6 Capnography

Laura A.M. Ilie*

Veterinary Specialty Center, Buffalo Grove, Illinois, USA

Capnography is the measurement of the partial pres- The gold standard measurement of the PaCO2 is
sure of carbon dioxide (CO2) in exhaled respiratory performed by analyzing an arterial blood sample (see
gases at the end of expiration. The exhaled CO2 in turn Chapter 5). Unfortunately, collection of arterial blood
is an indirect assessment of the partial pressure of CO2 samples is not always easily achieved in small animals
in the arterial blood (PaCO2) and as such provides and can be associated with pain, thrombosis, and pos-
insight into important life-sustaining systems includ- sible infection. Additionally, an arterial blood gas
ing the respiratory, circulatory, and metabolic systems. sample only provides a snapshot of the patient’s CO2
The measurement of the exhaled CO2 has been value at one point in time and requires repeat blood
used for many decades in human and veterinary medi- sampling to gage the animal’s condition over time.
cine to assess the adequacy of ventilation under gen- A noninvasive and indirect measurement of the
eral anesthesia, appropriateness of intubation and, PaCO2 can be obtained by measuring the CO2 level
more recently, the efficacy of chest compressions of the patient’s expired breaths (i.e. end-tidal CO2
during cardiopulmonary resuscitation (CPR). (ETCO2)) using a capnograph. In order to measure
ETCO2 the patient has to be intubated or to have a
tight-fitting mask. If ventilation and perfusion are
6.1 Basic Physiology
well matched, the ETCO2 should be nearly equal to
Carbon dioxide is a metabolic byproduct produced that of the PaCO2 (i.e. 35–45 mmHg). Usually the
when carbon is combined with oxygen as part of the ETCO2 value is 2 to 5 mmHg less than that of arte-
body’s energy-making processes. As it is formed, CO2 rial CO2 because alveolar gases containing CO2
diffuses from the tissues into the bloodstream and will mix with dead-space gases containing no CO2
then is transported to the lungs where it diffuses into in the anesthetic tubing, slightly reducing the
the alveoli. At the alveolar level, the red blood cells ETCO2 measurement versus the concentration of
are ‘unloading’ CO2. This carbon dioxide is then CO2 in the alveolus. Conditions that may interrupt
expelled through the breathing process (Fig. 6.1). the transfer of CO2 from the blood to the alveoli
The PaCO2 is carefully maintained by the body at an (i.e. pulmonary edema, hemorrhage, pneumonia,
approximate constant pressure of 35–45 mmHg in pulmonary embolism, emphysema) can lower the
non-sedated/anesthetized dogs and cats. This is because ETCO2. In these situations, the difference between
CO2 plays an important role in homeostasis. Specifically, PaCO2 and ETCO2 levels can be increased.
it acts as a buffer to maintain normal blood pH, plays In addition, ETCO2 provides insight regarding the
an important role in the regulation of cerebral perfu- function of the circulatory system. For the CO2 to
sion by regulating vascular tone, stimulates breathing travel from the cells to the alveolus, there must be
in the brain’s ventilator centers, and influences the appropriate cardiac output (CO) and at least relatively
affinity hemoglobin has for oxygen (O2). normal flow of blood through the heart and pulmo-
Measurement of the PaCO2 concentration pro- nary system. If the CO is decreased in conditions like
vides the clinician with useful information regard- hypovolemia or poor cardiac output or the blood does
ing the ventilation status of a patient. High PaCO2 not appropriately travel from the cells back to the
(hypercapnia) suggests hypoventilation while low alveolus (as occurs with vasodilatory shock or extreme
PaCO2 (hypocapnia) suggests hyperventilation. vasoconstriction), the ETCO2 will be low.

* Corresponding author: [email protected]

110 © CAB International, 2020. Basic Monitoring in Canine and Feline Emergency Patients
(eds E.J. Thomovsky, P.A. Johnson and A.C. Brooks)
 Tissue cells Systemic capillary

CO2

H2O
CO2
H2CO3

Hb Hb-CO2

Red
blood cell

Pulmonary capillary

Alveoli

H2CO3
H2O

CO2 CO2
Hb
CO2
Hb-CO2

Red
blood cell

Fig. 6.1. Carbon dioxide metabolism. Carbon dioxide is a metabolic byproduct produced by the tissue cells. While
some of the carbon dioxide remains dissolved in the plasma, most carbon dioxide diffuses into the red blood cells.
In the red blood cell, it either binds to water molecules and forms carbonic acid or binds to hemoglobin to form
carboxyhemoglobin. When the blood arrives in the lungs, the carbon dioxide diffuses into the alveoli. At the alveolar
level, the red blood cells are ‘unloading’ CO2 which is then expelled through the breathing process. CO2, carbon
dioxide; H2CO3, carbonic acid; H2O, water; Hb, hemoglobin; Hb-CO2, carboxyhemoglobin.

During CPR, measurement of ETCO2 can relia- ventilatory status as well as information regarding
bly provide the clinician with information regard- the cardiac output and blood flow through the
ing the quality of chest compressions as well as an heart and pulmonary system.
indirect assessment of the cardiac output and the
blood flow through the heart and lungs.
6.2 How Capnography Works
In conclusion, measurement of the ETCO2 pro-
vides the clinician with two important pieces of There are two different ways to analyze the CO2
information: indirect evaluation of the patient’s concentration: plotted against time (time capnogram)

