Chapter 22

Gas Monitoring
P. 686


Rel i abl e, af f ordabl e, and user-f ri endly moni t ors to measure respi ratory and
anesthet ic gas concent rati ons are now avai l abl e. Some use more than one
t echnol ogy to measure dif f erent gases. Some combi ne gas anal ysi s wi th other t ypes
of moni t oring such as electrocardi ograph, bl ood pressure, pul se oxi met ry, or
spi romet ry (Fi g. 22.1).
Definitions
Del ay t i me (transi t t ime, response ti me, t ransport delay, t ime del ay, lag t i me)
i s the t i me to achi eve 10% of a step change i n readi ng at t he gas moni t or.
Ri se ti me (response t ime) is the ti me requi red f or a change f rom 10% to 90%
of t he t otal change i n a gas val ue wi th a change i n concentrat ion at the
sampl i ng si t e.
Total system response ti me is t he sum of t he del ay and rise ti mes. A f ast
response ti me i s necessary to obtai n accurate values and waveforms. The
use of an i nst rument wi th a sl ow response may resul t in i ncorrect end-ti dal
values during rapi d venti lati on (1).
The sensor (measuri ng head or chamber) i s the part of a respi ratory gas
moni tor t hat i s sensi t i ve to the gas being measured.
P. 687



View Figure

Figure 22.1 Multipurpose monitor. Most gas
monitors are now part of a physiologic monitor that
includes other monitoring such as
electrocardiograph, blood pressure, pulse oximetry,
and the like. A gas monitor may also be part of the
anesthesia machine. Newer anesthesia machines
have one or more screens to display monitored
functions, and the gas concentrations and waveforms
may also be displayed.

A nondivert i ng (mai nstream, di rect probe, fl ow t hrough, i n-l i ne, on ai rway,
nonsampl i ng moni tor) moni tor measures the gas concent rati on at t he
sampl i ng si t e.
A di verti ng (si dest ream, wi thdrawal , sampl ing, aspi rati ng, snif f er, sampl ed
system moni tor) transports a porti on of the gas bei ng measured f rom t he
sampl i ng si t e through a sampl i ng t ube t o the sensor, whi ch i s remote f rom
t he sampl i ng si te.
The sampl ing si te (sensi ng si te) is t he l ocati on f rom which gas i s divert ed f or
measurement i n a divert i ng moni tor or t he locat ion of the sensor in a
nondi verti ng moni tor.
The sampl ing t ube (i nl et li ne, sampl e gas t ransport t ube, sampl e capi l lary
t ube, sampl i ng cat heter or t ube, transport tube, aspi rat i ng tube, sampl e l i ne)
i s the condui t f or t ransf erri ng gas f rom the sampl ing si t e to t he sensor i n a
di verti ng gas moni tor.
Gas l evel is the concentrati on of a gas in a gaseous mi xture. I t may be
expressed ei ther as part i al pressure or vol umes percent.
The part i al pressure of a gas is t he pressure t hat a gas i n a gas mi xture
woul d exert i f i t al one occupi ed the vol ume of t he mi xture at the same
t emperat ure.
The volumes percent (%, V/V, vol %) of a gas i s the vol ume of a gas i n a
mi xture, expressed as a percentage of the tot al vol ume.
Monitor Types
There are two general t ypes of moni tors i n cli ni cal use: divert i ng (si destream) or
nondi verti ng (mainstream) (2,3). These ref er t o t he measurement si te of t he gases
and not to t he technology bei ng used. Both can be i nt egrated into a si ngl e modul e.
Nondiverting
A nondiverti ng gas moni t or measures the gas by usi ng a sensor l ocated di rect l y i n
t he gas st ream. Onl y oxygen and carbon dioxi de (CO
2
) can be measured by
nondi verti ng moni tors.
Carbon di oxide i s measured by i nf rared technol ogy wi th t he sensor l ocated between
t he breathi ng system and t he pati ent (Figs. 22.2, 22.3). A nondi verti ng moni tor i s
avai l able f or the non-i ntubated pat ient, i n whi ch t he sensor at taches t o a
di sposabl e oral and nasal adaptor.
The mai nstream oxygen sensor uses el ect rochemi cal technology. I t i s usual l y
pl aced i n the breathing syst em inspi ratory l i mb. If the technol ogy i s f ast enough t o
measure both i nspi red and exhal ed oxygen, i t shoul d be pl aced bet ween the pat ient
and the breat hi ng system. Chapter 9 di scusses possible l ocat i ons of t he oxygen
moni tor sensor i n the ci rcl e breathing syst em.
Advantages
Mai nst ream CO
2
moni tors have f ast response ti mes because there is no
del ay t i me. The CO
2
wavef orm generated has bet ter f i del i t y than one
generated by a divert ing moni tor.
Because no gas is removed f rom t he breat hi ng system, i t i s not necessary to
scavenge these devices or t o increase the f resh gas f l ow t o compensate for
gas removed f rom the breat hi ng system.
Water and secreti ons are seldom a probl em wi t h this t ype of anal yzer,
al though secreti ons on the wi ndows of the cuvette used f or mai nst ream CO
2

moni tori ng can cause erroneous readi ngs. Water and secret i ons
P. 688

are general l y not a probl em wi t h oxygen sensors, as t hey are usual l y on the
i nspi ratory si de of t he breat hi ng system.

View Figure

Figure 22.2 Nondiverting gas monitor. A: The
sensor is in position over the cuvette, which is
placed between the patient and the breathing system.
The two clear tubings to the left are for spirometry
loops (Chapter 23). B: The sensor is separated from
the cuvette, which contains the window through
which the infrared light passes. C: Calibration cells.
For convenience, they are attached to the cable to
the sensor. During calibration, the sensor is placed
over each cell in sequence.

Sample contaminati on by f resh gas i s l ess l i kel y than wi t h a diverti ng
moni tor.
A standard gas i s not requi red for cal i brati on. Oxygen sensors are usuall y
cali brated by usi ng room ai r.
These moni tors use f ewer di sposabl e i tems than di verti ng moni tors.
Disadvantages
To obtai n accurate end-t i dal CO
2
values, t he ai rway adaptor must be pl aced
near the pat ient. The sensor wi l l add wei ght t o the breathing system and may
cause tracti on on the ai rway devi ce or breathi ng tubes.
The use of an adapt or bet ween t he pat i ent and the breathi ng syst em wi l l
i ncrease dead space. However, st udies show that end-t i dal CO
2
values
obtai ned by usi ng a mainstream anal yzer wi th a pedi atric adapt er i n heal thy
neonat es and i nf ants are close to arteri al values (4).
Leaks, disconnect i ons, and ci rcui t obst ruct ions can occur (5,6,7,8).
Wi th a mainst ream CO
2
moni t or, condensed water, secreti ons, or blood on
t he wi ndows of the cuvet te wi l l i nt erfere wi t h l ight t ransmissi on.
Wi th a mainst ream CO
2
moni t or, the sensor may become dislodged f rom the
cuvet te. If i t i s compl etel y dislodged, no waveform wi l l be seen. If i t is
sl i ght ly di sl odged (Fi g. 22. 4), t he readi ng may be i ncorrect al t hough the
waveform wi l l appear normal (9,10,11).
The expensi ve optical sensor for CO
2
i s vulnerabl e to cost l y damage.
At present , mai nst ream moni tors can measure onl y oxygen and CO
2
.
The adaptor f or t he CO
2
sensor must be cl eaned and di si nf ect ed bet ween
uses. There i s potent i al f or cross contaminati on between pat ients i f this i s
not done properl y. Di sposable adapt ors are avai l abl e but i ncrease the cost .
Thermal burns have been reported wi t h a mai nst ream CO
2
anal yzer despi te
use of mul ti pl e l ayers of gauze, whi ch kept t he sensor f rom di rect contact
wi th t he ski n (12). To prevent thi s, i t may be necessary t o interpose a piece
of al umi num f oi l bet ween t wo pieces of sof t materi al t o refl ect the radi ant
energy.
P. 689



View Figure

Figure 22.3 Mainstream infrared analyzer. A: Side
view. The light source and detector are housed in the
sensor, which fits over the cuvette. The infrared light
shines through the windows of the cuvette and is
detected by the photosensor. B: Cross-sectional
view. Gases pass through the airway adaptor
(cuvette). The infrared light that is transmitted
through the windows is filtered and then detected by
the photodetector in the sensor.

Prol onged contact of the CO
2
sensor assembl y wi t h the pati ent could cause
pressure i nj ury.
Diverting
A di verti ng moni tor uses a pump to aspi rat e gas f rom the sampl ing si t e through a
sampl i ng tubi ng to t he sensor t hat i s l ocated i n the mai n uni t. Keepi ng the sampl i ng
t ube as short as possible wi l l decrease t he del ay t i me and resul t in more
sati sf actory wavef orms. These anal yzers are usual l y zeroed usi ng room ai r and
cali brated usi ng a gas of known composi ti on. A mainstream moni tor wi th di verti ng
capabi l i t y is shown i n Fi gure 22. 5. Gas i s aspi rated through a special cuvett e and i s
analyzed by the sensor.
To avoid water or parti culat e contami nat i on i n the moni tor, a number of devi ces
have been used. These i ncl ude t raps (Fi g. 22.6) (which must be empti ed
peri odi cal l y), f i l ters and hydrophobi c membranes (whi ch must be changed
peri odi cal l y), and speci al tubi ng (whi ch al l ows wat er t o di ff use t hrough i ts wal l s)
(13,14).
Water dropl ets and secreti ons f rom the breathi ng system can enter t he sampli ng
t ube and i ncrease resistance in t he tubi ng, af f ecti ng the accuracy. Some
i nst ruments ei ther i ncrease the sampl ing f l ow or, t o cl ear t he contami nant f rom the
t ube, reverse the f l ow (purge) when they sense a drop i n pressure f rom a f l ow
rest ri ct ion (15). I f this f ail s, the sampl ing port and/or t he tube must be repl aced.
P. 690



View Figure

Figure 22.4 Mainstream infrared CO
2
analyzer with the
sensor not completely covering the windows of the cuvette.
This can result in falsely low CO
2
readings.

Accuracy decreases wi th i ncreasi ng respi rat ory rat e and longer sampl i ng l i nes (16).
Most di verti ng capnomet ers are accurate at those respi ratory rates t hat are
normal l y encountered i n cl inical pract ice (20 t o 40 breaths per mi nut e). At hi gher
respi ratory rates, accuracy i s l ower.
The sampl ing f l ow rat e should be proport i onal to the si ze of the pati ent. I t has been
recommended t hat a f l ow rate l ess t han 150 mL/mi nute shoul d not be used because
a low sampl ing f l ow may resul t in an el evated basel i ne, erroneousl y l ow peak
readi ngs, and absence of an end-t i dal pl ateau (Fig. 22.36), especi al l y when the
respi ratory rate i s f ast and ti dal volume i s smal l (17). A high f l ow rat e wi l l decrease
t he del ay and rise ti mes but may cause f resh gas to be ent rai ned i nt o the sampl e
l i ne wi t h some breathing syst ems. Thi s wi l l resul t i n incorrect end-t i dal readi ngs
and a capnogram wi th a decrease i n CO
2
at the end of t he expi ratory pl at eau (Fig.
22.37).

View Figure

Figure 22.5 Mainstream infrared CO
2
analyzer used as a
diverting monitor. Gas is drawn through the cuvette by a
pump.

Devices
Face Mask
A f ace mask has a rel ati vely l arge dead space relati ve to t i dal vol ume, making i t
more dif f icul t t o obtai n accurate end-t i dal values. Fi gure 22.7 shows a mask wi t h a
sampl i ng l ine f or CO
2
. A sampl i ng catheter can also be attached to t he upper l i p or
pl aced i n the pat ient' s nares or t he l umen of an oral or nasopharyngeal ai rway
under t he mask (18). Wi th a breathi ng syst em, the sampl i ng tube i s most of ten
at tached t o a component between the mask and the breathing syst em (Fi g. 22.8), or
t he
P. 691

sampl i ng tube may be i nsert ed through the ri ght-angle connector that at taches t o
t he mask (19, 20).

View Figure

Figure 22.6 Water trap. This should be emptied periodically
to prevent water from entering the monitor.


View Figure

Figure 22.7 Face mask with lines for oxygen administration
and gas sampling.

Tracheal Tube
To measure both i nspi red and exhal ed gases, the sampl i ng si t e must be between
t he pat ient and the breathi ng system. Most di sposabl e breat hi ng systems and heat
and moi st ure exchangers (HMEs) have bui l t-i n sample ports (Fi g. 22.8).
The sampl ing si te should be away f rom t he f resh gas port. When a Mapl eson
breat hi ng system i s used, conti nuous inf l ow of f resh gas that i s cl ose to t he
sampl i ng si t e can cause erroneous readi ngs and an abnormal wavef orm (Fi g.
22.37).
Tracheal tubes that i ncorporate a sampl i ng l umen that extends to t he mi ddl e or
pati ent end of the tube are avai l able (Chapter 19). Tracheal tube connectors wi t h
an at tachment or hole f or a sampl i ng tube are avai labl e or can be creat ed (21).
These may resul t i n measurements that more cl osel y approximate al veol ar val ues,
especi al l y i n smal l pati ents and wi th breathi ng systems i n whi ch the f resh gas f l ow
can mi x wi th exhal ed gases (22,23,24,25,26).

View Figure

Figure 22.8 Ports for gas sampling in breathing system
components.

Supraglottic Device
Wi th a supragl ot ti c ai rway devi ce, a sampl i ng tube can be i nserted through t he
connector (27,28). The pref erred sampl ing si te is the di st al end of the shaf t (29, 30),
but i n most pat ients, sampl i ng at the connecti on to the breathi ng system wi l l resul t
i n sat isfactory readi ngs (31,32, 33,34,35).
A sampl i ng tubi ng may be inserted i nto a nasal ai rway (36, 37,38).
Oxygen Supplementation Devices
A rel at i vel y new device, the OxyArm, al lows simul taneous admi ni st rat i on of oxygen
and carbon di oxi de moni tori ng (39,40). It consi sts of a headset that t raverses
across the t op of the head, oxygen suppl y and CO
2
sampl i ng l ines at tached to an
adj ustable boom and a disposabl e arm di ff usor. I t can be used t o admi nister oxygen
and moni tor CO
2
i n both nose and mout h breathers. A nasal cannul a can be
modi f i ed t o accept a sampl i ng t ubi ng
(39,40,41, 42, 43,44,45, 46,47,48,49,50,51,52,53,54, 55,56,57, 58,59,60, 61, 62,63, 64,6
5, 66,67). They are avai lable i n several conf i gurati ons (Fi gs. 22. 9, 22. 10). Mouth
breat hi ng, ai rway obstructi on, and oxygen del ivery t hrough t he i psi l ateral nasal
cannul a can af f ect accuracy (68). Caut i on should be observed i n adapti ng a nasal
cannul a; a pi ece may become di sl odged and present a choki ng hazard (69).
A pl ast ic oxygen mask may be fi t ted wi t h a sampl ing port (39, 70) (Fi g. 22.7).
Al ternati vel y, the sampl i ng t ube may be connected t o the mask outl et (71), i nsert ed
t hrough a vent hol e (42,57,72,73,74,75,76) or a sl i t i n the mask (77), or sl i pped
under t he mask and att ached near t he nostri ls (37, 78,79,80).
J et Ventilation
During j et vent i lat i on, an i nj ector i ncorporati ng a sampl i ng l umen (81,82,83,84) or a
sampl i ng tube pl aced i n the ai r way (85,86) may be used. The venti l atory f requency
may need to be l owered to measure t he end-t i dal CO
2
(83,87, 88).
Other
The end of a sampl i ng li ne can be pl aced i n f ront of or i nsi de the pat i ent' s nostri l
(89,90) or a nasopharyngeal ai rway (91). I f t he pat ient i s a mouth breather, t he
sampl e l i ne can be pl aced i n f ront of the mout h or i n the nasopharynx (89,92) or
hypopharynx (93,94). A catheter can be pl aced in t he trachea af t er extubati on f or
CO
2
moni t ori ng (95). A bi te bl ock can be modi f i ed to accommodate a sampl i ng l ine
(96). A sampl i ng l i ne can be pl aced over a tracheost omy stoma (97).
Opt imal pl acement shoul d be determi ned by t he CO
2
wavef orm. Mucosal i rri t ati on,
catheter blockage, and mechanical i nterf erence somet imes cause probl ems.
P. 692



View Figure

Figure 22.9 Devices for simultaneous administration of
oxygen and gas sampling. A: This device is designed for
patients who are predominantly mouth breathers. The longer
oral sampling prongs can be cut and shaped to suit
individual patients. (Courtesy of Biochem International,
Inc.) B: One prong is used for administration of oxygen and
one for gas sampling. There is a septum between the two
prongs. C: With this device, the two prongs are divided so
that oxygen is delivered and gas is sampled through each
prong.

