CAPNOGRAPHY

• Measurment of CO2 in respiratory gases.

• Integral part of monitoring in
anaesthesia,PACU,emergency
medicine,ICU,procedural sedation for diagnostic and
therapeutic purposes and neonatal resuscitation.
• Luft 1937 developed it from knowledge that co2
absorbs infrared radiation of particular wavelength.
• Collier – value of rapid IR CO2 analysis
• Value of end tidal sample – Ramwell
• 1978 Holland – first country to adopt capnography
as standard monitoring in anesthesia
Terminology
• Capnography:graphic display of CO2
concentration in exhaled air.If FCO2 is plotted
against time (time capnogram) or expired
volume (volume capnogram)
• Capnograph: Machine that generates
waveform.
• Capnogram: Actual waveform
Terminology
• Capnometry: numerical display of CO2
concentration in inspired and expired air.
• Capnometer: Device that performs the
measurement & display readings
• Breath to breath waveform needs to be
displayed for continuous monitoring
• It directly indicates elimination of CO2 from
lungs(pulm),indirectly the pulmonary
perfusion,metabolic process ,alveolar
ventilation,resp pattern,integrity of artificial
airway and anesthesia administration device.
Methods used for measurement
1. Raman spectometry –
• Gas sample is illuminated by high intensity
monochromatic Argon laser beam.
• Light is absorbed by molecules which is then
excited to unstable vibrational & rotational
energy states, called as ‘Raman scattering’
• Used to identify molecules in gas phase
including CO2 & inhalational agents
• INFRARED SPECTROMETRY
• CO2 a polyatomic gas absorbs light at specific
wavelength(4.3um)in IR light spectrum,and
absorbtion is proportional to conc of
CO2(BEER LAMBERTS law).
• Measured co2 is displayed as either volume%
or as partial pressure(mmhg)
• Based on location of IR sensors,there are 2
types
• MAIN STREAM • SIDE STREAM
• Increase in mech dead • Minimal dead space
space • Co2,o2,N2O,volatile
• Used for co2 and o2 anaesthetics
• Waveform in real time
• Sensors are heavy,so • Waveform is delayed(1-
kinking of circuit 4secs)
• Risk of infection with • Sensors were light
cross contamination weight.
CALIBRATION
• Capnographs must be calibrated periodically
• At least daily acc to manufacturers for main
stream
• Automatic Zeroing – side stream moniter
• Main stream calibration sample cell sealed
with mixtures of CO2 & N2
• Range upto 70mmHg in MODERN
CAPNOGRAPHS are fairly accurate.variation in
atmospheric pressure,humidity,O2,inhalational
anesthetics and N2O can affect measurements.
TIME CAPNOGRAM AND VOLUME
CAPNOGRAM
PHYSIOLOGY
• EXPIRATION
• PHASE I – only Dead space gas exhaled, no CO2
• PHASE II – Mixing of alveolar gas with dead space
gases
• PHASE III - Alveolar Plateau, CO2 reaches max
• INSPIRATION
• PHASE 0– Inspiration starts ,CO2 becomes zero
• PHASE 4-Patient inhales and co2 is zero.obesity
and pregnancy.
• α angle – PHASE II & PHASE III .1OO°to 110,
indirectly refers V/Q,increases in COPD
• β angle – PHASE III & PHASE 0, 90°,increases in
rebreathing.
• NORMAL PetCO2 IS 35-40mmHg.
• PaCO2-PetCO2 is3-5mmHg.It is an indirect
measure of physiological dead space
• End tidal co2 monitoring indicates patient
metabolic rate in controlled vetilation,but not
in spontaneous respiration.
• It changes with cardiac output,if ventilation is
constant.It reduces in pulmonary embolism.In
co2 embolism,there is initial rise in Petco2
followed by fall.
• Tracheal tube placement and monitor
effectiveness of chest compression during
CPR.IT should be maintained between 10-
20mmHg during compression.
• Useful in assuring correct placement of
endotracheal tube,supraglottic airway
device,malfunction of valves in breathing circuit
and detects occluded tube and accidental
extubation.
• Diagnose esophageal intubation,circuit
disconnection,cuff leak,airway
obstruction,change in compliance and ventilator
malfunction,tracheobronchial injury during
thoracoscopic procedures.
• Useful in tracheostomy,and confirm cannula
placement within the trachea during
cricothyrotomy and percutaneous
tracheostomy.
• Confirms brainstem death during apnoea test.
• Diagnose inadvertent tracheo bronchial
placement of NG tube.
• OTHER METHODS;
• MOLECULAR CORRELATION SPECTROGRAPHY
• MASS SPECTROGRAPHY
• PHOTOACOUSTIC SPECTROGRAPHY
• RAMAN SPECTROGRAPHY
PULSE OXIMETRY
 HISTORY
• MATHEES- father of oximetry

• HERTZMAN 1937 –use of photoelectric finger

plethsmography
• 1975 –concept of pulse oximetry –Japan
• YELDERMAN &NEW -1983 –Nellcor pulse
oximeter
 INTRODUCTION
• The maintenance of optimal O2 delivery is the
core concern during anaesthesia

• “Oxygen lack not only stops the machine but

wrecks the machinery ”– J.S. Haldane.