Capnography111
or against expired lung volume during a respiratory These devices are best utilized to confirm proper
cycle (volume capnogram). endotracheal intubation. The device is placed at the
The time capnogram gives an indication of the end of the endotracheal tube (ETT). If the color
efficiency of ventilation. It is the most commonly does not change, there is a high chance the ETT
used method because it is simple to use, evaluates tube is in the esophagus and it needs to be reposi-
both parts of the respiratory cycle (inspiration and tioned. It is important to wait for six breaths before
expiration), and is an excellent tool for patient deciding if the ETT is properly placed.
monitoring at bedside. The volume capnogram has
its own benefits too: it allows a breath-by-breath
Quantitative capnometry
quantification of the volume of lung ventilated, as
well as the measurement of alveolar dead space, and There are multiple physical methods that can be
physiological dead space. This means that the clini- used to quantitatively measure CO2 : (i) infrared
cian can assess the degree of ventilation/perfusion spectroscopy; (ii) molecular correlation spectros-
(V/Q) mismatch. Different physiological concepts copy; (iii) Raman spectrography; (iv) photo acous-
can be used (i.e. Bohr or Enghoff approach) to tic spectrography; (v) mass spectrography; and (vi)
quantify the global V/Q mismatches. This method chemical colorimetric analysis spectrography.
also allows separation of shunt fraction (blood The most commonly used principle is the meas-
passing by unventilated alveoli) and true dead space ure of infrared light; therefore, this method will be
(air not available for gas exchange). The major limi- described in more detail in this chapter. This prin-
tations of volume capnograms include the require- ciple uses the application of the Beer and Lambert
ment to use a mechanical ventilator and other Laws and infrared waves. This means that the
elaborate equipment and it only provides informa- quantity of infrared (IR) waveforms absorbed is
tion regarding the expiratory phase of the breathing proportional to the concentration of the infrared-
cycle (as the expired CO2 is plotted against expired absorbing substance. In other words, the quantity
lung volume). of infrared waveforms absorbed by CO2 molecules
This chapter will only focus on time capnograms. is proportional to the concentration of CO2 present
A time capnograph provides a graphic represen- in the expired gas. The higher the CO2 concentra-
tation (waveform) denoting the relationship of the tion the higher the quantity of IR absorbed. This
ETCO2 concentration to time. It also provides a concept might seem difficult to follow, but it will be
measured value of the maximum level of ETCO2 at described in more detail below.
the end of each breath. Changes in size, shape, and A capnograph using infrared spectroscopy con-
distribution of the waveforms are suggestive of tains three main components: (i) infrared source;
underlying pathologic conditions while changes in (ii) sample chamber; and (iii) infrared detector.
the level of measured ETCO2 reflect disease sever-
ity as well as response to treatment.
The infrared source
Capnometry is further classified based on the
technique used to measure CO2 concentration: As the name implies, the infrared source emits
infrared waves. The infrared waves are absorbed by
●● Qualitative capnometry: provides a color-coded
different gases present in the anesthesia circuit.
(colorimetric) capnogram representing the pres-
Each gas absorbs infrared waves of different wave-
ence of CO2 in the patient’s breath.
lengths. For example, CO2 absorbs infrared wave-
●● Quantitative capnometry: provides a numeric
lengths of 4.25 micrometers, nitrous oxide absorbs
value for the measured CO2 concentration. It
infrared wavelengths of 4.5 micrometers, while
can also provide a graphic form which is called
oxygen does not absorb infrared light.
‘quantitative capnography.’
Why is this important? Because knowing the
wavelength absorption of a certain gas (in our case
the CO2), a device can be designed with an infrared
Qualitative capnometry
source that will only emit that specific wavelength
Qualitative (colorimetric) capnographs are hand- and only measure the concentration of that gas. If the
held devices which contain a pH-sensitive impreg- source were to emit a wide spectrum of wavelengths,
nated paper. If the exhaled gas contains CO2, the then it might measure the concentration of other
color of the paper changes from purple to yellow. gases that are not of importance and the final reading

112 L.A.M. Ilie

will not be accurate. Therefore, in most capnographs be. This occurs because many infrared waveforms
the infrared source is designed to emit wavelengths reaching the detector mean that few infrared wave-
within very narrow limits. A graphic representation forms have been absorbed by the passing CO2
of the main components is found in Fig. 6.2. (therefore the concentration of CO2 is low). For
example, if the patient exhales a high concentration
of CO2, this will cause an increase in infrared
Sample chamber
absorption in the sampling chamber; therefore, a
This chamber is made of sapphire, which allows the low number of infrared waves will reach the detec-
infrared waves to pass through. When the patient tor, indicating a high ETCO2.
expires, the gas expired also passes through this There is a proprietary algorithm that implements
chamber. The infrared waves will be absorbed by the information received by the detector to deter-
the expired CO2 based on its concentration (i.e. the mine the exact ETCO2 value displayed on the
higher the expired CO2 concentration, the higher screen of the capnograph.
the absorption of the infrared light). See Fig. 6.2. Quantitative capnographs are also classified based
on the location of the infrared detector: (i) main-
stream capnographs; or (ii) sidestream capnographs.
Infrared detector
An infrared detector is located opposite to the mainstream capnography In the mainstream cap-
infrared source (on the other side of the sample nograph, an airway adapter is inserted directly
chamber). When infrared waves reach this detector, between the breathing circuit and the endotracheal
a signal will be transmitted to the monitor. The tube. An infrared source and detector are attached
higher the number of infrared waveforms that to the airway adapter (sometimes it can be found
reach the detector, the lower the CO2 reading will as a single unit or as separate parts, see Figs 6.3 to 6.5).

Infrared
CO2 detector
CO2

CO2
Sample chamber containing expired gases. Expired CO2
Infrared molecules absorb infrared (IR) waves and a small number of IR
source waves reach the infrared detector.

Endotracheal
tube

Patient

Fig. 6.2. Schematic representation of a capnograph using infrared spectrography with its three main components:
infrared source, sample chamber and infrared detector. Note the infrared source is emitting infrared waves toward
the sample chamber. The patient expires anesthesia gases, including CO2. The infrared waves will be absorbed by
the expired CO2 molecules based on its concentration (i.e. the higher the expired CO2 concentration, the higher the
absorption of the infrared light). The infrared waves not absorbed by the CO2 molecules will reach the detector and
a signal will be transmitted to the monitor. The lower the number of infrared waveforms that reach the detector, the
higher the CO2 reading will be. CO2, carbon dioxide.

Capnography113
 Endotracheal tube
adapter

Infrared source on one

side and IR detector on
the other side

Fig. 6.3. Mainstream capnograph with separate infrared sensor (IR) as well as an endotracheal tube adapter. The
endotracheal tube adapter fits inside the IR sensor. The smaller end of the endotracheal adapter attachs to the
endotracheal tube of the patient, while the larger end connects to the anesthesia circuit.

Infrared sensor with

incorporated
endotracheal tube
adapter

Fig. 6.4. Mainstream capnograph with endotracheal tube adapter incorporated within the infrared source/detector.

Display of ETCO2 value

(no waveform)

Infrared sensor attached

to endotracheal tube

Fig. 6.5. Mainstream capnometer attached to a patient’s endotracheal tube. Note that a waveform is not provided
with this device.

