RESOURCE GUIDE

INTRODUCTION TO
CAPNOGRAPHY

Slide 1 Introduction to Capnography

Slide 2 Table of Contents

Lesson 1: Normal Pulmonary Physiology
Lesson 2: Basic Principles of
Capnography
Lesson 3: Monitoring etCO2 Technologies
Summary: Final quiz

© 2015 Medtronic. All rights reserved. 1

Slide 3 Course Introduction
The Introduction to Capnography course
offers an overview of the basic principles of
capnography. Understanding the range of
normal values, or capnometry, in
conjunction with interpreting etCO2
waveforms, or capnography, is an integral
means in assessing the quality of patient
ventilation for the intubated and the non-
intubated patient.

This course begins with a review of the

tracheobronchial tree, end tidal CO2, SpO2
and the difference between oxygenation
and ventilation. Definitions of common
terms used in capnography will also be
reviewed. Additionally, the course
introduces the technology available for
monitoring CO2 removal during breathing
and assessing a patient’s ventilatory status.

Finally, the four phases of the exhalation

cycle are presented with their
corresponding waveforms. An opportunity
to identify normal and abnormal waveforms
and interpret the data provided by
capnographic waveforms will also be
provided.

Slide 4 Lesson 1 Objectives

The objectives for this lesson are:

• List the components of the upper airway,

the tracheobronchial tree and lower airway

• Differentiate the conducting zone and the

respiratory zone

© 2015 Medtronic. All rights reserved. 2

Slide 5 Upper Airway
To understand end-tidal CO2, or etCO2, it is
essential to know about the upper airway,
the tracheobronchial tree and lower airway.

The upper airway is made up of the nose,

oral cavity and pharynx. The primary
function of the upper airway is to conduct
warmed, humidified air and prevent foreign
substances from entering the lower airway.
No gas exchange takes place in the upper
airway.

Slide 6 Tracheobronchial Tree

The tracheobronchial tree contains
branching airways. The trachea, commonly
called the windpipe, bifurcates (splits) into
the right and left main stem bronchi. The
main stem bronchi branch into lobar,
segmental and subsegmental bronchi. The
subsegmental bronchi branch into terminal
and respiratory bronchioles and into alveolar
ducts and alveoli.

The conducting zone (conducting airway) is

the area where no gas exchange takes place
and consists of the right and left main stem
bronchi, bronchioles and terminal
bronchioles.

© 2015 Medtronic. All rights reserved. 3

Slide 7 Respiratory Zone
There are many branches or bifurcations of
the tracheobronchial tree, but gas exchange
only occurs in the very distant region. This
region is termed the respiratory zone, and is
where alveolar ventilation and gas exchange
take place. The respiratory zone includes
the respiratory bronchioles, the alveolar
ducts, sacs and alveoli. Alveolar volume and
alveolar minute ventilation are responsible
for changes in oxygen (O2) and carbon
dioxide (CO2). Alveolar minute ventilation is
the alveolar volume times the respiratory
rate. Alveolar volume is approximately two-
thirds of the tidal volume. Tidal volume is
defined as the volume of air that normally
moves into and out of the lungs in one quiet
breath. Normal adult tidal volume equals
approximately 500 ml of room air and
normal infant tidal volume equals
approximately 40 to 50 ml of room air.

Capnography measures the concentration

of CO2 in the exhaled breath at the end of
expiration of a normal tidal volume and is
termed end-tidal or etCO2.

Slide 8 Lesson 2 Objectives

The objectives for this lesson are:

• Explain basic principles of capnography

• Explore available capnography

technologies

• Define common terms in capnography

• List indications for capnography

• Differentiate oxygenation (SpO2) from

ventilation (etCO2)

• Define three techniques for obtaining

respiratory rates

© 2015 Medtronic. All rights reserved. 4

Slide 9 Carbon Dioxide in the Body
CO2 is produced as a byproduct of
metabolism. It is transported by the
vascular system from the cellular level to the
lungs, where it is removed during exhalation.
It is very important to note that breathing is
the primary way the body regulates CO2.
This is accomplished by the brain’s
respiratory centers, which send signals to
regulate both respiration rate and depth. If
CO2 is not regulated, a toxic accumulation in
the blood can occur, resulting in respiratory
failure.

