Recent technical innovations have made portable cap nographic monitoring systems available for intensive care unit use. Some of these systems require little tech nical expertise to operate. Capnography has several clin ically relevant applications. It may be used as a monitor of respiration (apnea monitor), of wasted ventilation, or as a reflection of arterial carbon dioxide tension. In some clinical settings, it may provide information about changes in lung perfusion or carbon dioxide produc tion. Because this technique is noninvasive and con tinuous, it offers certain advantages over intermittent arterial blood gas monitoring. The advantages and limi tations of this technique are discussed.
Get full access to this article
View all access options for this article.
References
1.
West JB, Fowler KT, Hugh-Jones P, O'Donnell TV. Measurement of ventilation-perfusion ratio inequality in the lung by analysis of a single expirate. Clin Sci1957;16:529-547
2.
West JB, Fowler KT, Hugh-Jones P, O'Donnell TV. Measurement of the inequality of ventilation and of perfusion in the lung by analysis of single expirates. Clin Sci1957;16:549-565
3.
Ayres SMUse of mass spectrometry for evaluation of respiratory function in the critically ill patient. Crit Care Med1976;4:219-222
4.
Riker JB, Haberman B.Expired gas monitoring by mass spectrometry in a respiratory intensive care unit. Crit Care Med1976;4:223-229
5.
McAslan TCAutomated respiratory gas monitoring of critically injured patients. Crit Care Med1976;4:255-260
6.
Smalhout B., Kalenda Z.An atlas of capnography. The Netherlands: Kerkebosch-Zeist , 1975
7.
Kalenda Z.Capnography during anesthesia and intensive care. Acta Anaesthesiol Belg1978;29:201-228
8.
Schena J., Thompson J., Crone RKMechanical influences on the capnogram. Crit Care Med1984;12:672-674
9.
Rahn H.A concept of mean alveolar air and the ventilation—blood flow relationship during pulmonary gas exchange. Am J Physiol1949;158:21-30
10.
Collier CR, Affeldt JE, Farr AFContinuous infrared CO2 analysis: fractional sampling and accuracy in determining alveolar CO2. J Lab Clin Med1955;45:526-539
11.
DuBois AB, Fowler RC, Soffer A., Fenn WOAlveolar CO2 measured by expiration into the rapid infrared gas analyzer. J Appl Physiol1952;4:526-534
12.
Nunn JF, Hill DWRespiratory dead space and arterial to end tidal CO2 tension difference in anesthetized man. J Appl Physiol1960;15:383-389
13.
Tulou PPDistribution of ventilation: clinical evaluation by rapid CO2 analysis . Dis Chest1966;49:139-146
14.
Tulou PP, Walsh PMMeasurement of alveolar carbon dioxide tension at maximal expiration as an estimate of arterial carbon dioxide tension in patients with airway obstruction . Am Rev Respir Dis1970;102:921-926
15.
Hatle L., Rokseth R.The arterial to end-expiratory carbon dioxide tension in acute pulmonary embolism and other cardiopulmonary diseases. Chest1974;66:352-357
16.
Fowler KT, Read J.Cardiogenic oscillations as an index of pulmonary blood flow distribution . J Appl Physiol1963; 18:233-243
17.
Fowler KT, Read J.Cardiac oscillations in expired gas tension and regional pulmonary blood flow . J Appl Physiol1961;16:863-868
18.
Hazerian TE , McGowan MS, Buckle FGContinuous bedside CO2 monitoring in the diagnosis of acute airway obstruction. Crit Care Med1985;13:449
19.
Benjamin E. , Kaplan JA, Iberti TJExpiratory sawtooth pattern or cardiogenic oscillations of the capnogram. Crit Care Med1986 ;14:172
20.
Carlon GC, Ray C., Miodownik S., et al. Capnography in mechanically ventilated patients. Crit Care Med1988; 16:550-556
21.
Suskind M., Bruce RA, McDowell ME, et al. Normal variations in end-tidal air and arterial blood carbon dioxide and oxygen during moderate exercise. J Appl Physiol1950; 3:282-290
22.
Jones NL, McHardy Gjr, Naimark A., Campbell Ejm.Physiologic dead space and alveolar-arterial gas pressure differences during exercise. Clin Sci1966;31:19-29
23.
