Journal of Clinical Monitoring and Computing (2010) 24:261–268
DOI: 10.1007/s10877-010-9243-3
A REVIEW OF PEDIATRIC CAPNOGRAPHY
1,2
Naveen Eipe, MBBS, MD and Dermot R. Doherty,
MB, BCh, BAO, FCARCSI, EDIC3
Preliminary work in this area was presented as a Poster at the
Society for Pediatric Anesthesia Winter Meeting, San Diego April
2008 and at the Canadian Anesthesiologist Society Annual Meeting,
Halifax June 2008.
From the 1The Ottawa Hospital (TOH), Ottawa, ON, Canada;
2
Department of Anesthesiology, University of Ottawa, 249C-1053
Carling Ave. Suite B310, Ottawa, ON K1Y 4E9, Canada;
3
Department of Anesthesiology and Intensive, Children’s Hospital
of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON
K1H 8L1, Canada.
Received 3 April 2010. Accepted for publication 1 July 2010.
Address correspondence to N. Eipe, Department of Anesthesiology,
University of Ottawa, 249C-1053 Carling Ave. Suite B310,
Ottawa, ON K1Y 4E9, Canada.
E-mail: neipe@toh.on.ca
Ó Springer 2010
Eipe N, Doherty DR. A review of pediatric capnography.
J Clin Monit Comput 2010; 24:261–268
ABSTRACT. Objectives. Capnography has become a standard
of perioperative monitoring in pediatric anesthesiology. It has
also begun to find application in a variety of situations outside
the perioperative setting. While the use of capnography has
been increasing, the dissemination and acceptability of
capnography in all areas of pediatrics has been variable. The
purpose of this study was to describe all the applications and
interpretations of capnography that have been reported in
children. Methods. In March 2010, we completed a search of
peer reviewed literature from MEDLINE (from 1950),
CINAHL (from 1982) and the Cochrane Library. Final search
results were limited to publications in which the primary intent
was to describe the application or interpretations of capnography
in children. Results. This search resulted in a list of 44
applications and interpretations of capnography. We classified
the applications and interpretations of capnography in children
into six categories—Anesthetic Delivery Apparatus, Airway,
Breathing, Circulation, Homeostasis and Non-perioperative. We
discuss the four randomized controlled trials describing the use
of capnography in children. Based on the available evidence, we
have also assigned grades of recommendations for these
applications and interpretations. Conclusions. Capnography
has been proven to be a useful non-invasive perioperative
monitor of the physiology and safety of the child. This list of the
clinical applications and interpretations of capnography could
find use in teaching and simulation in pediatrics.
KEY WORDS. Pediatric: anesthesiology, patient safety, monitoring,
Monitoring: perioperative, non-invasive CO2, capnography, tools:
teaching, simulation.
INTRODUCTION
Capnography has been widely used in children since its
application was first described in adult anesthesiology over
three decade’s ago [1] and has become a standard [2] of
perioperative monitoring in anesthesiology. Several
pediatric expert groups [3] strongly recommended its use
for monitoring children undergoing even minor diag-
nostic and therapeutic procedures outside the OR. The
objectives of this study were to describe all the applica-
tions and interpretations of capnography reported in
children.
METHODS
In March 2010, we completed a systematic electronic
literature search of databases—Medical Literature Analysis
262 Journal of Clinical Monitoring and Computing
and Retrieval System Online (MEDLINE, 1950 to March
2010 Week 3), Cumulative Index of Nursing and Allied
Health Literature (CINAHL, 1982 to December Week 1
2007 using the Ovid interface and updated to March 19
2010 using the EBSCO interface) and the Cochrane
Library (up to Issue 1, 2010). The search terms used
were– ‘‘Capnography’’, ‘‘Capnometry’’ and ‘‘End-tidal
CO2 monitoring’’. The searches were limited to material
published in English, French, German and Spanish. No
study design limits were imposed.
Final search results were limited to publications in
which the primary intent was to describe applications
and/or interpretations of capnography in clinical situa-
tions and scenarios with or without other monitoring
modalities in children. Randomized controlled trials
(RCTs) that compared capnography with another mon-
itoring modality and/or commented on the utility of the
monitor were identified.
Once the application was identified and if there were
multiple citations for the same application, the investiga-
tors chose the most relevant and recent reference that best
supported the capnography application or interpretation
described.