Advantages
Cal i brati on and zeroi ng are usuall y automati c. Occasi onal cal i brati on i s
necessary but i s usual l y easi l y accompl ished.
The added dead space is mi ni mal .
The potenti al f or cross cont ami nat i on bet ween pat i ents is l ow.
Dependi ng on the technology bei ng used, several gases can be measured
si mul taneousl y. Thi s al lows automatic correct ion f or ni t rous oxi de and/or
oxygen.
The sampl ing port can be used to admi ni ster bronchodi l ators (98) (Chapter
7).
These devices can be used when t he moni tor must be remote f rom the
pati ent (e.g., duri ng magnetic resonance i magi ng [ MRI] ) (99,100).
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View Figure

Figure 22.10 This device is used for CO
2
sampling in
nonintubated patients who are either exhaling by mouth or
nose.

Disadvantages
Probl ems wi th the sampl i ng system (l eaks, sampl ing tube obst ructi on, or
f ai l ure of t he aspi rator pump) can occur. Parti cul at e matter, bl ood,
secreti ons, or wat er can obst ruct the tubi ng (102). The sampl i ng l i ne can be
connected t o the wrong pl ace (103,104). If there is a l eak i n the sample l i ne,
ai r wi l l be added t o the sampl e. This wi l l di l ut e the sampl e and reduce the
values of end-t idal CO
2
and anestheti c agents (105,106,107) (Fig. 22. 29).
The sampl ing t ube can ki nk, but this can be prevented by usi ng an elbow
connector near t he at tachment to the pat ient end (108).
The aspi rat ed gases must be ei ther routed to the scavengi ng system or
returned to the breathi ng system. I f scavenging i s empl oyed, the f resh gas
f low may need to be i ncreased to compensate f or t he gas removed or
negat ive pressure wi l l be creat ed i n t he breat hi ng system (109).
I n some di verti ng moni t ors, room ai r used in t he cal i brati on process is added
t o t he gas exi ti ng the moni tor. I f this ai r i s ret urned to the breathi ng system,
i t wi l l create probl ems duri ng cl osed ci rcui t anesthesi a.
Some del ay ti me i s unavoi dable.
A supply of cal ibrati on gas must be avai l abl e.
A number of di sposabl e i tems (adaptors and catheters) must be used.
There may be deformati on of the wavef orm and erroneousl y low CO
2

readi ngs f rom the f resh gas di l ut i on (Fi g. 22.37).
Compared wi t h mainstream moni tori ng, si dest ream measurements produce
more variable di f ferences bet ween art eri al and end-t idal CO
2
l evel s (110).
Technology
There are a number of di ff erent t echnol ogi es avai l abl e to measure respi rat ory and
anesthet ic gases.
Infrared Analysis
I nf rared anal ysis i s by f ar the most common technol ogy i n use today (3,111,112).
Technology
I nf rared (I R) anal yzers are based on t he pri ncipl e t hat gases wi th t wo or more
di ssi mi lar atoms in the molecul e (ni t rous oxi de, CO
2
, and t he hal ogenated agents)
have specif i c and uni que i nf rared l ight absorpti on spect ra. Si nce the amount of
i nf rared li ght absorbed is proport ional to the concentrat ion of the absorbi ng
mol ecul es, the concent rati on can be determi ned by compari ng the i nf rared l i ght
absorbance i n the sampl e wi t h that of a known st andard. The nonpol ar mol ecules of
argon, ni trogen, hel ium, xenon, and oxygen do not absorb inf rared l i ght and cannot
be measured usi ng this t echnol ogy.
There are two general t ypes of inf rared t echnol ogy avai lable t oday.
Blackbody Radiation Technology
The most commonl y used i nf rared technology uti l izes a heated el ement cal led a
bl ackbody emi t ter as the source of i nf rared l i ght (113). Thi s produces a broad
i nf rared spectrum. The majori ty of the emi t ted radi at ion i s redundant and must be
removed. Fi l t ers block radiati on t hat i s outsi de the desi red range. Thi s method
cannot remove the radi at ion t hat f al l s bet ween di scret e absorbi ng l ines because of
t he cont i nuous emissi on nature of the blackbody. The opt ical detectors must be
cali brated t o recogni ze onl y i nf rared radi ation that is modulated at a certai n
f requency by usi ng a spi nni ng chopper wheel .
The anal yzer sel ects the appropri ate i nf rared wavelength, usi ng an i ndivi dual f i l ter
or a f i l ter wheel to maximi ze absorpti on by the sel ected gas at i ts peak wavelengt h
and to mini mi ze absorpti on by ot her gases and vapors t hat coul d int erf ere wi th
measurement of the desi red component . Some ol der i nf rared uni ts are equi pped
wi th a di al or swi tch t o sel ect the anesthet ic agent bei ng measured, whi le others
requi re a di f f erent f i l ter and scal e to measure each agent . Most uni ts i n use today
can recogni ze the agents that can be moni tored wi th t hi s t echnol ogy. Af ter the
sensor detects the t ransmi tted i nf rared energy, an elect ri cal signal i s produced and
ampl i f i ed, and the concent rat i on is di splayed.
Moni tors t hat i denti f y and quanti f y hal ogenated agents use a separate chamber to
measure absorpt i on at several wavelengths. Typi cal l y, these are si ngl e-channel ,
f our-wav el engt h i nf rared f i l t er phot ometers. There is a f i l ter for each anest het i c
agent and one to provi de a
P. 694

basel ine f or comparison. Each f i l ter transmi t s a speci f ic wavel ength of i nf rared
l i ght, and each gas absorbs dif f erentl y in t he sel ected wavel ength bands (114).

View Figure

Figure 22.11 Sidestream optical infrared analyzer. A beam
of infrared light is at one end, and a photodetection device is
at the other. The chopper wheel contains several filters,
which are divided into sections that will allow passage of
only the frequencies most readily absorbed by the gases to
be measured. The filtered and pulsatile infrared light is
directed through both the sample chamber and a reference
chamber with no absorption qualities. The amount of
infrared light absorbed at each frequency depends on the
gas level in the sample chamber.

Most i nf rared i nstruments have an accuracy of 0.2% f or CO
2
concent rati ons over
t he range of 0% to 10% and 2.0% f or ni trous oxi de concent rati ons f rom 0% to
100%. For t ypi cal hal ogenated agents, the accuracy i s 0.4% over a range of 0% to
5% (115). Most i nvest igators bel i eve that t hese moni t ors are suf f i cient l y accurate
f or cl i nical purposes (116, 117,118), al though they tend to underest i mate the
i nspi red level and overest i mate end-t i dal val ues at high respi ratory rat es.
Diverting
Fi gure 22. 11 shows a divert i ng (si de-st ream) i nf rared anal yzer. Inf rared l ight i s
conti nuousl y focused on a spi nni ng (chopper) wheel . The wheel has hol es wi th
f il ters speci al l y selected for t he gases to be measured. The gas t o be measured i s
pumped conti nuousl y through a measuri ng chamber. The fi l t ered and pulsed l i ght i s
passed through the sampl e chamber and also t hrough a reference chamber wi th no
absorpti on characteri st ics. The l i ght i s then focused on an inf rared phot osensor.
The amount of l i ght absorbed by the sampl e gas is proport ional to the part i al
pressures of gases whose i nf rared l i ght absorpt ion patt erns correspond to the
wavel engt hs sel ected by the f i l ters on t he chopper wheel . The changi ng l i ght l evels
on the phot osensor produce changes in the el ect ri cal current that runs t hrough i t.
Rotat ing the wheel thousands of ti mes per mi nute provi des hundreds of readings for
each respi rat ory cycl e. For pract i cal purposes, the wavef orm on t he di spl ay i s
conti nuous.
Monochromat ic sidest ream opti cal inf rared anal yzers use one wavel ength t o
measure potent i nhal at ional agents and are unable t o disti nguish between agents or
t o detect a mi xture of agents (119). When such an anal yzer is used, the cl i ni ci an
must sel ect which agent is to be moni tored. If an i ncorrect agent is sel ected,
i ncorrect val ues wi l l be reported (120, 121, 122). Pol ychromat ic i nf rared anal yzers
use mul t iple wavel engt hs to both i denti f y and quanti f y t he vari ous agents (123).
Thi s el i mi nates t he need f or t he user to select t he agent to be moni t ored and al l ows
a mixture of agents to be detected.
Most si dest ream anal yzers have a fi xed sampl i ng f low rat e, al though some permi t
selecti on of the f l ow rate. The measuri ng cel l is cal i brated to zero by using gas that
i s f ree of t he gases of i nterest (usual l y room ai r) and to a st andard l evel by usi ng a
cali brati on gas mi xture.
Nondiverting
Wi th a nondivert i ng (mai nst ream) CO
2
monit or, the gas st ream passes t hrough a
chamber (cuvette) wi t h t wo wi ndows t hat are t ransparent to i nf rared li ght (Fi g.
22.2). The cuvet te i s pl aced between the breathi ng system and the pati ent . The
sensor, whi ch houses both the l i ght source and detector, f i ts over the cuvette. To
prevent wat er condensat ion, t he sensor i s heated sl i ght l y above body temperature.
I nf rared l i ght shi nes through t he wi ndow on one si de of the adaptor, and the sensor
receives the l ight on t he opposi te si de. Af ter passi ng through the sampl e chamber,
t he l i ght goes through three port s i n a rotati ng wheel , whi ch cont ai ns (a) a seal ed
cell wi t h a known hi gh CO
2
concentrati on,(b) a chamber vented to the sensor' s
i nternal atmosphere, and (c) a seal ed cel l contai ni ng onl y ni trogen (Fi g. 22.2B).
The radi at ion then passes through a f il t er t hat screens the l i ght t o the correct
wavel engt h to i sol at e CO
2
i nf ormati on f rom i nterf eri ng gases and ont o a
photodetector. The si gnal is ampl i f i ed and sent to the displ ay modul e.
Cal i brati on i s perf ormed by usi ng t wo seal ed cel l s i n a pl ast i c uni t that at taches to
t he cont rol uni t (Fi g. 22. 2C). I t i s shaped so t hat the sensor can cl i p over ei ther
cell . The l ow cal i brati on cel l contains 100% ni trogen, whi le t he hi gh cel l contains a
known parti al pressure of
P. 695

CO
2
. Correcti ons f or ni trous oxi de and/or oxygen must be entered manuall y.
The sensor may become dislodged f rom the cuvett e. If i t is compl etel y di sl odged,
no wavef orm wi l l be seen. If i t i s sli ghtl y di sl odged (Fi g. 22.4), t he readi ngs may be
i ncorrect al t hough the waveform appears normal (9,10). Condensed wat er,
secreti ons or blood on the cuvette wi ndows wi l l i nt erfere wi t h l i ght transmi ssion and
cause erroneous readi ngs (124).
Microstream Technology
Mi crostream t echnol ogy ut il i zes l aser-based t echnol ogy t o generate inf rared
emi ssi on t hat precisely matches the absorpti on spectrum of CO
2
(113). It uti l i zes a
smal l er sampl e cel l and a l ow f l ow rat e (50 mL/minute).
The emi ssion source is a gl ass discharge l amp wi t hout an el ect rode that i s coupl ed
wi th an i nf rared transmi t ti ng wi ndow. El ect rons that are generated by a radio
f requency vol tage exci t e ni t rogen mol ecules. Carbon di oxi de mol ecul es are then
exci ted by col l i si on wi t h the exci t ed ni t rogen mol ecules. As t he exci ted CO
2

mol ecul es drop back to thei r ground stat e they emi t the si gnat ure wavel ength of
CO
2
.
The emi ssion i s spl i t so t hat one part is di rected to t he mai n opti cal detector vi a the
gas sampl e cel l whi l e t he other part passes through a ref erence detector. This
channel is used as a conti nuous ref erence detector, compensat ing for changes in
i nf rared output .
The i nf rared source i s el ect roni cal ly modul ated so that measurements are made
every 25 msec. This provi des a rapi d response ti me. The ampl i tude of t he si gnals
received by t he detector depends on t he amount of radi ati on absorbed f rom the gas
sampl e. The absorbed radi ati on i s proporti onal to the CO
2
concent rati on.
The ai rway adaptor has t hree channel s wi t h narrow hydrophobi c openi ngs, each
f aci ng a di ff erent di rect ion. Thi s permi ts the adapt or t o be used i n any ori entati on
and prevents the sampl e l i ne f rom bei ng occluded by wat er or secreti ons. The
sampl e l i ne has a hydrophobi c f i l ter. A wat er t rap i s not necessary.
Because of the l ow sampl e f low and smal l sampl e cel l , this technol ogy i s usef ul f or
measuri ng CO
2
i n very smal l pat i ents, hi gh respi ratory rates, l ow-f l ow appl i cati ons,
and unintubat ed pat ients. Readi ngs are not af fected by high concent rat i ons of
oxygen or anestheti c gases.
Advantages of Infrared Anal ysis
Multigas Capability
I nf rared anal yzers are capabl e of measuri ng CO
2
, ni trous oxi de, and al l of the
commonl y used potent vol at i l e agents.
Volatile Agent Detection
Al though monochromat ic anal yzers are unable t o i denti f y anestheti c agents and
mi xtures of agents, most newer model s provide agent det ect ion and can detect and
quant if y mixtures. Anal yzers handl e mi xtures of agents i n di f ferent ways. They may
gi ve a di spl ay sayi ng that there i s a mi xt ure of agents or may compensate f or the
addi ti onal agent.

View Figure

Figure 22.12 Microstream infrared analyzer. Small
handheld device. (Picture courtesy of Oridion Medical.)

