Capnography can be very confusing if you don’t know what to look for. In the previous article we discussed the physiology behind Capnography. In this article we will discuss a few of the most common traces that you will encounter, the features and some of the causes.
Please remember this is not an exhaustive list and much more can be learned from in depth study of Capnography but for the vast majority of the anaesthetic procedures in first opinion practice this should provide a useful guide.
Firstly, in Figure 1, a reminder of the parts of a trace.
Notes: For the purposes of this article:
- The End Tidal Carbon dioxide level is referred to as PECO2 in millimetres of Mercury (mmHg), although on some machines this may be displayed at EtCO2 (technically this is only when it is measured as a %).
- The Inspired Level of Carbon dioxide is referred to as PiCO2 in millimetres of Mercury (mmHg), although on some machines this may be displayed at FiCO2 or ICO2 (technically this is only when it is measured as a %).
- We have display a three breath capnogram to demonstrate the importance of looking for trends.
- There is a green shaded area on each diagram representing “normal” PECO2.
NB. Normal PECO2 was measured in conscious spontaneously breathing animals as 35-45mm Hg, but during anaesthesia there may be wider variation with the patient still clinically normal.
The Normal Trace
- The PECO2 level should be between 35 and 45 mmHg (these values are for the conscious, spontaneously breathing animal and not influenced by the use of anaesthetic and analgesic medications).
- The PiCO2 level, should be at or very close to Zero.
- Both inspiratory (Phase II) and expiratory (Phase 0) phases are steep, and the alveolar plateau (Phase III) slopes gently up, If it looks like a line of Elephants holding tails that what you are aiming for.
If you identify an abnormality in a single breath trace wait for the next ones. Subtle things (e.g. movement of the patient) can cause one or two abnormal looking complexes, as long as they return to ‘your line of elephants holding tails’ there should be no need for immediate concern.
The Scary Trace
In this case, the carbon dioxide being sampled is in rapid decline.
- PECO2 values rapidly decrease.
- Respiratory rate may or may not be reduced.
- Shape of capnogram is abnormal.
- Cardiovascular collapse - the capnogram is a very good and early indicator of cardiovascular collapse. This trace is not just a malfunction of ventilation but also a failure of delivery of CO2 laden blood to the lungs (a serious decrease in cardiac output), ventilation may appear more normal than you would expect.
- Patient disconnection or partial disconnection from the breathing system (Patient is “nice and pink”, capillary refill time, heart rate etc are within normal parameters)
- Pulmonary embolism (rare).
What to do
- Check the patient.
- If the patient is cyanotic with abnormal parameters. Institute CPR immediately, a good resource is the RECOVER guidelines3.
- If the patient is of normal colour and capillary refill time and heart rate are within normal parameters, check and reconnect the breathing system.
On a more positive note, once resuscitation has been successful you should see the following:
Return of Spontaneous Circulation (ROSC)
- Low level peaks coinciding with manual ventilation (the aim with CPR is to keep PECO2 over 15mm Hg 1, 3 to increase the chances of return to spontaneous circulation) followed by
- more normal trace with PECO2 levels at or above normal.
- As spontaneous cardiac function returns, CO2 is then delivered to the lungs again and the capnogram will return to more normal levels (sometimes PECO2 may be high than normal).
What to do
- If PECO2 levels are not normal, cardiac output may still be low. Efforts should be made enhance to enhance cardiac output, this may include fluid therapy and/or administering positive inotropes/vasopressors.
- Manual ventilation should be continued until spontaneous effort is resumed.
- Remember to check for the cause of the crash and resolve it e.g. excessive anaesthesic depth, hypovolaemia, cardiac or pulmonary compromise.
The Misleading Trace
- Phase II and III are normal.
- Phase 0 has the appearance of descending stairs.
- Phase I is normal.
- This trace is considered to be normal2. It may appear and disappear in the same patient. It is possibly caused by the beating of the heart affecting gas movement in the airways during inspiration.