Reference Manager Version 12 (www.refman.com)
was used to review the citations. The applications iden-
tified were then classified using a previously described
system of clinical applications and interpretation of cap-
nography [4]. Recommendations for each application
were assigned based on the guidelines from the Oxford
Centre for Evidence Based Medicine (CEBM) [5].
FINDINGS
The search methods identified eight hundred and 21 (875)
citations. From these, 44 different clinical applications or
interpretations of capnography in children were listed.
In Table 1, the applications or interpretations of cap-
nography in children are listed, classified into six catego-
ries [4] and recommendations for the use of each
application is made based on the CEBM level of evidence
[5].
Anesthetic delivery
Capnography is considered a basic anesthesia monitor and
its use during anesthesia, sedation or even in awake
children is primarily to detect and prevent hypoxemia [6].
Its use confirms adequate fresh gas flow (oxygen, air and
or nitrous oxide), effective intra-operative ventilation and
other intra-operative events. It has been used during
various anesthetic techniques—whether intravenous or
inhalational with spontaneous, assisted or mechanical
ventilated [6–8]. In inhalational anesthesia, capnography
can additionally detect breathing circuit disconnections or
other component malfunction [6]. During intravenous
anesthesia, respiratory rate, depth and effort have been
determined from capnography [9]. In non-rebreathing
systems capnography is used to detect rebreathing of ex-
haled carbon dioxide (CO2) can aid in prevention of
hypercarbia through the adjustment of fresh gas flow [10].
In closed anesthesia breathing systems, it detects soda lime
exhaustion, one-way valve malfunction, and sampling line
disconnections [11–13].
Airway
In awake children, the continued patency of the natural
airway is demonstrated by capnography [8, 14]. During
laryngoscopy and tracheal intubation, it is used both to
confirm tracheal and to rule out esophageal intubation
[15]. This is considered the ‘first and foremost’ use of
capnography. Volatile-based anesthetics with supraglottic
airway devices (laryngeal mask airways or laryngeal tubes)
in children have been monitored with continuous cap-
nography to detect dislodgement [16, 17]. Capnography
can indirectly detect a leak around an uncuffed tracheal
tube and thereby aid appropriate tube size selection in
children [18]. Blockage or kinking of the tracheal tube (or
other airway devices) has been detected by capnography
[6]. Its detection of CO2 that confirms tracheal serves as a
useful adjunct in difficult airway maneuvers such as
fiberoptic intubations, blind nasal intubations or bron-
choscopy [19–21]. Capnography has been used in anes-
thesia for pediatric thoracic surgery requiring lung
isolation techniques with the placement of double lumen
tubes [22].
Breathing
In the perioperative period, capnography has been used to
confirm adequacy of spontaneous or mechanical ventila-
tion [23, 24]. Careful observation of the trace can be
useful to detect the onset, waning or reversal of neuro-
muscular blockade [6]. It is useful to demonstrate distal
and small airway obstruction and or bronchospasm [25,
26]. The efficacies of advanced ventilatory strategies
including trans-tracheal or high frequency jet ventilation
have been monitored with capnography [27, 28]. Heliox
therapy in bronchiolitis and other distal airway diseases
have been monitored with capnography [29]. In all these
situations, adequate CO2 removal can be monitored with
Capnography. It has also been used to detect dead space
ventilation and estimate the dead space fraction from the
 Eipe and Doherty: Capnography in Children 263

Table 1. Applications and interpretations of capnography in children

Category [4] Application Example of Grade of

reference recommendation
[CEBM] [5]

Anesthetic delivery Detect circuit disconnections/adequate gas delivery [6] B

Define arterial—end tidal relationship [7] B
Intravenous sedation—detecting airway and respiratory events [9] B
Analysis of rebreathing circuits/adequate fresh gas flow [10] C
Detect exhausted soda lime [11] D
One way valve function [12] C
Sampling line disconnection [13] D
Airway Patency of natural airway [14] A
Confirms tracheal intubation/rules out esophageal intubation [15] A
Measure of arterial CO2 during spontaneous breathing through a LMA [16] C
Detect leak and determine size of un-cuffed tracheal tubes [18] C