Capnography noninvasively measures and

alerts the clinician to dangerous levels of
CO2 in patients through the continuous
measurement of inhaled and exhaled carbon
dioxide, and peak exhaled value of end-tidal
carbon dioxide (etCO2).

Slide 10 Capnography
The etCO2 represents the concentration of
CO2 in the exhaled breath at the end of
expiration of a normal tidal volume or end-
tidal CO2. The normal range for end-tidal
CO2 is between 35 millimeters to 45
millimeters of mercury. Capnography
monitors CO2 removal during breathing and
provides a breath-by-breath assessment of
the patient’s ventilatory status.

Although the numeric etCO2 value is

important, the waveform is equally
important. The waveform is a graphic
tracing of the inhaled and exhaled
concentration CO2 in each ventilatory or
breathing cycle plotted against time. The
waveform changes immediately when there
is a change in breathing, and it is the first
sign of a ventilatory problem.

© 2015 Medtronic. All rights reserved. 5

Slide 11 Capnography Terms Defined
Capnography is the noninvasive, continuous
measurement of inhaled and exhaled carbon
dioxide concentration, commonly referred
to as end-tidal carbon dioxide or etCO2
monitoring over time. Key terms associated
with capnography are:

• Capnometry

• Capnometer

• Capnogram

• Capnograph

Capnometry describes the numerical

measurement of the concentration of
carbon dioxide in an exhaled breath without
a waveform. This numerical measurement is
obtained by a device called a capnometer. A
normal value range is 35 - 45 millimeters of
mercury.

Capnogram refers to the graphical

representation of the concentration of
inhaled and exhaled CO2. This type of graph
is referred to as a waveform. A capnogram is
obtained through a device called a
capnograph. A capnography refers to a
device that provides the numeric end-tidal
CO2 value, a respiration rate and a
capnogram or waveform.

Both the numerical measurement and

capnogram are necessary to provide a
complete picture of the patient’s ventilation
for clinical evaluation.

© 2015 Medtronic. All rights reserved. 6

Slide 12 Intubated Applications
Capnography is widely used throughout the
hospital in many clinical environments to
provide the earliest indication of
hypoventilation, hyperventilation, airway
obstruction, and apnea or cessation of
breathing.

Capnography can help detect

hypoventilation and hyperventilation, verify
endotracheal tube placement, immediately
detect airway obstruction and other
ventilation problems, and facilitate in the
monitoring of cardiac output and
metabolism.

The respiration rate provided by

capnography is important because it is an
airway respiration rate, measured at the
airway, which can alert clinicians to changes
in the patient’s ventilatory status
immediately.

Capnography can assess ventilation for

intubated patients through the following
phases:
• Acute phase of illness and mechanical
ventilation assessment
• Recovery phase of illness, mechanical
ventilation assessment and noninvasive
ventilation
• Weaning phase of the patient from the
ventilator

© 2015 Medtronic. All rights reserved. 7

Slide 13 Non-Intubated Applications
Non-intubated patients who need etCO2
monitoring are found in many areas of the
hospital:
• ICU
• General care floor
• Emergency department
• Procedural sedation lab such as GI or cath
labs

Clinical goals of monitoring non-intubated

capnography patients are detecting apnea
(no breath) and hypoventilation (slow
breathing). Apneas and hypoventilation are
monitored while patients are receiving:
• Chest compressions during CPR, to
identify effective circulation and return of
spontaneous circulation (ROSC)
• Noninvasive ventilation by CPAP or Bilevel
device
• Pain medications via a patient-controlled
analgesia (PCA) pump on the general care
floor
• Procedures where a sedative is
administered to control pain while allowing
the patient to control spontaneous
breathing

Capnography can help:

• Detect hypoventilation and
hyperventilation
• Verify proper endotracheal tube
placement
• Detect airway obstruction immediately
• Alert clinicians of ventilation problems
associated with administration of pain
medication

The respiration rate provided by

capnography is important because the rate
is measured at the airway which can alert
clinicians to changes in the patient’s
ventilatory status immediately.

