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20 is abnormal and needs to be treated Ensure device leveled accurately Ensure good waveform before interpreting and reacting to pressures ***Pressure spikes that go up and stay up are of most concern and need treatment! November 30, 2013 by Tim Leeuwenburg 4 Comments End-tidal CO2 is increasingly becoming used outside of the Operating Theatre and it is prudent for the rural doctor to have an appreciation of what it is, how to measure it, when to measure it and ita€™s utility in common scenarios.
It is my belief that ETCO2 should be used not just in intubated patients, but as a valuable adjunct for procedural sedation, for monitoring patients a€?at riska€™ and to help guide resuscitation.
Devices such as the Easy-Cap or Pedi-Cap are designed to confirm the presence or absence of expired CO2 – a pH detector (metacresol purple on filter paper) detects pH shifts and changes to the colour yellow in the presence of expired CO2. A sample line is placed as a sidestream to the breathing circuit (usually via the HME filter at intersection of endotracheal tube and breathing circuit). As an alternative to sampling expired gas directly from the anaesthetic circuit or HME filter attached to an endotracheal tube, it may be useful to monitor ETCO2 for spontaneously ventilating patients, whether on room air, nasal specs or oxygen mask. I use this routinely during endoscopy, colonoscopy in the operating theatre, as well as when performing procedural sedation in the ED.
Remember that relying on SpO2 to confirm ventilation is inadequate – measured oxygen saturation may remain elevated for some time after cessation of breathing-A  and once a fall in SpO2 has been detected, your patient is already hurtling down the oxy-haemo-coaster.
End-tidal CO2 is classically considered as the standard of care when performing intubation. End-tidal CO2 monitoring is mandatory not just for the intubated patient, but should be used whenever using a neurolept eg: sedation in ED, monitoring of psychiatric patient etc. Even if you are not performing anaesthesia, know how to hook up ETCO2 monitoring for your spontaneously ventilating patients at risk of hypopnoea or apnoea.
Dedicated ETCO2 monitors exist, but most capnographs will hook up to existing monitors in OT, ED and ward defibs.
I am a Rural Doctor on Kangaroo Island, South Australia with interests in emergency medicine, anaesthetics & trauma.
Areas of interest include difficult airway management outside of theatre (rural-ED-ICU), human factors, use of crisis checklists and "guerilla" sim training. What I want to understand more clearly is why the intubated patients waveform changes shape when mechanically ventilated vs spontaneously ventilating. The graphical representation of the concentration or partial pressure of expired carbon dioxide during a respiratory cycle is shown in a waveform format and is known as a capnogram.
This provides information not only regarding pulmonary function, but also indirect cardiac function, ventilator function, and perfusion.
In the American Heart Association (AHA) 2015 Guidelines continuous waveform capnography is a Class I, LOE A recommendation for confirming and monitoring correct placement of an endotracheal tube. Because a sustained increase in PETCO2 during CPR is an indicator of ROSC, the AHA Guidelines also recommend using capnography in intubated patients to monitor CPR quality, optimize chest compressions, and detect ROSC during chest compressions or when the rhythm check reveals an organized rhythm (Class IIb, LOE C).
Mainstream capnography is most commonly used for mechanically ventilated patients and intubated patients who require intensive monitoring.
With mainstream capnography, the airway adapter is placed directly in the breathing circuit in between the ventilator “Y” and the elbow adapter, as shown in the diagram.
Capnography refers to the comprehensive measurement and display of CO2 including end-tidal and inspired CO2, and the CO2 waveform which is referred to as the capnogram. Sidestream CO2 sensorsare located away from the airway, requiring a gas sample to be continuously aspirated from the breathing circuit or patient and transported to the sensor by means of a pump. The principle of pulse oximetry is to transmit two specific wavelengths of light through a pulsating vascular bed. Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through. Capnography allows emergency providers to precisely monitor the performance of a number of critical human processesPhoto credit: Photo copyright Oridion Medical 1987 Ltd. Carbon dioxide (CO2) is a waste gas, so why do we care about it as long as we and our patients can get it out of the body? Long ago, Greek philosophers believed we had tiny internal combustion engines inside our bodies that produced “smoke,” or capnos.