114 L.A.M. Ilie

The detector is attached to the monitor via an stream capnograph. In addition, since mainstream
electrical wire. units do not remove gas from the anesthetic circuit,
there is no need to separately scavenge anesthetic
sidestream capnography In sidestream capnog- gases. Mainstream units are more durable than
raphy, the detector is in the main unit itself (away sidestream units, have fewer disposable compo-
from the airway) and a very small pump aspirates nents, do not require additional sample tubing, and
gas samples (usually 50–150 mL/min, depending on tend to be reasonable in cost. Mainstream analyz-
whether the machine measures other gases) from ers also provide instantaneous readings.
the patient's airway through a small tube into the In contrast, sidestream capnographs have the
main unit. This sampling tube is connected to a unique advantage of allowing monitoring of non-
T-piece inserted at the endotracheal tube or anes- intubated subjects by connecting the sidestream
thesia mask connector (Fig. 6.6A). The gas that is micro tube to a face mask or a nasal catheter line.
withdrawn from the patient often contains anes- When using nasal ETCO2, it is unlikely that dilu-
thetic gases; the exhausted gas from the capnograph tion of CO2 will occur and it has been demon-
must be routed to a gas scavenger or returned to the strated that the general waveform is comparable to
patient’s breathing system (Fig. 6.6B). and representative of the ETCO2 obtained from an
Each method of sampling comes with its own endotracheal tube (as long as the patient breathes
unique set of advantages and disadvantages. through its nose). When using a face mask, signifi-
Mainstream technology generally produces more cant dilution of CO2 is expected. This is because
sharply delineated waveforms compared to a side- the samples of expired gas are mixed with the

(A) (B)

Pump aspirating gas samples into the T piece connection to Exhausted gas Gas scavenger
main unit. endotracheal tube
The larger size plastic container below
the aspirating pump is a water trap.
Note that the infrared sensor is inside
the main unit thus not visible.

Fig. 6.6. Sidestream capnograph. (A) A sidestream capnographs with a small aspiration pump that takes a sample
of expired gas directly from the patient’s expired gas (which includes CO2 and anesthetic gas) and brings it to the
infrared sensor located inside the main unit. (B) After the gas sample is analyzed, the exhausted gas that has been
sampled from the patient by the capnograph is routed to a gas scavenger to remove CO2 and any waste anesthesia
gases (such as isoflurane). CO2, carbon dioxide.

Capnography115
atmospheric gases in the mask in addition to the
fresh gas flow into the mask. This dilutes the con-
centration of CO2 and leads to a falsely low
ETCO2 as compared to an intubated patient.
However, knowing that there is CO2 dilution, face
mask–derived ETCO2 readings can still be trended
over time within a single patient and provide clini-
cal information. It is noteworthy to mention that
some capnography systems (like the Oridion sys-
tems) have a dual nasal and mouth sampling device
that may give a better idea of real ETCO2 in
patients who are panting/breathing through their
mouth.
Other advantages of sidestream capnographs
include faster warm-up time than mainstream
units, low dead space added to the circuit, and the
capability to measure several respiratory gases at
once including anesthetic gases. The line and adap-
tor that attach to the ETT are also lightweight
which reduces the chance of kinking or disconnec-
tion of the system.
One other aspect of the sidestream capnograph
that needs to be mentioned is that condensation
from humidified gas and patient’s secretions may
develop and it can accumulate in the sampling line.
This can lead to inaccurate ETCO2 readings as it
can affect the sampling cell function or sometimes
cause occlusion of the sampling line. Frequent
replacement of the sampling line may be required.
To avoid this or to at least decrease the frequency
of sampling line replacement, most units come with
a water trap (see Fig. 6.7) located at the end of the
sampling tube. Some units also have water perme-
able tubing such as Nafion® tubing. This tubing has Fig. 6.7. Water trap sidestream capnograph. This is a
a unique property to transfer moisture from one sidestream capnograph and the water trap can be seen
side of the membrane to the other. This is done on the side of the machine.
chemically via differential vapor pressure (the
water molecules move from a higher pressure to a period between the mouth and the detection cham-
lower pressure) and is therefore very selective for ber than traditional sidestream technology and thus
water molecules only. If there is high moisture pres- a capnograph curve that is almost synchronized
sure in the tubing, the water molecules will be with the passage of air at the mouth. In addition,
transferred outside of the tubing and the gas that the microstream system has less dead space than
reaches the analysis chamber will be moisture-free traditional units (less than 0.5 mL of dead space),
and will not interfere with the CO2 reading. which makes this a useful ETCO2 monitor for the
A microstream system has also been developed small-sized patient. Other benefits of the micros-
which is a variation of the traditional sidestream tream technology include a low-flow 50 mL/min
units. In the microstream technology there is no sen- sample rate, no dilution with supplementary oxy-
sor at the airway. It uses laser-based molecular gen, and no cross reaction with other gases. Using a
spectroscopy as the infrared emission source. The low-flow sample rate is especially beneficial for our
expired CO2 travels along a thin tube before reach- small-sized patients which tend to have a low tidal
ing the chamber where the detector is located. The volume and a fast respiratory rate. Using a high-
microstream system allows for a smaller transition flow sampling rate (i.e. 150 mL/min used with