No Need to Scavenge Gases
Af ter measurement, t he gases can be returned to t he breat hi ng system, i f desi red.
Portability
The uni ts (Fig. 22.12) are smal l , compact, and l ightwei ght. They may be
i ncorporated i nto an anesthesia machine or physi ologi c moni tor and be used i n
remot e areas of the f acil i t y.
Quick Response Time
The response t ime i s f ast enough t o measure both inspi red and exhaled
concentrati ons. Response ti mes f or anestheti c agents and ni trous oxide are l onger
t han for CO
2
(115).
Short Warm-up Time
The warm-up ti me i s short . The i nst ruments do not need to be kept i n a standby
mode.
Convenience
Al though earl y uni ts requi red a compl i cat ed cal i brati on wi t h test gases wi th each
use, newer uni ts onl y requi re periodic cal i brat ion wi t h a standardi zed gas mi xt ure.
P. 696


Lack of Interference from Other Gases
Argon or l ow concent rati ons of ni tric oxide do not i nt erf ere wi t h vol at i l e agent
moni tori ng by i nf rared anal yzers (125,126). Inf rared spectromet ry i s accurate in t he
presence of 5% CO
2
(127).
Detecting Anesthetic Breakdown
Agent-i dent i f yi ng i nf rared anal yzers may provi de warni ng of desfl urane breakdown
t hat produces carbon monoxi de by displayi ng wrong or mixed agents (128).
Disadvantages
Oxygen and Nitrogen not Measured
Oxygen and ni t rogen cannot be measured by i nf rared technology.
Gas Interference
Whi le oxygen i s not absorbed by i nf rared l i ght , i t causes broadening of the CO
2

absorpti on spect ra, whi ch resul ts i n l ower CO
2
readi ngs (115). I n a t ypi cal i nf rared
CO
2
anal yzer, 95% oxygen causes a 0.5% decl i ne in measured CO
2
(101). Some
uni ts have a user-actuated el ect roni c off set f or oxygen.
There i s some overl ap of t he CO
2
and ni t rous oxi de i nf rared absorpt i on peaks so
t hat ni t rous oxi de can cause f al sel y hi gh CO
2
readi ngs, wi t h an increase of 0.1 to
1. 4 torr per 10% ni t rous oxi de. Most i nf rared anal yzers that measure both CO
2
and
ni trous oxi de aut omat icall y correct f or ni t rous oxi de' s ef f ect on the CO
2
reading.
Some requi re t he user to i ndi cate when ni t rous oxi de i s present .
I f the anal yzer is set to measure a vol ati l e agent di ff erent f rom that present i n the
gas mi xture bei ng anal yzed, CO
2
and ni t rous oxi de as wel l as agent readi ngs wi l l
be i ncorrect (129). A mixture of agents can cause erroneous readi ngs (130).
Desfl urane may di sturb the i nf rared CO
2
sensor so t hat i t reads hi gher-t han-
expected concentrati ons (131).
Hel i um i n the gas mixture may cause the i nf rared anal yzer t o underesti mate the
concentrati on of CO
2
(132).
Inaccuracy from Other Substances
Et hanol , methanol , i sopropanol , di et hyl ether, acet al dehyde, or acet one i n sampl ed
gases can cause spuri ousl y hi gh vol ati l e agent readi ngs
(122, 133,134,135, 136, 137,138). Ether t hat i s used to soak gauze that packed a
prosthesis can cause a moni t or t o i ncorrectl y i dent if y isof lurane (139).
Pol ychromati c anal yzers are l ess af f ected, and some di spl ay a warni ng that the
i nterf eri ng agent has been detected (118,123, 140, 141). Some anal yzers detect
hal ogenated propel l ants as anesthetic gases (142, 143,144,145, 146).
Met hane, whi ch can accumulat e duri ng low-f low anesthesi a, causes i naccuracies
wi th moni t ors t hat use the 3.3 m wavelengt h range (147,148).
Interference from Water Vapor
Water vapor absorbs inf rared l i ght at many wavel engt hs and wi l l cause increased
CO
2
and vol ati l e agent readings (115). Moni tors use speci al tubing, wat er t raps,
f il ters, and/ or hydrophobic membranes to mi ni mi ze thi s. Water t hat gets i nto the
moni tor can cause expensi ve or i rreversi bl e damage (102).
Slow Response Time
Wi th rapid respi ratory rat es, t he response ti me may be too sl ow t o measure
i nspi red and end-t idal l evels of vol ati l e agents accuratel y (149).
Radio Frequency Interference
Handhel d two-way radi os i n use near an infrared anal yzer may cause CO
2
readi ngs
t o be i ncreased (150).
Difficulty Adding New Volatile Agents
As new volati le agents are added t o the anesthetic armamentari um, these moni tors
need to be revi sed t o accept t he new agents. Thi s revisi on may requi re anyt hi ng
f rom a sof tware change t o an expensi ve change t o the anal yzi ng bench. I n some
cases, a correcti on factor can be used to convert one channel of a moni tor t o
moni tor another agent (151). In some cases, i t wi l l be necessary for the user t o
manual l y select the agent bei ng used (152,153).
Paramagnetic Oxygen Analysis
When i nt roduced i nt o a magnetic f ield, some substances locat e themsel ves i n the
st rongest porti on of the f i el d (154,155). These substances are t ermed
paramagnet ic. Oxygen is the onl y paramagnet ic gas that is i mportant i n anesthesia.
When a gas t hat cont ai ns oxygen i s passed through a swi t ched magneti c f i el d, the
gas wi l l expand and cont ract, causing a pressure wave that i s proport i onal to t he
oxygen part i al pressure.
To obtai n a hi gh degree of accuracy, i t is necessary t o compare t he pressure i n t he
gas sampl e wi t h a ref erence si gnal t hat i s obt ai ned by usi ng ai r or oxygen. When
ai r i s used as a reference gas, ni trogen may accumulate in t he breathi ng system
duri ng cl osed-ci rcui t anesthesi a i f the ref erence gases are redi rected to t he
anesthesi a ci rcui t. I f oxygen i s used as t he reference gas, the accumulat i on of
ni trogen is si gni f icant l y reduced (156).
A paramagneti c oxygen anal yzer i s shown i n Fi gure 22.13. Reference and sample
gases are pumped through the anal yzer. The two gas paths are j oi ned by a
di ff erenti al pressure or f l ow sensor. If the sample and ref erence gases have
di ff erent part i al pressures of oxygen, the magnet wi l l cause thei r pressures t o
di ff er. Thi s di ff erence i s detected by the transducer and convert ed int o an el ect ri cal
si gnal that i s di spl ayed as oxygen parti al pressure or vol umes percent .
The short ri se t ime al lows bot h i nspi red and end-ti dal oxygen l evel s to be measured
even at rapi d respi ratory rat es. Many moni tors combi ne i nf rared analysi s of CO
2
,
P. 697

volat i le anesthet ic agents, and ni t rous oxide wi t h paramagnet i c oxygen anal ysis i n
t he same moni t or usi ng the same divert ed gas (Fig. 22. 1). Thi s al lows most gases
of i nt erest to be moni tored by a si ngle moni t or.

View Figure

Figure 22.13 Paramagnetic oxygen analyzer. A reference
gas of known or no oxygen content and the gas whose
oxygen level is to be measured are pumped through the
analyzer and converge into a tube at the outlet. The two gas
paths are joined at their midpoints by a differential pressure
or flow sensor. The magnet is switched on and off at a rapid
rate. Because the reference and sample gases have different
oxygen levels, the pressures in the paths will differ. The
pressure difference is detected by the sensor.

I f the sampl e gas f rom the anal yzer is ret urned to t he breathing system and ai r was
used as a ref erence gas, i t wi l l di l ute the other gases and cause an i ncrease i n
ni trogen (101). Thi s i s especi al l y a probl em during closed-ci rcui t anesthesi a. I f
oxygen i s used as the ref erence gas, the accumul ati on of ni t rogen is signif icant l y
reduced (156). Desf l urane may disturb the paramagneti c oxygen sensor so that i t
reads hi gher than expect ed (131). Fai lure of a paramagnetic oxygen anal yzer has
been report ed (157).
Electrochemical Oxygen Analysis
An el ect rochemi cal oxygen anal yzer consi sts of a sensor, whi ch i s exposed to t he
gas bei ng anal yzed, and the anal yzer box, whi ch cont ai ns the electroni c ci rcui try,
di spl ay, and al arms (Fi g. 22.14). The sensor contains a cathode and an anode
surrounded by el ect rol yte. The gel i s hel d in pl ace by a membrane that is
nonpermeabl e to i ons, protei ns, and other such mat erials, yet i s permeable t o
oxygen. The membrane shoul d not be t ouched, because di rt and grease reduce i ts
usabl e area. In most cases, the sensor is pl aced i n the i nspi rat ory li mb of the
breat hi ng system.
Most of t hese anal yzers respond sl owl y t o changes i n oxygen pressure, so they
cannot be used to measure end-t i dal concentrati ons. Some newer sensors can
analyze oxygen qui ckl y enough to measure i nspi red and exhal ed concent rati ons.
Technology
Galvanic Cell (Fuel Cell, Microfuel Cell)
Oxygen di ff uses through the sensor membrane and el ect rolyte to the cathode,
where i t is reduced, causi ng a current t o f l ow (114,158,159,160). The rate at which
oxygen enters the cel l and generates current i s proport i onal to the parti al pressure
of oxygen in t he gas outsi de the membrane. For convenience, however, t he di spl ay
scal e i s usual ly marked i n percent oxygen. A gai n control al l ows the anal yzer to be
cali brated wi t h gas wi th a known part i al pressure of oxygen (usual l y ai r).
A gal vanic cel l sensor i s shown i n Figure 22.15. I t consists of an anode and two
cathodes surrounded by el ect rol yte. The cathode acts as the sensi ng el ect rode and
i s not consumed. The hydroxyl ions f ormed t here react wi th t he lead anode, formi ng
l ead oxi de. The anode is gradual l y consumed.
Cathode: O
2
+ 2H
2
O + 4e
-
4OH
-

Anode: 4OH
-
+ 2Pb 2PbO + 2H
2
O + 4e
-

P. 698



View Figure

Figure 22.14 Electrochemical oxygen analyzer. The sensor
is connected by a cable to the analyzer box, which contains
the meter, alarms, and controls. A thermistor compensates
for changes in oxygen diffusion caused by temperature. An
amplifier is present in the polarographic analyzer. Those
monitors with manual calibration require adjustment of a
gain control until the correct reading is obtained for a
standard oxygen concentration. Those with automatic
calibration simply require a button to be pressed in the
presence of a gas of standard concentration (usually air).
This puts the monitor into calibration mode, and it returns to
normal readings automatically when calibration is complete.

Si nce t here are t wo cat hodes, t wo vol tages are generat ed. These are compared,
and i f a cert ain amount of di ff erence i s present , the operat or i s prompted t o check
t he cel l . Because the current is strong enough to operate t he meter, a separate
power source i s not requi red to operate t he analyzer. A power source (ei t her
bat tery or mains current) i s requi red t o power t he al arms.
The chemi cal reacti on i s temperature dependent. I n order t o compensate f or
t emperat ure di f ferences, a temperature-dependent resi stor (thermi stor) may be
connected i n paral l el wi t h the sensor.

View Figure

Figure 22.15 Galvanic cell sensor. The membrane is
permeable to gases but not to liquids. At the cathode,
oxygen molecules are reduced to hydroxide ions. At the
anode, hydroxide ions give up electrons. An electron flow
between the anode and cathode is generated, which is
directly proportional to the partial pressure of oxygen in the
sample gas.

P. 699



View Figure

Figure 22.16 The life of a galvanic (fuel cell)
electrochemical oxygen analyzer can be prolonged by
leaving it exposed to room air when not in use.

The sensor comes packaged i n a seal ed contai ner that does not contain oxygen. Its
l if e span begi ns when the package i s opened. I ts usef ul l if e is ci t ed i n percent
hours, whi ch is the product of hours of exposure and oxygen percent age. I f i t i s
exposed t o a hi gh oxygen concent rati on, i ts l i fe expectancy wi l l be decreased.
Sensor l i fe can be prol onged by removi ng i t f rom t he breathi ng system and
exposi ng i t to ai r when not i n use (Fig. 22.16). Gal vanic sensors requi re no
membrane or electrol yt e replacement . The whol e sensor cartri dge must be repl aced
when i t becomes exhausted (Fi g. 22.17).
Polarographic Electrode
A pol arographi c (Cl ark el ect rode) sensor i s shown i n Fi gure 22.18. I t consi sts of an
anode, a cathode, an el ectrol yte, and a gas-permeabl e membrane. There i s a power
source (bat t ery or al ternati ng current [AC] li ne) f or i nduci ng a potenti al bet ween the
anode and t he cat hode.
Oxygen mol ecules dif f use through the membrane and el ect rol yt e. When a polari zi ng
vol tage i s appl i ed to the cathode, el ect rons combi ne wi t h t he oxygen mol ecules and
reduce t hem to hydroxi de i ons. A current t hat is proport ional to the oxygen part i al
pressure i n the sampl e f l ows bet ween t he anode and cathode.
Pol arographi c sensors may be ei ther preassembl ed di sposabl e cartri dges or uni ts
t hat can be di sassembl ed and reused by changi ng the membrane and/or el ect rol yte.
Use
Calibrati on
Cal i brati on shoul d be perf ormed dai l y before use and at l east every 8 hours af ter
t hat . Some i nst ruments remi nd the user when cal ibrat i on is needed and wi l l not give
a readi ng unti l cal i brat i on is perf ormed (Fi g. 22.19). The cal i brati on can be checked
by exposi ng the sensor t o room ai r and veri f yi ng that i t indicat es approxi mat el y
21% oxygen.
Checking the Alarms
The sensor should be put i n room ai r and the low oxygen alarm set above 21%. The
vi sual si gnal shoul d f l ash, and the audi bl e al arm shoul d sound. If t he uni t has a
hi gh oxygen al arm, the set ti ng for that shoul d be moved below 21%. Both visual
and audi bl e si gnal s should be acti vat ed. If t he vi sual si gnal fail s or t he audi bl e
si gnal i s weak, the batt eri es shoul d be replaced and the al arms rechecked. I f this
f ai l s to remedy the probl em, t he uni t shoul d not be used.

View Figure

Figure 22.17 Galvanic cell sensor. The entire sensor must
be replaced when it becomes exhausted.

P. 700



View Figure

Figure 22.18 Polarographic sensor. Oxygen diffuses
through the membrane and electrolyte to the cathode. When
a polarizing voltage is applied to the cathode, the oxygen
molecules are reduced to hydroxide ions. The current flow
between cathode and anode will be proportional to the
partial pressure of oxygen. (Redrawn from
Bageant RA. Oxygen analyzers. Respir Care 1976;21:415
.)