During difficult airway maneuvers [19] D
Bronchoscopy [21] C
Single-lung ventilation [22] D
Breathing Adequacy of spontaneous ventilation [23] C
Adequacy of mechanical ventilation [24] B
Onset, waning or reversal of neuromuscular blockade [6] C
Dead space calculation [25] D
Severity and treatment of asthma [26] B
Trans tracheal jet ventilation [28] C
Heliox therapy [29] C
Circulation Estimating cardiac output [31] C
Pulmonary embolism [32] C
Congenital heart disease [34] C
During cardiac surgery [37] C
Cardiac arrhythmias [38] C
Cardiac oscillations [39] D
Homeostasis Overall metabolic state [40] B
Sepsis, fever and malignant hyperthermia [41] B
Laparoscopic surgery [42] D
Respiratory failure [43] C
Metabolic acidosis [44] B
Cerebral effects [45] C
Nutritional/inotropic support [46] C
Non-Perioperative Out of hospital intubation [47] D
Transport monitor [48] B
ROSC/CPR [51] C
Sleep studies [52] C
Seizure studies [54] C
Monitoring for SIDS [55] D
Neonatal lung testing [56] D
Analysis of lung growth [57] C
Entral tube placement [58] B
Assessment of transcutaneous capnometry [59] B
CEBM grades of recommendation. A consistent level 1 studies. B consistent level 2 or 3 studies or extrapolations from level 1 studies. C level
4 studies or extrapolations from level 2 or 3 studies. D level 5 evidence or troublingly inconsistent or inconclusive studies of any level.
264 Journal of Clinical Monitoring and Computing
difference relationship between the arterial CO2 and the
end-tidal CO2 [25].
Circulation
In children, while heart rate and blood pressure moni-
toring are directly indicative of cardiovascular stability,
capnography has been described as an adjunctive, albeit
indirect measure of cardiac output [30]. Direct estimation
of cardiac output from the end-tidal CO2 concentration is
also possible and has been found in healthy children to be
comparable Fick method calculations [31]. The capno-
graphic features of venous air embolism in which a sudden
fall in the end-tidal CO2 concentration often precedes
that of the blood pressure or any other recordable effect
have been well described [1, 32]. The application of
capnography as an indirect indicator of pulmonary blood
flow has been reported in congenital heart diseases [33–
35]. It has been found useful during corrective or pallia-
tive cardiac surgery in which improvement in pulmonary
blood flow, cardiac output, or both are indicated by an
increase in the end-tidal CO2 concentration [36, 37]. In
instances where persistent cardiac arrhythmias correlate
with hypercarbia, capnography is useful in arrhythmia
evaluation [38]. The ‘cardiogenic oscillations’ often seen
on capnography are reflections of pulsatility of pulmonary
blood transmitted to the airway [39].
Homeostasis
Capnography has been used to reflect the child’s overall
metabolic state [40]. End-tidal CO2 concentration can
be elevated in sepsis, fever and malignant hyperthermia
[6, 41]. Capnography can estimate carbon-dioxide absorp-
tion during laparoscopic surgery 42]. It has been used as a
continuous monitor of acid–base balance in pediatric pa-
tients with diabetic ketoacidosis or respiratory failure, or in
those receiving sodium bicarbonate therapy [43, 44]. Non-
invasive and continuous end-tidal CO2 monitoring offer
an early warning system for unexpected changes in acidosis
that may decrease need for and cost of blood sampling.
Capnography has been used as an indirect monitor of
cerebral blood flow and intracranial pressure [45]. In
intensive care, nutritional support can affect weaning from
ventilatory support as the metabolism of carbohydrates
increases CO2 production. The effect of vasoactive drugs
on capnography has also been described [46].
Non perioperative
Capnography confirms tracheal intubations by paramedics
and ambulance crews [47]. During transport its use
monitors tracheal tube patency [48, 49]. Capnography has
proven invaluable during pediatric cardiopulmonary
resuscitation; presence of end-tidal CO2 during cardio-
pulmonary resuscitation (CPR) not only confirms tracheal
tube placement, but can be, in the continued absence of a
recordable pulse or blood pressure; the first sign of return
of circulation [50]. An important clinical corollary in
cardiopulmonary arrest situations is no end-tidal CO2
detection even when the tracheal tube is correctly placed
(‘true negative’), as a result of lack of circulation. Suc-
cessful resuscitation and prognosis thereafter have been
correlated with capnography [51].