116 L.A.M. Ilie

­classic capnographs) can result in erroneous ETCO2 return of spontaneous circulation. A declining or
measurements and distorted waveforms. Also, low- low ETCO2 value during CPR may suggest rescuer
flow sample rates minimize dispersion of gases in fatigue or ineffective chest compressions by the res-
the sampling tubes and there is a less likely chance cuer. It should also alert the clinician to seek other
of aspirating condensed water and secretions mini- factors contributing to declining cardiac output or
mizing the chances of occlusion. which are rendering chest compressions less suc-
cessful such as ongoing hemorrhage, cardiac tam-
ponade, or pneumothorax.
6.3 Indications for Capnography
in Small Animals
Feeding tube placement
Anesthesia or heavy sedation
Although, radiography remains the ‘gold standard’
The use of a capnograph along with pulse oximetry, method to confirm proper placement of
electrocardiogram, and blood pressure monitoring is ­nasoesophageal/gastric feeding tubes, capnography
recommended in every patient that undergoes gen- can be used as an adjunct technique. The partial
eral anesthesia or heavy sedation. Becoming familiar pressure of CO2 in the stomach and esophagus is
with the normal as well as abnormal waveforms negligible. Therefore, the ETCO2 value should be
provided by the capnograph, the clinician/technician zero in correctly placed feeding tubes and higher if
can gain a rapid visual evaluation of ventilation in the tube is mis-placed in the airways.
the anesthetized patient as well as detect problems
encountered along the way. More detail regarding
Upper airway emergencies
waveform interpretation is provided in Section 6.4.
Capnography may be beneficial in patients who
require intubation to treat life-threatening upper
Cardiopulmonary resuscitation
airway obstruction or severe upper airway inflam-
As mentioned at the beginning of this chapter, the mation (i.e. brachycephalic syndrome, laryngeal
measurement of ETCO2 provides the clinician with paralysis, etc.). In most cases, these patients have
two important pieces of information: an overview received a large volume of sedation and/or anxio-
of the patient’s ventilatory status as well as an idea lytic drugs prior to and in order to facilitate intuba-
of the cardiac output and the blood flow through tion, including but not limited to propofol, opioids,
the heart and pulmonary system. benzodiazepines, alpha-2 agonists, and aceproma-
Since ETCO2 is proportional to pulmonary zine. It is important to monitor the ETCO2 in these
blood flow (the better the blood flow, the more patients to ensure that they are not hypercapnic as a
CO2 is delivered to the alveoli to breathe out), result of respiratory depression from the sedation/
ETCO2 can be used as a measure of chest compres- anesthesia. If hypercapnia is noted, these patients
sion efficacy during CPR assuming the ventilations may need manual or mechanical ventilation until the
administered are unchanging in rate and size of drugs wear off or can be reversed and their ventila-
breath. During cardiopulmonary arrest there is no tory drive returns.
blood flow nor ventilation. When closed chest com-
pressions are performed, very few alveoli are per-
Mechanical ventilation
fused because the blood flow to the lungs is low. By
providing manual ventilation with an AMBU bag, In all patients being mechanically ventilated, it is
many alveoli are ventilated but are not perfused. useful to monitor paired PaCO2 and ETCO2 val-
During this time the ETCO2 will be low. If the ues. If the ETCO2 is proved to be representative of
blood flow to the lungs improves (CPR is success- the PaCO2 by comparison to the arterial blood gas
ful and return of spontaneous circulation is analysis in a particular patient, changes in ETCO2
achieved), more alveoli will be perfused and subse- may be assumed to signify similar changes in
quently the ETCO2 will increase. PaCO2. In that way the noninvasive ETCO2 allows
During chest compressions in CPR, the goal the patient to avoid numerous arterial punctures (if
value of ETCO2 should be above 15–20 mmHg. an arterial catheter is not in place already) and the
Lower values have been associated with a signifi- expense of running multiple blood gas analyses.
cant decrease in the likelihood of the patient having The capnograph also provides a continuous display

Capnography117
of the ETCO2 which allows for detection of sudden tilation (high PaCO2) can cause cerebral vasodilation
changes in the carbon dioxide values. It is impor- which in turn can increase intracranial pressure.
tant to remember that this relationship between Manual hyperventilation may be considered for
ETCO2 and PaCO2 will only be valid if there are no intubated patients with severe neurologic decom-
major respiratory or hemodynamic changes in the pensation or those at high risk of cerebral hernia-
patient. It is not recommended to use ETCO2 solely tion. The recommended ETCO2 target for this
to assess PaCO2 without at least periodic compari- sub-category of patients is 30-35 mmHg. If manual
sons to the arterial carbon dioxide value. hyperventilation is performed it should be limited
Measuring paired PaCO2 and ETCO2 values also to a duration of 4-6 hours (such as during advanced
allows the clinician to determine the difference imaging like magnetic resonance imaging; MRI) to
between the arterial and end-tidal CO2. This differ- prevent excessive cerebral vasoconstriction and
ence is referred to as the P(a-ET)CO2 gradient. The possible ischemic damage to the brain. It is not
arterial to ETCO2 gradient should be ≤ 5 mmHg in recommended to provide prophylactic hyperventi-
anesthetized normal dogs. The P(a-ET)CO2 gradient lation during the initial resuscitation of patients
can provide the clinician with valuable information with traumatic brain injury so as to avoid vasocon-
regarding the clinical progress of a critically ill striction that could impede oxygen delivery to
patient; trends of this value may be used to assess damaged brain cells.
improvement. Table 6.1 summarizes some of the
causes of altered PaCO2–ETCO2 gradient.
6.4 Interpretation of End-Tidal
Carbon Dioxide
Traumatic brain injury patients
Clinical information can be obtained from three
Patients with traumatic brain injury require careful sources in CO2 analysis: (i) numerical values of
monitoring of their ventilatory status. Hyperventilation ETCO2 (capnometry); (ii) shape of the waveform
(low PaCO2) leads to cerebral vasoconstriction which (capnogram); or (iii) the difference between ETCO2
helps to preserve intracranial pressure while hypoven- and PaCO2 (P(a-ET)CO2 gradient).

Table 6.1. The most common causes of altered P(a-ET)CO2 gradient.

Increased P(a-ET)CO2 gradient Examples

Ventilation perfusion mismatch Acute respiratory distress syndrome

Pulmonary infiltrates (edema, hemorrhage, pneumonia)
Diffusion barrier preventing diffusion of carbon dioxide into the alveoli (ETCO2 to
be significantly lower than PaCO2)
Pulmonary thromboembolism
Decreased lung perfusion and increased alveolar dead space causing ETCO2 to
be significantly lower than PaCO2
Increased alveolar dead space Chronic obstructive pulmonary-like disease
Pulmonary thromboembolism
These conditions tend to cause an incomplete alveolar emptying (i.e. chronic
airway obstruction causes gas to be trapped in the alveoli not allowing complete
gas exchange therefore the ETCO2 reads low)
Decreased cardiac output Heart disease
Less delivery of carbon dioxide from the tissues to the alveoli for gas exchange
resulting in low ETCO2
Low patient tidal volume to Increase in dead space ventilation
equipment dead space Patient exhaling into dead space; CO2 not measured by capnograph
Leak in the sampling system or Exhaled gases lost from system
around endotracheal tube False decrease in ETCO2 value measured by capnograph
PaCO2, arterial concentration of carbon dioxide (measured in mmHg); ETCO2, end-tidal carbon dioxide concentration (measured in
mmHg); P(a-ET)CO2, difference between arterial and end-tidal carbon dioxide concentrations.