Jones NL, Robertson DG, Kane JWDifference between end-tidal and arterial pCO2 in exercise. J Appl Physiol1979;47:954-960
24.
Moorchy SS, Losasso AM, Wilcox J.End-tidal pCO2 greater than paCO2. Crit Care Med1984;12:534-535
25.
Luft UC, Loeppky JA, Mostyn EMMean alveolar gases and alveolar arterial gradients in pulmonary patients . J Appl Physiol1979;46:534-540
26.
Hoffbrand BIThe expiratory capnogram: a measure of ventilation-perfusion inequalities . Thorax1966;21:518-523
Rossier PH, Buhlmann AA, Wiesinger K.Respiration: physiologic principles and their clinical applications. St. Louis: CV Mosby, 1960:58-62
29.
Kuwabara S. , Duncalf D.Effect of anatomic shunt on physiologic deadspace-to-tidal volume ratio: a new equation. Anesthesiology1969;31:575-577
30.
Hansen JE, Sue DYShould blood gas measurements be corrected for the patients temperature?N Engl J Med1980;303:341
31.
Ream AK, Reitz BA, Silverberg G.Temperature correction of PCO2 and pH in estimating acid-base status: an example of the emperor's new clothes? Anesthesiology1982;56:41-44
32.
Nunn JF, Bergman NA, Bunatyan A.Temperature coefficients for PCO2 and PO2 of blood in vitro. J Appl Physiol1965;20:23-26
33.
Bergman NATemperature coefficients for PCO2 and PO2 in bloods with varying acid-base status. J Appl Physiol1968 ; 24:225-228
34.
Whitesell R. , Asiddao C., Gollman D., Jablonski J.Relationship between arterial and peak expired carbon dioxide pressure during anesthesia and factors influencing the difference . Anesth Analg1981;60:508-512
35.
Donati F., Maille JG, Blain R., et al. End-tidal carbon dioxide tension and temperature changes after coronary artery bypass surgery. Can Anaesth Soc J1985;32:272-277
36.
Raemer DB, Francis D., Philip JH, Gabel RAVariation in PCO2 between arterial blood and peak expired gas during anesthesia. Anesth Analg1983;62:1065-1069
37.
Rebuck AS, Chapman KRMeasurement and monitoring of exhaled carbon dioxide. In: Nochomvitz M, ed. Noninvasive respiratory monitoring. New York: Churchill-Livingstone , 1986:189-201
38.
Tobin MJRespiratory monitoring in the intensive care unit. Am Rev Respir Dis1988;138:1625-1642
39.
Yamanaka MK , Sue DYComparison of arterial-end-tidal PCO 2 difference and dead space/tidal volume ratio in respiratory failure . Chest1987;92:832-835
40.
Birmingham PK, Cheney FW, Ward RJEsophageal intubation: a review of detection techniques. Anesth Analg1986; 65:886-891
41.
Howells TH, Reithmuller RJSigns of endotracheal intubation. Anesthesia1980;35:984-986
42.
Pollard BJ, Junius F.Accidental intubation of the oesophagus. Anaesth Intensive Care1980;8:183-186
43.
Murray IPModell JHEarly detection of endotracheal tube accidents by monitoring carbon dioxide concentration in respiratory gas. Anesthesiology1983;59:344-346
44.
Linko K., Paloheimo M., Tammisto T.Capnography for detection of accidental oesophageal intubation. Acta Anesthesiol Scand1983;27:199-202
45.
Huang KC, Kraman SS, Wright BDVideo stethoscope—a simple method for assuring continuous bilateral lung ventilation during anesthesia. Anesth Analg1983;62:586-589
46.
Shafieha MJ , Sit J., Kartha R, et al. End-tidal CO2 analyzers in proper positioning of the double-lumen tubes. Anesthesiology1986;64:844-845
47.
Potter WAMass spectrometry for innovative techniques of respirator care, ventilator weaning and differential ventilation in an intensive care unit. Crit Care Med1976;4:235-239
48.
Robin ED, Julian DG, Travis DM, Crump CHA physiologic approach to the diagnosis of acute pulmonary embolism. N Engl J Med1959;260:586-591
49.