Other uses of capnography include detecting sleep
associated gas exchange abnormalities in children [52] and
in the routine Sleep Lab Studies (polysomnography) for
obstructive sleep apnea [53]. It has been utilized as an
adjunct to neurophysiological monitoring of seizure
thresholds [54]. Home capnography has been suggested as
early detector of home cardiopulmonary events, such as
those which may occur in infants with high risk of sudden
infant death syndrome (SIDS). Capnography can act as a
substitute to pulmonary function testing in neonatal lung
testing [55]. Lung growth patterns have also been analyzed
non-invasively using capnography [56]. As the neonatal
lung grows and alveoli mature characteristic changes in
capnograms have been described [57]. Entral feeding tube
placements have been confirmed by capnography—the
absence of CO2 in a correctly placed feeding tube rules
out inadvertent placement within the airway [58]. Newer
monitoring equipment, notably transcutaneous capnom-
etry, has been compared to capnography [59].
DISCUSSION
Capnography is the non-invasive monitoring of this
concentration or partial pressure of carbon dioxide (CO2)
in respiratory gases. CO2 is produced in the tissues, carried
in the blood, exchanged in the lungs and expired through
a patent airway. We therefore consider capnography to be
an integrated indicator of the functions of the respiratory,
cardiovascular and metabolic systems and this concept was
the basis for the system of classification of the applications
or interpretations of capnography [4]. In the monitoring
of children, this review has confirmed capnography’s well
established role in anesthesiology and perioperative
medicine.
After tracheal intubation, the presence CO2 detected
by capnography is the most sensitive confirmation of the
correct position of the tube in the trachea. This test also
specifically rules out esophageal intubation. When the
failure to detect esophageal intubation was identified as

the leading cause of perioperative/anesthetic morbidity
and concurrently capnography identified as the most
sensitive monitor for preventing this—these two funda-
mental facts probably led to capnography become a stan-
dard of perioperative monitoring [2, 60]. The initial
American Society of Anesthesiologists (ASA) guidelines
(1986) determined capnography to be useful for confir-
mation of placement and continuous presence of a tracheal
tube. Updated ASA standards (2005), recommend standard
capnography use to confirm adequate ventilation during
general anesthesia with or without a tracheal tube [2].
During anesthesia, capnography is an indispensable
monitor of both the physiology and the safety of the
patient. Hypoventilation results in an increase in CO2
before the decrease in oxygen saturation and this caveat
makes capnography useful in the early detection (and
appropriate prevention) of hypoxemia [61]. Pulse oxim-
etry in combination with capnography have been dem-
onstrated to be reliable and sensitive intra-operative
monitors for the detection of critical incidents such as
malignant hyperthermia, circuit disconnection or leak,
equipment failure, accidental extubation etc. [6]. Detec-
tion of hypoventilation can be made by capnography prior
to a decline in arterial blood saturation on pulse oximetry
[14]. Capnographic abnormalities have alerted the health
care provider to impeding adverse events even when no
desaturation is observed [62].
Recent applications or interpretations described in
adults include the detection of opioid-induced respiratory
depression (during patient controlled analgesia) and for
the diagnosis of apnea in the diagnosis of brain death [63,
64]. As these have not yet been described in children they
were not included in our current list of applications
(Table 1).
Previous reviews of monitoring in children have
described the applications or interpretations of capnogra-
phy but have not attempted to classify them [30, 65]. We
applied Eipe and Tarshis’ system of classification because
of its simplicity and applicability [4]. We also presume it
would be easy to use in teaching and simulation.
Capnography deserves its status as a basic standard based
on observational data from adults [66] and all applications
or interpretations of capnography in pediatrics do not
require controlled trials before their use can be recom-
mended [59]. Despite the widespread acceptance of cap-
nography in anesthesiology, its use in intensive care and
emergency departments has often been variable [67, 68].
This is possibly related to the fact that some of the
important applications or interpretations may not have
been yet validated by studies of sufficiently high levels of
evidence to justify widespread use.
