Gas Monitoring

Presented by: Dr. Meenal AggarwalModerator: Dr. Dara Negi

Definitions

• Delay time: Time to achieve 10% of a step change in reading at the

gas monitor

• Rise time/response time: Time required for a change from 10% to

90% of the total change in a gas value

• Total system response time: DT + RT

Monitor types• 2 types: sidestream (diverting) or mainstream (nondiverting)

Mainstream:

• Sensor located directly in the gas stream (only for oxygen and CO2)

• Carbon dioxide: Using infrared technology with the sensor located

between the breathing system and the patient

• Also available for the non-intubated patient: sensor attaches to a

disposable oral and nasal adaptor

• Oxygen sensor: Uses electrochemical technology

Usually placed in the breathing system inspiratory limb.

Can measure both inspired and exhaled oxygen

Mainstream Infrared CO2 Analyser

• Advantages:

Fast response times, no delay time (waveform has better fidelity)

No gas is removed from the breathing system, so not necessary to

scavenge these devices or to increase the fresh gas flow

Water and secretions rarely cause a problem (although secretions on

the windows of the cuvette can cause erroneous readings: problem

with CO2 sensor)

Sample contamination by fresh gas is less likely

Standard gas is not required for calibration (Oxygen sensor:

calibrated by using room air)

Use fewer disposable items than diverting monitors

• Disadvantages:

Adaptor placed near the patient: cause traction/ weight

Dead space

Leaks, disconnections, circuit obstructions

Condensed water, secretions, blood on the windows of the cuvette

interferes with light transmission

Sensor may become dislodged from the cuvette

Expensive, vulnerable to damage

Available only for oxygen and CO2

CO2 sensor must be cleaned and disinfected between uses (potential

for cross contamination), disposable become expensive

Prolonged contact of the CO2 sensor assembly with the patient could

cause pressure injury

Sidestream:

• Aspirates gas from the sampling site,

sensor (located in the main unit)

• Sampling tube: short- decreases delay time

and more satisfactory waveforms

• Usually zeroed using room air and calibrated using a gas of known

composition

• Traps, filters and hydrophobic membranes

• Water droplets and secretions may increase resistance/ affect the

accuracy

• Clear or purge the sample line, or tube may be changed

• Accuracy at 20-40 bpm and short length, > 40 bpm decreases accuracy

• Sampling flow rate: less than 150 mL/minute should not be used.

Elevated baseline, falsely low peak readings on lower flows

Devices used:

• Face mask: Large dead space relative to tidal volume, difficult to obtain

accurate end-tidal values

can be attached to upper lip or placed in patient's nares or the

lumen of an oral or nasopharyngeal airway under the mask

With a breathing system, most often attached to a component

between the mask and the breathing system

• Tracheal Tube: Sampling site must be between the patient and the

breathing system (measurement for both exp and insp)

Sampling site should be away from the fresh gas port (in mapleson

circuits can l/t errors)

Tracheal tubes that incorporate a sampling lumen that extends to

the middle or patient end of the tube are available

Tracheal tube connectors with an attachment or hole for a sampling

tube are available or can be created

• Supraglottic devices: sampling tube can be inserted through the

connector (preferred site is the distal end of the shaft)

may be inserted into a nasal airway

• Oxygen Supplementation Devices:

OxyArm: allow simultaneous administration of oxygen and carbon

dioxide monitoring

In both nose and mouth breathers

A nasal cannula can be modified to accept

a sampling tubing (may l/t choking hazard)

Sampling tube may be connected to

mask outlet, inserted through a vent

hole or a slit in the mask

Accuracy affected by: Mouth breathing, airway obstruction, and

oxygen delivery through the ipsilateral nasal cannula

OxyArm

• Jet Ventilation: an injector incorporating a sampling lumen or a sampling

tube placed in the airway may be used

Ventilatory frequency may need to be lowered to measure the end-

tidal CO2

• Other ways:

Sampling line can be placed in front of or inside the patient's nostril

In mouth breather: in the nasopharynx or hypopharynx

Catheter placed in the trachea after extubation for CO2 monitoring

Bite block can be modified to accommodate a sampling line

Sampling line can be placed over a tracheostomy stoma

• Advantages of Diverting devices:

Calibration and zeroing usually automatic (Occasional calibration is

necessary, usually easy)

Added dead space is minimal.