Placement i n the Breathi ng System
Si tes f or placing t he sensor i n breathi ng systems are di scussed i n Chapter 9. The
sensor service l i fe of some gal vani c cel l anal yzers i s reduced by exposure to CO
2
,
so l ocati ng the sensor on t he inspi ratory si de of the system may be pref erable. The
sensor shoul d be upri ght or ti l t ed sl i ght l y to prevent moisture f rom accumul ati ng on
t he membrane. The junct ion between the cabl e and the sensor shoul d not be under
st rai n.
Setting Alarms Limi ts
The l ow oxygen al arm shoul d be set a l i t t le bel ow t he mini mum and t he hi gh oxygen
l evel al arm a l i tt l e above t he maxi mum accept abl e concent rat i ons. There should be
pl aces on the anesthesia record for recording the al arm set poi nts and oxygen
percentage.
Advantages
Easy to Use
El ect rochemi cal oxygen analyzers are dependabl e, accurat e, and user-f ri endl y.
Gal vanic anal yzers may be more rel iabl e t han polarographi c anal yzers (161).
Low Cost
These inst ruments cost l ess than ot her means of oxygen anal ysis.
Compact
Compared wi t h other technologi es for measuri ng oxygen, t he el ect rochemi cal
analyzer t akes up l i ttl e space.
No Effect from Argon
Argon does not af f ect galvani c cel l moni tori ng (126).
Disadvantages
Maintenance
Whi le mai ntenance on newer model s has been si mpl if i ed, some i nstruments need
f requent membrane and el ect rol yte changes. Pol arographi c moni t ors requi re more
mai ntenance than the galvani c cel l moni t ors (161).

View Figure

Figure 22.19 The display on the anesthesia machine
provides a reminder that the oxygen analyzer needs to be
calibrated.

P. 701


Calibration
These inst ruments need to be cal i brat ed bef ore use each day and at l east every 8
hours.
User Enabling
I nst ruments t hat are not an i ntegral part of anesthesia machines need t o be turned
on by the user.
Slow Response Time
Most of t hese anal yzers cannot be used to measure end-ti dal oxygen.
Piezoelectric Analysis
Technology
The pi ezoel ect ri c method uses vi brati ng crystal s that are coat ed wi th a layer of l i pi d
t o measure vol ati l e anestheti c agents (158,162,163,164) (Fi g. 22.20). When
exposed t o a vol at i l e anestheti c agent, the vapor i s adsorbed into t he l i pi d. The
resul ti ng change i n the mass of t he li pi d al ters the vibrat i on f requency. By usi ng an
el ect roni c syst em consi sti ng of t wo oscil l at ing ci rcui ts, one of whi ch has an
uncoated (ref erence) cryst al and t he other a coated (detector) crystal , an el ectric
si gnal that i s proporti onal to the vapor concent rati on i s generated. Pi ezoel ectric
analyzers are di vert ing devi ces. Some pi ezoel ect ri c-based uni ts have a separate
nondi spersi ve i nf rared sensor t o di ff erenti ate inspi rati on and expi rat i on.
Advantages
Accuracy
I nvesti gati ons show an accuracy of bet ter than 0. 1% (162,163). Wat er vapor and
ni trous oxi de aff ect the readi ng, but the worst -case i nterf erence i s less than 0.1%.
The anal yzer does not gi ve arti factual resul t s in t he presence of aerosol propel l ants
t hat are used to admi ni ster bronchodi l ators (142).
Fast Response Time
These anal yzers can measure i nspi red and expi red l evel s of hal ogenated agents.

View Figure

Figure 22.20 Piezoelectric analyzer. A: One vibrating
crystal is coated with lipid, and the other is uncoated. By
comparing the vibration frequencies of the crystals, the
level of anesthetic agent in the gas being analyzed can be
measured. B: Piezoelectric crystals. (Courtesy of
Biochemical International, Inc.)

P. 702



View Figure

Figure 22.21 Colorometric carbon dioxide detectors. A
color code around the outside provides a reference. A: Adult
size. The device is supplied with caps that must be removed
before use. (Reprinted by permission of Nellcor Puritan
Bennett, Inc., Pleasanton, CA.) B: Adult and pediatric
versions. The paper strip must be removed to activate the
device.

No Need for Scavenging
Because the agents are not al tered, t he gas removed can be returned to the
breat hi ng system.
Short Warm-up Time
The warm-up period i s short er t han wi th an i nf rared anal yzer.
Compact
These uni ts are smal l .
Disadvantages
Only One Gas Measured
Thi s anal yzer cannot measure oxygen, CO
2
, ni t rogen, or ni trous oxide.
No Agent Discrimination
Thi s device cannot di scri minate between agents. The user must tel l the moni tor
whi ch agent i s bei ng measured. If the wrong agent i s sel ected, the reading can be
i n error by as much as 118% (162).
Inaccuracy with Water Vapor
Water wi l l cause errors wi t h t he pi ezoel ect ri c moni tor. I n one case, t he l i nes t o the
pump were reversed so t hat water vapor was removed af t er i ts passage rather t han
before (165). Thi s caused erroneousl y hi gh readi ngs.
Chemical Carbon Dioxide Detection
A chemi cal (col ori met ri c) detector (Fi g. 22.21) consi sts of a pH-sensi t i ve indicat or
enclosed i n a housi ng (3,166, 167, 168,169). When the i ndicator is exposed to
carbonic aci d t hat is f ormed as a product of the reacti on bet ween CO
2
and wat er i t
becomes more aci di c and changes color. Duri ng i nspi rati on, the color ret urns to i ts
resti ng stat e unl ess i t i s used wi t h a breathi ng system that al l ows rebreathi ng.
The i nl et and out let ports are 15 mm, so the devi ce can be placed bet ween pati ent
and the breat hi ng system or resusci tati on bag. Wi th the Mapleson F system
(Chapter 8), i t may be pl aced bet ween the expi ratory l imb and t he bag (170).
Pedi at ric versi ons are avai l able (Fig. 22. 21B).
Technology
Hygroscopic
The hygroscopi c CO
2
detector contains hygroscopi c fi l t er paper t hat is i mpregnat ed
wi th a col orl ess base and an i ndi cator t hat changes col or as a f uncti on of pH. The
f il ter paper is visibl e through a cl ear wi ndow. The color chart on the dome was
designed t o be read under f l uorescent l ight. An auxi l i ary col or chart that i s i ncluded
i n each package shoul d be consul ted if other l i ghti ng i s encountered. A purpl e or
mauve (A) col or indi cat es a low CO
2
(<0. 5%) l evel . A bei ge (B) col or i ndi cates a
moderate l evel (0. 5% t o 2%). A yel l ow col or
P. 703

(C) i ndicates a hi gh l evel (>2%) (171, 172). The mean mini mum concent rati on of
CO
2
needed to produce a col or change is 0. 54%, wi t h a range f rom 0. 25% to 0.60%
(169).
The hygroscopi c CO
2
detector' s useful l i f e may l ast f rom a f ew mi nut es to several
hours, dependi ng on t he humi di t y of t he gas bei ng moni tored (173). Reduci ng the
rel ative humi di ty of exhal ed gases by usi ng an HME to trap moi sture before i t
reaches the devi ce prol ongs the det ector' s usef ul l if e.
Hydrophobic
A hydrophobi c indi cat or i n a colori met ri c devi ce shows a col or change f rom bl ue t o
green to yel low when exposed t o CO
2
(173,174). Li qui d water may cause the devi ce
t o not f unct i on properl y. If t he devi ce is al l owed t o dry, i t wi l l recover i ts acti vi ty. It
has a f ast er response t ime, performs bet ter at hi gh respi ratory f requencies, and i s
l ess af f ect ed by humi di ty than the hygroscopi c model (173, 174).
Use
A chemi cal CO
2
detector i s usef ul for conf i rmi ng successful tracheal i ntubati on
when a capnometer is not avai l abl e. I t i s usef ul f or i nt ubat i ons that are performed
out of t he hospi t al , i n the emergency depart ment , or on the wards
(175, 176,177,178). It can be used to det ermine the posi ti on of t he Combi tube (179)
(Chapter 21). I t can be used duri ng an i ntubat ion i n a hyperbari c chamber (180). A
manual resusci tator may have a bui l t-in colori metri c CO
2
detector (181, 182).
Because i t i s disposabl e, i t may be especi al l y usef ul t o conf i rm tracheal i nt ubat i on
i n pati ents wi th respi ratory di seases such as severe acut e respi rat ory syndrome
(SARS) (183).
Advantages
The devi ce is easy to use.
I ts perf ormance i s not af f ected by ni trous oxide or anestheti c vapors.
I ts smal l size, portabi l i t y, and l ack of need f or a power source al l ow i t to be
used i n l ocati ons where use of a CO
2
moni tor is not possi ble.
The cost i s low compared wi th other methods of CO
2
anal ysi s.
St udi es show t he device to be accurate i n di agnosi ng esophageal i ntubat ion
(166, 167,168,171, 176, 177,178, 182, 184,185, 186,187,188,189,190,191,192,19
3).
The devi ce can serve to evaluate resusci tati on or as a prognostic i ndi cat or of
successf ul short -t erm resusci tati on af ter the t racheal tube has been correctl y
posi t i oned (186, 188,194).
I t of fers minimal resistance to f l ow.
I t i s al ways ready for use, does not requi re cl eaning, and mi ni mi zes the risk
of t ransmi ssi on of inf ecti on.
Carbon monoxi de does not i nterf ere wi t h t he chemical CO
2
detectors (127).
Disadvantages
I t may take several breaths bef ore concl usions can be drawn about t he
t racheal tube l ocati on to avoi d errors caused by f alse-posi t ive resul ts, as
di scussed bel ow. I t i s usual l y recommended t o wai t si x breaths bef ore
maki ng a determinati on.
Fal se-negat ive resul ts may be seen wi t h very l ow t i dal volumes and low end-
t i dal CO
2
concentrati ons, such as i n cases of compromi sed l ung perf usi on
(190, 192). Duri ng cardi opul monary resusci tat i on, a posi ti ve test i ndi cates
t hat the tracheal tube i s i n the ai rway, but a negat i ve resul t (suggesting
esophageal placement) requi res an al ternate method of conf i rmi ng t racheal
t ube posi t i on. If there i s l i t tl e or no ci rcul ati on to the l ung, CO
2
wi l l not be
avai l able f or the detector t o verif y correct tracheal tube placement . Fai l ure to
i nf l ate the t racheal tube cuf f may cause equivocal col or change (167). Ot her
methods to determi ne t racheal tube posi t ion are di scussed i n Chapter 19.
Drugs i nst i l l ed in t he trachea or gastri c contents can cause i rreversi bl e
damage to t he device (195,196).
Fal se-posi ti ve resul ts can occur i f there i s CO
2
i n the stomach (f rom i ngest ed
carbonated beverages or antacids or mask venti l at ion) (197,198, 199,200).
The di splay may i ni ti al l y turn col or and onl y sl owl y revert t o i ts ori gi nal col or.
Di ff icul ty i n disti nguishi ng col or changes has been reported (197). It may be
di ff i cul t to determi ne whether a subt le color change is due to t he pat ient' s
l ow end-ti dal CO
2
or a mispl aced t racheal tube.
There i s no al arm or CO
2
wavef orm.
Thi s device may not be cost eff ect ive for rout i ne use when compared wi th
use of a capnometer (201). It s cost-ef f ecti veness may be greater wi t h a small
number of appl icat ions (202).
Ai rf low obst ructi on f rom a manuf acturi ng def ect has been reported (203).
Thi s device is semiquant i tat ive and cannot gi ve accurat e measurement of
CO
2
. For t hi s reason, i ts appl i cat ion i s l i mi ted to tracheal t ube posi ti on
veri f i cat i on.
Refractometry
I n an opt ical i nterf erence ref ractometer (i nterf erometer), one port ion of a spl i t l i ght
beam passes through a chamber i nt o whi ch the sampl e gas has been aspi rated,
whi l e t he other port i on passes through an identical chamber contai ni ng ai r
(204, 205,206,207). Because vapor slows t he veloci t y of l ight , the port i on passing
t hrough the vapor chamber i s del ayed. The beams are t hen recombi ned to f orm an
i nterf erence patt ern t hat consists of dark and l i ght bands. The posi ti on of t hese
bands, observed through an eyepi ece agai nst a scal e superi mposed on the pattern,
yi el ds the vapor concent rati on. In
P. 704

order t o use thi s devi ce, one must know t he ref ractivi t y number of the gas bei ng
analyzed. Ref racti vi ty i s a nonl i near f uncti on of the part i al pressure of t he gas.
Thi s i nst rument i s used pri mari l y f or vapori zer cali brati on. It cannot be used to
measure vapor l evel s of hal ogenat ed agents i n a t ypical anesthetic gas mi xture of
oxygen and ni t rous oxi de because of i ts sensi ti vi ty to ni trous oxi de (208).
Gas Measurement
Oxygen
The standards f or basi c anesthesi a moni tori ng of t he American Soci et y of
Anesthesi ol ogi sts (ASA) and American Associ ati on of Nurse Anestheti sts (AANA)
stat e that the concent rat i on of oxygen i n the pati ent breathing syst em shal l be
measured by an oxygen analyzer wi t h a l ow oxygen concent rati on al arm i n use. The
use of more than one devi ce to moni t or oxygen is desi rabl e.
Standard Requirements
I nternati onal and U.S. st andards on respi ratory gas moni tors anal yzers was
publi shed in 2004 and 2005 (209,210). The f ol l owi ng requi rements are i n those
standards.
Oxygen readi ngs shal l be wi thi n 2.5% of t he actual l evel . Thi s accuracy
shal l be mai ntai ned f or at l east 6 hours of conti nuous use.
The hi gh and low oxygen l evel al arms must be at l east medi um pri ori t y. A
hi gh-pri ori ty al arm i s requi red f or an i nspi red oxygen concentrati on below
18%. Al arm pri ori t izati on i s di scussed i n Chapter 26.
I t shal l not be possi bl e to set the l ow oxygen al arm l imi t bel ow 18%.
An oxygen anal yzer wi t h an alarm that can be set bel ow 18% i s dangerous (211).
Technology
Oxygen l evel s may be measured by usi ng el ect rochemi cal or paramagnet ic
t echnol ogy. I n most cases, el ect rochemical analysi s provides onl y mean
concentrati ons. Paramagnet ic technol ogy has a suff i ci entl y rapi d response t i me to
measure both i nspi red and end-t i dal l evels. It may be desi rabl e to measure t he
i nspi red oxygen wi th non-i ntubated, spontaneously breathi ng pat i ents. This i s
possi bl e wi t h a divert i ng devi ce such as a paramagnetic anal yzer but not wi t h an
el ect rochemical moni tor. End-ti dal oxygen can be measured duri ng j et venti l at i on
(212).
Applications of Oxygen Anal ysis
Detecting Hypoxic or Hyperoxic Mixtures
The f i rst l i ne of defense agai nst hypoxemi a i s to avoid a hypoxi c inspi red gas
mi xture. An oxygen moni tor provi des an earl i er warni ng of i nadequat e oxygen than
pulse oxi metry. I n a study of 2000 cri t ical i nci dents, 1% were fi rst detected by the
oxygen moni tor (213). Hypoxi a is di scussed i n Chapter 14.
Oxygen anal ysi s can al so hel p prevent probl ems resul ti ng f rom hyperoxygenat ion,
such as pat i ent movement duri ng surgery, awareness, damage to t he l ungs and
eyes, and fi res. Fi res are di scussed i n det ai l i n Chapt er 32.
Detecting Disconnections and Leaks
Di sconnecti on of the tubi ng to an oxygen mask may be detect ed by using a
di verti ng oxygen anal yzer (214).
An oxygen moni tor can detect di sconnect ions in t he breathing system
(215, 216,217). However, oxygen moni toring cannot be depended on for thi s
purpose (218,219). Whether or not the oxygen l evel fal l s at the poi nt being
moni tored depends on several f actors, i ncl udi ng the t ype of breathi ng system in
use, posi ti on of the sensor, si te of disconnect ion, al arm set poi nts, i f the pat ient i s
breat hi ng spontaneousl y or venti lati on i s cont rol l ed, and the t ype of venti lator in
use. I f oxygen is t he driving gas and t here i s no physi cal barri er bet ween the
driving oxygen f rom the venti l ator and the breathing syst em gas, a disconnect i on at
t he common gas out l et wi l l resul t i n a ri si ng percentage of oxygen (220).
Di sconnecti ons are di scussed i n Chapter 14.
Wi th a si dest ream anal yzer, a decrease i n inspi red and expi red oxygen may resul t
f rom a l eak in the sampl i ng system (221).
Detecting Hypoventilation
Normal l y, the dif f erence bet ween i nspi red and expi red oxygen i s 4% to 5%. A
di ff erence of more than 5% af ter a steady stat e has been reached i s a sensi t ive
i ndi cator of hypoventi lati on (222, 223, 224). Hypovent i l at ion i s di scussed i n detai l i n
Chapter 14.
Other
End-t idal oxygen has been used to measure t he adequacy of preoxygenat ion
(225, 226,227,228, 229).
Knowi ng t he expi red oxygen concentrat ion al l ows an esti mate of the pat ient' s
oxygen consumpti on and can ai d i n the di agnosing mal i gnant hypert hermi a. Oxygen
consumpti on can be esti mat ed f rom the di f ference bet ween the i nspi red and
exhal ed oxygen concentrati ons (230,231).
The concentrat ion of ni trous oxide can be est i mated f rom t he concent rati on of
oxygen.
End-t idal oxygen has been used to detect ai r emboli sm. When a si gnif icant amount
of ai r enters t he
P. 705

