Capnography

Erika A. Gibson, DVM Michigan State University Small Animal Clinical Sciences

What is capnography?
Capnography is the practice of recording the amount of carbon dioxide present

A capnogram is a graphic representation of the partial pressure of carbon dioxide over time

Gravenstein, Paulus, Hayes Capnograpy in Clinical Practice 1989

Physiology
Just after inhalation, the lungs are rapidly filled with oxygen and other gases (negligable CO2) CO2 diffuses across capillaries and into the alveoli as O2 moves from alveoli to capillaries As exhalation begins, CO2 rich air is expelled from first the upper and then the lower airways The capnogram represents the movement of CO2 over time All normal, healthy patients should ideally produce identical capnograms

Physiology (continued)
Any deviation from a normal wave is due to an altered physiological state, a pathological state, or equipment malfunction Any factor that affects the production, diffusion, elimination or partial pressure of CO2 will affect the capnogram The anesthetist must be able to distinguish between abnormal waveforms due to equipment failure/malfunction from those due to physiological conditions

Types of Capnographs
Trend capnograph Volume capnograph Time capnograph
displays the partial pressure of CO2 as a function of time
Main-stream
Side-stream

Main-stream
CO2 monitor is located between the ET tube and the breathing circuit Changes in vapor pressure do not affect the CO2 concentration Immediate recording of patients CO2 concentration Sensor is expensive to clean, heavy, and can become clogged with secretions

Side-stream
CO2 travels through a sampling tube to a sensor in the main unit Delayed recording due to time it takes gas to travel through tube Exhaled water vapor pressure affects the recorded CO2 pressure Can be used in awake patients

Clinical Applications
Check placement of endotracheal tube Monitor patient ventilation Identify potentially life-threatening situations (apnea, malignant hyperthermia) Monitor intracranial pressure and ventilation of comatose patients

Phases of the Capnogram

Phase I Phase II Phase III Phase 0

Expiration
Represents anatomical dead space

Expiration
Mixture of anatomical and alveolar dead space

Expiration
Plateau of alveolar expiration

Inspiration
Rapid fall in CO2 concentration

Phase IV Exhalation
Compromised thoracic compliance

Waveform Evaluation
Height
Evaluate the partial pressure of CO2 Assess ventilatory capability

Baseline
Is soda lime adequately removing CO2?

Shape
Are slopes too steep? To gradual?

Hyperventilation
Progressively lower plateau (phase II) segment

Baseline remains at zero

Decreasing CO2 levels

Hypoventilation
Steady increase in height of Phase II Baseline remains constant

Spontaneous Ventilation
Short Alveolar plateau Increased frequency of waveforms

Cardiogenic Oscillations
Ripples during Phase II and Phase III Due to changes in pulmonary blood volume and ultimately CO2 pressure as a result of cardiac contractions

Curare Cleft
Shallow dips in phase II plateau Can occur when patient is in a light plane of anesthesia Represent patient attempts to breathe independent of mechanical ventilation

Inspiratory Valve Malfunction

Increasing elevation of baseline
Increasing elevation of Phase II Smaller waveform represents rebreathing of CO2

Bronchospasm Airway Obstruction COPD

Sloping of inspiratory and expiratory segments Prolonged Phase II and Phase III

Rebreathing of Soda Lime Contamination with CO2

Elevation of Phase II segment and baseline

Progressive elevation of Phase II and baseline

Elevation of baseline and Phase II, smaller inspiratory efforts

Bain System
Smaller wave form represents rebreathing of CO2

Slow ventilation Incompetent inspiratory valve

Prolongation of Phase 0

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