Potential for cross contamination between patients low.

Several gases can be measured simultaneously, allows automatic

correction for nitrous oxide and oxygen.

Sampling port can be used to administer bronchodilators

These devices can be used when the monitor must be remote from

the patient (e.g., during MRI)

• Disadvantages of Diverting devices:

Leaks, sampling tube obstruction, or failure of the aspirator pump or can

kink (use elbow connector)

Sampling line can be connected to the wrong place

Leak in sampling line can l/t mixing with air and so dilution of sample

Aspirated gases must be either routed to the scavenging system (need to

inc fresh gas flow) or returned to the breathing system

Some delay time

Supply of calibration gas

Disposable items (adaptors and catheters) used

Fresh gas dilution

More variable differences between arterial and end-tidal CO2 level

Technologies

• Infrared Analysis

Black body Radiation technology

Microstream technology

• Paramagnetic oxygen analysis

• Electrochemical oxygen analysis

Galvanic cell

Polarographic electrode

• Peizoelectric Analysis

• Refractometry

Infrared Analysis:• Most common technology in use

• Principle: Gases with two or more dissimilar atoms in the molecule

(nitrous oxide, CO2, and the halogenated agents) have specific and unique

infrared light absorption spectra.

• Amount of infrared light absorbed is proportional to the concentration of

the absorbing molecules, the concentration can be determined

• Nonpolar molecules cannot be measured

• 2 technologies available:

Black body radiation

Microstream technology

Blackbody Radiation Technology:• Utilizes a heated element called a blackbody emitter as the source of

infrared light, produces a broad infrared spectrum (redundant radiation

to be removed using filters)

• Optical detectors must be calibrated to recognize only infrared radiation

that is modulated at a certain frequency by using a spinning chopper

wheel

• Analyzer selects the appropriate infrared wavelength, minimize

absorption by other gases that could interfere with measurement of the

desired component

• Then an electrical signal is produced and amplified, and the concentration

is displayed

• For halogenated agents: separate chamber to measure absorption at

several wavelengths (single-channel, four-wavelength infrared filter

photometers) have filter for each anesthetic agent and one to provide a

baseline for comparison

Diverting type:

• Gas to be measured is pumped continuously through a measuring

chamber

• Filtered and pulsed light is passed through the sample chamber and also

through a reference chamber (has no absorption characteristics)

• Light is focused on an infrared photosensor (partly absorbed by the

sample gas acc to conc)

• Changing light levels on the photosensor produce changes in the

electrical current running through it

• Provides hundreds of readings for each respiratory cycle (Continuous

waveform produced)

• Monochromatic analyzers use one wavelength to measure potent

inhalational agents (unable to distinguish between agents)

• Polychromatic analyzers use multiple wavelengths to both identify and

quantify the various agents

• Measuring cell is calibrated to zero (using gas that is free of the gases of

interest, usually room air) and to a standard level (using a calibration gas

mixture)

Non Diverting Type:

• Gas stream passes through a chamber (cuvette) with two windows,

placed b/w the breathing system and the patient

• Sensor (has both the light source and detector) fits over the cuvette

• Sensor is heated slightly above body temperature (to prevent

condensation)

• Infrared light passes through window on one side of the adaptor, sensor

receives the light on the opposite side

• Then light goes through three ports in a rotating wheel, containing

(a) a sealed cell with a known high CO2 concentration

(b) a chamber vented to the sensor's internal atmosphere

(c) a sealed cell containing only nitrogen

• Then passes through a filter (to isolate CO2 information)