118 L.A.M. Ilie

 In a clinical situation, it is important to interpret deal of information, sometimes even making the
the information provided by capnometry (i.e. the difference between life and death for the patient. A
numerical value of ETCO2) along with capnogra- normal capnogram shows a regular, nearly square
phy (the graphic representation of the waveform). waveform that represents the inhalation of CO2-
Numerical values should be used as a tool in free gases during inspiration and the path of CO2
­evaluation of the overall ventilatory status of the from the alveoli to the mouth during expiration.
patient while the shapes of the waveforms offer There is a very small volume of breath that does
more specific diagnostic clues. not participate in gas exchange (it is CO2 free)
called respiratory dead space. This anatomic dead
space represents the total volume of the conducting
Capnometry
airways from the nose or mouth down to the level
There are four major causes for increases or of the terminal bronchioles. The dead space can be
decreases in the numerical values of the ETCO2: increased in intubated patients due to presence of
endotracheal tubes that are too long or additional
●● cellular/metabolic reasons (changes in the rate of
tubing added to the anesthesia circuit (i.e. choosing
CO2 production in the tissues) as seen with
an anesthesia circuit that is too large for the size of
hypothermia, fever, seizures, etc.;
the patient).
●● variations in alveolar ventilation (secondary to
When the patient first starts to exhale, there will
pain, bronchospasm, drug therapy, etc.);
be no CO2 detected by the capnograph because the
●● alterations in pulmonary perfusion (changes in
gas from the dead space is exhaled first. As the exha-
delivery of blood and CO2 to the alveoli) as seen
lation continues, the concentration of CO2 increases
with cardiac failure, cardiac arrest, pulmonary
until it reaches a peak at the end of exhalation; then
thromboembolism, etc.; and
the CO2 concentration drops to baseline as the
●● technical malfunctions of the anesthesia machine.
patient starts to inhale CO2-free gases. This can be
Tables 6.2 and 6.3 summarize the most common seen best on a time capnogram (Fig. 6.8).
causes of increased and decreased ETCO2 values. As seen in Fig. 6.8, a time capnogram has two
important segments – inspiratory and expiratory –
as well as two angles (alpha and beta). The expira-
Capnogram
tory segment of a time capnogram includes phase I,
Understanding waveforms generated during ventila- II and III, while the inspiratory phase includes
tion and how to interpret them can provide a great phase 0 and the beginning of phase I.

Table 6.2. Most common causes of increased ETCO2 values (greater than 50 mmHg).

Cause Physiologic explanation

Cellular/metabolic Increased muscle activity or metabolic rate caused by seizures, fever, or

severe sepsis, leading to increased cellular CO2 production
Variations in alveolar ventilation Respiratory center suppression leading to decreased ventilation rate or depth:
due to neurologic disease, head trauma, toxin/drug induced, pain
Inability to perform full lung expansion: due to pleural effusion, pneumothorax
Inappropriate intubation (i.e. bronchial intubation leading to ventilation of only
one lung)
Decreased manual ventilation rate or decreased respiratory rate during
mechanical ventilation
Partial airway obstruction (mass vs mucus plug vs ETT kinked vs other)
Alterations in pulmonary perfusion Congestive heart failure – poor lung perfusion, thus poor gas exchange
Technical malfunction of the Expiratory valve malfunction (accumulation of expired gases including CO2)
anesthesia machine Slow fresh gas flow (with non-rebreathing systems) leading to build-up of CO2
in the system
Exhausted CO2 absorbent (rebreathing carbon dioxide)
ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; CO2, carbon dioxide.

Capnography119
Table 6.3. Most common causes of decreased ETCO2 values (less than 30 mmHg).

Cause Physiologic explanation

Cellular/metabolic ●● Decreased metabolic and cellular function due to hypothermia, metabolic acidosis leading to
decreased CO2 formation
Variations in ●● Pain or anxiety-induced tachypnea
alveolar ●● Excessive manual ventilation or increased respiratory rate during mechanical ventilation
ventilation ●● Bronchospasm, asthma, chronic bronchitis causing decreased gas exchange in the alveoli
●● Total airway obstruction blocking gas exchange in the alveoli
●● Apnea/respiratory arrest
Alterations in ●● Sampling line leak or obstruction in sidestream capnographs
pulmonary ●● Total airway obstruction or disconnected system
perfusion ●● Malfunctioning ETT cuff (deflated or too small for patient’s size) causing gas to be expired
around the tube rather than going through the analyzer Inappropriate placement of the ETT
(i.e. into the esophagus)
●● If a non-rebreathing system is used (patient smaller than 7 kg), the fresh gas flow may be
too high, causing dilution of the expired gas and lowering the ETCO2
●● Increased dead space (especially in small-sized patients) causing carbon dioxide to stay in
the system rather than pass through the capnograph
●● Accidental extubation
Technical malfunction ●● Expiratory valve malfunction (accumulation of expired gases including CO2) Slow fresh gas
of the anesthesia flow (with non-rebreathing systems) leading to build-up of carbon dioxide in the system
machine ●● Exhausted CO2 absorbent (rebreathing carbon dioxide)

ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; CO2, carbon dioxide.

●● Phase I (respiratory baseline): this phase repre- ●● Phase 0 (inspiratory downstroke): the CO2 con-
sents inspiration which means the CO2 concen- centration rapidly declines to zero during inha-
tration should be zero. The expiration phase lation as CO2-free gas is drawn into the lungs,
starts right before the end of this phase, but past the carbon dioxide sensor.
because it does not contain any expired CO2 ●● Alpha angle: the angle between phase II and III
(due to the presence of dead space) it is displayed is the α angle. This angle is typically considered
as a flat line. to be an indirect representation of the ventila-
●● Phase II (expiratory upstroke): as the name tion: perfusion status of the lung. The slope and
implies, in this phase the CO2 concentration the height of phase III can be influenced by air-
rises rapidly, and an upswing of the baseline will way resistance, cardiac output, and CO2 pro-
be seen. As the expiration progresses, the CO2 duction, resulting in changes in the degree of the
from the alveoli will replace the ‘CO2 -free gas’ alpha angle. Normally this angle is between
previously present in the trachea and endotra- 100° and 110°. For example, an increase in
cheal tube and be sensed by the capnometer. alpha angle may suggest increased airway resist-
●● Phase III (alveolar plateau): as expiration con- ance (i.e. an obstruction from things such as
tinues, the alveoli become empty and the CO2 asthma, bronchospasm, kinked endotracheal
level reaches a plateau level. Because not all the tube, etc.). The angle increases since it takes
alveoli empty at the same exact time, the alveolar longer to expel the carbon dioxide-rich gas from
plateau phase is slightly sloped. This happens the alveoli when there is airway spasm or other
because the alveoli with a low ventilation:perfusion airway obstruction.
ratio (i.e. well perfused with blood but not venti- ●● Beta angle: the angle between phase III and the
lated as effectively) have a higher CO2 concen- inspiratory downstroke is the β angle. This angle
tration and usually empty late in the exhalation is usually about 90 degrees. This angle is used to
phase. The highest point of phase III corresponds assess the degree of rebreathing; it will increase
to the actual ETCO2. as the rebreathing increases since it will take