Robin ED, Forkner CE, Bromberg PA, et al. Alveolar gas exchange in clinical pulmonary embolism. N Engl J Med1960;262:283-287
50.
Nutter DO, Massumi RAThe arterial-alveolar carbon dioxide tension gradient in diagnosis of pulmonary embolus. Dis Chest1966;50:380-387
51.
Levy SE, Stein M., Totten RSVentilation-perfusion abnormalities in experimental pulmonary embolism. J Clin Invest1966;44:1699-1707
52.
Marshall R. , Sabiston DC, Allison PRImmediate and late effects of pulmonary embolism by large thrombi in dogs. Thorax1963;18:1-9
53.
Phillips J. , Keith D., Hulka J., Keith L.Gynecologic laparoscopy in 1975. J Reprod Med1975;16:205-217
54.
Yacoub OF, Cardona I., Coveler LA, Dodson MGCarbon dioxide embolism during laparoscopy. Anesthesiology1982;57:533-535
55.
Bedford RF, Marshall WK, Butler A., Welsh JECardiac catheters for diagnosis and treatment of venous air embolism: a prospective study in man. J Neurosurg1981;55:610-614
56.
Kahn MA, Alkalay I., Suetsugu S., Stein M.Acute changes in lung mechanics following pulmonary embolism of various gases in dogs. J Appl Physiol1972;33:774-777
57.
Kunkler A., King H.Comparison of air, oxygen, and carbon dioxide embolization. Ann Surg1959;149:95-99
58.
Graff TD, Arbegast NR, Phillips OC, et al. Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system. Am J Obstet Gynecol1959;78:259-265
59.
Tateishi H.Prospective study of air embolism. Br J Anaesth1972;44:1306-1310
60.
Edmonds-Seal J., Prys-Roberts C., Adams APAir embolism: a comparison of various methods of detection. Anaesthesia1971;26:202-208
61.
Pattison WJEnd-tidal carbon dioxide levels in the early detection of air embolism. Anaesth Intensive Care1975; 3:58-59
62.
Hurter D., Sebel PSDetection of venous air embolism: a clinical report using end-tidal carbon dioxide monitoring during neurosurgery. Anesthesia1979;34:578-582
63.
Oppenheimer MJ, Durant TM, Stauffer HM, et al. In vivo visualization of intracardiac structures with gaseous carbon dioxide. Am J Physiol1956;186:325-334
64.
Shulman D., Aronson HBCapnography in the early diagnosis of carbon dioxide embolism during laparoscopy . Can Anaesth Soc J1984;31:455-459
65.
Marshall R. , Bates DB, Christie RVFractional analysis of alveolar air in emphysema . Clin Sci1952;11:297-307
66.
Comroe JH, Forster RE, DuBois AB, et al. The lung: clinical physiology in health and disease, ed 2. Chicago: Year Book Medical Publishers, 1962:107-108
67.
Anderson WHA simple test of abnormal ventilation perfusion relationships. Dis Chest1963;44:478-484
68.
Silverston SE, Fowler WSExpired alveolar CO2 tension in health and pulmonary emphysema. J Lab Clin Med1956; 47:869-884
69.
Sakamoto A. , Murao M.Studies on the expired carbon dioxide tension in pulmonary emphysema: with special reference to pulmonary artery hypertension . Jpn Heart J1960;1:37-55
70.
Kalenda Z.The capnogram as a guide to the efficacy of cardiac massage. Resuscitation1978;6:259-263
71.
Schoonees JAUse of capnography to monitor pulmonary circulation during cardiac resuscitation. Circulation1977; 51:890-891
72.
Weil MH, Bisera J., Trevino RP, Rackow RCCardiac output and end-tidal carbon dioxide. Crit Care Med1985;13:907-909
73.
Trevino RP, Bisera J.Weil MH, et al. End-tidal CO2 as a guide to successful cardiopulmonary resuscitation: a preliminary report. Crit Care Med1985,13:910-911
74.
Grundler W., Weil MH, Rackow ECArteriovenous carbon dioxide and pH gradients during cardiac arrest. Circulation1986;74:1071-1074
75.
Gudipati CV , Weil MH, Bisera J., et al. Expired carbon dioxide: a non-invasive monitor of cardiopulmonary resuscitation. Circulation1988;77:234-239
76.
