PE) is part of a group of
thromboembolic disorders with a clinical spectrum ranging
from mild symptoms to severe life-threatening right heart
failure. The occlusion of the pulmonary artery or its branches
⁎ Corresponding author. Tel.: +90 505 2762811; fax: +90 312 3552135.
E-mail address: aghhozlem@yahoo.com (O.K. Kurt).
clinical picture with high mortality and morbidity. According
to several reports, the incidence of PE has been reported
between 21 and 69/100 000 [1]. The co-presence of deep vein
thrombosis and PE is referred to as venous thromboembolic
disease and is a condition that is serious and difficult to
diagnose. Several studies have shown that the diagnosis of PE
is successfully made in less than half of patients before their
death [2,3]. In the International Cooperative Pulmonary

0735-6757/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2009.01.031
Diagnostic role of capnography in PE 461

Embolism Registry study, the 3-month crude death rate of Table 1 The characteristics of the patients with suspected PE
2454 patients with acute PE was 17.5% [4]. In reality, the PE % PE % P
actual prevalence of PE in autopsy series has not changed present absent
much in the past 3 decades (12%-15% of hospitalized patients)
Risk factor
[5]. Although the mortality rate is 30% in untreated cases, the
n 40 69 18 31
advent of anticoagulation therapy has seen this rate fall to 2%
Age (y) 64 54 .12
to 8%. It is for his reason that research has focused on (22-81) (22-77)
developing techniques for early and accurate diagnosis of this Sex
condition. In recent years, the use of capnography as a simple, Male 26 65 9 50 .28
noninvasive, fast, and practical test for the diagnosis of PE has Female 14 35 9 50
been under investigation as an intriguing modality based on Comorbidities
simple physiopathology [6-11]. Several studies have postu- COPD 5 12.5 2 11.1 .88
lated cutoff levels for alveolar dead space fraction (AVDSf), DM 2 5 3 16.7 .14
and when used in combination with other parameters such as ASCD 3 7.5 3 16.7 .36
clinical probability and D-dimer, has yielded very impressive HT 14 35 4 22.2 .33
History of smoking 20 50 8 44.4 .695
results in helping to rule out PE [8,9,11].
History of OC use 1 7.1 0 1.0
In this study on patients with suspected PE who presented
History of abortion 1 7.1 0 1.0
to the emergency department (ED) or the chest diseases Immobile for more 20 50 8 44.4 .695
clinic for further evaluation, we aimed to evaluate the benefit than 3 d
of alveolar dead space measurement using capnography, Operation within the 10 25 3 16.7 .481
alone or when used in combination with D-dimer and clinical previous 4 wk
probability, in the diagnosis of PE. Known history of 0 0
thrombophilia
History of DVT 7 17.5 0 .058
Malignancy (received 2 5 1 5.6 1.0
2. Materials and methods treatment within the
previous 6 mo)
This study was undertaken in the Ataturk Chest Diseases COPD indicates chronic obstructive pulmonary disease; DM, diabetes
and Thoracic Surgery Teaching and Research Hospital mellitus; ASCD, atherosclerotic coronary disease; HT, hypertension;
(Ankara, Turkey). The aim was to evaluate the diagnostic OC, oral contraceptive; DVT, deep vein thrombosis.
value of AVDSf measurement using capnography in patients
who were hospitalized in the emergency and chest diseases grouped by the presence or absence of a thrombus.
wards with suspected PE. Inclusion criteria included age Ventilation perfusion (V/Q) scintigraphy was done for 50
between 18 and 75 years, with no history of treated and/or patients, and consistent with the Prospective Investigation of
recurrent PE. Written consent was obtained for each enrolled Pulmonary Embolism Diagnosis study, patients were classi-
patient as per the Helsinki declaration. Those with confirmed fied as normal, low, intermediate, or high risk. All patients
or suspected pregnancy, known allergies to contrast solution, were evaluated with computed tomographic pulmonary
in poor general condition (comatose, disoriented and angiography (CTPA). Films were read by the same
uncooperative, intubated or meeting criteria for shock), or radiologist establishing the presence or absence of emboli.