• Monitoring of oxygenation using

pulseoximeter prevents hypoxemia.
• Fifth vital sign
• Non invasive method of Hb saturation (SpO₂)
• Older version – Required arterialisation, invasive
and expensive.
• Latest – LEDs, miniaturised photodetectors,
microprocessors. Smaller, less expensive, easy to
use.
• ASA has made it a standard and mandatory for
intra op and PACU (Post Anaesthetic Care
Unit)monitoring
 DEFINITION
• A SIMPLE,NON
INVASIVE,RELIABLE,REASONABLY
ACCURATE,CHEAP AND CONTINUOUSLY
MEASURING OXYGEN SATURATION OF THE
HAEMOGLOBIN
 OPERATING PRINCIPLES
1.ABSORBTION SPECTRO PHOTOMETRY
2.BEER LAMBERT LAW
• LAMBERT’S LAW states that when a light falls on a
homogenous substance,intensity of transmitted light
decreases exponentially as the distance through the
substance increase
• BEER’S LAW states that when a light is transmitted
through a clear substance with a dissolved solute
,the intensity of transmitted light decreases as the
concentration of the solute increases
• Absorbance of the medium is the ratio of
intensity of incident light (Iin) to the intensity of
transmitted light ( Itrans)
• Absorbance = Iin / I trans

• Optical density is the log to the base 10 of

absorbance

• Optical density (OD)=log 10 Iin/Itrans

1.Beer’s law states that the intensity of transmitted
light decreases exponentially as the concentration
of substance increases.

.log ₁₀ Iin/Itrans α concentration C

2.Lambert’s law states that the intensity of transmitted
light decreases exponentially as distance travelled
through the substance increases
.log ₁₀ Iin/Itrans α distance d
Combining equations 1 & 2,
log ₁₀ Iin/Itrans α c Χ d
or
log ₁₀ Iin/Itrans = Єcd
This is Beer Lambert’s equation. It is also
expressed as Itrans = Iin e -Єcd
C – concentration of the solute
Є – extinction coeffecient. It is a known
constant for a specific solute at a specified
wavelength
e - base of natural logarithm
Єcd – absorbance or optical density
 Hb-light absorption
• Reduced Hb – absorbs more light in red
band(660 nm).
• Oxy Hb – absorbs more light in Infra Red
band(940nm).
• .
Components of absorption signal
 PHYSIOLOGY

• Saturation is defined as ratio of O2 content to

oxygen capacity of Hb expressed as a
percentage.
• Desaturation leads to Hypoxemia – a relative
deficiency of O2 in arterial blood. PaO2 <
80mmHg – hypoxemia
• Oxygen saturation will not decrease until
PaO2 is below 85mmHg.
• At SaO2 of 90% PaO2 is already 60mmHg.
• Rough guide for PaO2 between saturation of
90%-75% is PaO2 = SaO2 - 30.
• SaO2< than 76% is life threatening
 PaO2 [mmHg] SaO2 [%]