120 L.A.M. Ilie

 Inspiratory downstroke

Alveolar plateau
ETCO2
(mmHg) Expiratory upstroke End-tidal CO2
60 value

50 III
40
α β
30
0 0
20 II
10
I
0

Time (seconds)
Expired baseline

EXPIRATION INSPIRATION EXPIRATION INSPIRATION

Fig. 6.8. Graphic representation of a normal time capnogram produced by mainstream or side stream capnography.
Phase 0-Inspiration; Phase I- Anatomical dead space, expired baseline; Phase II- Expiratory upstroke (mix of dead
space gas and alveolar gas); Phase III- Alveolar plateau; Alpha angle: Angle between phase II and phase III; Beta
angle: Angle between phase III and descending limb of inspiratory segment.

longer to replace the CO2 in the alveoli with frequency, baseline as well as the rhythm of the
fresh gas when there is rebreathing. waveform following the questions:

The shape of a capnogram from a healthy patient is 1. Is a waveform present?

very similar regardless of age, breed, or species. Lung 2. What is the shape of the waveform? (steep,
pathologies or equipment malfunctions will change ­sloping, prolonged?)
the appearance of the capnograph waveform. Any 3. What is the height of the waveform? (short, tall?)
anesthetist (doctor or technician) needs to recognize 4. How frequent are the breaths (too fast, too slow?)
normal from abnormal. Proper interpretation of cap- 5. What about the baseline? Where does it start? (is
nographic waveforms during anesthesia will help the there rebreathing?)
clinician identify life-threatening conditions and
equipment malfunctions (i.e. leak, esophageal intuba- Table 6.4 summarizes the most commonly encoun-
tion, rebreathing of CO2, loss of capnographic wave tered abnormalities in the capnographic waveform.
from disconnection of the anesthesia circuit, In patients undergoing endotracheal intubation,
obstructed/kinked endotracheal tube or respiratory capnography can help to show that the trachea, and
arrest hypercapnia/hypoventilation, and many more). not the esophagus, has been successfully intu-
bated. A series of successive, steady, normal capno-
graphic waveforms must be seen to rule out
Commonly encountered abnormal
esophageal intubation (Fig. 6.9). A similar graphic
capnographic waveforms
representation to Fig. 6.9 can be seen when there is
When interpreting a capnogram it is recommended disconnection of the anesthesia circuit or the
to do so in a systematic way each time to make sure endotracheal tube, occlusion, or disconnection of the
no important aspects are being overlooked. sampling catheter (when a sidestream system is
Evaluate the overall shape of the waveform, height, used) or if apnea is present.

Capnography121
Table. 6.4. Common abnormalities in the capnographic waveform.

Segment affected Possible causes Troubleshooting

Wave form Absent – suggests disconnection of the Check patient’s vital signs and start CPR if needed
breathing circuit; obstruction/kinking Check ETT connections
of the sampling line; cardiac arrest; Check sampling line
esophageal intubation Check proper placement of the ETT
Shape of the Slant (prolonged) phase II or III – Check ETT for obstruction/kinks
waveform suggests obstruction of the expiratory Check breathing circuit and ETT cuff for leaks
flow (i.e kinked ETT; bronchospasm; Consider a bronchodilator
asthma) or leaks in the breathing
system
Slant (prolonged) phase 0 – suggests
malfunction of the inspiratory valve Check inspiratory valve for malfunction
when a closed-circuit system is used
Frequency of Too fast – suggests hyperventilation Consider decreasing the respiratory rate if manually
the waveform or mechanically ventilated or increase the depth of
anesthesia if spontaneously breathing
Too slow – suggests hypoventilation Consider increasing the respiratory rate if manually
or mechanically ventilated or reduce depth of
anesthesia if spontaneously breathing
Inspiratory Gradual elevation – suggests Check sodalime as well as the inspiratory and
baseline rebreathing expiratory valves
Check the sidestream tubing and replace if needed
Sudden elevation along with increased Disconnecting the sampling line and flushing it with air
ETCO2 – suggests contamination of from a syringe can sometimes clear it, but it may be
the sampling cell with mucus or water necessary to replace these components. Elevating
the sidestream sampling line above the ventilator
circuit helps to prevent the entry of condensed water.
A humidity barrier such as Nafion® tubing is also
useful
Height of the Tall waveform – suggests hypoventilation Consider increasing the respiratory rate
waveform or increased metabolic rate
Short waveform – suggests Consider decreasing the respiratory rate
hyperventilation or a decrease in
metabolic rate or cardiac output
ETT, endotracheal tube; CPR, cardiopulmonary resuscitation; ETCO2, end-tidal carbon dioxide.

Rebreathing of carbon dioxide is easily seen on alveolar plateau noted as well as a prolonged inspir-
the capnogram as an elevated baseline and increase atory upstroke (Fig. 6.11). If a total obstruction is
in ETCO2 value (Fig. 6.10). Causes for rebreathing present, there will be no waveform as the gas sample
include: cannot reach the sample chamber.
It is not unusual to have the ETT cuff inflated
●● expiratory valve malfunction; too much or too little. Ideally a Possey CufflatorTM
●● low fresh gas flow (in the non-rebreathing c­ ircuits); should be used to properly measure the pressure in
●● the carbon dioxide absorber (soda lime) is chemi- the cuff. The Possey CufflatorTM is an endotracheal
cally exhausted (characterized by a change in color - tube inflator and manometer. It has an air vent but-
usually becomes purple/blue when exhausted). ton and inflator bulb to quickly adjust the ETT cuff
pressure. The inflator’s gauge on the manometer
Capnograms can also help us identify if there is a shows the recommended pressure range in centim-
total or partial obstruction of the ETT. If a partial eters of water (usually between 20–30 cm H2O).
obstruction is present, there will be a small or absent Should there be a leak of air around the endotracheal

122 L.A.M. Ilie

ETCO2
(mmHg)

50

40 Note the very minimal variation

in the ETCO2 value.
30
Fig. 6.9. Graphic representation of
20 esophageal intubation. There is only
a very small amount of CO2 in the
10 esophagus. Thus, the capnograph
displays very small to almost no
0 variation in the amount of CO2. ETCO2,
Time end-tidal carbon dioxide.