• Signal amplified and sent to the display module

• Calibration done using: low calibration cell contains 100% nitrogen, high

cell contains a known partial pressure of CO2

• Corrections for nitrous oxide and oxygen entered manually

Infrared Mainstream Analyser

Microstream Technology:• Uses laser-based technology to generate infrared rays that match the

absorption spectrum of CO2

• Smaller sample cell, low flow rate

• Emission source: Glass discharge lamp coupled with an infrared

transmitting window

• Electrons (generated by a radio frequency voltage) excite nitrogen

molecules Carbon dioxide molecules are excited by collision with the

excited nitrogen molecules These drop back to their ground state and

emit the signature wavelength of CO2

• This emission now passes through main optical detector and reference

detector (compensates for changes in infrared output)

• Measurements made every 25 msec

• As low sample flow and small sample cell, useful for measuring:

CO2 in very small patients

high respiratory rates

low-flow applications

unintubated patients

• Readings not affected by high concentrations of oxygen or anesthetic

gases

Advantages of Infrared Analysis:

• Multigas Capability

• Volatile Agent Detection

• Small, compact, lightweight

• Quick response times (faster for CO2)

• Short warm-up time

• Convenience (no complicated calibrations)

• Lack of interference from other gases (argon, low conc NO)

• Detecting anaesthetic agent breakdown (desflurane to CO will show as

wrong or mixed agent)

Disadvantages of Infrared Analysis:

• O2 and N2 cannot be measured

• Gas interference :

O2 causes broadening of CO2 spectrum l/t lower readings

N2O absorption spectrum overlaps with CO2 (l/t higher vlues): so need

either automatic or manual correction for N2O

He l/t underestimation of CO2

• Other substances l/t inaccuracies (ethanol, methanol, diethyl ether,

methane): give high volatile agent reading, polychromatic less affected

• Water vapors: Absorb infrared rays (l/t lower values), use water traps,

hydrophobic membranes

• Slow response time (with rapid resp rates)

• Difficulty in adding new volatile agents

Paramagnetic Oxygen Analysis:• Paramagnetic substances: Substances which locate themselves in the

strongest portion of the field when introduced into a magnetic field

• Oxygen is paramagnetic

• Principle: When a gas that contains oxygen is passed through a switched

magnetic field, the gas will expand and contract, causing a pressure wave

that is proportional to the oxygen partial pressure

• Pressure difference is detected by the transducer and converted into an

electrical signal that is displayed as oxygen partial pressure or volumes

percent.

• Short rise time so both inspired and end-tidal oxygen levels can be

measured

• Desflurane disturbs the paramagnetic oxygen sensor and it reads higher

than expected

Eletrochemical Oxygen Analysis:• Consists of a sensor, analyzer box, display, and alarms

• Sensor: A cathode and an anode surrounded by electrolyte

• Sensor is placed in the inspiratory limb

• Gel held in place by a membrane (nonpermeable to ions, proteins, but is

permeable to oxygen)

• Older ones respond slowly to changes in oxygen pressure, so cannot be

used to measure end-tidal concentrations (not so with new analyzers)

• Technology:

Galvanic cell/ fuel cell

Polarographic electrode

Galvanic cell:• Principle: Oxygen diffuses through the sensor membrane and electrolyte

to the cathode, where it is reduced, causing a current to flow

• Current generated is proportional to the partial pressure of oxygen in the

gas

Cathode: O2 + 2H2O + 4e- → 4OH-

Anode: 4OH- + 2Pb → 2PbO + 2H2O + 4e-

• Cathode is the sensing electrode, anode is usually consumed

• The current is strong enough to operate the meter so a separate power

source is not required to operate the analyzer.

• The chemical reaction is temperature dependent (a thermistor may be

connected in parallel with the sensor.)

