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Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Review

Volumetric capnography: lessons from the past and current clinical applications

Authors: Sara Verscheure, Paul B. Massion, Franck Verschuren, Pierre Damas, Sheldon Magder

Published in: Critical Care | Issue 1/2016

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Abstract

Dead space is an important component of ventilation–perfusion abnormalities. Measurement of dead space has diagnostic, prognostic and therapeutic applications. In the intensive care unit (ICU) dead space measurement can be used to guide therapy for patients with acute respiratory distress syndrome (ARDS); in the emergency department it can guide thrombolytic therapy for pulmonary embolism; in peri-operative patients it can indicate the success of recruitment maneuvers. A newly available technique called volumetric capnography (Vcap) allows measurement of physiological and alveolar dead space on a regular basis at the bedside. We discuss the components of dead space, explain important differences between the Bohr and Enghoff approaches, discuss the clinical significance of arterial to end-tidal CO2 gradient and finally summarize potential clinical indications for Vcap measurements in the emergency room, operating room and ICU.
Literature
1.
2.
Fowler WS. Lung function studies; the respiratory dead space. Am J Physiol. 1948;154(3):405–16.PubMed
3.
Fletcher R, Jonson B, Cumming G, Brew J. The concept of deadspace with special reference to the single breath test for carbon dioxide. Br J Anaesth. 1981;53(1):77–88.CrossRefPubMed
4.
Sinha P, Flower O, Soni N. Deadspace ventilation: a waste of breath! Intensive Care Med. 2011;37(5):735–46.CrossRefPubMed
5.
Siobal MS, Ong H, Valdes J, Tang J. Calculation of physiologic dead space: comparison of ventilator volumetric capnography to measurements by metabolic analyzer and volumetric CO2 monitor. Respiratory Care. 2013;58(7):1143–51.CrossRefPubMed
6.
Tusman G, Sipmann FS, Bohm SH. Rationale of dead space measurement by volumetric capnography. Anesth Analg. 2012;114(4):866–74.CrossRefPubMed
7.
Suarez-Sipmann F, Bohm SH, Tusman G. Volumetric capnography: the time has come. Curr Opin Crit Care. 2014;20(3):333–9.CrossRefPubMed
8.
Riley RL, Cournand A. Ideal alveolar air and the analysis of ventilation-perfusion relationships in the lungs. J Appl Physiol. 1949;1(12):825–47.PubMed
9.
Wagner PD, Saltzman HA, West JB. Measurement of continuous distributions of ventilation-perfusion ratios: theory. J Appl Physiol. 1974;36(5):588–99.PubMed
10.
Tusman G, Gogniat E, Bohm SH, Scandurra A, Suarez-Sipmann F, Torroba A, et al. Reference values for volumetric capnography-derived non-invasive parameters in healthy individuals. J Clin Monitor Comput. 2013;27(3):281–8.CrossRef
11.
12.
Severinghaus JW, Stupfel M. Alveolar dead space as an index of distribution of blood flow in pulmonary capillaries. J Appl Physiol. 1957;10(3):335–48.PubMed
13.
Bartels J, Severinghaus JW, Forster RE, Briscoe WA, Bates DV. The respiratory dead space measured by single breath analysis of oxygen, carbon dioxide, nitrogen or helium. J Clin Invest. 1954;33(1):41–8.CrossRefPubMedPubMedCentral
14.
Tusman G, Sipmann FS, Borges JB, Hedenstierna G, Bohm SH. Validation of Bohr dead space measured by volumetric capnography. Intensive Care Med. 2011;37(5):870–4.CrossRefPubMed
15.
Kallet RH, Daniel BM, Garcia O, Matthay MA. Accuracy of physiologic dead space measurements in patients with acute respiratory distress syndrome using volumetric capnography: comparison with the metabolic monitor method. Respir Care. 2005;50(4):462–7.PubMed
16.
Verschuren F, Heinonen E, Clause D, Zech F, Reynaert MS, Liistro G. Volumetric capnography: reliability and reproducibility in spontaneously breathing patients. Clin Physiol Funct Imaging. 2005;25(5):275–80.CrossRefPubMed
17.
Sinha P, Soni N. Comparison of volumetric capnography and mixed expired gas methods to calculate physiological dead space in mechanically ventilated ICU patients. Intensive Care Med. 2012;38(10):1712–7.CrossRefPubMed
18.
Crossman PF, Bushnell LS, Hedley-Whyte J. Dead space during artificial ventilation: gas compression and mechanical dead space. J Appl Physiol. 1970;28(1):94–7.PubMed