vascul ar bed, there is an i ncrease i n end-t idal oxygen and a decrease i n the
di ff erence between inspi ratory and end-t i dal oxygen concent rat i ons (232).
Carbon Dioxide Analysis
ASA gui del i nes f or basi c anestheti c moni tori ng st ate that when a tracheal t ube or
supraglott ic ai rway device i s i nserted, i ts correct posi t i oni ng must be veri f i ed by
i denti f yi ng CO
2
i n the expi red gas. Conti nual end-t idal CO
2
anal ysi s shal l be
perf ormed unti l t he device i s removed or the pati ent is t ransf erred to a
postoperati ve care l ocati on. In 2005, an audible al arm was added to t he moni tori ng
standard (233).
A court case has hel d that a reasonabl y prudent heal th care f aci l i ty woul d suppl y a
CO
2
moni t or t o a pati ent undergoi ng general anesthesia (234). Some st ates have
mandated the use of CO
2
moni tors (158).
Carbon di oxide anal ysi s provi des a means f or assessi ng metabol i sm, ci rcul ati on,
and vent i l at ion and can detect many equi pment - and pati ent -rel ated probl ems that
ot her moni t ors ei ther f ai l t o det ect or det ect so sl owl y t hat pat ient safet y may be
compromi sed. A cl osed cl ai ms anal ysi s f ound that capnography plus pul se oxi met ry
could potenti al l y prevent 93% of avoi dabl e anesthet i c mi shaps (235). In one study,
10% of i nt raoperative problems were i ni ti al l y di agnosed by CO
2
moni toring (236). I n
another study, end-t idal CO
2
was usef ul i n conf i rming 58% of al ready suspect ed
anesthesi a-relat ed cri ti cal inci dents and was the i ni t ial detector of 27% (237). In yet
another study, i t was esti mated that a capnometer used on i ts own woul d have
detected 55% of cri tical i nci dents i f they had been all owed to evolve and 43% woul d
have been detected bef ore any potent ial organ damage (238). Carbon di oxi de
moni tori ng detects acut e compl et e ai rway obstruct i on and extubati on more rapi dl y
t han pul se oxi met ry or vi tal si gn moni tori ng (239). In maj or t rauma victi ms, usi ng
capnography to gui de prehospi t al venti l ati on resul ted i n l ess hypoventi l at ion on
hospi tal admi ssi on (240,241).
The respi ratory cycl e (i .e. , i nspi rati on vs. expi rati on) i s def ined in t erms of CO
2

measurement , so end-t i dal values f or other gases depend on CO
2
measurement .
Terminology
Capnomet ry i s the measurement of CO
2
i n a gas mixture, and a capnometer i s the
device that perf orms the measurement and di splays the readings in numeri cal form.
Capnography i s the recording of CO
2
concent rati on versus t i me, whi l e a
capnograph i s the machi ne t hat generates the wavef orm. The capnogram i s the
actual waveform (242). I t may be possi bl e to connect a capnomet er t o another
pati ent moni tor and/or recorder t o generate a wavef orm. Wavef orms are avai lable
on al l modern physi ol ogi c moni tors.
The Capnometer
Standards Requirements
An i nternati onal and a U. S. standard on capnometers have been publi shed
(209, 210). They contai n the fol l owi ng specif i cat ions.
The CO
2
readi ng shal l be wi thi n 12% of the actual value or 4 mm Hg (0.53
kPa), whichever is greater, over the f ul l range of the capnometer.
The manufacturer must disclose any i nterf erence caused by ethanol ,
acetone, met hane, hel i um, t et raf l uoroet hane, and di chl orodi f luoromethane as
wel l as commonl y used halogenated anesthet i c agents.
The capnometer must have a hi gh CO
2
al arm for bot h i nspi red and exhaled
CO
2
.
An al arm f or l ow exhaled CO
2
i s requi red.
Technology
Met hods to measure CO
2
l evels i ncl ude i nf rared and chemi cal col ori met ri c anal ysis.
A wi de vari et y of di splay f ormats are avai l able on CO
2
moni t ors. The CO
2
l evel may
be reported as ei ther parti al pressure or vol umes percent and may be displ ayed
conti nuousl y or as the peak (normal l y end-ti dal ) value. Other parameters such as
respi ratory rate and I : E rati o may be di splayed.
Portabl e, bat t ery-operated CO
2
moni tori ng devi ces are avai l abl e
(243, 244,245,246, 247, 248,249, 250) (Fi gure 22.12). These are usef ul i n emergency
medi ci ne and pati ent transport (Fi g. 22.12). At l east one has been report ed t o not
gi ve correct val ues during rebreathi ng (251). MRI -compat ibl e i nf rared CO
2
moni tors
are avai l abl e.
Many capnometers are i ncluded i n mul t ipurpose physi ol ogi c moni tors wi th ot her
parameters such as bl ood pressure, pul se oxi met ry, and anal ysis of ot her gases.
The CO
2
wavef orm may be one of several on a di spl ay.
Atmospheric Pressure Effects
At mospheri c pressure can inf l uence CO
2
readi ngs (111, 112, 252,253,254,255).
Some i nst ruments i ncorporate a barometer t o compensate f or changes i n
at mospheric pressure. Others requi re the user t o enter the atmospheri c pressure
manual l y. Sti l l others do not correct f or atmospheri c pressure. The capnometer
standards (209,210) requi re that the manufact urer di scl ose the quanti t ative ef f ects
of barometri c pressure on capnomet er perf ormance i n the i nst ructi ons f or use.
Sidestream Analyzers
When a si destream inf rared reports resul ts i n vol umes percent, the at mospheri c
pressure at measurement ti me must be known t o correctl y compute the CO
2
val ue.
P. 706


TABLE 22.1 Capnography and Capnometry with Altered Carbon Dioxide Productiona
Waveform on
Capnograph
End-tidal
Carbon
Dioxide
I nspiratory
Carbon
Dioxide
End-tidal to
Arterial
Gradient
Absorption of CO
2
from
peritoneal cavity
Normal 0 Normal
Injection of sodium
bicarbonate
Normal 0 Normal
Pain, anxiety, shivering Normal 0 Normal
Increased muscle tone (as from
muscle relaxant reversal)
Normal 0 Normal
Convulsions Normal 0 Normal
Hyperthermia Normal 0 Normal
Hypothermia Normal ! 0 Normal
Increased depth of anesthesia
(in relation to surgical
stimulus)
Normal ! 0 Normal
Use of muscle relaxants May see
curare
cleft
! 0 Normal
Increased transport of CO
2
to
the lungs (restoration of
peripheral circulation after it
has been impaired, e.g., after
release of a tourniquet)
Normal 0 Normal
a
Normal end-tidal CO
2
is 38 torr (5%). Inspired CO
2
is normally 0. The arterial to end-
tidal gradient is normally less than 5 torr.

For exampl e:
Fet CO
2
= parti al pressure (at mospheric pressure - water vapor pressure) 100
At 760 mm Hg at mospheri c pressure and a CO
2
l evel of 38 mm Hg,
Fet CO
2
= 38(760 - 47) 100 = 5%
I f the atmospheri c pressure is reduced to 500 mm Hg,
Fet CO
2
= 38(500 - 47) 100 = 8%
I f a correcti on f or atmospheri c pressure i s not made, the capnomet er wi l l read
erroneousl y high volumes percent at i ncreased al ti tude. Ot her opti ons are to
cali brate at al ti tude wi t h a gas that has a known CO
2
concentrati on or t o set the
device to read parti al pressure.
Mainstream Infrared Analyzers
Mai nst ream i nf rared i nst ruments are cal i brat ed f rom seal ed gas cel l s of known
part ial pressure. These i nst ruments wi l l report measurements in uni ts of part i al
pressure correct l y (252). I f such an anal yzer reports resul ts in volumes percent , the
at mospheric pressure at measurement ti me must be known.
Cli nical Significance of Capnometry
Carbon di oxide i s produced i n the body t i ssues, conveyed by the ci rcul atory system
t o t he l ungs, excreted by the l ungs, and removed by t he breathi ng system.
Theref ore, changes i n respi red CO
2
may ref l ect al terati ons i n met abol i sm,
ci rcul ati on, respi rat i on, or the breathi ng syst em. Tabl es 22.1 t o 22. 4 l i st some
sources of changes i n CO
2
l evels.
TABLE 22.2 Capnographic and Capnometric Alterations as a Result of Circulatory
Changes
Waveform on
Capnograph
End-tidal
Carbon
Dioxide
I nspiratory
Carbon
Dioxide
End-tidal to
Arterial
Gradient
Decreased transport of CO
2

to the lungs (impaired
peripheral circulation)
Normal ! 0 Normal
Decreased transport of CO
2

through the lungs (pulmonary
embolus, either air or
thrombus; surgical
manipulations)
Normal ! 0 Elevated
Increased patient dead space Normal ! 0 Elevated

P. 707


TABLE 22.3 Capnometry and Capnography with Respiratory Problems
Waveform on
Capnograph
End-tidal
Carbon
Dioxide
I nspiratory
Carbon
Dioxide
End-tidal to
Alveolar
Gradient
Disconnection Absent 0
Apneic patient,
stopped ventilator
Absent 0
Hyperventilation Normal ! 0 Normal
Hypoventilation,
mild to moderate
Normal 0 Normal
Upper airway
obstruction
Abnormala 0 Elevated
Rebreathing, e.g.,
(under drapes)
Baseline
elevated
Normal
Esophageal
intubation
Absent 0
a
See Figure 18.34.

Metabolism
Moni tori ng CO
2
el i mi nati on gi ves an i ndicati on of t he pati ent 's metaboli c rate (256).
An i ncrease or decrease in end-t i dal CO
2
i s a rel i abl e i ndicator of metabol i sm onl y
i n mechanical l y venti l ated subj ects. For spont aneousl y breathing pat ients, Pet CO
2

may not increase wi th i ncreased metabol ism because of compensatory
hyperventi lat i on by the pat ient (257, 258).
Table 22.1 l ists some metabol i c causes of increased or decreased CO
2
excret i on.
These incl ude i ncreased temperat ure, shiveri ng, convul si ons, excessi ve
catechol ami ne product i on or admi ni st rati on (259), bl ood or bicarbonate
admi ni st rati on (260), rel ease of an art eri al clamp or tourni quet
(261, 262,263,264, 265), and parenteral hyperal i ment ati on (266). Carbon di oxide
producti on f al ls wi th decreased t emperature and increased muscl e rel axati on.
I ncreased exhaled CO
2
can resul t f rom CO
2
used to inf l at e the peri toneal cavi ty
duri ng laparoscopy (267, 268, 269,270, 271, 272), t he pl eural cavi ty duri ng thorascopy
(273, 274), a j oi nt duri ng art hroscopy (275), or t o increase vi sual i zat i on f or
endoscopi c vei n harvest (276).
TABLE 22.4 Capnographic and Capnometric Alterations with Equipment
Problem Waveform on
Capnograph
End-tidal
Carbon
Dioxide
I nspiratory
Carbon
Dioxide
End-tidal to
Arterial Gradient
Increased apparatus dead
space
Baseline
Elevated
Normal
Rebreathing with circle
system: faulty or exhausted
absorbent, bypassed
absorber (may be masked by
high fresh gas flow)
Baseline
Elevated
See
Figure
18.35
Normal
Rebreathing with Mapleson
system (inadequate fresh gas
flow, misassembly, problem
with inner tube of Bain
system)
Baseline
Elevated
See
Figure
18.35
Decreased
Rebreathing due to
malfunctioning
nonrebreathing valve
Baseline
Elevated
See
Figure
18.35
Decreased
Obstruction to expiration in
the breathing system
See
Figure
18.34
0 Decreased
Blockage of sampling line Absent 0 0
Leakage in sampling line See
Figure
18.39
! 0 Increased
Low sampling rate with
diverting device
See
Figure
18.41
! Increased
Too high a sampling rate
with diverting device
See
Figure
18.42
! 0 Increased
Inadequate seal around
tracheal tube
See
Figure
18.44
! 0 Increased