were morbid obese (≥140 kg) were excluded from the study. Finally, bedside levels of partial end-tidal carbon dioxide
After obtaining approval by the local ethic committee, a total pressure (PETCO2) were measured for all patients using the
of 58 patients who presented to our hospital with a suspicion TIDAL WAVE Sp Novametrix Handheld Capnography
of PE between October 2006 and January 2008 were included model 615, Novametrix Medical Systems Inc., Wallingford,
in this study. A detailed medical history and demographics Connecticut, USA, capnography device. With the help of
were recorded for each patient on admission, and patients arterial blood gas (ABG) analysis, the AVDSf was calculated
were questioned for risk factors for PE. The Wells score was using the PaCO2-PETCO2 gradient and the Bohr formula
completed for each patient, and subjects were divided into 3 (Formula 1). The alveolar-arterial oxygen gradient [P(A-a)]
groups according to their score (b2, low probability; 2-6, was calculated using Formula 2.
intermediate probability; N6, high probability).
Quantitative measurement of D-dimer was performed in AVDSf ðmm HgÞ = ðPaCO2  PETCO2 Þ=PaCO2 Formula1
56 patients using an AMAX AUTO D-Dimer kit, Trinity
PðA−aÞO2 = ð140  PaCO2 =0:8Þ  PaO2 Formula2
Biotech, Bray, Ireland (polystyrene, microparticle agglutina-
tion assay). Patients were grouped based on D-dimer levels of Age-adjusted P(A-a)O2 predicted levels were obtained
b500 and ≥500 μg/L. Fifty-six patients also underwent using Formula 3.
bilateral lower-extremity venous Doppler ultrasonography
(VDUSG) at the local radiology department. Patients were PðA  aÞO2 = 10 + 0:43ðage  20Þ Formula3
462 O.K. Kurt et al.

Statistical analysis was done using the Statistical Package

for Social Sciences 16.0 for Windows (SPSS, Chicago, Ill),
and a P value of less than .05 was considered statistically
significant.

3. Results

The characteristics of the 58 patients with suspected PE

are summarized in Table 1. According to CTPA findings,
40 patients (69%) had confirmed PE, with a median age of
64 years compared to the median age for those without PE
which was 54 years. In the PE group, the most common
symptoms were chest pain (82.5%), shortness of breath
(72.5%), redness and swelling of the legs (50%), hemoptysis
(40%), cough (35%), palpitations (10%), and syncope (5%).
Rales on auscultation (40%), Homans sign (35%), tachy-
Fig. 1 Receiver operating characteristic curve for the optimal
cardia (25%), and an accentuated pulmonary component of
cutoff point of the predictive value of AVDSf in the diagnosis of PE.
S2 (2%) were the most commonly encountered physical
examination findings.
The patients' laboratory results, Wells scores, ABG serum glucose, and renal function tests, patients with PE had
analysis, P(A-a), PETCO2, and AVDSf are summarized in significant hypoxia and hypocapnia. For the patients with
Table 2. Although there was no significant difference PE, the mean AVDSf was 0.174 compared with 0.136 in the
between the 2 groups with regard to complete blood count, normal group (P = .047). The cutoff value for AVDSf in the
detection of PE was calculated as 0.083 or higher using the
receiver operating characteristic (ROC) analysis (sensitivity,
72.5%; specificity, 61.1%; area under the curve, 0.664
Table 2 Laboratory results, Wells scores, ABG, PETCO2, [0.516-0.812]; P = .047) (Fig. 1). The sensitivity, specificity,
P(A-a)O2, and AVDSf values of patients with suspected PE
positive predictive value (PPV), negative predictive value
PE present PE absent P (NPV), and κ agreement value were calculated for every
n 40 18 AVDSf value between 0.03 and 0.17. An AVDSf value of
Leukocytes 8.5 (3.7-28.9) 9.2 (5.1-14.2) .77 0.09 was found to have the most statistically significance,
(×103/mm3) with the highest sensitivity, specificity, and κ agreement
Hemoglobin 13.2 (9.8-15.2) 13.4 (12.8-16.1) .66 values. This value was consistent with that obtained from the
(g/dL) ROC analysis.