• Normal 97 to ≥80 97 to ≥95

• Hypoxia < 80 < 95

• Mild 60-79 90-94
• Moderate 40 – 59 75 – 89
• Severe <40 < 75
Oxy Hb dissociation curve
 TYPES OF PULSE OXIMETRY
Transmitted light is absorbed by photodetector &
generates a proportional voltage
Pulse oximetry – two types.
1)Transmission pulse oximetry – commonest type
• Light beam is transmitted through vascular bed & is
detected on the opposite side of that bed.
2)Reflectance pulse oximetry – Relies on light that is
reflected to same side.
• Probe has an LED and a photodiode (photodecetor
)side by side.commonly used on fore head.
• Reflection depends upon the different reflective
indices of the materials which interfaces between
them.
 COMPONENTS OF PULSE OXIMETRY
1)Probe: contains two LEDS ( that emits light &
detects the light)
2)Cable : Connects oximeter to the probe
3)Microprocessor : Analyses DC & AC
components at 660 & 940 nm.
4)Console / monitor :
two type – .free standing unit
.Hand held unit
5)Miniatured photodetcters
Console / monitor displays-
1. Percentage of Hb saturation
2. Pulse rate
3. Alarm limits
4. Plethysmograph (waveform)
- Operated by –
Electricity,battery charged,rechargeable units.
Available as reusable/disposable forms and in
various sizes
 SITES OF APPLICATION
1. Finger 9. Laryngeal
2. Toe 10.Palm
3. Nose 11. Foot
4. Ear 12.Penis
5. Tongue 13.Ankle
6. Cheek 14. Arm
7. Oesophagus 15. Calf
8. Forehead
1)Finger : Most Commonly used.
Lower failure rates
More accurate.
.Thumb – preferred.
. Index finger
Disadvantages-
-Performance is improved by adequate circulation
e.g) Finger block, digital pulp space infiltration,
vasodilator, vigorous rubbing can improve
circulation
• Relative sensitivity to sympathetic vasoconstriction
• Dark nail polish / synthetic finger nails- probe oriented
from side to side of finger, that allows transmission of
light.
• Exception is clear acrylic nails (i.e –centrally placed)
• Detection of desaturation slower than with a centrally
placed probe.

Toe : late detection of desaturation- 1 to 2min

• Reliable parameter for the success of epidural
block,resulting in increase of amplitude
2)Nose-sites : bridge,wings of nostrils, septum.
• Early detection of saturation changes.
• Recommended in hypothermia
hypotension
infusion of vasoconstrictor drugs
• Trendelenburg position – venous congestion –
low sat. levels.( SPo₂)
3)Tongue: Reflectance oximetry used
• In extensive burns
• Quicker detection of saturation changes
• Resistant to signal interference from
electrosurgery.
Disadvantages :
• Tongue quivering mimics tachycardia
• venous congestion – head down position
• Oral secretions
4)Cheek : more accurate than finger.
Applied over the cheek or lips.
Metal strip /clip is applied particularly on
the buccal surface.

• Effective in Hypothermia
Decreased cardiac output
Increased SVR
Low pulse pressure
In burns
Disadvantages : Difficult placement
Poor acceptance in the awake
Artifacts during airway-
manuouvers
5)Esophagus: use of reflectance oximetry
used in – Hemodynamic instability
Extensive burns
Disadvantages: placement requires practice
difficulty in obtaining a reliable signal
6)Forehead :- flat reflectance oximetry
- Placed just above the eye brows after
cleaning the site with alcohol.
- easily accessible
- Resistant to vasoconstriction
- Signals improved with headband/pressure
dressing.
Disadvantages: venous pooling- low sat. reading.
Others:
• Pharyngeal pulse oximetry – probe is attached to
LMA in patients with poor peripheral perfusion.
• Flexible probes used on palm, foot, penis, ankle,
lower calf, arm in infants
• TESTING OF PULSE OXIMETRY
Done by-
1. Appearance of reliable wave patterns.
2. SPo₂ readings must be correlated with other
pulse oximetry.
3. Compare PR/HR values with that of ECG
monitor
 APPLICATIONS OF PULSE OXIMETRY
1. Monitoring O₂ Saturation -
Anaesthetising areas:
• During induction,emergence,maintanance
• To detect bronchial intubation.Not always reliable when
high Fio2 is used.
• Managing one lung ventilation.Effectively with pulse
oximetry.
• Under regional anaesthesia,MAC..
• To Confirm tracheal tube placement,i.e) by ↑ SPo₂ levels
 .
Other areas Transport of the patient
• Post Anaesthetic CareUnit
• ICU – to wean ventilators
• During CPR
• Reflectance oximetry to monitor fetal
oxygenation ( fetal SPo₂ ).
2. Monitoring peripheral circulation :
• During different arm positions
• During lithotomy positon
• During Shoulder arthroscopy – brachial artery
compression
• Blood flow to fracture areas, to know circulation
compromised or not distal to it.
• Mediastinoscopy – risk for brachiocephalic artery and
aortic arch compression.
• To know the effect of sympathetic block.
• To know the effect of angiography,to know the
existence of the collateral circulation or not.
• To monitor reimplanted or revascularised digits.

• To measure palmar collateral circulation.