ETCO2
(mmHg) Note gradual increase in
ETCO2 value

80

60
55
45
40

20

0
Time

Fig. 6.10. Graphic representation of hypercapnia and rebreathing. Note the ETCO2 value increases with each breath
and it is above 50 mmHg while rebreathing is noted as the presence of an elevated baseline. ETCO2, end-tidal carbon
dioxide; CO2, carbon dioxide.

cuff, there will be a dilution of the ETCO2 and phase 0 of the waveform undulates rather than
the number will be artificially lowered. going to a flat baseline as a result of the beating
Graphically we will see a shorter alveolar plateau heart ‘compressing’ the lungs and altering the cap-
that blends in with the inspiratory downstroke nograph waveform. Cardiogenic oscillations are
(Fig. 6.12). usually seen in mechanically ventilated patients
Common causes for hypoventilation leading to and its presence suggests either superficial breaths
hypercapnia (increased ETCO2 number) include (not deep enough) or not enough breaths per min-
sedation or an underlying condition affecting the ute. If cardiogenic oscillations are seen in an anes-
respiratory center in the brain (neurologic dis- thetized patient with spontaneous breathing,
ease, toxin, trauma, etc.). In those cases, the cap- assisted or mechanical ventilation may be consid-
nogram will display an increase in ETCO2 (see ered to improve the depth and quality of respira-
Fig. 6.10). tions (Fig. 6.13).
A less commonly-seen change in the capnogram Shallow breathing or panting causes transient
is cardiogenic oscillation. The end of phase III and lowering of ETCO2 because shallow breaths are

Capnography123
 ETCO2
(mmHg)
Note phase II is angled and prolonged while
phase III is not present
60

50

40

30

20

10

0
Time

Fig. 6.11. Graphic representation of an obstructed endotracheal tube. In this case, the CO2 cannot be easily expelled,
thus the ascending slope (phase II) is prolonged and there is no alveolar plateau (phase III). There is no obvious
alpha angle. This usually happens when the endotracheal tube obstruction is severe enough to prevent complete
expiration of the gas during the expiratory phase by the time the next inspiratory phase occurs. Due to absence of
phase III, the alpha angle is not obvious either. ETCO2, end-tidal carbon dioxide.

ETCO2
(mmHg) The alveolar plateau is blunted and blends
with the downstroke of the capnogram
60
50
40
30
20
10
0
Time

Fig. 6.12. Graphic representation of leak around the endotracheal tube cuff. If air leaks around the cuff, it will dilute
the ETCO2 making it a lower concentration. This will shorten the alveolar plateau as the CO2 drops. Note a shorter
alveolar plateau (phase III) and an undulating shape of phase 0. ETCO2, end-tidal carbon dioxide.

largely dead-space ventilation. This can be distin- patient’s condition. If the patient is stable clinically,
guished from true decreases in ETCO2 because the consider the possibility of malfunction of the anes-
ETCO2 will rise again after a deep inspiration thetic circuit or the capnograph or poor connection
when full gas exchange occurs. between capnograph and anesthesia circuit/patient.
A flat line may be seen when there is severe bron-
chospasm leading to complete obstruction, tracheal
tube obstruction, obstruction of the sampling tubing, 6.5 Pitfalls of the Monitor
apnea, cardiac arrest, or a disconnected capnograph.
General comments
If an abnormal ETCO2 value is obtained, evalu-
ate the patient prior to attributing the abnormal Capnography is valuable for monitoring a patient’s
value to equipment malfunction or a change in the respiratory status. However, capnograms must

124 L.A.M. Ilie

 ETCO2
(mmHg) The alveolar plateau is blunted and blends
with the downstroke of the capnogram
60
50
40
30
20
10
0
Time

Fig. 6.13. Cardiogenic oscillations. Note the irregular shape of the phase III and phase 0. The wavy shape of phase
0 is due to the heart transmitting its vibrations to the lung and airway during inspiration. If cardiogenic oscillations are
seen in an anesthetized patient with spontaneous breathing, assisted or mechanical ventilation may be considered to
adjust the depth and rate of breathing. ETCO2, end-tidal carbon dioxide.

always be interpreted in conjunction with other circuit and to the water trap on the capnograph and
physiological variables and the clinical situation. that the water trap is firmly attached to the machine.
The ETCO2 does NOT replace arterial and venous
blood gas analysis. As mentioned above, at con-
Specific drawbacks
stant ventilation the ETCO2 will represent the
ventilatory status of the patient as well as provide When using a colorimetric capnogram, there are
information about the cardiac output. If there is some limitations. First, the pH-sensitive paper will
lung pathology present or the patient is very sick, respond to anything that changes its pH. Therefore,
the ETCO2 will not accurately reflect the ventila- contamination with things such as vomitus will
tory status nor the cardiac output, necessitating alter the color of the paper and not be appropri-
measurement of the PaCO2 as well as other param- ately representative of the ETCO2. A colorimetric
eters assessing cardiac output. The sicker the capnogram cannot be used during chest compres-
patient is, the more likely the perfusion to the lungs sions in CPR as it will not provide a level of CO2.
is negatively affected. Therefore, in critically ill The rescuer needs a numerical quantity of CO2
intubated patients, the patient’s PaCO2 is at least as exhaled with each breath in order to assess the
high if not higher than the displayed ETCO2 meas- quality of the chest compressions and to determine
urement. It is therefore important to document the return of spontaneous circulation (ROSC).
actual carbon dioxide concentration in the blood. When using a quantitative capnogram, each
method of sampling (mainstream versus sidestream)
comes with its own unique set of advantages and
General equipment shortcomings
disadvantages. Disadvantages of the mainstream
With all carbon dioxide analyzers, water can inter- analyzers include increased dead space (the analyzer
fere with CO2 analysis and lead to errors. Therefore, is part of the breathing circuit) and sometimes mild
it is important to prevent condensation of moisture false elevation in CO2 readings secondary to accumu-
from the patient’s expired breath on the analyzer lation of condensation inside the unit. Also, the
(some units have a sensor within the airway adapter weight of the analyzer probe may cause accidental
that contains a heater or other means to prevent disconnection from the anesthesia circuit, especially
condensation). with a small ETT.
In addition, loose connections (especially impor- Disadvantages of sidestream analyzers include a
tant in the sidestream analyzer) can lead to falsely time delay in the waveform (allowing for the time to
low ETCO2 values. Always ensure that the side- suction the gas sample from the anesthesia circuit
stream sampling line is securely connected to the and analyze it; this is done at a fixed rate per minute).