Hematocrit (%) 37.7 ± 4.3 39.8 ± 2.1 .86 Table 3 shows a comparison of CTPA findings with D-
Platelet 254 (110-422) 226 (143-649) .45 dimer levels, bilateral lower-extremity VDUSG findings,
(×103/mm3) Wells scores, and V/Q scintigraphy alone or in combination
ESR (/h) 44 (4-84) 60 (23-85) .71
with AVDSF in patients with suspected PE.
Glucose 126 (60-308) 131 (110-137) .52
(mg/dL)
Patients were grouped based on their Wells score, with 7
BUN (mg/dL) 22 (10-42) 21 (11-54) .94 (12.1%) patients falling into the low probability group,
Creatinine 1.0 (0.7-1.5) 1.1 (0.5-1.8) .88 whereas the intermediate and high probability groups had 30
(mg/dL) (51.7%) and 21 (36.2) patients, respectively. Pulmonary
SO2 (%) 92 (70-97) 96 (85-97) .06 embolism detected by CTPA was observed in 1 patient
D-dimer 1061 (285-6500) 735 (263-5995) .99 (14.3%) in the low-probability group, in 18 patients (31%)
(ng/mL) from the intermediate-probability group, and in all 21
pH 7.42 (7.34-7.52) 7.40 (7.38-7.48) .68 patients (100%) in the high-probability group. Patients in
PCO2 (mm Hg) 34.5 (28.1-48.6) 38.4 (35.6-52.1) .057 the high-probability group were considered as having PE,
PO2 (mm Hg) 63.0 (32.4-85) 64.6 (49.3-132) .86 whereas those in the low- and intermediate-probability
P(A-a)O2 33.7 ± 2.3 32.0 ± 3.7 .71
groups were accepted as not having PE (Table 3).
PETCO2 28 (19-40) 35 (30-40) .003
Wells score 7.0 (3.0-10.5) 2.5 (0-5.5) b.001
Ventilation perfusion scintigraphy was performed in 50
AVDSf 0.174 ± 0.12 0.136 ± 0.14 .047 patients (86%). Findings were normal in 6 (12%), whereas
pCO2-PETCO2 4.7 [-2.8- (+18.6)] 5.6 [-1.0- (+17.1)] .094 for 10 patients (20%), the result was low probability. Eight
patients (16%) were considered as having intermediate
ESR indicates erythrocyte sedimentation rate; BUN, blood urea nitrogen.
probability for PE, whereas 26 (52%) had high probability.
Diagnostic role of capnography in PE 463

Table 3 The comparison of CTPA with D-dimer levels, lower-extremity VDUSG findings, Wells scores, and V/Q scintigraphy results
alone and in combination with AVDSf
PE Embolus Sn Sp PPV NPV Accuracy κ P
on CT
+ − % % % % %
AVDSf ≥0.09 + 28 7 70 61.1 80 47.8 67.2 0.289 .025
AVDSf b0.09 − 12 11
D-dimer ≥500 + 27 13 71.1 27.8 67.5 31.2 57.1 -0.012 .928
D-dimer b500 − 11 5
D-dimer + AVDSf + 35 13 89.7 27.8 72.9 55.6 70.2 0.202 .092
− 4 5
VDUSG + 24 3 60.0 81.2 88.9 44.8 66.1 0.332 .005
− 16 13
VDUSG + AVDSf + 33 8 82.5 55.6 80.5 58.8 74.1 0.386 .005
− 7 10
Wells + 21 0 52.5 100 100 48.6 67.2 0.407 b.001
− 19 18
Wells + AVDSf + 32 7 80.0 61.1 82.1 57.9 74.1 0.405 .002
− 8 11
V/Q + 24 2 64.9 84.6 92.3 45.8 70.0 0.388 .002
− 13 11
V/Q + AVDSf + 33 8 82.5 52.9 80.5 56.2 73.7 0.361 .009
− 7 9
Sn indicates sensitivity; Sp, specificity.