Galvanic cell

Fuel cell Oxygen Analyzer

• Sensor comes packaged in a sealed container that does not contain

oxygen

• Its useful life is cited in percent hours: the product of hours of exposure

and oxygen percentage

• Sensor life can be prolonged by removing it from the breathing system

and exposing it to air when not in use

• Whole sensor cartridge must be replaced when it becomes exhausted

Polarographic Electrode:

• Components: anode, a cathode, an electrolyte, and a gas-permeable

membrane

• Needs power source for inducing a potential between the anode and the

cathode

• Same principle as galvanic cell

• May be either preassembled disposable cartridges or units that can be

disassembled and reused by changing the membrane and/or electrolyte

Advantages:

Easy to use, low cost, compact

No effect of argon

Disadvantages:

Maintenance (more in polarographic)

Need to be calibrated every day (every 8 hrs)

Slower response time

Peizoelectric Analysis:• Uses vibrating crystals that are coated with a layer of lipid to measure

volatile anesthetic agents

• Principle: When exposed to a volatile anesthetic agent, the vapor is

adsorbed into the lipid resulting change in the mass of the lipid alters

the vibration frequency

• By using an electronic system consisting of two oscillating circuits, one

has an uncoated (reference) crystal and the other a coated (detector)

crystal, an electric signal that is proportional to the vapour concentration

is generated

• Diverting devices

Advantages:

Accuracy

Fast response time

No need for scavenging

Short warm up time

Compact

Disadvantages:

Only one gas measured

No agent discrimination

Inaccuracy with water vapours

Chemical Carbon Dioxide Detection• Consists of a pH-sensitive indicator

• Principle: When the indicator is exposed to carbonic acid that is formed

as a product of the reaction between CO2 and water it becomes more

acidic and changes color

Technology:

Hygroscopic

Hydrophobic

Uses:

• For confirming tracheal intubation when a capnometer is not available

• Disposable so it may be useful to confirm tracheal intubation in patients

with respiratory diseases (e.g.SARS)

Advantages:

• Easy to use, small size, low cost

• Not affected by N2O, volatile anaesthetics

• Offers minimal resistance to flow

• CO doesn’t interfere

Disadvantages:

• Recommended to wait six breaths before making a determination

• False-negative results may be seen with very low tidal volumes

• Drugs instilled in the trachea or gastric contents can cause irreversible

damage to the device

• False-positive results can occur if CO2 in the stomach

• Semiquantitative, cannot give accurate measurement of CO2 (So use

limited to check endotracheal intubation)

Refractometry:• Optical interference refractometer (interferometer): Light beam passes

through a chamber into which the sample gas has been aspirated, also

passes through an identical chamber containing air.

• Vapour slows the velocity of light, the portion passing through the vapor

chamber is delayed

• Beams form dark and light bands, position of these bands yields the

vapor concentration

• Used primarily for vaporizer calibration

• Sensitive to nitrous oxide (so cannot be used to measure halogenated

agents in a O2, N2O, agent mixture)

Gas MeasurementOxygen:

• Standard requirements:

Oxygen readings shall be within ±2.5% of the actual level (min for 6hrs

together)

The high and low oxygen level alarms must be at least medium

priority, oxygen concentration below 18% (should be high priority

alarm)

It shall not be possible to set the low oxygen alarm limit below 18%

• Technology used:

Electrochemical Technology

Paramagnetic Technology: Rapid response time, even for non-

intubated

Applications of Oxygen Analysis:

• Detecting Hypoxic or Hyperoxic Mixtures:Oxygen monitor provides earlier warning of inadequate oxygen than

pulse oximetry

Problems resulting from hyperoxygenation: patient movement during

surgery, awareness, damage to the lungs and eyes, fires

• Detecting Disconnections and Leaks:However not dependable

• Detecting Hypoventilation:Normal: Difference b/w inspired and expired oxygen is 4% to 5%

