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  • Cited by 29
Cambridge University Press
Online publication date:
August 2011
Print publication year:
Online ISBN:

Book description

In recent years capnography has gained a foothold in the medical field and is fast becoming a standard of care in anaesthesiology and critical care medicine. In addition, newer applications have emerged which have expanded the utility of capnographs in a number of medical disciplines. This new edition of the definitive text on capnography reviews every aspect of this valuable diagnostic technique. An introductory section summarises the basic physiology of carbon dioxide generation and transport in the body. A technical section describes how the instruments work, and a comprehensive clinical section reviews the use of capnography to diagnose a wide range of clinical disorders. Edited by the world experts in the technique, and with over 40 specialist contributors, Capnography, second edition, is the most comprehensive review available on the application of capnography in health care.


Review of the first edition: ‘… addresses the physiologic and technological considerations that need to be understood to make capnography a clinically useful tool and should be standard reading for those who depend on it as an anesthetic monitor.'

Source: Anesthesiology Journal

Review of the first edition: ‘… a good addition to the reference library of departments of anesthesiology, critical care and emergency medicine.'

Source: Canadian Journal of Anesthesiology

'The inclusion of informative chapters on neonatal monitoring, sleep medicine, sedation, and veterinary medicine usefully widens the appeal of the book … [It] should be seen as an essential specialist reference book for the departmental library that those interested and/or needing to gain knowledge in capnography … can dip in and out of when required.'

Source: British Journal of Anaesthesia

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Page 1 of 2

  • 10 - Neonatal monitoring
    pp 80-95
  • View abstract


    This chapter examines different time- and volume-based capnograms, and analyzes them from a clinical perspective, with a special focus on problems related to ventilation, by far the most common clinical application of capnography. A water trap with a large internal volume can introduce artifacts when high airway pressures during inspiration compress gas in the trap. The capnogram provides evidence of acutely reduced pulmonary perfusion coincident with a drop in cardiac output. The most important use of capnography in the field, in the intensive care unit, and in the operating room comes with the establishment of an artificial airway. An individual tracing of the time-based capnogram left a number of questions unanswered, which the single breath volume-based capnogram provides. The data offered by the volume-based capnogram refine the information offered by time-based capnography.
  • 12 - Conscious sedation
    pp 102-114
  • View abstract


    Since gas exchange is a primordial function of the lungs and the conductive airways, respiratory assessment is of paramount importance. Capnography has been utilized in surgical patients for over three decades to confirm tracheal intubation and assess ventilation. Nitrogen washout provides an estimate of functional residual capacity, total lung volume, deadspace volume, and alveolar volume. Clinicians typically utilize exhaled CO2 concentration against time during a respiratory cycle. A number of applications are available in and out of the operating room. Capnography can be used as a continuous monitor of alveolar ventilation in patients with lung disease or hemodynamic instability. Mainstream capnometry appears to provide more accurate PETCO2 than conventional sidestream capnometry during spontaneous breathing in non-intubated patients. In the opinion of some investigators, the technology should be employed in all cases requiring sedation in or out of the operating room.
  • 13 - Capnometry monitoring in high- and low-pressure environments
    pp 115-126
  • View abstract


    The ability to safely and effectively manage the airway is among the most fundamental and challenging aspects of out-of-hospital (OOH) emergency medical treatment. Commonly used devices to facilitate OOH airway management encompass a spectrum from basic means, such as the bag-valve mask (BVM), to more advanced and invasive means, such as the esophageal-tracheal combitube, laryngeal mask airway (LMA), laryngeal tube airway (LT), endotracheal tube (ET), and, ultimately, emergency surgical airways. End-tidal carbon dioxide (PetCO2) monitoring has emerged as the technology that can best confirm endotracheal or endobronchial location of an endotracheal tube. The threshold for detection of exhaled CO2 is significantly lower for capnometry and capnography as opposed to colorimetric devices. The use of capnography for OOH airway management enhances patient safety and can prevent the problem of unrecognized misplaced intubation (UMI) and should be a mandatory component of OOH airway management.
  • 14 - Biofeedback
    pp 127-134
  • View abstract