19.
Tang Y, Turner MJ, Baker AB. A new equal area method to calculate and represent physiologic, anatomical, and alveolar dead spaces. Anesthesiology. 2006;104(4):696–700.CrossRefPubMed
20.
Suarez-Sipmann F, Santos A, Bohm SH, Borges JB, Hedenstierna G, Tusman G. Corrections of Enghoff's dead space formula for shunt effects still overestimate Bohr's dead space. Respir Physiol Neurobiol. 2013;189(1):99–105.CrossRefPubMed
21.
Kuwabara S, Duncalf D. Effect of anatomic shunt on physiologic deadspace-to-tidal volume ratio--a new equation. Anesthesiology. 1969;31(6):575–7.CrossRefPubMed
22.
Niklason L, Eckerstrom J, Jonson B. The influence of venous admixture on alveolar dead space and carbon dioxide exchange in acute respiratory distress syndrome: computer modelling. Crit Care. 2008;12(2):R53.CrossRefPubMedPubMedCentral
23.
Nuckton TJ, Alonso JA, Kallet RH, Daniel BM, Pittet JF, Eisner MD, et al. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med. 2002;346(17):1281–6.CrossRefPubMed
24.
Kallet RH, Alonso JA, Pittet JF, Matthay MA. Prognostic value of the pulmonary dead-space fraction during the first 6 days of acute respiratory distress syndrome. Respir Care. 2004;49(9):1008–14.PubMed
25.
Cepkova M, Kapur V, Ren X, Quinn T, Zhuo H, Foster E, et al. Pulmonary dead space fraction and pulmonary artery systolic pressure as early predictors of clinical outcome in acute lung injury. Chest. 2007;132(3):836–42.CrossRefPubMed
26.
Lucangelo U, Bernabe F, Vatua S, Degrassi G, Villagra A, Fernandez R, et al. Prognostic value of different dead space indices in mechanically ventilated patients with acute lung injury and ARDS. Chest. 2008;133(1):62–71.CrossRefPubMed
27.
Kallet RH, Zhuo H, Liu KD, Calfee CS, Matthay MA, National Heart L, et al. The association between physiologic dead-space fraction and mortality in subjects with ARDS enrolled in a prospective multi-center clinical trial. Respir Care. 2014;59(11):1611–8.CrossRefPubMed
28.
Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med. 1975;292(6):284–9.CrossRefPubMed
29.
Tusman G, Suarez-Sipmann F, Bohm SH, Pech T, Reissmann H, Meschino G, et al. Monitoring dead space during recruitment and PEEP titration in an experimental model. Intensive Care Med. 2006;32(11):1863–71.CrossRefPubMed
30.
Tusman G, Suarez-Sipmann F, Bohm SH, Borges JB, Hedenstierna G. Capnography reflects ventilation/perfusion distribution in a model of acute lung injury. Acta Anaesthesiol Scand. 2011;55(5):597–606.CrossRefPubMed
31.
Mosing M, Kutter AP, Iff S, Raszplewicz J, Mauch J, Bohm SH, et al. The effects of cardiac output and pulmonary arterial hypertension on volumetric capnography derived-variables during normoxia and hypoxia. J Clin Monitor Comput. 2015;29(1):187–96.CrossRef
32.
Blanch L, Lucangelo U, Lopez-Aguilar J, Fernandez R, Romero PV. Volumetric capnography in patients with acute lung injury: effects of positive end-expiratory pressure. Eur Respir J. 1999;13(5):1048–54.CrossRefPubMed
33.
Beydon L, Uttman L, Rawal R, Jonson B. Effects of positive end-expiratory pressure on dead space and its partitions in acute lung injury. Intensive Care Med. 2002;28(9):1239–45.CrossRefPubMed
34.
Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. Eur Respir J. 2002;20(4):1017–28.CrossRefPubMed
35.
Gattinoni L, Vagginelli F, Carlesso E, Taccone P, Conte V, Chiumello D, et al. Decrease in PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndrome. Crit Care Med. 2003;31(12):2727–33.CrossRefPubMed
36.
Charron C, Repesse X, Bouferrache K, Bodson L, Castro S, Page B, et al. PaCO2 and alveolar dead space are more relevant than PaO2/FiO2 ratio in monitoring the respiratory response to prone position in ARDS patients: a physiological study. Crit Care. 2011;15(4):R175.CrossRefPubMedPubMedCentral
37.
Johannigman JA, Davis Jr K, Miller SL, Campbell RS, Luchette FA, Frame SB, et al. Prone positioning for acute respiratory distress syndrome in the surgical intensive care unit: who, when, and how long? Surgery. 2000;128(4):708–16.CrossRefPubMed
38.
Soro M, Garcia-Perez ML, Belda FJ, Ferrandis R, Aguilar G, Tusman G, et al. Effects of prone position on alveolar dead space and gas exchange during general anaesthesia in surgery of long duration. Eur J Anaesthesiol. 2007;24(5):431–7.CrossRefPubMed
39.