Capnography125
Also, as mentioned previously, sidestream units ­istorted by the fresh gas flow. However, when
d
require connection to a scavenging system in order using a catheter or needle, there can be disconnec-
to remove inhaled anesthetic gases. As it removes tion at the site of insertion into the ETT or obstruc-
inhaled anesthetic gas from the patient, there can tion of the catheter or needle by secretions or
uncommonly be inadvertent exposure of the envi- bending. In rare cases, the ETT may have to be
ronment and the staff to the gas. Finally, the small discarded after use if the catheter or needle has cre-
sampling tubing can become obstructed with water, ated a leak in the tube. A third alternative is to use
blood or secretions and become non-functional. an airway adapter that has an inner lumen with a
In addition, small patients (less than 7 kg) are small diameter (Fig. 6.15). The smaller diameter of
usually connected to a non-rebreathing anesthesia the inner lumen reduces the dead space of the
system which uses a high fresh gas flow. This can adapter as it fits perfectly to the ETT connector
result in distortion of the sidestream capnograph through which the patient’s gas stream will pass.
waveform leading to an erroneously low ETCO2 This adaptor is easier to use than an additional
reading. Several options exist to overcome this needle or catheter and carries a minimal risk of
limitation. One alternative is to use the lowest pos- blockage or contamination by secretions. This type
sible sampling rate on your monitor. A second of airway adaptor is commonly used in exotics.
option is to insert a catheter or needle into the ETT When using microstream technology, the biggest
(Fig. 6.14). The catheter or needle technique may disadvantage is the need to replace the microstream
result in a more normal waveform as it is less tubing every 4–8 hours per the manufacturer’s

Needle attached to the side stream

capnograph and inserted in the
endotracheal tube.

Fig. 6.14. Alternative to sampling between the endotracheal tube and the breathing system. The insertion of a needle
into the endotracheal tube allows for a more accurate waveform and ETCO2 value. By inserting the needle closer to
the patient, it reduces dead space.

Note the smaller diameter of the

inner tube which will reduce the dead
space for very small size patients

Fig. 6.15. Airway adapters for small size animals (exotics). The tube to the right has an inner lumen with a very small
diameter, thus reducing the dead space significantly for small size patients. Compare to the adapter on the left side
which does not have an inner tube and is commonly used for larger size dogs.

126 L.A.M. Ilie

recommendations. In addition to the frequent sacculectomy and wedge resection of his nares. He
changes, all attachments and tubing must be was stable under anesthesia and was transferred to
ordered directly from the manufacturer which can the recovery area. The nurse noticed it was taking
limit its availability. him a very long time to wake up and she was
unable to extubate him. His vital signs (heart rate,
respiratory rate, systolic blood pressure, and
6.6 Case Studies oxygenation level via pulse oximetry (SpO2)) were
closely monitored and recorded to be within nor-
Case study 1: The importance of close
mal limits. He had received 0.1 mg/kg hydromor-
monitoring until patient is fully recovered
phone 1-hour prior.
A 2-year-old male neutered healthy French Bulldog When his ETCO2 was checked it was found to be
underwent soft palate resection, everted laryngeal elevated (over 70 mmHg) (Fig. 6.16). The patient

ETCO2

Invasive blood pressure

reading

Fig. 6.16. Multiparameter monitor attached to an intubated patient recovering from anesthesia. Note the ETCO2 is
elevated (75 mmHg) while all other vital signs including invasive blood pressure and heart rate are within normal limits.

was manually ventilated and hydromorphone was level improved while receiving 100% oxygen sup-
reversed with naloxone. The patient’s ETCO2 plementation and assist-controlled breathing with
improved and he was successfully extubated. Please pressure support. The patient was closely moni-
note that elevated levels of carbon dioxide can act tored and serial readings of his ETCO2, SPO2,
to make a patient continue to be anesthetized and invasive blood pressure, and heart rate/rhythm
in humans can cause drowsiness. were recorded. All his vital signs were within nor-
It is important to monitor every patient’s vital mal limits, including capnograph readings consist-
signs (including ETCO2, SPO2, blood pressure, ently between 45–50 mmHg. When an arterial
electrocardiogram, etc.) until the animal is fully
­ blood gas was performed, the PaCO2 was noted to
recovered and able to swallow on its own. be 82 mmHg. There were three possible reasons
for the huge difference between the ETCO2 read-
ing and the actual PaCO2 in this dog.
Case study 2: The importance of serial
ETCO2 and PaCO2 monitoring
1. Increased dead space: it is possible that there
A 13-year-old male neutered Brussels Griffon with were areas of the lung that were not perfused.
a history of severe mitral and tricuspid valve regur- Therefore, it is possible that the alveoli were not
gitation was recently diagnosed with a solitary receiving carbon dioxide back from those areas.
lung mass in the right caudal lung lobe. A lateral Alternatively, there could have been areas of the
right thoracotomy and a right caudal lung lobec- lung that were not well ventilated due to atelectasis
tomy were performed. The patient’s PaO2 2 hours and collapse of the airways leading to decreased gas
after surgery on 4 L/min nasal oxygen was exchange. Atelectasis is common in patients who
50 mmHg. Mechanical ventilation was instituted have been in a particular position for a long period
due to severe hypoxemia. The patient’s oxygenation of time receiving surgery.

Capnography127
2. Decreased cardiac output: this patient has under- which improved with increased ventilation. An
lying heart disease and is recovering from anesthesia. echocardiogram was also performed at this time and
Medications he received intraoperatively and post- moderate pulmonary hypertension was present with-
operatively could have decreased his cardiac output out further worsening of his c­ ardiac function making
and lung perfusion. decreased cardiac output less likely. A pulmonary
3. Pulmonary thromboembolic event: it is possible thromboembolism could still not be ruled out.
that this patient had a pulmonary thromboembo- This case demonstrates one of the limitations
lism postoperatively that decreased perfusion to the of ETCO2 monitoring in anesthetized patients:
lungs and therefore impeded carbon dioxide deliv- the value of the displayed ETCO2 informs the
ery to the lungs. Postoperative patients, especially clinician that the PaCO2 is at least the value of
those with underlying diseases such as neoplasia or the recorded ETCO2 but it is not uncommon for
cardiac disease are hypercoagulable and more likely the blood PaCO2 to be higher in critically ill
to produce blood clots. patients. Therefore, it is very important to check
the PaCO2 not only when the patient’s ETCO2
In response to his condition, the dog’s respiratory reading is climbing but also periodically (at least
rate was increased from 20 to 28 and the PaCO2 every 8 to 12 hours) to ensure that the ETCO2 is
decreased to normal limits. This response to treat- properly representative of the PaCO2 reading
ment made us believe the patient had poorly venti- even when the ETCO2 remains constantly within
lated areas of his lungs such as occur with atelectasis, normal limits.

128 L.A.M. Ilie