Lepilin MG, Vasilyev AV, Bildinov OA, Rostovtseva NA End-tidal carbon dioxide as a non-invasive monitor of circulatory status during cardiopulmonary resuscitation: a preliminary clinical study . Crit Care Med1987;15:958-959
77.
Garnett AR, Ornato JP, Gonzalez ER, Johnson B.End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA1987;257:512-515
78.
Falk JL, Racknow EC, Weil MHEnd-tidal carbon dioxide concentration during cardiopulmonary resuscitation . N Engl J Med1988;318:607-611
79.
American Heart Association Subcommittee on Emergency Cardiac Care.Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA1986;255:2905-2992
80.
Del Guercio L, Coomaraswamy R., State D.Cardiac output and other hemodynamic variables during external cardiac massage in man. N Engl J Med1963;269:1398-1404
81.
Weale FE, Rothwell-Jackson RLThe efficiency of cardiac massage. Lancet1962;1:990-992
82.
Grundler W. , Weil MH, Masonobu Y., Michaels S.The paradox of venous acidosis and arterial alkalosis during CPR. Chest1984;86:282 (Abstract)
83.
Weil MH, Racknow EC, Trevino R., et al. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. N Engl J Med1986;315:153-156
84.
Weil MH, Grundler W., Falk JL, et al. Selective acidosis in venous blood during CPR in human patients . Circulation1984;70:382
85.
Sanders AB, Ewy GA, Bragg S., et al. Expired PCO2 as a prognostic indicator of successful resuscitation from cardiac arrest. Ann Emerg Med1985;14:948-952
86.
Sanders AB, Kern KB, Otto CW, et al. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: a prognostic indicator of survival. JAMA1989 ;262:1347-1351
87.
Burton GWMeasurement of inspired and expired O2 and CO2. Br J Anaesth1969;41:723-730
88.
Evans JM, Hogg MJ, Rosen M.Correlation of alveolar PCO2 estimated by infrared analysis and arterial PCO2 in the human neonate and the rabbit. Br J Anaesth1977;49:761-764
89.
Weinger MB, Brimm JEEnd-tidal carbon dioxide as a measure of arterial carbon dioxide during intermittent mandatory ventilation. J Clin Monit1987;3:73-79
90.
Hedenstierna G., McCarthy G.The effect of anaesthesia and intermittent positive pressure ventilation with different frequencies on the anatomical and alveolar deadspace. J Anaesth1975;47:847-852
91.
MacIntyre NRRespiratory function during pressure support ventilation. Chest1986;89:677-683
92.
Capan LM, Ramanathan S., Sinha K., Turndorf H.Arterial to end-tidal CO2 gradients during spontaneous breathing, intermittent positive-pressure ventilation and jet ventilation. Crit Care Med1985;13:810-813
93.
Butler WJ, Bohn DJ, Bryan AC, Froese ABVentilation by high frequency of oscillation in humans. Anesth Analg1980;59:577-584
94.
Ngeow YK, Mitzner W., Erlich W.Carbon dioxide clearance during high frequency ventilation. Anesthesiology1980;53: S400
95.
Chang HKMechanisms of gas transport during ventilation by high-frequency oscillation . J Appl Physiol1984;56:553-563
96.
Weisman IM, Rinaldo JE, Rodgers RMPositive end-expiratory pressure in adult respiratory failure. N Engl J Med1982;307:1381-1384
97.
Shapiro BA, Cane RD, Harrison RAPositive end-expiratory pressure in acute lung injury. Chest1983;83:558-563
98.
Kraig KC, Pierson DJ, Carrico CJThe clinical application of positive end-expiratory pressure (PEEP) in the adult respiratory distress syndrome (ARDS). Respir Care1985;30: 184-201
99.
Dantzker DR , Brook CJ, Dehart P., et al. Ventilation-perfusion distributions in adult respiratory distress syndrome. Am Rev Respir Dis1979;120:1039-1052
100.
Jardin F., Farcot JC, Boisante L., et al. Influence on positive end-expiratory pressure on left ventricular performance. N Engl J Med1981:304:387-392
101.
Downs JB, Klein EF, Modell JHThe effect of incremental PEEP on PaO2 in patients with respiratory failure. Anesth Analg1973;52:210-214
102.