    In the hospital setting, patients in the emergency room and intensive care units are at high risk for complications. This chapter reviews the specific role of capnography in the successful airway management of the hospitalized patient. Initiating airway intubation in the emergency room or in the intensive care unit allows significant opportunity for miscalculations that can take the form of esophageal intubations, delays in securing ventilation due to a difficult airway, and inadequate ventilation due to inappropriate settings. The most frequent cause of a false-positive result occurs when a large amount of expired gas is forced into the esophagus during bag-mask ventilation. As it relates to airway maintenance, continuous capnography provides graphical and numerical assurance of airway patency. During routine intensive care radiographic evaluations, inappropriate enteral tube placement has been identified as often as endotracheal tube malposition.
  • 15 - Capnography in non-invasive positive pressure ventilation
    pp 135-144
  • View abstract


    The usually more controlled circumstances of airway management in the operating room (OR) often provide better conditions, better monitoring, and more experienced personnel, particularly when a problem occurs, than is available in other critical care environments or the emergency department. While the detection of CO2 by capnography after completion of a difficult intubation procedure may suggest success, it may more precisely indicate only that the tube tip is somewhere in the respiratory path, although perhaps not exactly where the intubationist desires. A capnography pattern indicating declining CO2 in each subsequent breath over several breaths will help identify esophageal intubation. Unilateral pathophysiologic conditions that cause unilateral hypoventilation or high airway resistances would result in a biphasic waveform. Many techniques to facilitate blind nasal tracheal intubation use the detection of significant exhaled gas flow from a spontaneously breathing patient to indicate the proximity of the tube tip to the glottic opening.
  • 16 - End-tidal carbon dioxide monitoring in postoperative ventilator weaning
    pp 145-147
  • View abstract


    Anesthesiologists monitor their patients' breathing by listening to the lungs or auscultating over the trachea, counting the respiratory rate, watching chest movement and tidal volume, and employing pulse oximetry and capnography. This chapter focuses on issues related to capnography specific to anesthesia and the operating room. Capnography is the best monitor to identify complete disconnection of the breathing circuit. Exhaled tidal volume is a sensitive indicator of leaks and partial disconnects during mechanical ventilation. Capnography will continue to detect expired CO2 as long as the patient's exhaled tidal volume passes sidestream or mainstream sampling ports. Patients with chronic obstructive pulmonary disease or asthma exhibit typical capnograms with upsloping expired values brought about by the slow emptying of partially obstructed segments of the lungs. Intermittent PaCO2 determination has been used as a routine parameter for acid-base management during cardiopulmonary bypass (CPB).
  • 17 - Optimizing the use of mechanical ventilation and minimizing its requirement with capnography
    pp 148-159
  • View abstract


    Continuous monitoring of end-tidal carbon dioxide (PETCO2) is a long-established standard of care in the operating room (OR). Carbon dioxide can be useful to monitor the mechanically ventilated patient when used in conjunction with other monitors of the patient's clinical status. CO2 monitoring is affected by changes in metabolism or CO2 production, cardiovascular function, and respiratory function. Comparison of the gradient between arterial and end-tidal CO2 (PaCO2-PetCO2) can offer valuable information regarding a patient's clinical status. In newborns, the therapeutic administration of CO2 in the ventilator circuit has been used in the preoperative management of hypoplastic left heart syndrome. Volumetric capnography or volumetric CO2 (VCO2) is the measurement of CO2 as a function of volume as opposed to time. When CO2 production increases with constant minute ventilation, PaCO2 will increase. Alveolar minute ventilation can be used as a guide for predicting the PaCO2 that may result from adjusting ventilation parameters.
  • 18 - Volumetric capnography for monitoring lung recruitment and PEEP titration
    pp 160-168
  • View abstract