There are three physiological processes for human life: metabolism, circulation and ventilation. Capnography is a powerful tool for providing continuous real-time objective data to qualify and quantify the status of metabolism, circulation and ventilation.
Continuous waveform capnography is recommended to EMS for verification of endotracheal tube (ETT) placement.1 The 2010 ACLS guidelines have elevated the role of capnography to recommending continuous waveform CO2 monitoring during resuscitation. Capnography is can also provide valuable cardiopulmonary information to assist paramedics in caring for non-intubated patients. Recent studies have dulled the significance of endotracheal intubation, and many EMS providers are relying more on alternative methods of securing the airway.3 Capnography is just as easily applied to alternative airways like the Combitube, King airway or laryngeal mask airway (LMA).
The capnography waveform assists in determining proper ventilation with any device that securely attaches to a bag-valve mask.
EMS providers can position the monitor so the compressors can view the EtCO2 readings as well as the ECG waveform generated by their compressions. A rapid rise in EtCO2 during chest compressions can be the first indicator of return of spontaneous circulation (ROSC), possibly even before a pulse is detectable. Clinical Death ConfirmationWhile EtCO2 can be used to gauge the effectiveness of resuscitation, it can also be used as a determining factor in the decision to cease resuscitative efforts. With the advent of induced hypothermia in the treatment of cardiac arrest patients, new research is now needed to set guidelines for the use of EtCO2 in determining when to cease resuscitation efforts. Capnography can help paramedics optimize ventilation in intubated patients with suspected increased intracranial pressure (ICP). Capnography can be used to differentiate between the varying causes of respiratory distress often seen by paramedics in the field, such as asthma, COPD exacerbation and CHF. By analyzing the CO2 waveform over time, the paramedic can monitor the severity of asthma or chronic obstructive pulmonary disease (COPD) and the effectiveness of therapy provided. Congestive heart failure (CHF) patients have circulatory compromise, which results in changes in carbon dioxide delivery. Paramedics frequently are required to administer medications that have a depressant effect on the central nervous system (CNS). At times, paramedics encounter patients who are “self-medicated” with CNS depressants, including alcohol, GHB, OxyContin, Xanax and many of the prescription compounds listed above. Waveform capnography is a direct measure of the changes in elimination of CO2 from the lung and indirectly indicates changes in the production of CO2 at the cellular level. Seizure ManagementFor patients who breathe during a seizure, capnography is a powerful tool to determine the aggressiveness of seizure management.
To properly assess ventilation, it is important to understand what determines respiration and ventilation in the human body. David Wampler, PhD, LP, is an assistant professor of Emergency Health Sciences, University of Texas Health Science Center, San Antonio, TX. Exhaled gas is sampled by a dedicated analyser (anaesthetic monitor or some defibrillators).
The ones I worry about most are the absent or rapidly disappearing ETCO2 rtace seen in inadvertent oesophageal intubation…and the falling ETCO2 waveform with loss of cardiac output. Most ETCO2 sampling equipment is dedicated to sit in-line as either an adaptor between ETT and circuit, or as a filter line to attach to HME filter. Either colorimetric or waveform capnography can be used to confirm the presence of exhaled CO2 and hence confirm desired tracheal vs inadvertent oesophageal intubation.

Also why does the inspiratory slope decrease with inspiratory valve malfunction, but only the baseline increases with expiratory valve malfunction. Mainstream devices can also used on non-intubated patients but require a mouthpiece or a mask.
