Dr.

Radhika Dhanpal

[email protected]

Professor and Head
Department of Anesthesiology and Critical Care,
St. Johns Medical College Hospital
Bangalore
www.anaesthesia.co.in
Email: [email protected]

ASA
House of delegates July 1, 2011 implementation of Oct 2010
decision Standards for Basic Anesthesia MonitoringDuring
regional anesthesia (with no sedation ) or local anesthesia (with no
sedation ), the adequacy of ventilation shall be evaluated by
continual observation of qualitative clinical signs. During moderate
or deep sedation, the adequacy of ventilation shall be evaluated by
continual observation of qualitative clinical signs and monitoring for
the presence of exhaled CO2 unless precluded or invalidated by the
nature of the patient, procedure or equipment

ISA Desirable standard 1999


Definition : Graphic display of instantaneous CO2
concentration

Luft
Collier
Ramwell
Holland in 1978 , was the first country to adopt it as a standard
of monitoring during anaesthesia .





Terminology


Capnometer The machine
Capnography Wave form
Capnometry Numerical Valve
Methods of measurement

Infrared spectrography

Raman spectrography

Mass spectrography

Photoacoustic spectrography

Chemical colorimetric analysis




Raman spectrography

Gas sample is aspirated into the analysing chamber where it is
illuminated by a high intensity monochromatic argon laser beam.
The light is absorbed by molecules which are then excited to unstable
vibrational or rotational energy states, these Raman scattering signals
are then measured.



Mass spectrography

It separates gases and vapors of different molecular
weight on the basis of their mass into a spectrum. By
analyzing the spectrum, the composition and relative
abundance of each gas in a sample can be determined .



Infrared method :

Infrared waves at 4.3 mm are absorbed by certain gases
producing absorption bands on the infrared electromagnetic
spectrum.


Photoacoustic gas measurements


The gas to be measured is irradiated by modulated light of a
pre-selected wavelength . The light beam when chopped,
generates an acoustic signal which is detected by two microphones.


Colorimetric method

Chemically treated foam indicator attached to
endotracheal tube.

Factors influencing the reading ;

a) Atmospheric pressure : Changes in atmospheric pressure are usually
of the order of 20 mm Hg . This results in a change in PaCO2 of less
than 0.5 - 0.8 mm Hg
b) PEEP .
c) Water vapour : Can condense on the sensor cell and produce falsely
high readings. This may be prevented by
Heating sensor above body temperature
sampling tube can be made of a semipermeable polymer that
allows water vapour to pass outside.
Absorbent filters.
TYPES - I
Side stream capnography
A pump aspirates gas samples from the patients airway
through a 6 foot long capillary tube into the main unit at a
rate of 50-200 ml/min
Disadvantages
Children
Multiple sites for leaks and breakage
Delay
Scavenging needed
Advantages
Spontaneous breathing subjects
Patients on O2 nasal cannula
Easy to sterilise
Use in unusual positions.

TYPES II
Main stream capnography

Disadvantages :
Heavy
Hot
Window to be kept clean

Advantages :
Faster
No gas is removed
No uncertainity by rate of gas sampling



Calibration :

Periodically

Gas of known CO2 concentration

Calibration cells with mixtures of CO2 and N2 are available.

Sampling tube should be the same type as the one used on the
patient.

Type of capnogram

Time capnogram

Volume capnogram

Fast 7mm/sec

Slow 0.7 mm/sec

Time capnogram

Inspiratory segment

Expiratory segment

Alpha angle

Beta angle

Phase I No CO2 Anatomical and apparatus dead space gas
Phase II Rising CO2 Mixing of dead space gas and alveolar gas.
Phase III Static or
rising CO2
Alveolar gas
Phase IV Falling
CO2
Beginning of inspiration
angle - 100-110 ; Airway Obstruction causes larger angle.

angle - 90 ; Rebreathing increases the angle.



Volume capnogram
Advantage s
Volume of CO2 per exhaled
breath can be measured
Significant changes in the
morphology of the expired
wave form can be detected
Dead space can be
partitioned
Disadvantages
Intubation mandatory
Elaborate equipment
Only monitors expiration
Interpretation of the waveform

Height

Frequency

Rhythm

Baseline

Shape

PaCo2 PEtCo2-1
Normal 2-5 mmHg
Increased Decreases
Age Large TV
Pulmonary disorders Low Frequency Ventilation
PE Pregnancy
CO Infants
Hypovolemia
Anaesthesia
CO2 insufflation ( peritoneum , Pleura , joint )
Metabolic PaCo2 PEtCo2-2

Increase Decrease
Hyperpyrexia Hypothermia
Shivering Increased Muscle relaxation
Convulsions
Blood /NaHCO3 administration
Release of an arterial
clamp/tourniquet
Dextrose containing fluids
Parenteral hyperailmentation
PaCo2 PEtCo2-3

Circulatory
Increase Decrease
Epinephrine injection CO
CPR Surgical manipulations
of the heart, great vessels,
wedged PAC, PE
Air Embolism

Uses
Anaesthesia

Verification of tracheal intubation
Assist in blind oral or nasal intubation
Needle cricothyroidotomy
Jet stylet introducer
Fiberoptic bronchoscopy
Double lumen tube placement
Monitoring of spontaneous ventilation
Curare cleft
HFJV
Detection of circuit leaks
Detection of malfunction of valves or faulty anaesthetic system.






























































Critical Care

CPCR
Determine the needs during mechanical ventilation
Weaning
Placement of NG tube

Others

PACU
Patient transfer
Post operative ward
Procedural sedation
Apnea test for brain death
Emergency Department



REBREATHING WITH ELEVATED BASELINE




ESOPHAGEAL INTUBATION WITH
CARBONATED BEVERAGES IN STOMACH






CO2 ABSORBENT EXHAUSTION






ESOPHAGEAL INTUBATION






ESOPHAGEAL INTUBATION FOLLOWING MASK
VENTILATION.



EXPIRATORY VALVE MALFUNCTION







SPONTANEOUS BREATHING







NORMAL WAVEFORM




CURARE CLEFT





AIR LEAK




HYPERVENTILATION




CONTAMINATION OF
CO2 SENSOR



CARDIAC ARREST,
SUCCESSFUL RESUSCITATION






HYPOVENTILATION



BRONCHOSPASM







IMV WITH INTERPOSED SPONTANEOUS
RESPIRATION.



CARDIOGENIC OSCILLATIONS (RIPPLE
EFFECT)



INSPIRATORY VALVE
MALFUNCTION







POST SINGLE LUNG TRANSPLANTATION.






BAIN CIRCUIT/MAPELSON D (SIGNATURE
CAPNOGRAM)





Thank You
www.anaesthesia.co.in
Email: [email protected]