Suter PM, Fairley BM, Isenberg MDOptimum end-expiratory pressure in patients with acute pulmonary failure. N Engl J Med1975;292:284-289
103.
Baehrendtz S., Bindslev L., Hedenstierna G., Santesson J.Selective PEEP in acute bilateral lung injury: effects on patients in lateral posture. Acta Anaesthesiol Scand1983;27: 311-317
104.
Romano E. BestPEEP: a still unsolved problem. Chest1985; 87:551-552
105.
Albert RKLeast PEEP: primum non nocere. Chest1985; 87:2-4
106.
Murray IP, Modell JH, Gallagher TJ, Banner MJTitration of PEEP by the arterial minus end-tidal carbon dioxide gradient . Chest1984;85:100-104
107.
Siegel JH, Giovannini I., Coleman B.Ventilation:perfusion maldistribution secondary to the hyperdynamic cardiovascular state as the major cause increased pulmonary shunting in human sepsis. J Trauma1979;19:432-459
108.
Jardin F., Genevray B., Pazin M., Margairaz A.Inability to titrate PEEP in patients with acute respiratory failure using end-tidal carbon dioxide measurements. Anesthesiology1985;62:530-533
109.
Matamis D. , Lemaire F., Harf A., et al. Redistribution of pulmonary blood flow induced by positive end-expiratory pressure and dopamine infusion in acute respiratory failure. Am Rev Respir Dis1984;129:39-44
110.
Scheid P., Pipper J.Intrapulmonary gas mixing and stratification. In: West JB, ed. Pulmonary gas exchange. Vol 1. New York: Academic Press, 1980:87-130
111.
Blanch L., Fernandez R., Benito S., et al. Effect of PEEP on the arterial minus end-tidal carbon dioxide gradient. Chest1987;92:451-454
112.
Demedts M. , Clemenys J., Stanescu DC, Van de Woestijne KPInflection point on the transpulmonary pressure-volume curves and closing volume. J Appl Physiol1975;38:228-235
113.
Matamis D. , Lemaire F., Harf A., et al. Total respiratory pressure-volume curves in adult respiratory distress syndrome. Chest1984;86:58-66
114.
Pesenti A., Marcolin R., Prato P., et al. Mean airway pressure vs positive end-expiratory pressure during mechanical ventilation. Crit Care Med1985 ;13:34-37
115.
Benito S., Lemaire F., Mankikian B., Harf A.Total respiratory compliance as a function of lung volumes in patients with mechanical ventilation. Intensive Care Med1985;11:76-79
116.
Perrin F., Perrot D., Holzapfel L., Robert D.Simultaneous variations in PaCO2 and PACO2 in assisted ventilation. Br J Anaesth1983;55:525-530
117.
Fletcher R. , Johnson B.Deadspace and the single breath test for carbon dioxide during anesthesia and artificial ventilation: effects of tidal volume and frequency of respiration. Br J Anaesth1984;56:109-119
118.
Takki S., Aromaa U., Kauste A.The validity and usefulness of the end-tidal PCO2 during anaesthesia . Ann Clin Res1972;4:278-284
119.
Askrog VF, Pender JW, Smith TC, Eckenhoff JEChanges in respiratory dead space during halothane, cyclopropane, and nitrous oxide anesthesia. Anesthesiology1964;25:342-352
120.
Shankar KB , Moseley H., Kumar Y., Vemula V.Arterial to end tidal carbon dioxide tension difference during Caesarean section anaesthesia. Anaesthesia1986;41:689-702
121.
Stock MCNon-invasive carbon dioxide monitoring. Crit Care Clin1988;4:511-526
122.
Hoffman RA , Krieger BP, Kramer MR, et al. End-tidal carbon dioxide in critically ill patients during changes in mechanical ventilation. Am Rev Respir Dis1989;140:1265-1268
123.
Healy CJ, Fedullo AJ, Swinburne AJ, Whal GWComparison of non-invasive measurements of carbon dioxide tension during withdrawal from mechanical ventilation. Crit Care Med1987;15:764-768
124.
van Genderinger HR, Gravenstein N., van der Aa JJ, Gravenstein JSComputer-assisted capnogram analysis. J Clin Monit1987;3:194-200