• End tidal Oxygen Measurement:Assess pt’s oxygen consumption (Malignant hyperthermia)

To detect air embolism (inc ET O2)

Carbon Dioxide Analysis:

• Means for assessing metabolism, circulation, and ventilation

• ASA guidelines: Correct positioning of ET tube must be verified by

identifying CO2 in the expired gas

• Capnometry: Measurement of CO2 in gas mixture

• Capnography: Recording of CO2 Conc versus time

Standard requirements of Capnometer:

• CO2 reading shall be within ±12% of the actual value or ±4 mm Hg

• Must have a high CO2 alarm for both inspired and exhaled CO2

Technology:

• Infrared Analysis

• Chemical colorimetric analysis

Clinical Significance of Capnometry:

• Metabolism

• Respiration

• Circulation

• Equipment Function

• Confirming endotracheal and enteric tube placement

• Dec ET CO2:

Impaired peripheral circulation

Impaired lung circulation (Pulmn embolus)

Increased patient dead space

Hyperventilation

Hypothermia

Increased depth of anaesthesia

Use of muscle relaxants

Leak in sampling line

Leak around ET

• Increased ET CO2:

Absorption of CO2 from peritoneal cavity

Injection of NaHCO3

Convulsions

Hyperthermia

Pain, anxiety, shivering

Increased muscle tone (reversal of muscle relaxation)

Hyperventilation

Upper airway obstruction

Rebreathing

Increased circulation from tissues to lung (release of tourniquet)

• Absent waveform:

Esophageal intubation

Disconnection

Apnea

Blockade of sampling line

Correlation between Arterial and End-tidal Carbon dioxide levels

• Normal: PaCO2 – ET CO2 = 2-5 torr

• Altered with:

Reduced FRC (Pregnancy, Obese pt)

Rebreathing

Neurosurgical procedures

During one lung ventilation

(In these cases transcutaneous CO2 monitoring more accurate)

Capnography

• Examined for:

Height (Depends on ETCO2)

Frequency (R.R.)

Rhythm

Baseline (normally zero)

Shape (Top hat or Sine wave

is normal)

Capnography cont…

• Phase 1: E (Inspiratory baseline)

• Phase 2: B to C (Expiratory upstroke), S shaped- represents transition

from dead space to alveolar space

• Phase 3: C to D (all from alveoli)

• End of Phase 3 (Point D): End tidal point (Max CO2)

• Alpha : Angle b/w Phase 2 & 3 (normal 100-110 degree)

• Beta: B/w end of phase 3 & Descending limb (90 degree)

• The slope of phase 3 (C to D) increases:

With PEEP

Airway obstruction

V/Q mismatch

And so angle Alpha also increases

And angle Beta decreases

• Angle Beta increases with:

Rebreathing

Prolonged response time

Unusual waveforms:

• Leak in sample line: Brief peak at the end of plateau

• Partially paralysed (making intermittent resp effort) :Curare cleft

• Cardiogenic occilations:

Seen in pediatric pts

(d/t heart beating against

Lungs)

Volatile Anaesthetic Agents:

• Standard Requirements:

Difference in value shall be within ) 0.2% vol%

High conc alarm is mandatory, low conc alarm is optional

• Measurement technique:

Infrared Analysis

Refractometry

Peizoelectric Analysis

• Significance:

Assess vaporizer function and contents

Information of patient uptake of the agent (insp & exp conc)

Information on Anaesthetic depth

Detecting contaminants/ disconnection

Nitrous Oxide:

• Measurement technique:

Infrared Analysis

• Significance:

Assess flowmeter function

Nitrogen:

• Previously measured using Raman spectroscopy or mass spectrometry

• Now no longer available

• Significance:

Verifying adequate denitrogenation before induction (imp for

pediatric pt, in lung ds, dec FRC)

Detecting air emboli (Inc ET N2)

Thank You