10

Assessment of Respiratory Function CHAPTER 10

CHAPTER
Assessment of Respiratory Function

OUTLINE
NONINVASIVE MEASUREMENTS OF BLOOD GASES Transcutaneous PCO2
Pulse Oximetry Technical Considerations
Physiological and Technical Concerns INDIRECT CALORIMETRY AND METABOLIC MEASUREMENTS
Clinical Applications Overview of Indirect Calorimetry
Capnography (Capnometry) Technical Considerations
Technical Considerations ASSESSMENT OF RESPIRATORY SYSTEM MECHANICS
Physiological Considerations Measurements
Clinical Applications Airway Pressure Measurements
Volumetric Capnometry Flow Measurements
Exhaled Nitric Oxide Monitoring Clinical Applications
Transcutaneous Monitoring Summary
Transcutaneous PO2

KEY TERMS
• Capnography • Indirect calorimetry • Quantitative
• Fractional hemoglobin saturation • Pulse oximetry • Transcutaneous monitoring
• Functional hemoglobin saturation • Qualitative

LEARNING OBJECTIVES On completion of this chapter, the reader will be able to do the following:

1. Describe the principle of operation of the pulse oximeter. 9. Explain the theory of operation of transcutaneous PO2 and PCO2
2. Identify physiological and technical factors that can influence the monitors and list the clinical data that should be recorded when
accuracy of pulse oximetry readings. making transcutaneous measurements.
3. Describe how various clinical conditions can affect CO-oximetry, 10. Provide the respiratory quotient (RQ) value associated with
oxygen saturation (SaO2) and pulse oximetry, oxyhemoglobin substrate utilization patterns in normal, healthy subjects.
saturation (SpO2). 11. Discuss some clinical applications of metabolic monitoring in
4. Discuss the normal components of a capnogram. critically ill patients.
5. Give examples of pathophysiological conditions that can alter the 12. Briefly describe devices that are used to measure airway pressures,
contour of the capnogram. volumes, and flows during mechanical ventilation.
6. Discuss how arterial-to-end-tidal partial pressure of carbon dioxide 13. Calculate mean airway pressure, dynamic compliance, static
(P(a-et)CO2) is affected by changes in ventilation-perfusion compliance, and airway resistance.
relationships. 14. Identify pathologic conditions that alter lung compliance and
7. Discuss how volumetric CO2 tracings can be used to assess gas airway resistance and measurements of the work of breathing.
exchange during mechanical ventilation. 15. Define the pressure–time product, and discuss its application in
8. Describe how exhaled nitric oxide measurements can be used in the management of mechanically ventilated patients.
the management of patients with asthma.

P
rocedures and devices, such as pulse oximetry, capnography Noninvasive Measurements of Blood Gases
(capnometry), transcutaneous monitoring of blood gases,
exhaled nitric oxide (NO), indirect calorimetry, and bedside
PULSE OXIMETRY
lung function testing have made it possible for respiratory thera-
pists to monitor respiratory function noninvasively in mechani- Hypoxemic events in mechanically ventilated patients are most
cally ventilated patients. When it is used appropriately, noninvasive often associated with apnea, airway obstruction, equipment failure
monitoring can provide valuable information for clinicians manag- or disconnection, and incorrect gas flow settings. Visual recogni-
ing patients receiving ventilatory support. However, if it is used tion of hypoxemia by physical examination is often unreliable
indiscriminately, it can be distracting and confusing for the clini- because of intraobserver variability, differences in patients’ skin
cian and economically costly for the patient. pigmentation, and interference by ambient lighting.1,2 Laboratory

161
162 CHAPTER 10 Assessment of Respiratory Function

measurement of arterial blood gases (ABGs) remains the gold stan- As Fig. 10-2 illustrates, at a wavelength of 660 nm (red light),
dard for measuring the level of hypoxemia (see Evolve website for deoxygenated hemoglobin absorbs more light than oxyhemoglo-
a review of ABGs); however, this procedure is performed intermit- bin. Conversely, oxyhemoglobin absorbs more light at 940 nm
tently and may fail to detect transient hypoxic episodes. (infrared light [IR]) than does deoxygenated hemoglobin.
Pulse oximetry provides continuous, noninvasive measure- Pulse rate is determined by relating cyclical changes in light
ments of arterial oxygen saturation.3 A sensor is placed over a digit, transmission through the sampling site with blood volume changes
an earlobe, the forehead, or the bridge of the nose; this sensor that occur during ventricular systole and diastole. That is, as local
measures the absorption of selected wavelengths of light beamed (e.g., finger, toe, or earlobe) blood volume increases during ven-
through the tissue (Fig. 10-1). For example, oxyhemoglobin can be tricular systole, light absorbency increases and transmitted light
differentiated from deoxygenated hemoglobin by shining two decreases. In contrast, as blood volume decreases during diastole,
wavelengths of light (660 and 940 nm) through the sampling site. absorbency decreases, and transmitted light increases. Figure 10-3
illustrates the pulsatile or alternating current (AC) and nonpulsa-
tile or direct current (DC) components of a typical pulse oximetry
signal.
The percentage of oxyhemoglobin present can be determined
by first calculating the ratio of absorbencies for pulsatile and non-
pulsatile flow, at the two specified wavelengths, or
Red Infrared = Pulsatile660 nm Nonpulsatile660 nm
÷ Pulsatile 940 nm Nonpulsatile940 nm