- It is more common in deep chested dogs and those animals with slower respiration such as bigger breeds.
What to do
- Continue monitoring
In the following examples we will review how rate of respiration may affect the capnogram.
In this case, a rise in respiratory rate (given that the total amount of CO2 from the animal is the same) results in a reduction to the PECO2.
- Normal shape trace.
- PiCO2 still at or near zero.
- PECO2 trending down below 35 mm Hg.
- Phase I may be shorter.
- Increased respiration rate.
- Patient is of normal mucous membrane colour and oxygen saturation.
- The anaesthesia is too light (common) or
- insufficient pain relief (common).
- May also be accompanied by an increase in heart rate.
- IMPORTANT: This trace may also be seen due to a decrease in Cardiac output or arterial blood pressure (V/Q mismatch). Always check that the patient is not cyanotic or hypotensive. See the section below on reduced cardiac output (C.O.).
What to do
- Check the anaesthetic depth and adjust if necessary.
- Check timings and potency of analgesics and administer further analgesia if required.
- Check colour and arterial blood pressure.
Similarly, a fall in respiratory rate will result in a rise in PECO2 and steps should be taken to correct both the high PECO2 (by giving a couple of breaths) and the lower respiration rate. In a patient that is excessively deep, the higher PECO2 may be what is stimulating them to breathe. Lowering the PECO2 without addressing the excessive depth of anaesthesia may cause apnoea.
- Capnogram of normal or near normal shape.
- PiCO2 at or near zero.
- PECO2 trending upwards above 55-60 mmHg.
- Respiration rate is decreased.
- More severe respiratory depression will be associated with a decrease in heart rate.
- Excessive depth of anaesthesia is the most common cause.
- If there is no decrease in respiration rate, the cause may be positional, especially during prolonged anaesthesia. E.g. due to lung atelectasis.
What to do
- Manually ventilate once or twice per minute. This should help to reduce the PECO2 to more normal levels. Care should be taken not to over ventilate and not to use excessive pressure.
- Check the depth of anaesthesia. Decrease the level of inhalational agent, reverse a sedative agent previously given or even reverse an opioid if the hypoventilation is severe and prolonged (recommended only as a last resort due to also antagonising analgesic component).
Note that in both the above examples, the PiCO2 is at or near zero. If the PECO2 is high and the PiCO2 is above zero, then you are looking at a case of rebreathing.
- PECO2 is above normal and rising.
- PiCO2 is above normal and rising.
- May be accompanied by a rise in respiratory rate due to the stimulatory effect of the high levels of CO2 on the respiratory centre.
- Excessive dead space.
- Fresh gas flow is insufficient (especially T piece and Bain).
- Exhausted soda lime (rebreathing circuit).
- Insufficient time of exhaled breath in soda lime (large dog with a small canister).
What to do
- Change the soda lime canister (fresh soda lime or a bigger canister).
- Increase fresh gas flow.
- Re-intubate with a shorter endotracheal tube.
Reduced Cardiac Output
- The capnogram shape is near normal.
- PiCO2 is at or near zero.
- PECO2 is below normal.
- Respiratory rate is near normal.
- Reduced cardiac output (patient may appear pale or cyanotic, BP is low) or a
- Endotracheal tube that is letting gas past (you may smell inhalational agent!!) the tube is either too small or the cuff is not inflated properly. The CO2 is being produced but is not reaching the detector.
- Reduced minute volume (e.g. from a tension pneumothorax).
- Hypothermia- CO2 is not being produced by the animal.
- Fresh gas flow too high
- Patient has a small tidal volume (e.g. small animals, rabbits or small cats) and capnograph machine is sidestream – remember sidestream capnographs take out 100-150 ml per min so there may not be enough volume to measure properly. Fresh gas flow may also be a component of this due to dilution of the patient’s tidal volume.