There are till date, four randomized controlled trails
(RCTs) that describe an application or interpretation of
Eipe and Doherty: Capnography in Children 265
capnography compared with another monitoring modal-
ity [14, 62, 69, 70]. The double blind RCT reported by
Lightdale et al. (Pediatrics 2006) [14] included 163 children
between 6 months and 19 years undergoing 174 elective
gastrointestinal procedures under moderate sedation. All
children received routine care and supplemental oxygen
and capnography (blinded to all patients and endoscopy
staff). For patients randomized to the intervention arm
(n = 83), independent trained observers signaled to the
clinical staff if capnograms detected alveolar hypoventi-
lation for >15 s. Patients in the intervention arm were
significantly less likely to become hypoxemic (<95% for
>5 s) than those in the control arm. Odds Ratio and 95%
confidence intervals were 0.36 and 0.15–0.87 respec-
tively.
In a single blind RCT, Cote et al. (Anesthesiology 1991)
[62]; randomized 402 children to four groups of moni-
toring—pulse oximetry, capnography, both or none to
detect ‘major’ or ‘minor’ intraoperative events. They
reported that blinding of the oximeter and capnography
data significantly increased the number of ‘major’ desat-
uration and ‘minor’ capnographic events (p = 0.003 and
0.0026 respectively). They concluded that the number of
problems observed can be significantly reduced when
both monitors are used.
Mallick et al. report a RCT, (Anaesthesia 2003) [69]; on
55 patients (adults and children) undergoing percutaneous
tracheostomy who had tracheal tubes. Patients were ran-
domized to either capnography or bronchoscopy. The
authors concluded that capnography would be as useful as
bronchoscopy to confirm needle placement for this pro-
cedure. We note that all patients below 18 years were in
the capnography group and bronchoscopy was not pos-
sible in one patient (as it interfered with ventilation).
These findings support the use of capnography over
bronchoscopy in percutaneous tracheotomy.
In a double blind RCT evaluating pre-hospital venti-
lation of trauma patients, Helm et al. (British Journal of
Anaesthesia 2003) [70] report 97 patients (adults and
children) who were monitored during transfer with
standard monitors. While all were monitored with cap-
nography, 57 were randomized to have their caregivers
observe the capnogram during the transfer. They found
that the incidence of normoventilation significantly
increased while that of hypoventilation significantly
decreased (p < 0.0001). The incidence of hyperventila-
tion was however not reduced in the monitor group.
There has been considerable ongoing debate about the
accuracy of capnography in the dynamic monitoring of
patients during mechanical ventilation [71, 72].
Criticism of our study of the applications or interpre-
tations of capnography in children may firstly include the
methodology and analysis of the results. Our primary
266 Journal of Clinical Monitoring and Computing
objective was to design a simple tool that could be used in
teaching and simulation. Since we found only four RCTs
comparing capnography to another monitoring modality,
no systematic review or meta-analysis was deemed pos-
sible. We also did not score each citation individually
because of the heterogeneity of the studies that have re-
ported these applications. Secondly, we have not attempted
to independently describe the analyses and interpretation
of abnormal traces and values seen in capnography. This
and all the causes of gradual (or sudden) decreases or
increases in the end-tidal CO2 concentration have been
mentioned in standard textbooks [73–75]. Finally, we
chose to list the references for each application or inter-
pretation that were the most recent, pertinent and or
supportive. Other investigators interested in this subject or
monitor may use cross reference methods in any elec-
tronic search engine to expand the information on the
applications of capnography.
This review nevertheless probably represents the most
comprehensive list of the applications or interpretations of
capnography in children to date. As the use of capnogra-
phy becomes universal, this list of applications and inter-
pretations serves to inform clinicians of the widespread
potential for capnography use and applications in children.
For the experienced clinician capnography could reason-
ably form part of a diagnostic algorithm for abnormalities.
For trainee anesthetists, intensivists or physicians this sys-
tem of classification could serve as an aide-de-memoir for
capnography’s great potential for pediatric use.
CONCLUSIONS
Capnography is a useful indicator of respiratory and car-
diovascular system functions as well as of the maintenance
of homeostasis. Capnography also assesses the delivery of
anesthesia. Capnography continues to find wide applica-
tion and interpretation outside the perioperative settings.
This study further confirms the indispensable place of
capnography in the perioperative monitoring of children
and encourages further exploration of application and
interpretation.
We also acknowledge the contributions of Margaret Sampson,
Manager, Library Services (CHEO) for the electronic searches,
Raymond Daniel for assistance with the use of the Refman software
and Dr Hilary Writer, FRCPC for help with the manuscript.
Department and Institution to which work should be attributed:
Anesthesiology, Children’s Hospital of Eastern Ontario (CHEO).
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