© 2015 Medtronic. All rights reserved. 8

Slide 14 Airway Respiration Rate
The respiration rate is the frequency of a
breathing cycle, and the volume or
amplitude of each breath. During normal
breathing, respiration rate and depth are
adjusted to regulate CO2 levels in the blood.

In normal healthy lungs, as the respiration

rate and depth increase, more carbon
dioxide is removed. As respiration rate and
depth decrease, less carbon dioxide is
removed. This concept is important
because during extreme hypoventilation
states, which are very low respiration rates
or decreased breath size, there is
insufficient CO2 removed to prevent a toxic
buildup in the blood.

Capnography provides early indication of

hypoventilation, airway obstruction and
episodes of no breath. The capnography
alarm will alert the clinician before a manual
assessment of the patient to facilitate early
intervention. This alert can be sooner than
pulse oximetry, such as in cases where a
patient is on supplemental oxygen.

Slide 15 Oxygenated Ventilation

Oxygenation and ventilation are two
separate physiologic processes of the
respiratory cycle. These two processes
facilitate the transport of oxygen and
carbon dioxide into and out of the lungs and
are known as gas exchange. The efficiency
of gas exchange is dependent on ventilation.

Ventilation is the cyclical breathing

movements that alternately move gas into
and out of the lungs. Inspiration fills the
lungs with oxygenated air, and expiration
removes carbon dioxide.

Oxygenation is the process of oxygen being

inhaled into the lungs, dispersed by the
alveoli to the blood, distributed to and
metabolized by the cells of our muscles and
organs.

© 2015 Medtronic. All rights reserved. 9

Slide 16 Important but Different Measurements
Pulse oximetry monitors oxygenation while
capnography monitors ventilation. Both
monitoring systems provide important but
different physiologic measurements. Just as
capnography monitoring does not measure
oxygenation, pulse oximetry does not
measure ventilation.

Pulse oximetry monitors oxygenation. This

is SpO2, which reflects the percentage of red
blood cells saturated with oxygen. This can
be a late indicator with hypoventilation,
airway obstruction and apnea. Additionally,
the use of supplemental oxygen can further
delay the detection of airway compromise
when monitoring with pulse oximetry.

Capnography monitors ventilation, which

reflects the effectiveness of breathing and is
represented by a waveform graphic of each
breath in real time. Capnography provides
earlier indication of hypoventilation, airway
obstruction and episodes of no breath. The
capnography alarm alerts the clinician for
early intervention, before physical
assessment. Capnography also measures
airway respiration rates at the airway.

Slide 17 Obtaining Respiration Rates

Obtaining an accurate respiratory rate
measurement is important to providing
better patient outcomes, and different
techniques can result in different
measurements. Historically, there are three
techniques for obtaining respiratory rates.

A manual respiratory count reflects a single

moment in time where you observe and
count the patient’s chest rise and fall and/or
listen to breath sounds. Blankets or patient
position can limit the visualization of chest
movement. Also with complete airway
obstruction, there may continue to be chest
movement as the patient attempts to
breathe. Last, there is no automated
documentation or alarm if your patient fails
to breathe when you are not in the room.

Impedance pneumography, or measuring

© 2015 Medtronic. All rights reserved. 10

 respiratory rate with ECG leads, provides a
respiratory rate based on respiratory effort.
The attempt to breathe or any other
sufficient movement of the chest can also
be measured.