This ratio is then applied to an algorithm that relates ratios of these

two absorbencies to oxyhemoglobin saturation.4

Physiological and Technical Concerns

Pulse oximeters generally are accurate for oxygen saturations
greater than 80%.5,6 Pulse oximeter saturations less than 80%
should be confirmed with laboratory analysis of ABGs, including
CO-oximetry.7,8 A number of physiological and technical factors
can influence the accuracy of pulse oximetry measurements,
including low perfusion states, the presence of dysfunctional
hemoglobins and dyes, variations in patients’ skin pigmentation,
and ambient light interference. The following is a summary of
various factors that can influence pulse oximetry readings. A more
detailed discussion of each of these factors can be found in the
Fig. 10-1 Pulse oximeter. (Courtesy Nonin Medical, Plymouth, Minn.) references listed at the end of this chapter.

10

Methemoglobin
Extinction coefficient

Oxyhemoglobin

Reduced
hemoglobin
.1

Carboxyhemoglobin
.01
600 640 680 720 760 800 840 880 920 960 1000
Log Wavelength (nm)

Fig. 10-2 Absorption characteristics of four types of hemoglobin: reduced hemoglobin, oxyhemoglobin, carboxyhemoglobin,
and methemoglobin.
 Assessment of Respiratory Function CHAPTER 10 163

Pulsatile component saturation are fractional and functional saturations. Fractional

(arterial blood) hemoglobin saturation is calculated by dividing the amount of
oxyhemoglobin measured by the sum of concentrations of all four
types of hemoglobin present, or
Fractional O2 Hb = O2 Hb [HHb + O2 Hb + COHb + MetHb]

Functional hemoglobin saturation is calculated by dividing the

Light absorption

oxyhemoglobin concentration by the concentration of hemoglobin

capable of carrying oxygen, or
Functional O2 Hb = O2 Hb [HHb + O2 Hb]

Laboratory CO-oximeters measure all four types of hemoglobin by

Baseline component using separate wavelengths of light to identify each species, whereas
(stable absorbance of venous
tissues and capillary blood) pulse oximeters use only two wavelengths to quantify the amount
of O2Hb and HHb present. Laboratory CO-oximeters are therefore
capable of reporting fractional oxyhemoglobin saturations, and
pulse oximeters are typically described as evaluating functional
Time
hemoglobin saturations.
Fig. 10-3 Output signal generated by pulse oximeter illustrating pulsatile and This description of a pulse oximeter capability may be some-
nonpulsatile components. Saturation is based on the ratio of light absorption during what misleading because, as Fig. 10-2 shows, O2Hb and COHb
pulsatile and baseline phases. (From Kacmarek RM, Stoller JK, Heurer AJ, editors: have similar absorption coefficients for red light (660 nm), whereas
Egan’s fundamentals of respiratory care, ed 10, St Louis, 2013, Elsevier.) COHb is relatively transparent to infrared light (940 nm). Addi-
tionally, MetHb and HHb have the same absorption coefficients for
red light; however, MetHb demonstrates a greater absorbency for
Low Perfusion States infrared light (940 nm) than does oxyhemoglobin. Accordingly,
It should be apparent that the accuracy of a pulse oximeter reading the presence of significant levels of COHb, as occurs in carbon
is dependent on the identification of an arterial pulse. In cases monoxide poisoning, will lead to an overestimation of SpO2 (Key
where perfusion is low, such as hypovolemia, the pulse oximeter Point 10-1).8 Methemoglobinemia, a potential complication of
may not be able to accurately identify a pulsatile signal, resulting administering nitric oxide, benzocaine (topical anesthetic), and
in either an intermittent or absent SpO2 reading. Other situations dapsone (an antibiotic used to treat malaria and Pneumocystis
that may contribute to this problem include administering periph- carinii), can cause erroneous SpO2 values because MetHb absorbs
eral vasoconstrictors, hypothermia, and heart–lung bypass (i.e., both red and IR light.6,11 If enough MetHb is present to dominate
extracorporeal membrane oxygenation).9 Although some oxime- all pulsatile absorption, the pulse oximeter will measure a red-
ters are better than others in dealing with low perfusion states, to-IR ratio of 1 : 1, corresponding to an SpO2 of about 85%.
compensation for the weak signal associated with low perfusion Consequently, the pulse oximeter reading will overestimate or
states is limited. The reason for this limitation is that a low perfu- underestimate the true oxyhemoglobin saturation, depending on
sion state produces a low signal-to-noise ratio and, thus, a signal whether the actual SaO2 is less than or greater than 85%.9,11
that can potentially be altered by motion artifacts.
The Masimo Signal Extraction Technology (SET) (Masimo
Corp, Irvine, Calif.) pulse oximeter is a relatively new processing Key Point 10-1 Abnormal hemoglobin, such as carboxyhemoglo-
system that uses special algorithms to minimize interference from bin (smoke exposure), produces an erroneously high SpO2. If abnormal hemoglobin
motion artifacts. Conventional pulse oximetry assumes that arte- levels are suspected, a CO-oximeter should be used to evaluate the oxygen
rial blood accounts for the pulsations or AC component of the saturation.
pulse oximetry signal, while venous blood produces a nonpulsatile
or DC component of the signal. During patient motion, the venous
blood may also contribute to the pulsatile signal and cause the It is well documented that intravascular dyes can adversely affect
pulse oximeter to underestimate the SpO2 because it cannot distin- SpO2 values by absorbing a portion of the incident light emitted by
guish between the arterial and venous blood. Masimo SET signal the pulse oximeter diodes. Scheller and colleagues12 demonstrated
processing identifies the venous blood signal, isolates it, and using that injection of methylene blue and indigo carmine into human
adaptive filters, cancels the noise and extracts the arterial signal. volunteers caused a false drop in SpO2, whereas indocyanine green
When tested on healthy individuals simulating various motion had little effect on pulse oximeter values.
artifacts, the Masimo SET oximeter exhibited a much lower error
rate compared with conventional pulse oximeters. Studies with Nail Polish
critically ill patients also demonstrated fewer false alarms of hypox- Nail polish (particularly blue and black nail polish) can affect SpO2
emia when compared to conventional pulse oximeters.10 readings. It has been suggested that nail polish causes light to be
shunted around the finger periphery (called optical shunting).13,14
Dysfunctional Hemoglobins and Dyes The transmitted light never comes in contact with the vascular bed;
Adult blood typically contains four types of hemoglobin: reduced consequently, SpO2 values can be erroneously high or low, depend-
or deoxygenated hemoglobin (HHb), oxyhemoglobin (O2Hb), ing on whether this light takes on a pulsatile character. Placing the
carboxyhemoglobin (COHb), and methemoglobin (MetHb). device over the lateral aspects of the digit rather than over the nail
Two terms that are often used when describing oxyhemoglobin can largely alleviate this problem.
164 CHAPTER 10 Assessment of Respiratory Function