P. 708


Mal ignant hypert hermia i s a hypermet abol i c state wi th a massive increase i n CO
2

producti on. The i ncrease occurs earl y, bef ore t he rise i n temperature. Earl y
detecti on of thi s syndrome i s one of the most import ant reasons f or routi nel y
moni tori ng CO
2
(236, 277). Capnometry can be used to moni tor t he eff ect i veness of
t reatment.
Circulation
Table 22.2 l ists some of the ci rcul atory changes that af f ect exhal ed CO
2
. A
decrease i n end-ti dal CO
2
is seen wi t h a decrease in cardi ac output if vent i l ati on
remai ns constant (278,279,280,281,282). End-t idal CO
2
i ncreases wi th i ncreased
cardi ac output (283).
I n addi ti on t o reduced cardi ac output, reduced bl ood f l ow t o the l ungs can resul t
f rom surgi cal mani pul at ions of the heart or thoraci c vessel s (284), a dissecti ng
aort ic aneurysm compressing a pulmonary art ery (285), wedgi ng of a pul monary
artery catheter, and pulmonary embol ism (thrombus, t umor, gas, fat, marrow, or
amni ot i c f l ui d) (286,287,288,289,290,291,292,293,294,295). If t he embol i zed gas i s
CO
2
, the end-ti dal CO
2
wi l l i ni ti al l y i ncrease and then decrease
(296, 297,298,299, 300, 301). Al though not as sensi t ive as the Doppl er f or detect i ng
ai r emboli sm, CO
2
moni t oring i s l ess subject ive, i s unaf fected by el ect rosurgery
apparatus, and can be used i n maj or ear, nose, and throat (ENT) cases f or which
t he Doppl er method i s not appl i cabl e. Capnometry may not be suff i ci ent ly sensi t ive
t o detect f at and marrow mi croembol i (302).
During resusci tati on, exhal ed CO
2
is a bet t er gui de t o the ef f ectiveness of
resusci tati on measures than the el ect rocardi ogram (ECG), pul se, or bl ood pressure
(303, 304,305,306, 307, 308,309, 310, 311,312). The capnometer i s not suscepti bl e to
t he mechani cal art if acts that are associ ated wi t h chest compressi on, and chest
compressi ons do not have to be i nterrupted to assess ci rcul at ion. The col ori met ri c
CO
2
detecti on device has al so been shown t o be an eff ecti ve moni t or duri ng
resusci tati on. However, i f hi gh-dose epinephri ne or bi carbonate i s used, end-t idal
CO
2
i s not a good resusci t ati on i ndi cator (313,314,315,316,317, 318).
End-t idal CO
2
l evels may be of use i n predicti ng the outcome of resusci tati on
(186, 304,307,310, 319, 320,321, 322, 323,324, 325,326,327,328,329,330,331,332) and
t he resol uti on of a pul monary embol us (333).
Respiration
Carbon di oxide moni t oring gives i nformat ion about the rate, f requency, and depth of
respi rati on. It can be used t o evaluate the pat ient' s abi l i t y to breathe spontaneousl y
as wel l as the ef fect of bronchodil ator or ni tri c oxide t reatment or al tered vent i l at i on
parameters. I t al lows cont rol of vent il ati on wi t h f ewer bl ood gas determi nat ions.
End-t idal anal ysi s is noni nvasive, avail abl e on a breat h-by-breath basis, and not
af fected by hypervent i l at ion t hat is i nduced by drawi ng an arteri al bl ood sampl e.
Table 22.3 l ists some respi ratory causes of i ncreased and decreased end-t i dal CO
2
.
A capnometer can warn of esophageal i ntubat ion, apnea, extubati on, di sconnecti on,
venti l ator mal funct ion, a change in compl iance or resi stance, ai rway obst ructi on,
poor mask f i t , or a l eaking t racheal t ube cuf f .
A dependable means to determine when a tracheal tube has been correct ly
posi t i oned i n the t racheobronchi al tree obviousl y i s of great val ue. Esophageal
i ntubat ion has been a l eading cause of deat h and cerebral damage i n the past . A
di scussi on of ways to detect i nadvertent esophageal pl acement i s f ound i n Chapter
19. Carbon di oxi de moni tori ng i s usual l y considered t he most rel i abl e method.
Carbon di oxide measurement to detect esophageal pl acement has some drawbacks
and l i mi t at ions, so i ts use as the onl y means of correct tube placement should be
st rongl y di scouraged. Absence of ci rcul ati on, severe bronchospasm, equi pment
mal f unct ion, and appl icati on of cri coid pressure occl udi ng the tracheal tube t ip can
resul t i n fai l ure to detect CO
2
(334,335,336,337,338,339,340,341,342,343,344). The
analyzer may be i n a cal i brati on mode when t he tube i s placed.
Wi th esophageal i nt ubat i on, smal l waveforms may be transientl y seen as a resul t of
CO
2
t hat has entered the stomach during mask venti lati on or f rom carbonated
beverages or medi cati ons (197, 199, 345,346,347,348). This coul d give the
i mpressi on that the tube is correct ly placed i n the trachea. However, rapi dl y
di minishi ng concent rati ons and abnormal wavef orms wi l l usuall y di f f erent iate
esophageal f rom t racheal i ntubati on (345,349,350).
A case has been report ed where a normal capnogram was present despi te an
esophageal i ntubati on (351). There was a cuf f ed oropharyngeal ai rway i n place,
and the pat i ent was breathing spontaneousl y. Carbon di oxi de f rom the t rachea was
t hought to have got ten under the cuff ed ai rway and f orced down t he esophagus,
where i t was aspi rated f rom the t racheal tube. I nf l at i ng the t racheal tube cuf f
i nterrupted the wavef orm.
Whi le esophageal int ubati on wi l l l i kel y be detected by usi ng end-ti dal CO
2
, t here is
no guarantee t hat the t ube i s i n the trachea. Carbon dioxi de can be sensed f rom a
t racheal tube t hat is posi ti oned above t he vocal cords (352).
A di verti ng CO
2
moni tor can be used to moni t or respi rat ory rate and exhaled CO
2
i n
uni ntubated pati ents who are breathing spont aneousl y
(50,51,52, 53, 54,55,67, 72,78,89,90,353,354,355,356,357,358,359). Apnea, ai rway
obstruct i on, or disconnect i on of t he oxygen source may be detect ed. If venti l ati on
of t he breathi ng space under the surgical drapes i s i nadequate, rebreathi ng wi l l
occur and may be detected by a ri si ng i nspi red CO
2
level (52,354,360).
Capnomet ry has been used to hel p determine the posi ti on of a doubl e-l umen t ube
(361, 362). Met hods to determine proper doubl e-l umen tube pl acement are
di scussed i n Chapter 20. Correct pl acement can be checked by exami ni ng the
waveform f rom each l ung duri ng cl ampi ng and uncl ampi ng procedures. However,
t hat method
P. 709

i s l ess rel i abl e than other methods t hat are used for t hi s purpose (363,364,365).
During i ndependent l ung vent i l at i on, capnography can be used to determi ne the
proper set ti ngs f or vent i l at ion of each l ung (366). Capnography can be used to
detect tracheobronchi al i nj ury duri ng thoracoscopi c procedures (274).
Carbon di oxide moni t oring can serve as a warni ng of accident al bronchi al
i ntubat ion. Thi s may resul t i n a t ransi ent fal l or ri se in end-t i dal CO
2
(367,368,369).
Carbon di oxide moni t oring can be usef ul duri ng weani ng f rom art i fi ci al venti l at ion
(370, 371,372,373, 374, 375,376, 377). However, end-t idal CO
2
moni tori ng al one may
not be a rel i abl e tool during weani ng wi thout knowi ng the art eri al -ETCO
2
gradi ent .
Thi s i s discussed i n more detai l l ater in t hi s chapter. Carbon di oxide moni t oring can
assi st wi th t he deci si on t o provide venti lat ory support (378). I t provi des a means to
measure the severi t y of bronchospasm (379, 380).
Equipment Function
A probl em wi t h t he breathi ng system can cause an i nspi red CO
2
l evel great er than
zero. Exampl es of such probl ems are l i sted i n Tabl e 22.4 and include leaks, faul t y
or exhausted absorbent, channel ing, a bypassed absorber, i ncreased dead space,
l ow f resh gas f l ow t o a Mapl eson system, a def ect in the inner t ube of a Bain
system, accidental admi ni st rati on of CO
2
, and a defective nonrebreathing valve
(381, 382,383,384, 385, 386,387, 388).
I ncompetent uni di rect ional valves are an i nherent danger of the ci rcl e system. An
i ncompetent expi ratory val ve al l ows reverse f l ow of gas that cont ai ns CO
2
f rom the
expi ratory l i mb duri ng t he inspi ratory phase, resul t ing i n an el evated basel i ne on
t he capnogram (389) (Fi g. 22. 30). If the i nspi ratory valve i s i ncompetent, CO
2
wi l l
enter t he i nspi ratory l i mb duri ng exhalati on. Duri ng the next inspi rat i on, CO
2
wi l l be
rebreat hed. Thi s wi l l cause the plateau on the capnogram t o be l engthened and a
decrease i n the st eepness of the i nspi ratory downsl ope (Fi g. 22.32) (390). An
i ncrease i n the basel i ne may not be seen. A spi rogram that pl ots CO
2
agai nst
volume (Fi g. 22.22) wi l l i l l ust rate t he inspi ratory val ve l eak by a decreased
downsl ope on t he inspi ratory si de of t he loop (391).
Carbon di oxide anal ysi s can be used to detect a di sconnected oxygen tubi ng to a
mask over t he f ace duri ng local or regi onal anesthesi a (355). If the oxygen source
becomes detached, there wi l l be a ri se in CO
2
because of rebreat hi ng.
Rarel y a phantom CO
2
wave may be noted despi t e a disconnect ion. One case was
reported when the gas sampl e l ine f rom the CO
2
moni tor was connect ed to the
breat hi ng system j ust upst ream of the expi rat ory uni di recti onal val ve (392). Duri ng
i nspi rati on, the i nspi rat ory unidi rect i onal val ve opened, al l owi ng f resh gas pl us the
gas (contai ni ng CO
2
) f rom the moni t or t o pass to the pati ent , where i t was detected
duri ng inspi rati on. This probl em does not occur i f the gas i s ei ther di rected t o the
scavengi ng system or ret urned to t he breathing syst em downstream of t he
expi ratory valve. In anot her case, square wave capnographi c tracings were
observed af ter a pat ient was di sconnected f rom a venti l ator that had not been
t urned OFF (393). The gas anal yzer aspi rated CO
2
f rom the expi ratory t ubi ng,
generati ng a seri es of di minishi ng traci ngs on the capnograph.

View Figure

Figure 22.22 A spirogram that plots CO
2
against volume
will illustrate the inspiratory valve leak by a decreased
downslope on the inspiratory side of the loop better than a
capnogram. (Redrawn from
Breen PH, Jacobsen P. Carbon dioxide spirogram [but not
capnogram] detects leaking inspiratory valve in a circle
circuit. Anesth Analg 1997;85:13721376
[Fulltext Link]
[CrossRef]
[Medline Link]
.)

Other Uses
A di verti ng capnometer can be used to local i ze the si t e of l eaks i n CO
2
insuf f l at ion
equipment (394), di agnose a tracheoesophageal or bronchoesophageal f i stul a
(395, 396), gui de bl i nd i ntubat ion (397,398,399,400,401,402, 403,404,405),
determine when the t i p of an exchange cathet er or f i berscope is i n the t rachea
(406, 407), or conf i rm that the needl e or catheter is posi ti oned i n the t rachea duri ng
a
P. 710

cricot hyrotomy or percutaneous di l atati onal tracheostomy (Chapter 21)
(408, 409,410).
Carbon di oxide anal ysi s may be used to assess the posi t ion of an ent eric tube
(411, 412,413,414, 415, 416,417, 418, 419,420, 421,422,423). If the tube is pl aced i nto
t he trachea, CO
2
wi l l be det ected at the f ree end. I f CO
2
i s not detected, the t ube i s
l ikel y i n the esophagus. If an ent eric tube passes i nt o the t rachea i n an i ntubated
pati ent , the capnograph wi l l show a downslopi ng alveol ar pl at eau (424).
Correlation between Arterial and End-tidal Carbon Dioxi de
Levels
Numerous studies have shown that the correl at i on bet ween arteri al and end-ti dal
CO
2
t ensi ons i n chi l dren and adul ts wi t hout cardi orespi ratory dysfuncti on i s good
enough to warrant rout i ne moni tori ng (4, 110,271,425,432). End-t i dal CO
2
i s usual l y
l ower t han PaCO
2
by 2 to 5 torr (433). The gradient may be l ess or even negative i f
t he funct ional resi dual capaci ty i s reduced, as i n pregnant or obese pat i ents
(428, 434,435) and i s reduced wi t h rebreat hi ng (436). Tables 22.1 through 22.4
show some condi t i ons wi th al t ered end-ti dal to arteri al gradi ents.
Predi ct ion of PaCO
2
f rom end-t i dal CO
2
al one i s unrel iabl e i n some pati ents and
may be potenti al l y deleteri ous i n some pat ient subgroups. A study of neurosurgi cal
pati ents found that end-t i dal CO
2
di d not accuratel y ref l ect changes in t he arteri al
CO
2
t ensi on (437), al though i n heal thy pat i ents duri ng el ective neurosurgical
procedures, the PaCO
2
-PetCO
2
di f ference remains stable over t i me (430).
Transcutaneous CO
2
moni tori ng has been found to be more accurate i n eval uat i ng
CO
2
l evels duri ng one-l ung venti l ati on (438,439), i n obese pat ients (440), duri ng
neurosurgical procedures i n adul ts (441), and i n ol der chil dren (442, 443).
The rel ati onshi p bet ween arteri al and end-ti dal CO
2
tensi on may be constant or
vary, somet i mes i n di ff erent di rect i ons, bot h wi t hi n and bet ween pati ents (444).
Al though t here usual l y is a l i near rel ati onshi p bet ween end-t i dal and art eri al CO
2
,
t he gradi ent may be unexpectedl y large or even negat ive
(445, 446,447,448, 449, 450). End-ti dal CO
2
cannot repl ace the measurement of
PaCO
2
i n the i ntensive care uni t or emergency room, al though i t i s usef ul f or
t rending or screeni ng (430,450,451, 452,453).
Problems with Sampling
Accurate measurement of end-t idal CO
2
i s especi al l y di ff i cul t wi th hi gh venti l atory
f requencies (16). I n smal l pati ents, sampli ng at the pati ent end of t he tracheal t ube
resul ts i n a cl oser approxi mati on to arterial CO
2
t han sampl i ng at t he breat hi ng
system end (22,23,24,25,26). Whi l e placi ng the gas sampl i ng l i ne on the machi ne
si de of an HME may avoi d contami nat ion and wat er l oggi ng of the sample, this may
resul t i n erroneous val ues and poor wavef orms (454,455,456).
One source of sampli ng error i s a l eak at t he i nterf ace between the pati ent and the
equipment . Poor mask f i t , usi ng an uncuf fed t racheal tube or a tube wi t h a def ect ive
cuff , or a l oose connecti on or l eak i n the sampl i ng catheter may cause erroneousl y
l ow end-ti dal CO
2
readi ngs (106). The correl ati on between art erial and end-t i dal
CO
2
t ensi ons i s bet ter duri ng venti lati on wi th a supragl ot t ic device than a f ace
mask (457). The correl at ion can be i mproved by sampl i ng at the pati ent end of t he
supraglott ic devi ce (30).
Wi th uni ntubated, spontaneousl y breathi ng pati ents, poor correl ati on between end-
t i dal and art eri al CO
2
i s associ ated wi th part i al ai rway obst ructi on, high respi ratory
rates, l ow ti dal vol umes, oxygen del ivery t hrough the i psi lateral nasal cannul a, and
mouth breathi ng (68,93,458). Resul ts may be improved by isol ati ng i nsuff l ated
oxygen f rom exhal ed gases, observi ng the wavef orm f or normal conf igurati on, and
decreasi ng the oxygen f l ow rat e (53,459).
When a si destream capnometer i s used wi t h a Mapleson system, exhaled gas may
be di l uted by f resh gas duri ng the latt er port i on of expi rati on i f t he expi ratory f low
rate i s less than the sampl ing f l ow rat e of the capnometer. Thi s wi l l cause the end-
t i dal CO
2
readi ng to be l owered even if the al veolar phase of t he capnogram i s f l at
or has a smal l posi t ive sl ope. The amount that the end-ti dal CO
2
is l owered wi l l
depend on several f actors, i ncl udi ng whether spontaneous or control led vent il ati on
i s used, the t ype of vent i l ator and breathing ci rcui t , the f resh gas f l ow, t he sampl i ng
rate, and t he expi ratory f low rate (22,460,461). Maneuvers t o obtai n a PetCO
2