3. Determining systolic BP- cuff applied to same

arm as the pulse oximeter,SBP correspond to the
absence of reading
4.Locating arteries –
• Axillary artery- keep the pulse oximetry on same side
press the axilla ,and observe the pulse wave form
disappears or not.
• Femoral or dorsalis pedis
5.Avoiding hyperoxemia – develop of retinopathy of
prematurity & other pathological conditions, if Spo₂ is
>95% for a pronlonged period in neonates.
6.Monitoring vascular volume & symp tone:
• skipped beats suggests-Hypovolemia .
• Amplitude changes- indicates -vascular distensibility
7.Other uses: To know the effectiveness of ;
• High frequency jet ventilation
• Effectiveness of therapeutic bronchoscopy,PFT
lab,exercise and sleep lab.
 ADVANTAGES
1. Accuracy
2. Independance from gases/ vapours
3. Fast response time
4. Noninvasive
5. Continuous measurements
6. Separate respiratory and circulatory variables
CVS –Perfusion is indicated by the pulse signal strength.
Resp.- Oxygenation is indicated by % of saturation ( SPo₂
8. Pulse Tone modulation-To detect hypoxic episodes,by
hearing the change in the pitch of pulse oximetry
tone.
9. Light weight & compact
10. Probe variability
11.No heating required
12.Battery operated
13.Economy
14.Needs minimal training
DISADVANTAGES & LIMITATIONS
1.Failure to determine O₂ saturation due to Poor
function with poor perfusion ( SPo₂)
2.Difficulty in detecting high oxygen partial pressures
(Pao₂) beyond 100% saturation
3.Hypoxic event detection delayed due to time lag
4.Erratic performance with dysrhythmias
5.Inaccuracy readings in the following conditions
a) Different Hbs-
Methaemoglobinaemia –
 normal levels < 1%
 Drugs responsible – nitrobenzene, benzocaine,
prilocaine, dapsone
 Absorbs light equally at red and infra red
wavelengths
 Saturation is around 85%
Carboxyhaemoglobin – has absorbtion spectrum
similar to that of oxy Hb.
• SpO₂is over read.
Fetal Hb – more absorbtion of o₂ & less delivery
.so, false low levels of SPO₂.
HbS – inaccurate readings
Sulfhaemoglobin- causative drugs are
metaclopramide, phenacetin, dapsone,
sulfonamides.
• Displays low saturation levels
Other haemoglobinopathies –
.Hb H – high readings
-Hb koln
- Hb constant springs - low readings
-α thalassemia 2
- Heinz body hemolytic
anaemia
. Hb Hammersmith
.Hb Milwaukee - not useful
b) Low saturations- oximetry is less accurate when SpO₂ is
less than 75-80% because of dark skin ,cyanotic
heart diseases.
c) Malpositioned probe – penumbra or optical shunting
effect (light from the emitter to the detector grazes the
tissue instead of passing through it .)
-Causes false low readings due to signal to noise ratio is
decreased results in spurious SPo₂.
d) venous pulsations – High airway pressures during
artificial ventilation causes phasic venous congestion,
sev TR,interpreted as pulse wave
e) mixing probes i.e) probe & console are of different
companies.
f) severe anaemia - overestimates SpO₂ at low sats
g)Dyes – methylene blue, indocyanine green, lymphazurin,
indigocarmine, nitrobenzene, patent blue – low readings
• Used to confirm IV catheter placement ( either in vein or
in artery by measuring SPO₂ levels ).
• Used to assess C-output by dye dilution method
h) Optical interference – lights flickering at frequencies
similar to that of LEDs
i)Nail polish & coverings- low SPo₂ levels seen -with
brown,black, blue,green nail polish ,but not with red or
purples.
-synthetic nails,onycomycosis,dirty nails,blood stained
finger,taking docetaxel drug except Acrylic nails ( hear
normal/ high Spo₂).
j) Electrical interference-
• Prevented by- locating the ElectroSurgical ground
plate as close to surgical field as possible.
• Routing the cable & console as far from surgical
field as possible
• Electro Surgical apparatus & pulse oximeter not
to be plugged to the same circuit
K) Motion artifacts- mistaken for pulsations.
 COMPLICATIONS
1.Corneal abrasions.
2.Pressure and ischaemic injuries.
3.Burns – due to
○ Incompatibility between probe and monitor
○ Damaged probe
4. Electric shock
 MASIMO SET PULSE OXIMETRY
SPECIAL FEATURES ARE
1 It is not bounded by conventional red over
infra red ratio approach
2 To sense even at low signal states/conditions
3 To sense even at low perfusion conditions
4 To sense even at noise intensive environments
5 It is superior to conventional methods
6 It is clinically validated one
-Signal processing differs from the conventional types
-Adaptive digital filtering
-Able to adapt the varying physiological signals/
noise and separate them into fractional components
-Processing algorithm DST(discrete saturation
transform)
-It identifies noise,isolate it and by using adaptive
filters cancels it
THANK YOU