LITFL | Critical Care Compendium | Capnography Waveform

Interpretation

Capnography Waveform Interpretation

OVERVIEW

Capnography waveform interpretation can be used for diagnosis and ventilator-trouble

shooting

The CO2 waveform can be analyzed for 5 characteristics:

Height
Frequency
Rhythm
Baseline
Shape

NORMAL CAPNOGRAM
4 phases

Phase I (inspiratory baseline) reflects inspired gas, which is normally devoid of carbon
dioxide.

Phase II (expiratory upstroke) is the transition between VDana, which does not
participate in gas exchange, and alveolar gas from the respiratory bronchioles and
alveoli.

Phase III is the alveolar plateau. Traditionally, PCO2 of the last alveolar gas sampled at
the airway opening is called the PETCO2.

Phase 0 is the inspiratory downstroke, the beginning of the next inspiration

Other features:

Normal end-tidal PCO2 is approximately: 38 mmHg or 5%

the alpha angle is the transition from Phase II to Phase III

the beta angle is the transition from Phase III to Phase I (the start of inspiration)

an additional phase IV (terminal upstroke before phase 0) may be seen in pregnancy

ETCO2 only represents alveolar CO2 when a relatively horizontal plateau phase (phase III) is
seen.

From Kodali 2013 (Fig 1) click on image for source and to read caption (read the
whole article while youre there!)
FLAT ETCO2 TRACE

Ventilator disconnection

Airway misplaced extubation, oesophageal intubation

Capnograph not connected to circuit

Respiratory/Cardiac arrest

Apnoea test in brain death dead patient

Capnongraphy obstruction

INCREASED ETCO2
CO2 Production

Fever

Sodium bicarbonate

Tourniquet release
2

Venous CO2 embolism

Overfeeding

Pulmonary perfusion

Increased cardiac output

Increased blood pressure

Alveolar ventilation

Hypoventilation

Bronchial intubation

Partial airway obstruction

Rebreathing

Apparatus malfunctioning

Exhausted CO2 absorber

Inadequate fresh gas flows

Leaks in ventilator tubing

Ventilator malfunctioning

DECREASED ETCO2
CO2 production

Hypothermia

Pulmonary perfusion

Reduced cardiac output

Hypotension

Hypovolemia

Pulmonary embolism

Cardiac arrest
3

Alveolar ventilation

Hyperventilation

Apnea

Total airway obstruction (note high airway pressures)

Extubation

Apparatus malfunctioning

Circuit disconnection (note low airway pressures)

Leaks in sampling tube

Ventilator malfunctioning

SUDDEN DROP IN ETCO2 TO ZERO

Kinked ET tube

CO2 analyzer defective

Total disconnection

Ventilator defective

SUDDEN CHANGE IN BASELINE (NOT TO ZERO)

Calibration error

CO2 absorber saturated (check capnograph with room air)

Water drops in analyzer or condensation in airway adapter

SUDDEN INCREASE IN ETCO2

ROSC during cardiac arrest

correction of ET tube obstruction

ELEVATED INSPIRATORY BASELINE

CO2 rebreathing (e.g. soda lime exhaustion)

Contamination of CO2 monitor (sudden elevation of base line and top line)
4

Inspiratory valve malfunction (elevation of the base line, prolongation of down

stroke, prolongation of phase III)

IMPORTANT PATTERNS TO RECOGNISE

See Figure 2 of Kodali 2013 and Interpret your capnogram at Capnography.com

esophageal intubation (<6 waveforms of decreasing height)

right main bronchus intubation (ETCO2 can increase, decrease or stay the same, can
also cause a bifid capnogram)

curare cleft (partially paralysed patient on mechanical ventilation)

cardiogenic oscillations

camel hump (seen in patients in lateral position)

Rebreathing capnogram of Mapleson D circuit

phase IV in pregnancy

Dilution of expiratory gases by the forward flow of fresh gases during the later part of
expiration when expiratory flow rate decreases below the forward gas flow rate

sometimes see reverse phase 3 slope seen in patients with emphysema (alveolar
destruction leads to rapid delivery of CO2 to airways)

