APNOGRAPHY Measurment of CO2 in respiratory gases. Integral part of anesthesia monitoring.

Luft 1943 developed it from knowledge that co2 is absorbs infrared radiation of particular wavelength. Collier value of rapid IR CO2 analysis Value of end tidal sample Ramwell 1978 Holland first country to adopt capnography as standard monitoring in anesthesia

3. GUIDELINES ASA included capnography in its standrads for basic monitoring. ISA designated it as desirable monitor in anesthesia. ISA Anesthesia monitoring standards recommended in India for basic monitering from 1999.

4. Terminology Capnography: display of instanteneous CO2 conc. Vs time (time capnogran) or expired volume (volume capnogram) Capnograph: Machine that generates waveform. Capnogram: Actual waveform

5. Terminology Capnometry: Measurment & numerical display Capnometer: Device that performs the measurement & display readings Breath to breath waveform needs to be displayed for continuous monitoring

6. Methods used for measurement Raman spectometry scatering Gas sample is illuminated by high intensity monochromatic Argon laser beam. Light is absorbed by molecules which is then excited to unstable vibrational & rotational energy states, called as Raman scattering Used to identify molecules in gas phase including CO2 & inhalational agents

7. Methods used for measurement Mass spectrometry Photoacoustic gas measurement Colorimetric method

8. Types of capnographSIDE STREAM MAIN STREAM 9. TYPES OF CAPNOGRAPH SIDE STREAM MAIN STREAM CO2 sensor located in main Cuvette containing CO2 sensor monitor inserted between breathing Tiny pump aspirates gas from circuit & ETT. patients airway IR rays detector Transferred by 6 ft long No need of sampling & capillary tube in to main unit scavenging. Rate 50 200 ml/min To prevent condensation of Contamination of FGF water vapour, heated to

40C Water trap Skin burns Gas should be retrieved & Kinking of tube reinjected False reading if not clean Spontaneous respiration Better in children 10. CALIBRATION Capnographs must be calibrated periodically At least daily acc to manufacturers for main stream Automatic Zeroing side stream moniter Main stream calibration sample cell sealed with mixtures of CO2 & N2 Range is up to 100mmHg which is useful in rare cases like malignant hyperthermia, hypoventilation. 11. NORMAL CAPNOGRAM 12. NORMAL TIME CAPNOGRAM I II III IV 13. PHYSIOLOGY EXPIRATION PHASE I Dead space gas exaled, no CO2 PHASE II Mixing of alveolar gas with dead space PHASE III Alveolar Plateau, CO2 reach INSPIRATION PHASE IV Inspiration starts CO2 becomes zero angle PHASE II & PHASE III 1OO V/Q angle PHASE III & PHASE IV 90 REBREATHING 14. NORMAL VOLUME CAPNOGRAM 15. VOLUME CAPNOGRAPHY 16. VOLUME CAPNOGRM 17. TYPE OF CAPNOGRAMSTIME CAPNOGRAM VOLUME CAPNOGRAM 18. CLINICAL USES NORMAL VALUE: 35 45 mmHg Metabolism Increased with increase in metabolism Increased temp, shivering, convulsions,excess catecholamine, blood & bicabonate administration, release of torniquet with reperfusion, glucose containing iv fluids Laproscopy, thoracoscopy. 19. How to interpret capnogram? Respiratory Rate (speed of paper to be known) Height of capnogram ( value of max exp & inspiratory conc of

CO2) Shape ( altered in abnormal states) Baseline of capnogram (rebreathing) 20. 13 HYPERMETABOLISM 21. 16 MALIGNANT HYPERTHERMIA 22. HYPOTHERMIA 23. 5 REBREATHING 24. 4 REBREATHING 25. 1 REBREATHING 26. TORNIQUET RELEASE 27. CIRCULATION Reduced with reduction in cardiac output if ventilation is normal. Reduced blood flow to lungs reduces as in thoracic su rgery, manipulation to heart. Rapid reduction in ETCO2 in absence of changes in BP, HR, CVP indicates pulmonary embolism. Large embolism - reduce CO further reduction in CO2 28. Cardiac output relation 29. STEADY STATE 30. AIR EMBOLISM 31. SMALL PULMONARY EMBOLISM 32. 18 CARDIAC OSSILATIONCardiac pulsations transmitted to vessels to lungs 33. RESPIRATORY Intubation verification Blind nasal intubation Awake fiberoptic intubation Cricothyroidectomy Jet ventilation Double lumen tube Monitoring of respiratory rate Partial airway obstruction 34. HYPOVENTILATIONGradual increase in CO2 with 0 baseline

35. 3 BRONCHOSPASM Increased angle, obstruction to expiration 36. OESOPHAGEAL INTUBATION 37. 10 OESOPHAGEAL INTUBATION Carbonated products in stomach 38. DVT & PULMONARY EMBOLISM 39. KHYPHOSCOLIOSIS 40. Anesthesia Disconnection Partial paralysis Minute ventilation Circuit leak Total occlusion In partial rebreathing circuit & low flow anesthesia

41. 11 DISCONNECTION Sudden fall to zero 42. 6 CURARE CLEFT cleft in phase III due to spontaneous breath 43. SPONTANEOUS BREATHS IN BETWEENShape change of spontaneous & mechanicalventilation

44. ENDOBRONCHIAL TUBE 45. INSPIRATORY VALVE NOT CLOSED 46. EXPIRTORY VALVE DYSFUNCTION Expiratory valve stuck Increased inspiratory co2

47. PROMBLEMS IN SAMPLE LINELOW SAMPLING RATE CONTAMINATION BY FGF

48. AIR DILUTION FGF 49. LEAK IN SAMPLE LINE WITH IPPV 50. RELATION TO PaCO2 51. NON STEADY STATE 52. LMA & ETT

53. TAKE HOME MESSAGES Capnography included as standard of basic monitoring. Side stream & main stream advantages & disadvantages. Helpful in monitoring of respiratory rate, ETCO2, rebreathing, prediction of PaCO2 Shapes of capnogram help in diagnosis of abnormal conditions. Must be calibrated periodically. Must be cleaned or disposed to prevent cross infection.

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