Question 3

College Answer

The answer required an explanation of the causes of the difference between the PaCO₂ and ETCO₂. This required recognising how the end point of phase 3 of the capnograph trace corresponds with end tidal CO₂. The difference is caused by the alveolar dead space. The difference is normally very small in healthy adults with the ETCO₂ being lower than the PaCO₂. It is increased with increasing alveolar dead space. Many incorrectly attributed anatomical dead space as a contributor to the PaCO₂-ETCO₂ gradient. Discussion of the various types of dead space did not score marks. Marks were awarded for the processes that cause an increased gradient e.g. low cardiac output and pulmonary embolism. Recognising physiological factors such as increasing gradient with increasing age scored marks. Marks were not awarded for descriptions on how dead space is measured.

Discussion

This question is virtually identical to Question 9 from the first paper of 2009 and Question 21 from the first paper of 2017, although looking at the latter would be rather pointless, as the examiners remarks were limited to "many candidates didn’t distinguish between the different types of dead space"and "in general this topic was not well understood".

• Normal PaCO₂-EtCO₂ difference = 2-5 mmHg  (Satoh et al, 2015)
• This is due to alveolar dead space, which is small in healthy adults
  • If there was no alveolar dead space, end-tidal CO₂ would be identical to alveolar CO₂
  • Alveoli which are ventilated but not perfused (i.e. alveolar dead space) contain a gas mixture which is identical to inspired gas
  • Thus, the addition of their content to expired gas dilutes the expired CO₂ concentration and decreases the end-tidal CO₂ value
  • Anatomical dead space does not contribute to the end-tidal CO₂ concentration because at the end of expiration all of the anatomical dead space volume has already emptied
• Factors which increase the PaCO₂-EtCO₂ difference include:
  • Changes in pulmonary perfusion
    • Regional decreases in pulmonary perfusion
      • Pulmonary embolism
      • Fat embolism
      • Air embolism
    • Globally reduced pulmonary perfusion:
      • Pulmonary hypertension
      • Cardiac failure (RHF)
      • Cardiac arrest
      • Extreme hypovolaemia (eg. haemorrhagic shock)
      • Very high PEEP or positive inspiratory pressure
  • Changes in ventilation
    • Increased V/Q mismatch or increased alveolar dead space
      • High PEEP or positive airway pressure
    • High FiO2 (causing shunt into poorly ventilated alveoli)
    • Oesophageal intubation
    • Very large shunt fraction (>30%)
  • Measurement error
    • 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)
    • The presence of nitrous oxide can confuse some capnograph devices, and the N₂O may be misinterpreted as CO₂
    • The use of an inline HME filter can reduce the end-tidal CO₂ concentration.
    • The timing of the measurement may be wrong: the measurement is only valid if it is truly end-tidal, and so any scenario where the measurement is taken before the end of expiration would produce a falsely depressed value.

Satoh, Kenichi, et al. "Evaluation of differences between PaCO2 and ETCO2 by Age as measured during general anesthesia with patients in a supine position." Journal of Anesthesiology 2015 (2015).

Nunn, J. F., and D. W. Hill. "Respiratory dead space and arterial to end-tidal CO2 tension difference in anesthetized man." Journal of Applied Physiology 15.3 (1960): 383-389.

Shankar, Kodali Bhavani, et al. "Arterial to end tidal carbon dioxide tension difference during caesarean section anaesthesia." Anaesthesia 41.7 (1986): 698-702.

Fletcher, R., and B. Jonson. "Deadspace and the single breath test for carbon dioxide during anaesthesia and artificial ventilation: effects of tidal volume and frequency of respiration." British journal of anaesthesia 56.2 (1984): 109-119.

Donnellan, Michael E. "Capnography: Gradient PACO2 and PETCO2." Applied Technologies in Pulmonary Medicine. Karger Publishers, 2011. 126-131.

Kodali, Bhavani Shankar. "Capnography outside the operating rooms." Anesthesiology: The Journal of the American Society of Anesthesiologists 118.1 (2013): 192-201.