Capnography measures respirations at the

airway through respiratory gas movement
at the mouth or nose. A respiration is
counted when there is a qualifying amount
of carbon dioxide exhaled. The CO 2
waveform can immediately detect
hypoventilation, airway obstruction and
apnea followed by derived RR and etCO 2
values. Capnography provides an accurate
respiratory rate remotely.
Slide 18 Lesson 3 Objectives
The objectives of this lesson are:
Differentiate colorimetric CO2 detectors,
mainstream, sidestream and Microstream®
technologies
List the limitations of colorimetric CO2
detectors
Identify the limitations of mainstream and
sidestream technology
Describe how Microstream technology
improves conventional sidestream
technology

© 2015 Medtronic. All rights reserved. 11

Slide 19 etCO2 Technologies Overview
A capnometer, by definition, is either
diverting (i.e., sidestream) or non-diverting
(i.e., mainstream). The difference between
mainstream capnography and sidestream
capnography is where CO2 is clinically
measured, at the sample site or at a monitor
distant from the sample site.1 There are
various technologies used to measure and
monitor etCO2, including Covidien products
such as colorimetric CO2 detectors, and
mainstream, sidestream and Microstream®
sampling lines.

Traditional technologies such as

colorimetric CO2 detectors, and
mainstream and sidestream sampling lines
have certain limitations that can contribute
to inaccurate readings and can cause their
use to be restricted within certain patient
populations. Newer technologies, such as
Microstream sampling lines, address some
of the limitations of the more conventional
systems. With a focused CO2-specific
infrared light beam, low flow rate of 50
ml/min and miniature 15 microliter sample
cell, the Microstream sampling line can be
used with a wider range of patient
populations, including intubated and non-
intubated patients, along with all patient
types (neonatal, pediatric and adult).

Slide 20 etCO2 Technologies

© 2015 Medtronic. All rights reserved. 12

Slide 21 etCO2 Technologies – Colorimetric
CO2 Detector
Subset One

Colorimetric detectors use litmus paper

that responds to the presence of carbon
dioxide in the breath by changing color.
Traditionally, these detectors were used in
emergency situations to verify endotracheal
tube placement.

Slide 22 etCO2 Technologies – Colorimetric

CO2 Detector
Subset Two

Colorimetric detectors are still used but

they do have limitations. These limitations
include the following:
• The detector only indicates the presence
of CO2; it does not quantify the CO2
• The detector does not provide a graphic
representation or waveform to quantify the
amount of CO2 detected
• The functionality of the detector can be
compromised by contact with moisture,
light or a patient’s secretions into the
detector
• The detector has a limited shelf life after
exposure to ambient air and light
• The detector may show altered readings in
conditions of low pulmonary perfusion, such
as cardiac arrest

© 2015 Medtronic. All rights reserved. 13

Slide 23 etCO2 Technologies – Mainstream
Subset One

In mainstream capnography, the CO2 sensor

is located at the sample site between the
endotracheal tube and ventilator circuit. A
sample cell is inserted directly in the airway
between the breathing circuit and the
endotracheal tube. A lightweight infrared
sensor, attached to the airway adapter,
emits infrared light through the airway
adapter windows to a photodetector,
typically located on the other side of the
airway adapter. The light, which reaches the
photodetector, is used to calculate etCO2
based on the amount of light wave
absorption. The data is transmitted to the
monitor via a cable that transmits the
amplified detected signals to the monitor.
The monitor displays the partial pressure of
etCO2 value in millimeters of mercury
(mmHg) and also displays a CO2 waveform.

Slide 24 etCO2 Technologies – Mainstream

Subset Two

There are several pieces of equipment

associated with mainstream capnography.
Figure 1 shows the airway adapter, sensor
and cable for intubated applications. Note
the calibration and zeroing windows
attached to the cable. Figure 2 shows a
mask designed for use with mainstream
technology. Figure 3 depicts the placement
of the mask and sensor.