As the patient exhales, the CO2-rich gas passes through the airway adapter, where it is measured. Capnography depicts respiration which includes all three components of respiration; metabolism, transport, and ventilation and therefore gives an excellent picture of the respiratory process. Mainstream CO2 sensorsare placed at the airway of an intubated patient, allowing the inspired and expired gas to pass directly across the IR light path. These wavelengths are based on the red and infrared light absorption characteristics of oxygenated and deoxygenated hemoglobin.
Deoxygenated (or reduced) hemoglobin absorbs more red light and allows more infrared light to pass through.
However, with digital technology and new processing specific for low perfusion cases the SpO2 readings have become more reliable and can indicate when return of circulation is achieved. Just like an automobile’s performance can be monitored by a probe put in the exhaust pipe, an evolving technology allows emergency providers to precisely monitor the performance of a number of critical human processes in an ill or injured patient. So, a person standing at sea level under normal weather conditions would have 1 atmosphere of pressure being exerted by the gases in the air he breathes. In fact, oxygen loading onto hemoglobin and transport to the tissues is highly dependent on the tight regulation of CO2. Metabolism is the utilization of hydrocarbons to produce energy and power tissues, organs and the entire body. Metabolism is assessed by determining the quantity of CO2 being exhaled and following this over time. As with the endotracheal tube, proper and improper ventilation can be monitored with alternative airways and corrected where necessary. No matter which device is in use, capnography can provide immediate indication of the loss of proper position or function. It is important to encourage prehospital personnel to perform quality chest compressions to keep the EtCO2 number as high as possible. In 1997, a study in the New England Journal of Medicine established that an end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. In the induced hypothermia patient, the metabolic rate will be lowered, thus diminishing the production of cellular CO2. Avoiding hypo- and hyperventilation in these patients is absolutely critical and difficult. Hyperventilation may occur early in an acute asthma attack, lowering EtCO2 levels with a slightly abnormal waveform.
This means that as the disease worsens, or as the patient approaches decomposition, EtCO2 will continue to decline as alveolar perfusion decreases.
This may include narcotic analgesics (morphine sulfate, fentanyl), benzodiazepines (Valium, midazolam, lorazepam) or other sedative agents (etomidate, ketamine). It reflects the delivery of CO2 to the lungs by the circulatory system.14 With no pulmonary or circulatory disorders, EtCO2 may indicate patient anxiety or a metabolic disorder.
A patient with a sudden drop in cardiac output will show a diminished CO2 waveform and a drop in the EtCO2 number that may occur regardless of any change in breathing rate. If capnography reveals ventilatory failure, this will require aggressive airway and pharmacologic intervention. Factors such as metabolic rate, acid-base status, central CO2 respiratory drive, physiologic dead space and lung mechanics all play a role.
It assists the EMS provider in measuring and monitoring metabolism, circulation and ventilation. All sources I have found simply state that “this is how the waveform changes in this instance” but does not explain why??
Because the mainstream sensor is not in direct contact with the patient, it cannot be contaminated by moisture or secretions.
The major advantages of mainstream sensors are fast response time and elimination of water traps.
This article describes the use of technology to monitor metabolism, circulation and ventilation in the emergency patient. Our internal combustion engines are really mitochondria that are fueled by hydrocarbons (sugars, fats and proteins) essential in the human diet. Furthermore, CO2 can act as a molecular signal affecting both nervous and smooth muscle tissues. Oxygenation involves loading hemoglobin with oxygen for delivery to the tissues, while ventilation addresses clearance of CO2 from the blood.
This has been well documented over the past few years.1,2Capnography can also be useful in detecting a change in position of the endotracheal tube. As with endotracheal intubation, when using alternative airways it is critical to continuously monitor the airway and assess ventilatory status.
No carbon dioxide in exhaled air indicates either an improperly placed tube or no cardiac output. This represents effective cellular perfusion, allowing cells to metabolize and circulation to deliver carbon dioxide to the lungs. A guideline for CPR termination based on an EtCO2 of less than 10 mmHg for 20 minutes may not be adequately conservative for those patients receiving hypothermia treatment during CPR.