readi ng that i s cl oser to the PaCO
2
wi th Mapl eson systems i ncl ude usi ng lower
f resh gas fl ows, extending the t i me of expi ratory f l ow, addi ng dead space between
t he breathi ng system and gas sampl ing poi nt, and usi ng a ci rcui t that automat i cal l y
i nterrupts the f resh gas f l ow af ter i nspi rati on or prevents mi xi ng of exhaled and
f resh gases (460,462). A quick method of checki ng t o see whet her the PetCO
2
i s
arti f actual l y l ow i s to temporari ly disconnect t he f resh gas suppl y (463). I f t here i s
an abrupt ri se i n PetCO
2
when the dil uti ng ef f ect of the f resh gas i s removed, then
t he f i rst breaths that f ol l ow wi l l give a bett er measure of the true PetCO
2
.
During high-f requency venti l ati on, PetCO
2
is a poor i ndex of PaCO
2
(88). In order
t o measure the end-ti dal CO
2
, t he hi gh-f requency vent il at ion shoul d be i nterrupted
t o i mpose a f ew sl ow breaths (83,87,88,464, 465,466).
Disturbances in the Ventilation:Perfusion Ratio
When t here is venti l ati on-perf usi on mismatchi ng, the relati onshi p between end-t i dal
and art eri al t ensions of CO
2
i s di sturbed. Cl i nical condi ti ons t hat can al ter the
volume and/or di st ri but ion of pul monary bl ood f l ow i ncl ude pul monary embol i sm,
pul monary art ery st enosi s or
P. 711

occl usi on, reduced cardi ac output, pulmonary hypotensi on, hypovolemia, and
cert ai n heart l esi ons (433,467,468,469,470,471,472).
The end-ti dal to arteri al CO
2
gradi ent increases as venous admi xture (ri ght t o lef t
shunt ) occurs. Thi s can be caused by atel ectasis, bronchial intubat ion, or certai n
heart condi t ions. The eff ect is l ess dramati c t han t hat caused by an increase i n
dead space, but when t he venous admi xture i s l arge (as i n cyanoti c congeni tal
heart disease), i ts cont ri but i on can be consi derabl e (425, 469,473,474).
Changes i n body posi ti on, such as the l ateral or prone posi t i on, may cause an
i ncrease i n the Pa/PetCO
2
gradient (475,476).
Pat i ents wi t h pul monary di sease have an uneven distributi on of vent il ati on and, t o a
l esser extent , bl ood f l ow. Thi s l eads t o an increased gradi ent (433,477,478,479).
Si nce posi ti ve end-expi ratory pressure (PEEP) may decrease the gradient
(480, 482), t he arteri al -end-t idal CO
2
gradi ent can be a useful tool f or opt i mizing
PEEP (377,482). A pati ent who has a gradient that narrows whi l e PEEP i s graduall y
i ncreased may have a wi dened gradient when the opti mal l evel has been exceeded.
Capnometer Problems
I f there i s a l eak or break i n t he sampli ng l ine or i ts connect i ons, ai r wi l l be added
t o t he sample, and t he end-t idal CO
2
readi ng wi l l be l ower than the actual val ue
(483, 484,485) (Fi g. 22.37). An obstructed sampli ng cat heter can cause the
capnogram to be dampened and cause falsel y hi gh i nspi red and f al sel y low end-
expi red CO
2
values (486). An occl uded sampl i ng or exhaust l i ne can resul t i n no
CO
2
being detected (344,487). An internal leak in t he anal yzer can resul t i n
arti f actual l y high val ues (488).
Ot her probl ems that may resul t i n an i naccurate PetCO
2
readi ng i ncl ude i ncreased
sampl i ng tube resi stance, changes i n atmospheri c pressure, i mproper cal ibrat i on,
dri f t , si gnal noi se, sel ectivi t y, pressure eff ects f rom the sampl i ng system or pat i ent
envi ronment, water vapor, and forei gn subst ances (252). Wi th some anal yzers, the
gas used f or zeroi ng i s obtained f rom room ai r. If CO
2
-containing gas ent ers t he
zeroi ng sample, there wi l l be f alsel y l ow CO
2
readi ngs wi th a normal -l ooking
waveform (489).
Other
A si gni f i cant di screpancy between PaCO
2
and PetCO
2
may occur in pat i ents taki ng
acetazol ami de, which delays the conversion of HCO
3
-
to CO
2
, causing a decrease
i n end-ti dal CO
2
(490).
Gas solubi l i ty changes wi t h temperature, so the arteri al t o end-ti dal gradi ent may
i ncrease wi t h hypothermi a unl ess the PaCO
2
i s corrected f or hypothermia (491).
I nadvertent addi t ion of CO
2
to t he inspi red gas f rom a CO
2
l aser may cause
el evated readings (492).
Capnography
Most CO
2
moni tors i ncl ude a waveform. Waveforms can be displ ayed on an
osci l l oscope or pri nted on paper (112,242, 493,494). Slow speeds can be used to
show t rends. Faster speeds are used f or exami ni ng i ndi vi dual wavef orms.
Exami nati on of the waveform wi l l of t en expl ai n readi ngs that appear i naccurate. I f
t he capnomet er reads several peaks per breath or breaths that do not have a
pl at eau, the respi ratory rate and peak CO
2
readi ngs wi l l be i naccurate.
The wavef orm shoul d be exami ned systemat i call y f or hei ght , f requency, rhythm,
basel ine, and shape. Hei ght depends on the end-ti dal CO
2
. Frequency depends on
t he respi rat ory rate.
The basel i ne is normal l y zero. An el evated basel i ne (Fi g. 22.30) can resul t f rom
del i berat e admi nistrat ion of CO
2
, rebreat hi ng, exhausted absorbent, a cont ami nat ed
sampl e cell , or an incompet ent expi ratory uni di recti onal valve. The basel i ne may or
may not be el evated wi th an i ncompetent i nspi ratory unidi rect i onal valve.
The shape of the normal wavef orm i s i l l ust rat ed i n Fig. 22.23. Onl y one shape (t op
hat or si ne wave) i s considered normal . Phase I (i nspi ratory baseli ne) begi ns at E
and i s normal l y zero, ref l ecti ng i nspi red gas, whi ch i s normal l y devoi d of CO
2
.
Phase II (expi ratory upst roke) begi ns at B and conti nues to C. This rapi d S-shaped
upswi ng represents the t ransi ti on f rom gas f rom t he dead space that does not
part ici pate i n gas exchange and al veolar gas that contai ns CO
2
.
Phase II I begins at C and conti nues t o j ust before D. As gas comi ng almost enti rel y
f rom al veol i i s exhal ed, a pl ateau i s normall y seen. If a plateau is not seen, the
maxi mum val ue obtai ned may not be equival ent t o the end-t i dal l evel and t he
correlati on bet ween art eri al and end-t i dal CO
2
i s not l i kel y to be good. The slope of
t his phase i s i ncreased by vent il at i on-perfusion abnormal i t ies in the l ung (495) as
wel l as external fact ors such as a ki nked t racheal tube.
The very l ast porti on of Phase II I , ident if i ed by D, i s ref erred to as the end-t i dal
poi nt . The CO
2
l evel here i s normal l y at i ts maxi mum. In normal i ndi vi duals, this i s
5% to 5.5%, or 35 to 40 t orr.
The angl e between Phases II and I II i s cal l ed the ! (takeof f , el evati on) angle (496).
Normal l y, i t i s bet ween 100 and 110 degrees. It i s decreased wi th obstruct ive lung
di sease, as the dead space vol ume takes l onger to be exhal ed. The sl ope of Phase
I II depends on the l ung's vent il at i on-perf usi on status. Ai rway obstructi on and PEEP
cause an i ncreased sl ope and a l arger ! angl e (379,380,496). Ot her factors that
af fect the angl e are the
P. 712

capnometer' s response t i me, sweep speed, and the respi ratory cycle t i me (242).

View Figure

Figure 22.23 Normal carbon dioxide waveform. EA (Phase
I) is the latter part of inspiration, during which the CO
2
level
remains at zero. BC (Phase II) represents the emptying of
connecting airways and the beginning of the emptying of
alveoli. As exhalation continues, gas from alveoli in regions
with relatively short conducting airways appears and mixes
with dead space gas from regions with relatively long
conducting airways, resulting in an increasing CO
2
level.
CD (Phase III) shows the alveolar plateau. Because of
uneven emptying of alveoli, the slope continues to rise
gently. Point D shows the best approximation of alveolar
CO
2
(end of expiration, beginning of inspiration). In DE
(Phase IV), as the patient inhales, CO
2
-free gas enters the
patient's airway, and the CO
2
level abruptly falls to zero.
Characteristics of the normal capnogram include (a) rapid
increase from B to C, (b) nearly horizontal plateau between
C and D, (c) rapid decrease from D to E to zero, and (d) a
zero baseline (EA AB). A good alveolar plateau greatly
increases the chances that the end-tidal reading is a reliable
estimate of the alveolar level.

The angl e between the end of Phase II I and the descendi ng l i mb of the capnogram
i s cal led the " angl e. Normall y, i t i s approxi matel y 90 degrees. The angl e wi l l be
i ncreased wi t h rebreathi ng. Another possibl e cause of an i ncreased " angl e i s a
prol onged response t i me compared wi th t he respi ratory cycl e ti me, part i cul arl y i n
chil dren (242). The angle wi l l be decreased i f the sl ope of Phase II I i s i ncreased.

View Figure

Figure 22.24 Low end-tidal CO
2
with a good alveolar
plateau may be the result of hyperventilation or an increase
in dead space ventilation. Comparison of PetCO
2
with
PaCO
2
is necessary to distinguish these two conditions.

P. 713



View Figure

Figure 22.25 Elevated end-tidal CO
2
with good alveolar
plateau may be caused by hypoventilation or increased CO
2

delivery to the lungs.
I n Phase I V, the pat ient i nhal es. Normal l y, CO
2
f al ls abruptl y to zero and remai ns
at zero unti l the next exhal ati on.
A number of si t uat ions can cause unusual waveforms. Some are shown in Fi gures
22.24 t o 22. 42. There i s an Internet websi te devoted t o capnography
(htt p: // www. capnography.com).
I f there i s a l eak i n the sampl e li ne duri ng posi t ive-pressure venti lat i on or at t he
pati ent connect ion, the capnogram wi l l have a bri ef peak at the end of the pl at eau
(106, 221,502,504, 505, 509,510, 511, 512,513) (Fi g. 22.34). I f there i s a l eak i n a
sampl i ng l ine that runs through the l umen of t he expi ratory l i mb, the basel i ne wi l l
be el evated, f alsel y i ndicati ng rebreat hi ng (514).

View Figure

Figure 22.26 Curare cleft or notch, which is seen during
spontaneous ventilation. The capnogram on the left shows
the notch. As the muscle relaxant is reversed, the curve
becomes normal in shape. The cleft is in the last third of the
plateau and is caused by a lack of synchronous action
between the intercostal muscles and the diaphragm, most
commonly caused by inadequate muscle relaxant reversal.
The depth of the cleft is proportional to the degree of
muscle paralysis. The position of the cleft is fairly constant
on the same patient but is not necessarily present with every
breath. The notch also is seen in patients with cervical
transverse lesions, flail chest, hiccups, and pneumothorax
and when a patient tries to breathe during mechanical
ventilation.

Pat i ents who are part ial l y paral yzed wi t h muscl e rel axants may make respi ratory
ef forts anyt i me duri ng the respi ratory cycle wi th control l ed venti lat i on (Fi g. 22.27).
I f the pati ent is spontaneousl y breathi ng and t he depression occurs i n the l ater
t hi rd of t he wavef orm, i t is ref erred t o as a curare cl ef t (515) (Fi g. 22.26).
P. 714



View Figure

Figure 22.27 Spontaneous respiratory efforts during
mechanical ventilation. The capnogram shows small breaths
at various places during expiration and inspiration. Causes
include maladjusted ventilator (hypoventilation), inadequate
muscle paralysis, severe hypoxia, or the patient waking up.
The end-tidal CO
2
may rise slightly because of increasing
metabolism of the contracting respiratory muscles. This
pattern may also be caused by pressure on the patient's chest
or ventilator malfunction.


View Figure

Figure 22.28 Cardiogenic oscillations appear as small,
regular, toothlike humps at the end of the expiratory phase.
They may be single or multiple, and the heights may vary
considerably. They are believed to be due to the heart
beating against the lungs. A number of factors contribute to
the appearance of cardiogenic oscillations, including
negative intrathoracic pressure, a low respiratory rate,
diminution in the vital capacity:heart size ratio, a low
inspiratory:expiratory ratio, low tidal volumes, and
muscular relaxation (268,269,497). In many cases,
adjustment of the ventilator rate, flow, or tidal volume will
remove this pattern from the screen. Other times, however,
it cannot be corrected. Cardiogenic oscillations are the rule
rather than the exception in pediatric patients because of the
relative size of the infant's heart and thorax. Capnograms
from patients with severe emphysema tend not to register
cardiogenic oscillations. Less sophisticated capnometers
may count each oscillation as a breath, displaying a
respiratory rate higher than actual. Cardiogenic oscillations
may result from the positions of the components in the
breathing system in relation to the sampling site. Placing the
sampling site on the patient side of an HME may remove
the oscillations (454,498) The addition of low level positive
end-expiratory pressure can also be used to eliminate these
oscillations (499).
A capnogram wi t h two peaks (biphasi c) may be caused by uni l ateral condi t i ons that
cause uni l ateral hypoventi l ati on or hi gh ai rway resistance, si ngl e l ung
t ranspl antat ion, bronchial i ntubati on, or severe kyphoscol i osis
(516, 517,518,519, 520).
Volatile Anesthetic Agents
Measuri ng concentrati ons of vol ati le anest het ic gases i s common practi ce. In some
count ri es (but not the Uni ted States at the ti me of this wri t i ng), agent moni tori ng i s
a st andard of care (122). The anest hesi a workstati on st andard (524) requi res that
t he workstati on be provided wi t h a devi ce to moni tor t he concent rati on of anestheti c
vapor i n the i nspi ratory gas.
An anest het ic agent moni tor may be a st and-al one devi ce or part of a
mul ti paramet er moni tor.
Standard Requirements
I nternati onal and U.S. st andards f or anesthet i c gas moni t ors are avai l abl e
(209, 210). The f ol l owi ng are provi si ons of bot h standards.
For hal ogenated anestheti c gases, the di ff erence between the mean
anesthet ic gas reading and the anestheti c gas l evel shal l be wi t hi n 0.2% vol
% + 15% of the anesthet ic gas level .
A hi gh concent rati on al arm i s mandatory. A l ow concent rat i on alarm is
opti onal .
Measurement Techniques
The volati l e anestheti c agents can be measured by using i nf rared anal ysi s,
ref ractomet ry, or pi ezoel ect ri c anal ysi s. When an agent i s used f or whi ch an
analyzer i s not
P. 715

programmed, i t may be possi bl e to appl y a conversi on f actor so that t he anal yzer
may be used to moni t or t hat agent (525,526).

