Question 6

Critically evaluate  the use and limitations  of End-Tidal Carbon Dioxide measurement in Intensive Care practice.

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College Answer

Measurement of ETCO2 implies the use of a quantitative device, and usually this is one which allows assessment of waveform morphology (ETCO2 vs time). Specific roles include: confirmation of tracheal placement of artificial airway, pattern recognition of ETCO2 waveform, use of value of ETCO2 during cardiac arrest or hypotensive states, prediction of arterial PaCO2.
Confirmation of tracheal placement is highly sensitive and specific in the presence of pulmonary blood flow. False negative values may occur with minimal pulmonary blood flow, but should not usually occur with adequate CPR. False positives are very uncommon and short lived (eg. CO2 in stomach).
Waveform pattern can assist in the diagnosis in particular of expiratory flow obstruction (and gas trapping) and attempts at spontaneous breathing particularly during apnoea testing.
During cardiac arrest, the absolute level of ETCO2 is proportional to pulmonary blood flow (and hence cardiac output). It may be used to guide cardiac compression, but apart from this it adds little to prognostication (ie. confirms patient that patient likely to die is likely to die). Sudden decreases
in ETCO2 may be indicative of the decrease in pulmonary blood flow associated with pulmonary emboli.
Prediction of PaCO2 from ETCO2 is fraught with difficulty. Very few candidates demonstrated an understanding of this area. The major limiting factors are pulmonary blood flow and V/Q balance. Unless these factors are constant, even the trending of the relationship of between PaCO2 and ETCO2 unreliable. Unfortunately if the PaCO2 is important (eg. major head injuries), it must be measured.
Utility in neonates and children may be impaired by small tidal volumes.


Though EtCO2 has been discussed in Question 9.2 from the second paper of 2008, it was not a "critically evaluate" style of question.

A systematic "critical evaluation" should resemble the following:


  • CO2 elimination is an important component of gas echange
  • This can be assessed indirectly by serial measurements of arterial PaCO2; however ideally the measurement should be performed continuously.
  • Trends in gas exchange are an important parameter to observe in patients whose respiratory function is compromised
  • CO2 monitoring is also of critical importance in patients with increased intracranial pressure

Applications in ICU

  • Confirmation of ETT placement
  • Airway disconnection alarm
  • Monitoring during transport
  • During CPR to assess adequacy of cardiac compression
  • Recognition of spontaneous breath during apnoea test
  • Neurosurgical patient to provide protection against unexpected hypercapnia
  • Quick bedside assessment of bronchospasm
  • Alert of sudden changes in pulmonary perfusion (eg. PE)
  • Early alert of PEA in the absence of continuous BP monitoring
  • More accurate monitoring of respiratory rate


  • Continuous monitoring
  • Immediate feedback regarding cardiac output and ETT position
  • Waveform analysis is possible
  • Cheap
  • Increased safety; decreased risk of undetected airway circuit disconnection


  • Produces vigilance-impairing false alarms
  • EtCO2 values may not correlate with PaCO2 values and the two may be substantially different
  • The monitor in-line connector creates a small amount of apparatus dead space
  • The adaptor fitted to the end of the ETT may be heavy, and may increase the risk of accidental extubation, particularly in children and neonates
  • The gas sampling models of EtCO2 monitors can diminish the delivered minute volume, as they access the circuit gas at a rate of about 200ml/min.
  • Nitrous oxide can confuse some capnometers (i.e. be mistaken for CO2)
  • The presence of helium can cause the EtCO2 measurement to be incorrectly elevated in some capnometers (i.e. those which use a reporting algorithm that assumes that the only gases present in the sample are those that the device is capable of measuring)

Evidence and Guidelines

  • EtCO2 rapidly detects lifethreatening complications in transported patients.
  • American Heart Association Guidelines for Cardiopulmonary Resuscitation make the following recommendations
    • Use EtCO2 to assess ETT position
    • Use EtCO2 to assess efficacy of CPR
    • Use EtCO2 to confirm the return of spontaneous circulation

Capnography is discussed in greater detail elsewhere:

There is also an excellent site by Prasanna Tilakaratna which explains infra-red absorption spectrophotometry using vividly colourful diagrams.


The best, most detailed review:

Walsh, Brian K., David N. Crotwell, and Ruben D. Restrepo. "Capnography/Capnometry during mechanical ventilation: 2011." Respiratory care 56.4 (2011): 503-509.


Whitaker, D. K. "Time for capnography–everywhere." Anaesthesia 66.7 (2011): 544-549.


Kodali, Bhavani Shankar. "Capnography outside the operating rooms." Anesthesiology 118.1 (2013): 192-201.


Yamauchi, H., et al. "Dependence of the gradient between arterial and end-tidal PCO2 on the fraction of inspired oxygen." British journal of anaesthesia (2011): aer171.


Razi, Ebrahim, et al. "Correlation of End-Tidal Carbon Dioxide with Arterial Carbon Dioxide in Mechanically Ventilated Patients." Archives of trauma research 1.2 (2012): 58.


Ahrens, Tom, Helen Wijeweera, and Shawn Ray. "Capnography. A key underutilized technology." Critical care nursing clinics of North America 11.1 (1999): 49-62.


Kingston, E. V., and N. H. Loh. "Use of capnography may cause airway complications in intensive care." British journal of anaesthesia 112.2 (2014): 388-389.


Ortega, Rafael, et al. "Monitoring ventilation with capnography." New England Journal of Medicine 367.19 (2012).


Rückoldt, H., et al. "[Pulse oximetry and capnography in intensive care transportation: combined use reduces transportation risks]." Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie: AINS 33.1 (1998): 32-36.