© 2015 Medtronic. All rights reserved. 14

Slide 25 etCO2 Technologies – Mainstream
Subset Three

Mainstream capnography also has

limitations. These limitations include the
following:
• The mainstream sensor is designed
specifically for intubated patients; it cannot
easily or reliably monitor non-intubated
patients
• Because the mainstream sensor sample
cell is attached between the endotracheal
tube and ventilator circuit, the tube can
become dislodged because of the added
weight of the sensor on the tube
• Secretions and moisture can clog the
sensor window causing erroneous CO2
readings that require the ventilator circuit to
be broken in order to clean the sensor
• The sensor must be calibrated before each
use, including resetting the sensor to
baseline or zero, and compensating for
oxygen, nitrous oxide and anesthetic gases.

Slide 26 etCO2 Technologies – Sidestream

Subset One

In sidestream capnography, the CO 2 sensor

is located in the monitor away from the
patient’s airway. A pump aspirates gas
samples from the patient's airway into the
monitor. The sampling tube is connected to
a T-piece inserted at the endotracheal tube,
anesthesia mask connector or a specially
designed nasal cannula used for non-
intubated patients. The tubing directs the
gas sample through a water trap to control
condensation buildup in the sampling line
prior to entry into the monitor. The
sampling flow rate, or the amount of pull or
aspiration to get a sample, is typically up to
200 ml/min.

© 2015 Medtronic. All rights reserved. 15

Slide 27 etCO2 Technologies – Sidestream
Subset Two

Sidestream capnography also has

limitations. These limitations include the
following:
• Because of the high flow rate in the tubing,
moisture that collects in the breath
sampling line can cause sampling
obstructions and the need for frequent line
changes. In addition, the water traps in the
sidestream technology require frequent
emptying so that moisture does not collect
in the sampling line.
• High flow rate also precludes use of
sidestream technology on pediatric or
neonatal patients because of loss of tidal
volume.
• Since the gas moves from the patient to
the monitor, a delay in data delivery can be
an issue.
• As with mainstream capnography, many
sidestream technologies still require
calibration or zeroing by the user to ensure
accurate etCO2 readings.

Slide 28 etCO2 Technologies –

Microstream® Technology
Microstream® technology improves upon
colorimetric CO2 detectors, and
mainstream and sidestream technologies,
because it is molecular-specific to CO2 and
requires a low sample flow rate of 50 ml/min,
along with a small sample size of 15
microliters. In addition, Microstream
technology does not require a sensor at the
airway and can be used to monitor all patient
populations, neonatal through adult,
intubated and non-intubated. There is no
routine calibration or zeroing required.
Because of the accuracy at small tidal
volumes and high respiratory rates,
Microstream technology is ideal for pediatric
and neonates. The low flow rate
requirement promotes moisture handling.

© 2015 Medtronic. All rights reserved. 16

Slide 29 Course Summary
Colorimetric CO2 detectors, mainstream,
sidestream, and microstream technologies
are used to monitor etCO2. Microstream
offers benefits with a focused CO2 specific
infrared light beam, low flow rate of 50
ml/min, and miniature 15 microliter sample
cell.

In understanding pulmonary physiology and

pathophysiology, the differences between
oxygenation and ventilation become clear.
Pulse oximetry applies to oxygenation, and
capnography applies to ventilation. The
normal range for CO2 is between 35-45
mmHg. Capnography monitors the removal
of CO2 in each breath and provides a real
time assessment of the patient’s ventilatory
status.

Intubated and non-intubated patients are

monitored with capnography in various
settings though out the hospital.
Capnography can help detect
hypoventilation, verify endotracheal tube
placement, immediately detect airway
obstruction, and alert clinicians of
ventilation problems associated with
administration of pain medication.
Capnography provides an airway respiration
rate that is measured at the airway and can
alert clinicians to changes in the patient’s
ventilatory status immediately.

© 2015 Medtronic. All rights reserved. 17