Increased ICP may be caused by a head injury, intracerebral hemorrhage, a tumor or mass, or an infection. These patients, all of whom may experience bronchospasm in the lungs, can be identified by a unique characteristic change seen in the EtCO2 waveform. As the attack progresses, the EtCO2 may read in the normal range, with a more prominent looking shark fin waveform on the monitor. Respiratory distress due to CHF does not typically result in bronchoconstriction, so the waveforms will not necessarily have a shark fin appearance unless the patient has a pulmonary comorbidity. Capnography is invaluable and proven to be the earliest indicator of respiratory compromise due to medications with pain or sedative association.12,13 The EtCO2 waveform dampens prior to a change in pulse oximetry due to the oxygen reserve in human anatomy.
In diabetic ketoacidosis (DKA), Kussmaul’s respirations result in hyperventilation as a means for patients to lessen their ketone load and attempt to correct metabolic acidosis.14 The increased rate of breathing causes EtCO2 to decrease. Capnography should be used on all trauma and cardiac patients and any patient at risk for shock. There are factors that increase ventilatory demand, such as arterial hypoxemia, increased metabolic rate, increased physiologic dead space, metabolic acidosis, pulmonary edema, increased work of breathing, confusion and central nervous system stimulation. Used with pulse oximetry, it provides insight into the management of many emergencies involving the pulmonary and circulatory systems.
The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Assessing the impact of prehospital intubation on survival in out-of-hospital cardiac arrest. The use of laryngeal tube by nurses in out-of-hospital emergencies: Preliminary experience. Initial end-tidal CO2 is markedly elevated during cardiopulmonary resuscitation after asphyxial cardiac arrest.

Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. If the mainstream airway adapter becomes contaminated with secretions, water, or by an aerosolized medication, it can be removed and replaced. After eating and movement through the digestive processes, sugars enter the mitochondria, where they are “combusted” and carbon dioxide is “exhausted.” Once CO2 is transported to the lungs via the circulatory system, it is exhaled with alveolar air.
If the atmosphere contains approximately 79% nitrogen and 20% oxygen, the partial pressure of each is 600 mmHg nitrogen and 150 mmHg oxygen.
Technologies for monitoring oxygenation have been extraordinarily useful to EMS providers for the past 20 years. It is important to note, however, that several hours after cardiac arrest, some residual metabolism (liver, skeletal muscles, skin, etc.) will continue to produce CO2. Capnography is the only technology able to display respiratory rate based upon the partial pressure of exhaled CO2 while providing the unique pattern recognition of CO2.
In EMS, this is important, as the endotracheal tube may be accidentally displaced while moving the patient.
Systemic and pulmonary perfusion during cardiac compressions transports CO2 to the alveolar space.
It is important to note, however, that administration of sodium bicarbonate could also produce a “bump” in the EtCO2 as a result of bicarbonate ion conversion to CO2 during correction of acidosis. The study suggests that cardiopulmonary resuscitation may reasonably be terminated in such patients.10 Caution must be taken, however, that rescuers are not hyperventilating the patient if capnography is used as a determinant for termination of efforts.
Hyperventilation of patients with increased ICP has been associated with increased mortality.11 Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow, thereby increasing the risk of cerebral ischemia.
Bronchospasm will produce a “shark fin” capnography waveform due to difficulty emptying alveoli.12 The characteristic shark fin appearance is a result of regional obstruction, which causes a turbulent mixing of dead space air with alveolar air.
Finally, as the attack becomes severe, the EtCO2 rises and the wave becomes indistinguishable in its shark fin form.
Capnography can alert to early recognition in CHF, even before the onset of pulmonary edema is apparent.