Sticking inspiratory valve

expiratory valve malfunction

mandatory versus spontaneously triggered breaths

dual capnogram in lung transplants

air leak

malignant hypertherima

air / oxygen dilution during mask samplang of spontenously breathing patients

LITFL | Critical Care Compendium | Capnography and CO2 Detectors

Capnography and CO2 Detectors

USES
To detect and/or measure exhaled CO for 3 main reasons:
2

help confirm endotracheal intubation

monitor ventilation during procedural sedation (e.g. via Hudson mask)

without mechanical ventilation

monitoring during mechanical ventilation

Monitoring uses include

airway disconnection alarm

detect ETT dislodgement

allows recognition of different wave forms types which can correspond to

various pathologies (e.g. bronchospasm)

prediction of PaCO2

assess CPR quality during cardiac arrest (cardiac output) and detect ROSC

recognition of spontaneous breath during apnoea testing

to provide protection against unexpected hypercapnia in the neurosurgical

patient

sudden decrease -> sudden decrease in pulmonary blood flow -> PE

DESCRIPTION

Qualitative coluorimetric devices

e.g. Easy Cap

detects breath to breath colour changes through a pH detector (metacresol

purple on filter paper changes to yellow in the presence of CO )

TM

Quantitative devices

Capnometry devices provides measurement and numeric display of end

tidal CO (ETCO )
2

Capnography provides a display of the quantity of exhaled CO with time

which produces a characteristic waveform

Infrared analysers are most commonly used

METHOD OF USE

placed in line with ventilation and patients airway

production of a quantitative ETCO2 value and allows assessment of

waveform morphology (ETCO2 vs time)

Qualitative colourimetric devices

devices are inserted on the end of an endotracheal tube or tracheostomy

tube and connected to a ventilator circuit (via universal connectors)

colour changes when ventilation occurs

can only be used once (colour does not change back, hence only useful for
confirmation of ETT position in the trachea during intubation, not ongoing
monitoring)

Quantitative devices

require calibration

Infra-red analysers

some are connected mainstream (flow through via an in-line adapter with
universal connectors)

others are sidestream devices (with aspiration of gas that is transported to

a sensor located a variable distance away)

the detected CO absorbance is converted to a quantitative amount and

displayed with a waveform

older systems used Mass Spectrometry

OTHER INFORMATION
7

normally ETCO is up to 5 mmHg/0.7kPa lower than PaCO as some alveolar

dead space is always present

test quantitative devices by blowing on them and seeing am ETCO2 trace

before placing in the patient circuit

Infrared analysers

Infra-red analysers use spectroscopic sensors to detect CO in a gaseous

environment by its characteristic absorption wavelength

gas passes through a chamber made of material transparent to infrared

light (e.g. sapphire)

light is focussed through the chamber onto a photodetector and the

amount detected quantified and converted to a calibrated quantity of CO

single beam (sample gas passes through only) or double beam (additional
beam with no CO to act as a control) systems
2

COMPLICATIONS/LIMITATIONS

False positive CO detection

oesophageal intubations after consumption of carbonated beverages or
vigorous bag and mask ventilation (although this rapidly ceases after 20
30s or 6-8 ventilations; quantitative devices with waveforms reveal a
characteristic decrementing, non-square pattern)
high levels of other gases that absorb the infrared light can lead to
falsely high readings (e.g. nitrous oxide in operating theatres)
colourimetic CO2 detectors may change colour if exposed to acidic fluid
(e.g. stomach contents, adrenaline solution from ampoules)

false negative results can occur (e.g. cardiac arrest states, a low
pulmonary flow due to PE, or large alveolar dead space)

Mainstream devices
need time to heat up to avoid condensation on the heater
add dead space and weight to the circuit

prediction of PaCO2 from ETCO2 is variable (the major limiting factors =

pulmonary blood flow and V/Q mismatch) and ETCO may be misleadingly
different in conditions with significant V/Q mismatch

Sidestream devices
can result in a time delay
prone to blocking as not in line with gas flow
may be inaccurate if low tidal volumes as fresh gas may be entrained
(e.g. paediatrics)
analysed circuit gases can also leak to the environment

utility in neonates and children may be impaired because of small tidal

volumes
8

INCREASED ETCO2 PaCO2 GRADIENT

This usually reflects an increase in alveolar dead space; about 5 mmHg is normal (ETCO2
should always be lower than PaCO2)

Low cardiac output or cardiogenic shock

Pulmonary embolism

Cardiac arrest

Positive pressure ventilation and use of PEEP

High V/Q ratios

inaccurate calibration of capnometer