What to do
- Monitor Blood Pressure and take steps to correct if below normal by administering fluids or positive inotropes/vasopressors.
- Check fit of Endotracheal tube, inflation of cuff and connections in breathing system.
- Urgently address minute volume deficiency if suspected.
- Monitor temperature.
More rarely hyperthermia may cause more CO2 to be produced and result in high PECO2 readings with a normal or increased respiration rate.
When analysing the capnogram it is important to remember which phase if the capnogram is which and that inspiration is active, while expiration is generally passive. The below capnogram is commonly seen with an obstruction (folded tube, mucus).
- Slanting and prolonged Phase II.
- Increased slope of phase III.
- Obstructed ETT.
- Bronchospasm (e.g. anaphylaxis, asthma).
- Expiratory valve malfunction.
- Pressure relief valve (to scavange) is closed.
What to do
- Check inflation of bag, open valve if over-inflated.
- Check (physically and by listening) ETT and breathing system (including valves).
- Consider administering a bronchodilator.
On the other hand, increased inspiratory resistance would look like this:
- Slanting and prolonged phase 0.
- Abnormal phase III.
- Pressure on the chest e.g. a vet or nurses hand on the chest (or even a stethoscope in small animals), it can also be seen where there is something else impeding inspiration, e.g.
- Abdominal contents compressing the thoracic cavity.
- Diaphragmatic hernia.
- Malfunctioning inspiratory valve.
- Too low a Fresh Gas Flow.
What to do
- Remove whatever is causing the pressure on the chest.
- Check breathing system with particular reference to the inspiratory limb.
- Check reservoir bag and Increase Fresh Gas Flow if noticed to have deflated.
Finally, another commonly seen trace is caused by muscle fasciculations in the patient. Common causes include certain drugs (e.g. propofol or ketamine), lack of adequate pain relief or depth of anaesthesia (e.g. immediately following induction or prior to recovery).
- PECO2 is normal.
- PiCO2 is normal.
- Capnogram is normal shaped but does not appear smooth.
- Muscle twitching affecting smooth breathing.
What to do
- Check premedication and induction protocol including analgesia.
We are all aware that occasionally it is necessary to administer sadation, and even general anaesthesia, to cats via the intramuscular route. In this article Matt Gurney, RCVS and European specialist in Veterinary Anaesthesia and Analgesia, discusses some useful protocols for the IM administration of alfaxalone in cats, and describes when and why this drug may prove valuable.Read On...
Anaesthetic recovery is a high risk period for complications and death (Brodbelt et al, 2008). In this article Courtney Scales DipVN NCert(Anaesth) RVN discusses how we can reduce the potential risks and improve the recovery experience for our patients.Read On...
Paper summary: Nebulised adrenaline in the postoperative management of brachycephalic obstructive airway syndrome in a Pug
Laryngeal oedema is a potentially life-threatening complication of invasive BOAS surgery. In this case study by Ellis and Leece (2017) the use of nebulised adrenaline to successfully manage this condition is described.Read On...
Sadly, complications can occur during the peri-anaesthetic period with potentially detrimental effects on the patient. In this article Lou Northway, VNCertECC NCert(Anaesth) RVN, examines the most common causes of adverse peri-anaesthetic events and the steps that can be taken to reduce their incidence.Read On...
This paper by Pottie et al (2007) examines the effects of hypothermia on recovery from general anaesthesia in the dog.Read On...
Uncooperative, aggressive or stressed cats are commonly encountered in the veterinary clinic. This article examines the aims for calming these patients, the importance of planning and considers selected sedative protocols.Read On...
Paper summary: Intramuscular butorphanol/alfaxalone combination for sedation of cats prior to echocardiography
The sedation of cats prior to cardiac examination requires a drug protocol that has minimal effects on the cardiovascular system. This study examined a combination of butorphanol and alfaxalone administered intramuscularly on echocardiographic assessment and on cardiovascular function.Read On...