Capnography can be utilized in any patient who has ingested a significant quantity of CNS depressant, particularly those who are somnolent. End-tidal carbon dioxide is linearly related to bicarbonate (HCO3) in healthy subjects, and has been found to be significantly and chronically lower in children with DKA. Cardiac output and end-tidal partial pressure of carbon dioxide (PEtCO2) were highly related in diverse experimental models of circulatory shock in which cardiac output was reduced by more than 40% of baseline values. However, a vascular blockage prevents blood flow to areas of the lungs, so the EtCO2 decreases because there is essentially fresh air being exhaled from the non-perfused portion of the lung. This includes not only respiratory compromise but factors also affecting perfusion and metabolism. This is considered “functional” oxygen saturation which identifies oxyhemoglobin and deoxyhemoglobin.
The approximately 10 mmHg of air pressure remaining is composed of all of the other gases and vapors—mostly water vapor. More recently, technologies are being developed to enhance EMS’s abilities to measure the effectiveness of ventilation. Capnography quantifies patient ventilation in terms of transport of CO2 from the pulmonary circulation across the alveoli for exhalation. Given some of the untoward and noisy environments where cardiac arrest occurs, confirming ETT placement by lung sounds alone can be problematic and sometimes even deceiving, especially in smaller patients. In a recent study of head-injury patients, those patients with EtCO2 monitoring had a lower incidence of hyperventilation.
Once treatment is decided upon and the bronchoconstriction decreases, the EtCO2 number may increase initially as gas exchange improves. It is important to note that a patient with significant pulmonary edema may have a significant disparity (due to the relative solubility of O2 vs. Measurement of EtCO2 is a noninvasive alternative for continuous assessment of cardiac output during low-flow circulatory shock states.16 A patient with low cardiac output from a shock state does not deliver as much CO2 per minute back to the lungs to be exhaled, which results in decreased EtCO2.
Waveform capnography provides further insight into caring for your patient in many clinical states and is a tool paramedics should not be without.
The capnography waveform is a key vital sign when determining treatment for patients in the field. It also provides a graphic picture of the patient’s ventilatory status, presents an early warning of changes in the patient’s cardiopulmonary status, supplies indisputable documentation of the patient’s airway patency, and alerts clinicians to the presence of pulmonary pathology. A 2005 study compared prehospital intubations using continuous capnography to confirm tube placement with those not using capnography.
The AHA (American Heart Association) Guidelines call for quality compressions (“push hard, push fast, push deep”)2 and direct rescuers to switch places every two minutes to maintain effective CPR.
A target EtCO2 recommendation is outside the scope of this article, but ventilation should be tightly controlled in this patient population, using local protocol. It is important to note that the shark fin appearance of the capnograph has a direct physiological cause and is characteristic of bronchospasm.
It doesn’t necessarily mean the patient is hyperventilating or has a reduced arterial CO2 level.
Capnography sampling devices are useful in all types of airways, whether or not the patient is intubated. The portion of pressure being exerted by carbon dioxide is called partial pressure and is typically 35–45 mmHg in the healthy person at rest. Take, for example, the moderately sick asthma patient demonstrating a “shark fin” pattern with an elevated EtCO2 but 100% oxygen saturation. Air must move in and out of the alveoli effectively to get rid of carbon dioxide and other waste products, and to inhale fresh oxygen. Abnormal capnography values can be traced to diseases affecting ventilation, perfusion or metabolism. By analyzing the EtCO2 waveform, a clinician can detect rescuer fatigue before the rescuer is aware of tiring. The monitoring process can be either discrete (one time or quick look) or continuous.Capnography works by capturing exhaled air and redirecting it into the capnography device.
The air then passes between a light and a detector that measures how much light is shining on it. As the concentration of CO2 increases, more light is absorbed by the CO2 and less light is transmitted onto the detector plate. The monitor presents the CO2 concentration to the capnographer as both a number and a waveform. The respiratory rate can be very accurately estimated and reported by measuring the tides between CO2 peaks.

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