    Capnography and capnometry provide useful information that may help improve decision-making and reduce complications during transport. This chapter reviews specific clinical applications of capnography and capnometry: assuring proper endotracheal tube placement, monitoring airway circuit integrity, monitoring the consistency of mechanical ventilation, improving safety in procedural sedation, assessing cardiac output, and evaluating patients in cardiac arrest. Capnometry and capnography aid in the confirmation of correct endotracheal tube placement. End-tidal CO2 (ETCO2) measurement can accurately detect esophageal intubation because CO2 is exhaled through the trachea, and not the esophagus. Once an airway device is in place, continuous monitoring is important to assure ventilator circuit patency, including that of the endotracheal tube, and to assure consistent levels of ventilation. Capnography is the gold standard for monitoring patients on airway appliances and ventilator circuits, and there are useful roles for the technology during procedural sedation and evaluating patients in the time surrounding arrest states.
  • 19 - Capnography and adjuncts of mechanical ventilation
    pp 169-182
  • View abstract


    It is important to keep in mind the differences between PETCO2, alveolar CO2, and arterial PCO2 (PaCO2) as extremes of temperature and altitude, and the potential for sensor interference by condensation or various body fluids, may significantly affect the performance of these devices. This chapter presents the evidence for use of PETCO2 monitoring to guide ventilation in the field and reviews each type of device available, discussing the advantages and disadvantages of each. In theory, monitoring of PETCO2 data should lead to a low incidence of hyperventilation, regardless of whether manual or mechanical ventilation is used. Quantitative capnometry has great potential for guiding ventilation in the prehospital arena. Advances in the technology for PETCO2 monitoring, including capnometry and capnography, have allowed these devices to be small and durable enough to be carried into the field, where they can help avoid hyperventilation and injurious ventilation patterns.
  • 20 - Cardiopulmonary resuscitation
    pp 185-194
  • View abstract


    The range of measurements for the CO2 fraction (FCO2) or the corresponding partial pressure (PCO2) in the breathing gas is identical in neonates and adults. The much lower amount of exhaled CO2 makes capnography in neonates more difficult, because there are objective limits for the size of the analyzer chamber or the magnitude of suction flow used with sidestream devices. For intraoperative monitoring, time-based capnography is commonly used, and the shape of the capnogram provides robust qualitative data and the PETCO2. In emergency medicine, critically ill infants often require tracheal intubation before transportation to the hospital. Capnography is a simple, non-invasive technique used to obtain information on alveolar ventilation and the deadspaces of the respiratory system. Compared with the more simple, time-based capnography, volumetric capnography measurements have a much higher informative potential, and enable the calculation of the different airway deadspaces.
  • 21 - Capnography and pulmonary embolism
    pp 195-207
  • View abstract


    This chapter focuses on the importance of the potential role of capnography during sleep. It provides a clear definition of the unique changes in ventilation that accompany the sleep state and its various components. With the evolution of significant clinical interest in sleep-related breathing disorders, the use of polysomnography has been expanded to include more detailed assessment of breathing during sleep. Capnometry is the measurement of CO2 concentration in a gas mixture denoted by a continuous waveform display. Sleep serves multiple functions in humans, including biochemical (anabolic hormone secretion, protein synthesis, energy conservation), physiologic, and neurological. It is extensive in its monitoring capacity, but retains significant limitations in its capability to evaluate changes in ventilation and breathing outside of frank obstructive sleep apnea (OSA) for which it was designed. Comprehensive incorporation of capnography into clinical practice has great potential for enhancing the sleep evaluation in many patients.
  • 22 - Non-invasive cardiac output via pulmonary blood flow
    pp 208-224
  • View abstract


    The term conscious sedation was a source of confusion almost since its introduction by the American Dental Association. In October 2002, the American Dental Association adopted the Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists. Almost as soon as capnography became widely utilized for patients undergoing general anesthesia in an operating room setting, clinicians began seeking a way to monitor exhaled CO2 in unintubated, spontaneously ventilating patients. Pulse oximetry is considered by many clinicians to be an adequate monitor of ventilation during sedation. Essentially all drugs used for sedation are ventilatory depressants. Drug combinations typically have a synergistic, rather than simply additive, effect on ventilation. As evidenced by the disparity in guidelines from different specialty societies, opinions on the value of capnometry vary widely based on the venue and specialty of the sedating physician.

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