Improving efficiency and “saving time” are key to increasing throughput in busy clinical practice, especially when the normal working environment has been disrupted, where there is an increased demand for services, or when surgical lists become overloaded. This article provides potential solutions for some common bottlenecks and inefficiencies during the anaesthetic process.Read On...
The maintenance of heart rate and cardiac output are essential to ensure adequate organ perfusion. This study by Okushima et al examined the effects of alfaxalone versus propofol on heart rate at the time of induction of anaesthesia.Read On...
Paper summary: Effect of intravenous dose escalation with alfaxalone and propofol on the occurrence of apnoea in dogs.
Apnoea following induction of anaesthesia can result in both morbidity and mortality if not identified early and managed successfully. In this 2012 article by Keates and Whittem alfaxalone and propofol were administered to dogs at 1x, 2x, 5x, 10x and 20x multiples of the labelled dose to determine the incidence of apnoea and the respiratory safety profile of each drug.Read On...
In this article Karen Heskin, Veterinary Technical Manager for Jurox UK, and Carl Bradbrook, RCVS & European Veterinary Anaesthesia and Analgesia Specialist and President of the Association of Veterinary Anaesthetists, discuss the three most commonly used intravenous induction agents for cats, dogs and pet rabbits in the UK. To complement this discussion we have created three useful summaries to download as quick reference guides for your clinical personnel.Read On...
As clinics and hospitals reduce routine treatments and move towards critical and emergency care during the COVID-19 crisis, to complement our previously published articles on ASA classification and the use of checklists in anaesthesia, we have created this short slide presentation to act as a useful summary.Read On...
It is recognised that brachycephalic dog breeds are more likely to experience dystocia and require Caesarean section. This study examined the influence of breed on the incidence of interventional surgery.Read On...
In this first of four parts discussing anaesthesia for the Caesarean section we examine the anaesthesia-relevant physiological changes that occur during pregnancy.Read On...
The monitoring of blood pressure under anaesthesia is critical for patient care. In this article Claire Roberts, RVN and owner of SynergyCPD, examines the physiology, monitoring and management of blood pressure in anaesthetised patients.Read On...
This study by Mair et al (2016) examined what effect the placement of swabs of different thicknesses and colour would have on pulse oximetry readings.Read On...
Pulse oximetry is one of the most commonly performed monitoring procedures in veterinary anaesthesia. In this article Courtney Scales, RVN and owner of Anursethesia discusses the why and how we use pulse oximeters, the advantages and pitfalls, and how to manage abnormal readings.Read On...
Paper summary: Comparison of direct and oscillometric blood pressure assessment using a veterinary specific device
Blood pressure management requires accurate monitoring. In this summary of an article by Acierna et al (2013) we compare a veterinary specific oscillometric device to direct blood pressure measurement.Read On...
Having their best interests at HEART: Coronary collateral circulation in the rabbit, stress & the effects of alpha-2 agonists, phenothiazines and volatiles.
How extensive is the coronary collateral circulation in the rabbit and what are the effects of stress and drugs on the heart of this species?Read On...
Paper summary: Comparison of direct and Doppler arterial blood pressure measurements in rabbits during isoflurane anaesthesia.
How do Doppler and direct blood pressure measurement compare in the anaesthetised rabbit?Read On...
In this article Matt Gurney, RCVS/ECVS specialist in Veterinary Anaesthesia and Analgesia, examines whether co-induction techniques are advantageous.Read On...
What are the benefits of slow administration of alfaxalone and does co-induction with alfaxalone/midazolam have any benefits in healthy dogs?
In this summary of a study by Miller et al (2019) we examine if there are any benefits to an alfaxalone/midazolam induction over alfaxalone alone in the healthy dog.Read On...
In this article Carl Bradbrook discusses the peri-ananesthetic management of the canine gastric dilatation and volvulus (GDV) patient.Read On...
Paper summary: Clinical efficacy and cardiorespiratory effects of alfaxalone, or diazepam/fentanyl for induction of anaesthesia in dogs that are a poor anaesthetic risk.