View Figure

Figure 22.29 Prolonged expiratory upstroke. The left curve
shows a normal waveform. The other three curves show
progressive slanting and prolongation of the expiratory
upstroke. As expiration is progressively prolonged,
inspiration may start before expiration is complete so that
the end-tidal PCO
2
reading is decreased. This is indicative
of obstruction to gas flow caused by a partially obstructed
tracheal tube or obstruction in the patient's airways (chronic
obstructive lung disease, bronchospasm, or upper-airway
obstruction).

Signi ficance
Vaporizer Function and Contents
An advantage of moni tori ng potent agents is the abi l i t y to assess vapori zer
accuracy. It i s recommended that vapori zer output be veri f i ed twi ce a year as wel l
as at any ti me a vapori zer i s di sconnected f rom t he anesthesi a machi ne and t hen
rei nstall ed (208). When a vapori zer is suspected of mal funct ion, i t can be easi l y
checked by pl aci ng the end of the sampl i ng cat heter i n the f resh gas f low.
Agent-speci fi c anal yzers can det ect an incorrect agent, and non-agent -speci f i c
analyzers wi l l usual ly
P. 716

exhibi t unusual readi ngs when an agent error is made (129,130).

View Figure

Figure 22.30 The baseline is elevated, and the waveform is
normal in shape. This may be caused by an incompetent
expiratory valve or exhausted absorbent in the circle
system; insufficient fresh gas flow to a Mapleson system;
problems with the inner tube of a Bain system; deliberate
addition of CO
2
to the fresh gas; or in some cases, an
incompetent inspiratory valve. It may also be the result of
rebreathing under drapes in a spontaneously breathing
patient who is not intubated.


View Figure

Figure 22.31 Return to spontaneous ventilation. The first
breath is typically of small volume. Subsequent breaths
show progressively higher peaks with gradual resumption of
a normal waveform.
Anesthet ic agent moni tori ng wi l l al ert the user when a vapori zer has become empty
or i s turned OFF, when i t i s inadvert ent ly i n the ON posi ti on, or when a vapori zer
not i n use i s al l owi ng si gni fi cant amounts of vapor to l eak i nto t he f resh gas li ne
(527).
The dif ference bet ween t he vapori zer set ti ng and t he measured i nspi red
concentrati on of the agent puzzl es many cl i ni ci ans. There i s usual l y a dif f erence
bet ween t he t wo val ues, wi t h the i nspi red concentrati on being l ower at t he
beginni ng of a case and hi gher at the end. This discrepancy resul ts f rom the t i me
needed to equi li brat e the concentrat ion i n the rel at ivel y l arge vol ume of gas in the
breat hi ng system as wel l as by agent upt ake by the pat i ent . If l ow f resh gas f l ows
are used, the t i me needed f or equi li brati on wi l l be longer. I f the vol ati l e anestheti c
agent i s react ing wi t h desi ccated absorbent (Chapter 9), the dif ference wi l l be
i ncreased.

View Figure

Figure 22.32 Incompetent inspiratory unidirectional valve.
The waveform shows a prolonged plateau and a slanting
inspiratory downstroke. The inspiratory phase is shortened,
and the baseline may or may not reach zero, depending on
the fresh gas flow. A similar pattern may be seen with
suction applied to a chest tube.

Information on Uptake and Elimination
Moni tori ng volati l e anesthet i c agents provi des i nf ormat i on on uptake and
el i mi nati on. The di ff erence between i nspi red and expi red l evel s provides a measure
of pati ent saturati on.
Teaching
Anesthet ic agent moni tori ng can be used t o demonstrat e the rel ati onshi p bet ween
agent concentrat ion i n the f resh gas l i ne and that i n the breathi ng system. Thi s
makes agent moni tori ng useful for teachi ng l ow-f l ow anesthesia.

View Figure

Figure 22.33 Irregular plateau and/or baseline may result
from displacement of the tracheal tube into the upper larynx
or lower pharynx with intermittent ventilation of the
stomach and lungs or from pressure on the chest, which
causes small volumes of gas to move in and out of the
lungs.
P. 717



View Figure

Figure 22.34 A leak in the sampling line during positive-
pressure ventilation will result in an upswing at the end of
Phase III (71,500,501,502). A plateau of long duration is
followed by a peak of brief duration. The height of the
plateau is inversely proportional to the size of the leak. The
brief peak is caused by the next inspiration, when positive
pressure transiently pushes undiluted end-tidal gas through
the sampling line. If the patient is breathing spontaneously a
falsely low end-tidal carbon dioxide reading may be seen,
owing to air entrainment, but no terminal hump is seen. An
upswing at the end of Phase III may also be seen in obese
and pregnant patients (242,503,504,505).

Information on Anesthetic Depth
Knowl edge of volati l e agent concent rati ons may provi de evidence that t he pat i ent
who i s paral yzed i s nei ther awake nor grossl y overdosed, may permi t more rapi d
awakeni ng of t he pati ent , and may aid i n t he di agnosi s of delayed emergence.
Awareness due to a l ow concent rati on of i nhal ati onal agent may be avoi ded (528).
Measuri ng concentrati ons of vol ati le anest het ic agents may hel p to avoi d cardiac
arrests due to overdosage. Thi s i s part i cul arl y a probl em in pediatric pati ents (529).

View Figure

Figure 22.35 If the compliance, airway resistance, or
ventilation-perfusion ratios in one lung differ substantially
from the other lung, a biphasic expiratory plateaus may be
seen (506). This type of capnogram has been reported in a
patient with severe kyphoscoliosis (507) and following
single-lung transplantation (508).
These devices are not true moni tors of anestheti c depth, as the condi t ion of the
pati ent depends on many other t hi ngs besi des t he inhal ed anestheti c agent
concentrati on. Anestheti c agent moni t ori ng shoul d not be regarded as a
repl acement f or other means of measuring anesthet i c depth but as an addi ti onal
source of i nformat ion. A study of anesthet i zed pati ents found that predi ct ion of
arteri al l evels f rom end-t i dal concentrat ions was di ff icul t (530). Agent moni tori ng
has not been shown t o resul t in an i mprovement i n i nt raoperat ive hemodynami c
stabi l i ty or earl y recovery wi th ei ther hi gh or l ow total gas f l ows (531,532,533).
Detecting Contaminants
Contami nants i n the ni t rous oxi de suppl y were detected wi th an agent moni tor t hat
i ndi cated the presence of a vol at i l e agent when no vapori zer was turned ON (534).
An agent moni tor i ndi cated a warning that a f orei gn agent was present when a
defective temperature-compensati on devi ce i n a vapori zer rel eased di ethyl ether
i nto t he vapori zi ng chamber and the i nspi red gas (141).
Information for the Electronic Record System
Wi th the expected i ncrease i n automated record keepi ng, t he abi l i t y to
automati cal l y add i nformat ion such as t he concent rati on of vol ati l e agent to the
record is i mportant (Chapt er 28).
P. 718



View Figure

Figure 22.36 Too low a sampling rate with a sidestream
capnometer will result in a low peak and, often, elevation of
the baseline. Erroneous values for both inspired and end-
tidal CO
2
will be reported.


View Figure

Figure 22.37 Contamination of expired sample by fresh gas
or ambient air may be caused by placing the sampling site
too near the fresh gas inlet, a leak, or too high a sampling
flow rate. A: A large leak is indicated by the progressive
decrease in the plateau. B: Here, the contamination is of
lesser magnitude and a dropoff occurs at the end of the
plateau.

P. 719



View Figure

Figure 22.38 A sudden drop of end-tidal CO
2
to zero is
usually caused by an acute event relating to the airway, such
as extubation, esophageal intubation, complete breathing
system disconnection, ventilator malfunction, or a totally
obstructed tracheal tube. It may also be the result of a
plugged gas sampling tube.
Detecting Disconnections
I f a disconnect i on occurs between the CO
2
sensi ng si te and the breathi ng system
whi l e t he pati ent i s spontaneousl y breathi ng, the agent concent rati on may drop
whi l e t he end-t i dal CO
2
l evel wi l l be unchanged (535).
Nitrous Oxide
Technology
Ni trous oxide can be measured di rect l y onl y by inf rared t echnol ogy. There are and
i nternati onal and U. S. standards coveri ng the requi rements (209,210). When
oxygen and ni t rous oxi de are used t ogether, t he ni trous oxide concent rat i on can be
approxi mated by the oxygen anal yzer.

View Figure

Figure 22.39 The causes of a sudden drop of end-tidal CO
2

to a low but nonzero value include a poorly fitting tracheal
tube or mask, a leak or partial disconnection in the breathing
system, and a partial obstruction of a tracheal tube.

View Figure

Figure 22.40 Events that cause an exponential decrease in
end-tidal CO
2
include sudden hypotension owing to massive
blood loss or obstruction of a major blood vessel,
circulatory arrest with continued pulmonary ventilation, and
pulmonary embolism (air, clot, thrombus, or marrow).
Signi ficance
Anal ysi s of ni trous oxide wi l l show whether t he f l owmeters are f uncti oni ng properl y.
At t he end of a case, washout of ni t rous oxi de wi l l avoi d di ff usi on hypoxia.
Nitrogen
Previ ously, ni trogen coul d be measured by using Raman scatt ering or mass
spect rometry. At the ti me of thi s wri ti ng, both of these technol ogi es were no longer
avai l able f or cl i nical use. This const i tutes a l oss for the cl i ni ci an because t here are
advantages to moni tori ng ni trogen. These advantages are di scussed (pp. 721722)
i n hopes t hat in t he fut ure some technol ogy wi l l be devel oped that wi l l all ow thi s
moni tori ng.
Verifying Adequate Denitrogenation
An i mportant use of ni t rogen moni t ori ng i s to ensure adequate deni trogenati on
before induct i on. This i s especi al l y a concern wi t h pedi at ri c pat i ents, i n pat i ents
wi th l ung di sease, and in pati ents wi th a reduced f uncti onal resi dual capaci t y
P. 720

(e.g., obesi t y or pregnancy) as wel l as during a rapi d sequence i nduct ion.

View Figure

Figure 22.41 Small air embolus with resolution.

View Figure

Figure 22.42 Release of a tourniquet or unclamping of a
major vessel may result in a sudden increase in end-tidal
CO
2
that gradually returns to normal.
Detecti ng Venous Air Embol i
A ri se i n exhal ed ni t rogen may indi cat e that ai r f rom some source has ent ered the
breat hi ng system (536). Ni trogen moni t oring can provi de inf ormat ion t hat i s hel pf ul
i n disti nguishing ai r embol i f rom other events that cause reduced CO
2
el i mi nat i on.
Monitori ng Breathi ng System and Anesthesia Machine
Integrit y
Normal l y duri ng general anesthesi a, the l evel of ni trogen i n the breathing system
drops rapi dl y at fi rst and then more sl owl y. A sl ow drop or a ri se may be caused by
room ai r enteri ng through a l eak, di sconnect i on, poorl y fi tt i ng mask, an uncuff ed or
l eaki ng t racheal tube, or a change i n vapori zers (537,538).
A leak in t he sampli ng system can cause ni trogen to be detected. To determi ne if
t his i s occurri ng, pure oxygen f rom t he anesthesi a machi ne shoul d be sampl ed. If
t he moni tor cont i nues t o show ni trogen, ai r i s l eaki ng into t he sampl i ng li ne.
Detecti ng Nitrogen Accumul ation
Despi te hi gh i ni t i al gas f l ows, ni t rogen can bui l t up i n the breathi ng syst em duri ng
l ow-f l ow anesthesi a. Thi s can cause a si gni f icant decrease i n the l evels of oxygen,
ni trous oxi de, and vol ati l e agents.
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P. 727


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. Advantages of a nondi verti ng monitor i ncl ude
A. Quick response t ime
B. Water i s less l i kel y t o cause problems
C. Scavengi ng of gases i s not necessary
D. A standard cali brati ng gas can be used
Vi ew Answer2. Disadvantages of a nondi verti ng moni tor i ncl ude
A. Onl y CO
2
and oxygen can be measured by this method
B. Bl ood on the curet te wi l l cause accuracy probl ems
C. The sensor can be damaged by mi shandl i ng
D. I t cannot be used on pati ents who do not have a t racheal tube i n pl ace
Vi ew Answer3. Possi ble sampl ing si tes for a di verti ng monitor i nclude
A. An HME
B. The base or i nside of the nose
C. An el bow adaptor
D. The distal end of a t racheal tube
Vi ew Answer4. If the sampl ing flow rate of a di verti ng moni tor i s too l ow,
A. The del ay ti me and rise t i me wi l l be decreased
B. The peak readi ngs on the capnogram wi l l be l owered
C. The basel i ne on the capnogram wi l l be depressed
D. The plateau on the capnogram wi l l be absent
Vi ew Answer5. Advantages of a diverting gas monitor include
A. Cal i brati on and zeroing are usual ly automati c
B. The pat ient connecti on is usual l y disposabl e
C. Remote moni t ori ng i s possi ble i n the MRI sui te
D. Low dead space
Vi ew Answer6. Disadvantages of a diverting gas monitor i nclude
A. Dead space in t he breathing system is i ncreased
B. Gases f rom the moni tor must be returned t o the breathi ng system or scavenged
C. Warm-up i s usual l y prol onged
D. The del ay ti me is prol onged
Vi ew Answer7. Advantages of infrared moni tors include
A. They do not need t o be kept on standby
B. Response ti me is f ast enough to measure both i nspi ratory and end-ti dal val ues
C. Uni ts are small and l i ghtwei ght
D. Peri odi c cal i brati on wi th a standard gas i s suf f i ci ent
Vi ew Answer8. Disadvantages of infrared gas analysi s i ncl ude
A. Water vapor wi l l cause i nterf erence
B. I t i s dif f icul t t o add new agents
C. Hel i um causes arti factual l y l ow CO
2
val ues
D. Sampled gases must be scavenged af ter anal ysis and cannot be added to the
breat hi ng system
Vi ew Answer9. Which of the foll owing defini ti ons is correct?
A. Delay t i me i s the t i me to achi eve 10% of a st ep change in readi ng at the gas
moni tor
B. The parti al pressure of a gas i s the pressure that a gas in a gas mi xture woul d
exert i f i t al one occupied the vol ume of the mi xture at the same t emperature
C. Ri se t ime i s t he t ime requi red for a change f rom 10% to 90% of the tot al change
i n a gas val ue wi th a change i n concent rat ion at the sampl i ng si te
D. The sampl i ng si t e is the l ocat i on f rom whi ch gas i s diverted f or measurement i n
a di verti ng moni t or or t he l ocat i on of the sensor i n a nondi vert ing moni tor
Vi ew Answer10. Concerni ng microstream technology,
A. I t ut il i zes l aser-based t echnol ogy
B. I t provi des a rapi d response t i me
C. Readi ngs are not af f ected by hi gh concent rati ons of oxygen or anesthet i c gases
D. The ai rway adaptor has t wo channel s, each f aci ng a dif f erent di recti on
Vi ew Answer