Computed tomographic pulmonary angiography detected PE
in 3 (50%), 5 (50%), 5 (62.5%), and 24 (92.3%) of patients in
the normal-, low-, intermediate-, and high-probability
groups, respectively. Patients in the normal-, low-, and
intermediate-probability groups were judged to be free of PE
(Table 3).
4. Discussion
Pulmonary embolism is a condition that is serious and
difficult to diagnose with high mortality and morbidity. The
importance of early diagnosis and treatment highlights the
need for easier diagnostic modalities. Clinical assessment is
the cornerstone of the diagnosis of PE in patients suspected
of having the condition. In our study we used the likelihood
algorithm proposed by Wells et al [12], which combines
clinical findings with risk factors, electrocardiogram, and
chest x-ray findings in patients suspected of having PE. In
this study, patients with confirmed PE fell into the high-
probability group (median Wells score, 7), whereas those
without PE fell into the low-probability group (median score,
2.5), and the difference between both groups was statistically
significant (P b .001) (Table 2).
Several noninvasive tests have been proposed to help
decrease the dependency on invasive tests in patients with
suspected PE. D-dimer is one such test. It is quite safe on

Table 4 Comparison of our study results on capnography for PE with other reports from the literature
Test Sn (%) Sp (%) PPV (%) NPV (%)
Kar Kurt et al AVDSf (0.09) 70 61.1 80 47.8
AVDSf + Wells scores 80 61.1 82.1 57.9
AVDSf + D-dimer 89.7 27.8 72.9 55.6
AVDSf + VDUSG 82.5 55.6 80.5 58.8
V/Q + AVDSf 82.5 52.9 80.5 56.2
Kline et al [8] AVDSf (0.20) 67.2 76.3
D-dimer 93.8 67.1
D-dimer + AVDSf 98.4 51.6
Rodger et al [9] AVDSf (0.15) 79.5 70.3
D-dimer 83 57.6
Hogg et al [10] AVDSf (0.32) 95.3 20 6.2 98.7
Sanchez et al [11] AVDSf (0.15) 68.5 81.5 71.1 79.5
AVDSf + Wicki scores 70 61.1 80 47.8
464
ruling out PE, thus helping to avoid further unnecessary
testing [13]. However, it has low specificity, particularly in
the elderly, pregnant women, patients with cancer, and
hospitalized patients where the D-dimer test correctly
excludes PE in only 30% of the patients [14]. In our study,
D-dimer had a sensitivity of 71.1% and specificity of 27.8%.
In PE, the affected lung parenchyma has normal
ventilation, but perfusion is affected. In the nonperfused
alveolar space, the amount of carbon dioxide expressed is
low. In summary, PE increases the amount of alveolar dead
space, thus resulting in a decrease in carbon dioxide in
expired air. However, several studies have shown that
AVDSf values obtained using bedside capnography did not
satisfactorily exclude PE [8,11]. In the same studies, it was
demonstrated that the concomitant use of other tests such as
D-dimer, Wells score, USG, and V/Q scintigraphy signifi-
cantly increased the sensitivity and NPV of AVDSf in ruling
out PE. For their ease, D-dimer and clinical probability
scores have been used more commonly (Table 4).
Sanchez et al [11] studied 270 patients with suspected PE
who had positive D-dimer tests. Capnography and ABG
measurements were obtained for each patient before spiral
CT and lower-extremity VDUSG was performed. In this
study, an AVDSF value of less than .15 was considered
normal. Patients with negative spiral CT and USG findings,
and those with low Wicki scores falling into the low-and
intermediate-probability groups were excluded from study as
not having PE. Patients with normal USG and spiral CT
findings, but high-probability Wicki scores, were included in
the study; and within the first 48 hours they underwent either
one or both of V/Q scintigraphy and pulmonary angiography.