In this summary of a paper by Psatha et al (2011) we examine the clinical benefits of alfaxalone in high-risk patients when compared to the induction protocol of diazepam + fentanyl.Read On...
In this article Miranda discusses the challenges of anaesthetising patients with cardiac disease and how protocols can be modified to accommodate these patients.Read On...
A prospective multi-centre clinical trial comparing buprenorphine vs butorphanol for postoperative analgesia in cats.Read On...
Paper summary: Analgesic effects of maxillary and inferior alveolar nerve blocks in cats undergoing dental extractions.
With dental surgery one of the most commonly performed procedures in small animal practice, what benefits do dental nerve blocks provide in cats?Read On...
What should we consider when anaesthetising both adult and senior patients admitted for dental treatment?Read On...
This article summarises and combines "Anaesthesia for the geriatric patient" and "What should we consider when anaesthetising patients, including geriatrics, for dental procedures?" into a single checklist for anaesthesia for the geriatric dental patient. A downloadable summary is also available by following the link.Read On...
In this article Ian Self, Associate Professor in Veterinary Anaesthesia and Analgesia, School of Veterinary Medicine and Science, Nottingham, reflects on the recognition, assessment and management options for chronic pain in companion animalsRead On...
With an increasing number of anaesthetics being performed in older pets is there anything we should be aware of or do differently? In this article Carl Bradbrook examines the management of anaesthesia in geriatrics..Read On...
Paper summary: What effect does does rapid, high volume fluid therapy have on cardiovascular function?
In this summary of a paper by Valverde (2012) we examine the effects of high-volume, rapid fluid therapy on cardiovascular function and hematological values during isoflurane-induced hypotension in healthy dogs.Read On...
In this summary of a paper by Joubert (2007) we examine the value of pre-anaesthetic screening in geriatric dogs and how the results influence the anaesthetic process.Read On...
Cushing's disease (hyperadrenocorticism) is relatively common in the dog and this article discusses the appropriate pre-anaesthetic assessment we should perform and why careful monitoring is essential.Read On...
Paper summary: How frequently are intravenous catheters removed as a result of complications due to bacterial contamination?
In this summary of a paper by Ramos (2018) we examine the incidence of bacterial colonisation of intravenous catheters removed as a result of cannula complicationRead On...
Peripheral venous cannulation is a common invasive procedure in small animals, but what are the best-practice insertion techniques and what can we do to avoid complications?Read On...
Paper summary: Heated intravenous fluids alone fail to prevent hypothermia in cats under general anaesthesia.
In this summary of a paper by Jourdan et al (2017) we examine the common practice of warming intravenous fluids and the effect on patient temperature.Read On...
This summary of a publication by Panti et al., examines the effect of orally administered omeprazole on gastro-oesophageal reflux in the anaesthetised dog.Read On...
In this paper we explore perceptions and opinions of Canadian pet owners about anaesthesia, pain and surgery in small animals.Read On...
How can a Veterinary version of the ASA Physical Status Classification help you achieve safer anaesthesia? To find out how watch our webinar.Read On...
This scientific paper assessed whether the American Society of Anesthesiologists (ASA) Physical Status Classification correlated with the risk of anaesthetic death in dogs and cats.Read On...
This is our third product launch this year, and the latest addition to our anaesthesia and analgesia portfolio, Methadyne, contains 10mg/ml methadone as its active ingredient. It can be administered for analgesia of moderate to severe pain in dogs and cats, to provide neuroleptanalgesia, and as part of a patient’s premedication protocol prior to general anaesthesia.Read On...
A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs.
In this review we summarise a publication by Bini (2018) examining two protocols for the administration of methadone following TPLO surgery in dogs.Read On...
In this article we have identified the key clinical peer reviewed papers to support the use of Alfaxan for maintenance of Anaesthesia in Cats and Dogs.Read On...