Kline JA, Israel EG, Michelson EA, O'Neil BJ, Plewa MC, Portelli DC. Diagnostic accuracy of a bedside D-dimer assay and alveolar dead-space measurement for rapid exclusion of pulmonary embolism: a multicenter study. JAMA. 2001;285(6):761–8.CrossRefPubMed
40.
Verschuren F, Liistro G, Coffeng R, Thys F, Roeseler J, Zech F, et al. Volumetric capnography as a screening test for pulmonary embolism in the emergency department. Chest. 2004;125(3):841–50.CrossRefPubMed
41.
Eriksson L, Wollmer P, Olsson CG, Albrechtsson U, Larusdottir H, Nilsson R, et al. Diagnosis of pulmonary embolism based upon alveolar dead space analysis. Chest. 1989;96(2):357–62.CrossRefPubMed
42.
Verschuren F, Sanchez O, Righini M, Heinonen E, Le Gal G, Meyer G, et al. Volumetric or time-based capnography for excluding pulmonary embolism in outpatients? J Thrombosis Haemostasis. 2010;8(1):60–7.CrossRef
43.
Manara A, D'Hoore W, Thys F. Capnography as a diagnostic tool for pulmonary embolism: a meta-analysis. Ann Emerg Med. 2013;62(6):584–91.CrossRefPubMed
44.
Verschuren F, Heinonen E, Clause D, Roeseler J, Thys F, Meert P, et al. Volumetric capnography as a bedside monitoring of thrombolysis in major pulmonary embolism. Intensive Care Med. 2004;30(11):2129–32.CrossRefPubMed
45.
Moreira MM, Terzi RG, Carvalho CH, de Oliveira Neto AF, Pereira MC, Paschoal IA. Alveolar dead space and capnographic variables before and after thrombolysis in patients with acute pulmonary embolism. Vascular Health Risk Management. 2009;5(1):9–12.PubMedPubMedCentral
46.
Tusman G, Bohm SH, Suarez-Sipmann F, Turchetto E. Alveolar recruitment improves ventilatory efficiency of the lungs during anesthesia. Can J Anaesthesia. 2004;51(7):723–7.CrossRef
47.
Maisch S, Reissmann H, Fuellekrug B, Weismann D, Rutkowski T, Tusman G, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients. Anesth Analg. 2008;106(1):175–81. table of contents.CrossRefPubMed
48.
Bohm SH, Maisch S, von Sandersleben A, Thamm O, Passoni I, Martinez Arca J, et al. The effects of lung recruitment on the Phase III slope of volumetric capnography in morbidly obese patients. Anesth Analg. 2009;109(1):151–9.CrossRefPubMed
49.
Tusman G, Groisman I, Fiolo FE, Scandurra A, Arca JM, Krumrick G, et al. Noninvasive monitoring of lung recruitment maneuvers in morbidly obese patients: the role of pulse oximetry and volumetric capnography. Anesth Analg. 2014;118(1):137–44.CrossRefPubMed
50.
Tusman G, Bohm SH, Suarez-Sipmann F. Dead space during one-lung ventilation. Curr Opin Anaesthesiol. 2015;28(1):10–7.CrossRefPubMed
51.
Unzueta C, Tusman G, Suarez-Sipmann F, Bohm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2012;108(3):517–24.CrossRefPubMed
52.
Ferrando C, Mugarra A, Gutierrez A, Carbonell JA, Garcia M, Soro M, et al. Setting individualized positive end-expiratory pressure level with a positive end-expiratory pressure decrement trial after a recruitment maneuver improves oxygenation and lung mechanics during one-lung ventilation. Anesth Analg. 2014;118(3):657–65.CrossRefPubMed
53.
Hubble CL, Gentile MA, Tripp DS, Craig DM, Meliones JN, Cheifetz IM. Deadspace to tidal volume ratio predicts successful extubation in infants and children. Crit Care Med. 2000;28(6):2034–40.CrossRefPubMed
54.
Gonzalez-Castro A, Suarez-Lopez V, Gomez-Marcos V, Gonzalez-Fernandez C, Iglesias-Posadilla D, Buron-Mediavilla J, et al. Utility of the dead space fraction (Vd/Vt) as a predictor of extubation success. Medicina Intensiva. 2011;35(9):529–38.CrossRefPubMed
55.
Peyton PJ, Venkatesan Y, Hood SG, Junor P, May C. Noninvasive, automated and continuous cardiac output monitoring by pulmonary capnodynamics: breath-by-breath comparison with ultrasonic flow probe. Anesthesiology. 2006;105(1):72–80.CrossRefPubMed
56.
Tusman G, Groisman I, Maidana GA, Scandurra A, Arca JM, Bohm SH, et al. The sensitivity and specificity of pulmonary carbon dioxide elimination for noninvasive assessment of fluid responsiveness. Anesth Analg. 2016;122(5):1404–11.CrossRefPubMed
Metadata
Title
Volumetric capnography: lessons from the past and current clinical applications
Authors
Sara Verscheure
Paul B. Massion
Franck Verschuren
Pierre Damas
Sheldon Magder
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1377-3

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