In 45 patients (16.6%), the combination of low clinical
probability and normal capnography managed to exclude PE
in 99.1% sensitivity. In the 34 patients with high clinical
probability and positive capnography, this combination had
been 100% specific and 31.5% sensitive in correctly
diagnosing PE. Overall, the combination of capnography
and Wicki scores had a sensitivity of 70% and specificity of
61.1%. In this study by Sanchez et al, D-dimer was measured
using the rapid quantitative enzyme-linked immunosorbent
assay test. By excluding patients with D-dimer levels of less
than 500, they enrolled a select group. Therefore, the
sensitivity and specificity values provided for AVDSf are
actually representative of its combination with D-dimer, and
with clinical probability a triple combination.
In our study, the AVDSf cutoff point was set at 0.09 after
analysis of the ROC. This value differs from that obtained in
previous studies (0.15-0.32) [8-11]. Our results with AVDSf
alone or in combination with Wells score, D-dimer, and
lower-extremity VDUSG have been compared with previous
studies in Table 4. The sensitivity of capnography in our
study was increased from 70% to 89.7% with combination of
D-dimer.
In a prospective multicenter study by Kline et al [8], 380
patients who presented to the ED were enrolled. They aimed
to demonstrate that D-dimer and AVDSf values could help in
O.K. Kurt et al.
ruling out PE. D-dimer was measured using whole-blood
agglutination assay (Simpli-RED, Agen Inc, Brisbane,
Australia) on blood samples obtained for ABG analysis
necessary for calculating AVDSf. Pulmonary embolism was
confirmed in 64 patients (16.8%) in this study. The high PE
ratio in our study could be attributed to the fact that
hospitalized patients were included in our study, whereas
patients who presented to the ED who had normal D-dimer
and CTPA findings were excluded. Kline et al considered an
AVDSf value of ≤0.20 as normal, with a sensitivity of 67.2%
and specificity of 76.3%. In the same study, D-dimer had a
sensitivity of 93.8% and specificity of 67.1%. Positivity of
either one of D-dimer or AVDSf (63/64 patients) had a
sensitivity of 98.4% and specificity of 51.6%. In our study,
the sensitivity and specificity of D-dimer were 71.1% and
27.8%, respectively, whereas for AVDSf these values were
70% and 61.1%. Either one of them being positive (34/40)
successfully predicted PE with sensitivity of 89.7% and
specificity of 27.8% (P = .092, κ = 0.202).
The low specificity of this combination in our study may
have been because of the technique used in measuring D-
dimer levels. Kline et al reported a mean AVDSf value of
0.33 in 8 patients who eventually died of PE, whereas in the
remaining 56 patients with PE, the mean value was 0.23. In 6
patients who did not have PE, but died due from other
causes, this value was 0.11. It was suggested that AVDSf
may play an important role in determining the severity of PE.
Because the patients in our study were not followed up, we
could not evaluate the link between AVDSf and overall
survival. In the study by Kline et al, patients with suspected
PE with a negative D-dimer value and normal AVDSf were
found to have a 1% probability for having PE.
In a similar study by Rodger et al, PE was detected in 49
of 246 patients with suspected PE. An AVDSf value of less
than 0.15 was considered normal [9]. A negative D-dimer
value excluded PE with a sensitivity of 83.0% and a
specificity of 57.6%. A normal value for AVDSf ruled out PE
with 79.5% sensitivity and 70.3% specificity. The combina-
tion of negative D-dimer with a normal AVDSf value was
98.4% sensitive and 38% specific in ruling out PE. The mean
AVDSf value for those with confirmed PE was 0.27
compared with 0.11 for those without PE.
In a study by Hogg et al on 425 patients who presented
with pleurisy, 5% had detectable PE, and AVDSf had a
sensitivity and specificity of 95.3% and 20%, respectively,
with an NPV of 98.7% and a PPV of 6.2% [10]. The
combination of a positive AVDSf value obtained using the
Bohr equation and a positive D-dimer value had a sensitivity
of 90.5% and a specificity of 72.3% with NPV and PPV
values of 99.3% and 13.2%, respectively.
In our study, the median PETCO2 obtained from capno-
graphy measurements for patients with confirmed PE was 28
(19-40), whereas in those without PE, this value was 35 (30-
40), a statistically significant difference (P = .003). This
result is consistent with physiologic PETCO2 variation.