Paper summary: Effect of benzodiazepines on the dose of alfaxalone needed for endotracheal intubation in healthy dogs
This paper examined whether a benzodiazepine, administered as a co-induction agent with alfaxalone, improved endotracheal intubation, and reduced the dose of alfaxalone, in the dogRead On...
In this article we examine why methadone could be considered the analgesic of choice for many of our patients and understand its importance in modern veterinary medicine. The article includes a link to a downloadable summary sheet.Read On...
In this article from the Perspectives on Premeds series, Karen takes us through the properties and uses of phenothiazines in modern veterinary practice.Read On...
This study looks at the effects of three methadone doses combined with acepromazine on sedation and some cardiopulmonary variables in dogs.Read On...
We have extended our anaesthesia and analgesia portfolio with the launch of AceSedate®. Containing the tried and trusted, long-acting sedative agent acepromazine as its active ingredient, AceSedate can be used for the premedication, sedation and tranquilisation of cats and dogs.Read On...
Caesarean Section Survival Guide. Part 2: Anaesthetic Protocol Selection & Peri-operative Considerations.
In this second instalment of the 2-part article, we explore premedication, induction, maintenance & monitoring, recovery and analgesia for the Caesarean section patient.Read On...
In the first instalment of this 2-part review Karen examines the physiological changes that occur during pregnancy and how those adjustments can affect the selection of anaesthetic protocols for the increasingly common Caesarean section.Read On...
No leeway for the spay: A comparison between methadone and buprenorphine for perioperative analgesia in dogs undergoing ovariohysterectomy.
This recent paper compares post-operative pain scores and requirement for rescue analgesia following premedication with methadone or buprenorphine, in combination with acepromazine or medetomidine, in 80 bitches undergoing ovariohysterectomy.Read On...
Cardiac arrest in dogs and cats is, thankfully, relatively rare. However, when it does happen it can have devastating consequences for the animal, owner and the veterinary team. This study examined the common causalities leading up to a cardiac arrest with the aim of changing protocols to improve outcomes.Read On...
In this article, Carl focuses on the benefits of introducing a safety checklist in practice to reduce patient morbidity, mortality and to improve communication between members of the veterinary team. The article contains links to the AVA safety checklist as well as a link to a customisable list that you can adapt to your practice needs.Read On...
The effects of hypothermia are very far reaching throughout the peri-anaesthetic process. In this article, James takes us through the interesting mechanisms of body cooling and warming, the clinical relevance of hypothermia and what we can do to prevent it.Read On...
All patients are exposed to the risks associated with general anaesthesia. Continuously monitoring anaesthetised patients maximises patients safety and wellbeing. In this article, Dan takes us through the common monitoring techniques that provide information about the cardiovascular status of your patient.Read On...
Despite being widely recognized in humans, postoperative nausea and vomiting (PONV), and the role of maropitant in reducing inhalational anaesthetic requirements have been poorly documented in dogs. This recent study evaluates PONV and isoflurane requirements after maropitant administration during routine ovariectomy in bitches.Read On...
Little information is available about the effect that different doses of medetomidine and butorphanol may have when using sevoflurane for maintenance of anaesthesia in dogs. This recent study evaluates heart rate and median sevoflurane concentration required at different dose rates.Read On...
Pain, what a Pain! (Part 2) – Practical Tips On How To Perform Dental Nerve Blocks In Companion Animal Practice
In this second article of the Pain, what a Pain! series, Dan takes us through the LRA techniques associated with dental and oral surgery. In this article, you will find practical tips and pictures on common dental nerve blocks as well as safety concerns to consider.Read On...
This recent retrospective study looks at the cases of 185 pet rabbits admitted for sedation or general anaesthetic and evaluates the incidence and risk factors contributing to peri-anaesthetic mortality and gastrointestinal complications.Read On...
Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)
In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent yearsRead On...
Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol.Read On...
This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.Read On...