Interpret your capnogram  

Bhavani Shankar Kodali MD

Compiled:  by Ahalya Kodali

This section provides a variety of capnograms put together in one group. Several E-mails have prompted us to compile this section. If you happen to see a capnogram and you wanted to know what the underlying cause is, this section should provide an answer. Match your capnogram against the following; the explanation is either self explanatory or' click' on the 'detail' to open a new window. Close the window to return to this page. Majority of these capnograms have bee discussed elsewhere in the website. If you do not see a matching capnogram, please E-mail us (Bhavani@capnography.com) with your explanation or explanation referenced elsewhere for inclusion. 

 

1

Air-leak - Loose connection between sampling tube
and capnograph / broken connection or filter. (Detail)
Following one lung transplantation.
If the tip of the endotracheal tube is too close to the carina thereby resulting in differential lung ventilation due to partial obstruction. (see 15 and 23)

2

Rebreathing capnogram of Mapleson D circuit.
Bain circuit. (Detail)
Exhausted CO2 absorber. See below ()

 

3

Cardiogenic oscillations - Ripple effect - Seen during low frequency ventilation. (Detail)

 

4

Bronchospasm / COPD / Emphysema/ obstructed endotracheal tube -Slanting and prolonged phase 2 and increased slope of phase 3 (see 14)

 

5

Contamination of capnograph
Trend showing abrupt elevation of baseline and capnogram. See 43

6

Trend capnogram  during cardiac arrest / resuscitation.

 

7

 Upward slanting of phase 4. A normal variant in pregnant women during anesthesia. (Detail) 

8

Trend showing gradual elevation of baseline.
Rebreathing

 

 

 

 

9

Curare cleft (see 10)

 

10

Resembling curare cleft due to an artifact created by surgeon leaning on the chest, or pushing against the diaphragm during expiration.
Partial disconnect of main stream capnometer (Detail)

11

Dilution of expiratory gases by the forward flow of fresh gases during the later part of expiration when expiratory flow rate decreases below the forward gas flow rate.

12

Elevation of base line- A classic representation of rebreathing.

Exhausted CO2 absorber

13

A gradual decrease in end tidal carbon dioxide can occur during reduced metabolism, hypothermia, hyperventilation, small tidal volume ventilation due to inadequate alveolar sampling, and leaks in the sampling system, decrease in cardiac output  see 13

14

Occasionally, there can be a reverse phase 3 slope seen in patients with emphysema. Most like this may be due to destruction of alveolar capillary system in emphysematous lungs resulting in the delivery of carbon dioxide to expired gases. 

 

 

15

Endobronchial intubation may not result in a characteristic waveform. However, occasionally, it may be like the one seen in COPD or the above. Read the 3 sections.  (Detail)   (Detail)  (Detail) (detail) see (15)

16

The CO2 waveform has two humps. Kyphoscoliosis resulted in a compression of the right lung. Differential lung emptying. (Detail)

17

Esophageal intubation.

18

Esophageal intubation: Small CO2 spikes. Esophageal or gastric CO2 due to mask ventilation

 

 

19

Warming up CO2 analyzer is necessary before it begins recording CO2 wave forms.

20

The monitor will zero periodically. Will show CO2 numerical value with no waveform.

21

Ventilator IMV breath during spontaneous ventilation.

22

Sticking inspiratory valve - Inspiratory flip - Red indicates possible rebreathing

23

Air leak due to a broken connection between sampling tube and capnograph (Detail) see (1)

24

Lung transplant - Dual capnogram (Detail) see 1, 15 and 23

25

Increased CO2 due to hypoventilation, hypermetabolic states and rebreathing. See 8, 39

26

Capnogram during spontaneous ventilation in adults (see 27)

 

 

27 - 31

These capnograms can occur in children and neonates. Variations are normal and due to faster respiratory rates, smaller tidal volumes, relatively longer response time of the capnographs. Recent technological advances such as micro-stream analyzers are reducing the artifacts due to faster response time and thereby producing normal looking capnograms even in children and neonates. 

 

27 - 31

 

 

 

 

 

27 - 31

27 - 31

27 - 31

 

 

32

Sampling problems such air or oxygen dilution during nasal or mask sampling of carbon dioxide in spontaneously breathing patients. 

33

Slit sampling tube can result in a pig tail capnogram. A variation of 23 (Detail)

34

A terminal upswing at the end of phase 3, known as phase 4, can occur in pregnant subjects, obese subjects and low compliance states. (Detail) see also physiology section-phase 4.

 

 

35

Expiratory valve malfunction can result in prolonged abnormal phase 2 and phase 0.(Detail)

 

36

Inspiratory valve malfunction predominantly results in abnormal phase 0. (Detail)

 

37

Esophageal intubation resulting few abnormal capnograms with relatively normal initial CO2 numerical values. (Detail)

38

Hyperventilation gradually results in lowering of ETCO2 values. see 13

39

Hypoventilation gradually increases CO2 values with normal base line. see 8 and 25

40

Rebreathing producing gradual elevation of base line and ETCO2 values. See 8  

41

Carbonated beverages in the stomach can result in abnormal capnograms with progressively decreasing CO2 values following esophageal intubation. See other variations 17, 18, 37

42

Unrecognized exhaustion of CO2 absorber resulted in substantial rebreathing and rising  ETCO2 values. The closed circuit without functioning absorber mimicked Mapleson D circuit. (Detail)

43

Contamination of capnometer results in the sudden elevation of base line as well as ETCO2 values. See 5