Studies have shown that a normal PaCO2-PETCO2 gradient
Diagnostic role of capnography in PE
is not sensitive enough to safely exclude a diagnosis of PE
[15]. Verschuren et al [15] reported that a cutoff value of 3
had a sensitivity of 77% and specificity of 70%. In our study,
the median gradient in the PE group was 4.7 compared with
5.6 in those without PE (P = .094).
In recent years, the use of capnography as a simple,
noninvasive, fast, and practical test for the diagnosis of PE
has been under investigation as an intriguing modality based
on simple physiopathology. Meaningful results have been
reported in studies on the value of AVDSf (obtained from
capnography measurements using the Bohr equation)
combined with parameters such as clinical probability and
D-dimer in ruling out PE [9]. Capnography may help avoid
unnecessary further testing in up to 30% of patients [11].
In our study, as with other similar studies, we concluded
that capnography has its shortcomings when used alone in
the diagnosis of PE. However, the use of AVDSf in
combination with any of the several scoring systems that
evaluate the clinical likelihood of PE (eg, Wells, Wicki, and
Pisa) and D-dimer levels resulted in higher sensitivity and
specificity rates for the diagnosis of PE. In fact, combining
all 3 modalities may alleviate the need for imaging
techniques in the diagnosis of PE. Of course there is dire
need for large-scale studies to support our findings.
References
[1] Fennerty T. The diagnosis of pulmonary embolism. BMJ 1997;314:
425-9.
[2] Dalen J. Clinical diagnosis of acute pulmonary embolism. In: Morpugo
M, editor. Pulmonary embolism. NewYork: Dekker; 1994. p. 55-66.
465
[3] Rubinstein I, Murray D, Haffsten V. Fatal pulmonary emboli in
hospitalized patients. Arch Intern Med 1988;148:1425-6.
[4] Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism:
clinical outcomes in the International Cooperative Pulmonary
Embolism Registry (ICOPER). Lancet 1999;353:1386-9.
[5] Stein PD, Henry JW. Prevalence of acute pulmonary embolism among
patients in a general hospital and at autopsy. Chest 1995;108:78-81.
[6] Nutter DO, Massumi RA. The arterial-alveolar carbon dioxide
tension gradient in diagnosis of pulmonary embolus. Dis Chest 1966;
50:380-7.
[7] Hatle L, Rokseth R. The arterial to end-expiratory carbon dioxide
tension gradient in acute pulmonary embolism and other cardiopul-
monary diseases. Chest 1974;66:352-7.
[8] Kline JA, Israel EG, Michelson EA, et al. Diagnostic accuracy of a
bedside D-dimer assay and alveolar dead-space measurement for rapid
exclusion of pulmonary embolism: a multicenter study. JAMA 2001;
285:761-8.
[9] Rodger MA, Jones G, Rasuli P, et al. Steady-state end-tidal alveolar
dead space fraction and D-dimer: bedside tests to exclude pulmonary
embolism. Chest 2001;120:115-9.
[10] Hogg K, Dawson D, Tabor T, et al. Respiratory dead space
measurement in the investigation of pulmonary embolism in out-
patients with pleuritic chest pain. Chest 2005;128:2195-202.
[11] Sanchez O, Wermert D, Faisy C, et al. Clinical probability and alveolar
dead space measurement for suspected pulmonary embolism in
patients with an abnormal D-dimer test result. J Thromb Haemost
2006;4:1517-22.
[12] Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for
safe management of patients with suspected pulmonary embolism.
Ann Intern Med 1998;129:997-1005.
[13] Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of deep
venous thrombosis and acute pulmonary embolism: a systematic
review. Ann Intern Med 2004;140:589-602.
[14] Perrier A, Desmarais S, Miron MJ, et al. Noninvasive diagnosis of
venous thromboembolism in outpatients. Lancet 1999;353:190-5.
[15] Verschuren F, Liistro G, Coffeng R, et al. Volumetric capnography as a
screening test for pulmonary embolism in the emergency department.
Chest 2004;125:841-50.