Skin Pigmentation Percent saturation

Theoretically, skin pigmentation should have no effect on pulse hemoglobin
oximeter readings. In practice, however, SpO2 readings are typically
higher for patients with dark skin pigmentation. For example, an Increased affinity
Acute alkalosis
SpO2 of 95% in an African American patient may actually represent 100 Decreased PCO2
an SaO2 of only 92%.15-17 Many clinicians, therefore, use higher Decreased temperature
90
threshold values (i.e., SpO2 >92%) for initiating oxygen therapy in Low levels of 2,3 DPG
Carboxyhemoglobin
African American patients. Although using higher target SpO2 80
Methemoglobin Normal
values does not lead to untreated hypoxemia in most of these 70 Abnormal
patients, some will have arterial oxygen pressure (PaO2) values as hemoglobin
60 Decreased affinity
high as 200 mm Hg when therapy is based on measured SpO2.
Acute acidosis
Bilirubin, a breakdown product of heme metabolism, is the 50 High CO2
pigment responsible for the yellow discoloration seen in jaundiced Increased temperature
40
patients. Although an elevated bilirubin level (>20 mg/dL) has High levels of 2,3 DPG
been shown to affect O2Hb values recorded with CO-oximetry, 30 Abnormal hemoglobin
pulse oximetry measurements do not appear to be affected by 20
hyperbilirubinemia.18,19
10
Ambient Light 0
Direct sunlight and external light sources (e.g., fluorescent lights,
0 20 40 60 80 100
heat lamps, fiberoptic light sources, and surgical lamps) have been
PO2 (mm Hg)
shown to affect SpO2 readings adversely.20-22 Most commercially
available pulse oximeters attempt to compensate for this interfer-
Fig. 10-4 Oxyhemoglobin dissociation curve for arterial blood.
ence by continually cycling the transmitted red and IR light on and
off at a rate of about 480 cycles per second.

Clinical Applications guidelines for pulse oximetry. These guidelines provide valuable
The usefulness of pulse oximetry as an early warning system for information, which practitioners should use to determine whether
detecting hypoxemia in patients with unstable oxygenation status SpO2 values are valid.
is well recognized. Pulse oximetry is an excellent trending device Advances in light-emitting diode (LED) technology have led to
in critically ill patients, providing a continuous display of oxygen simplification of pulse oximeter transmitters and sensors, making
saturation. However, changes in SpO2 may not represent an equiva- them easy to use and available at a relatively low cost. Pulse oxim-
lent change in actual SaO2.23,24 This discrepancy is particularly etry probes are available in neonatal, pediatric, and adult sizes. The
evident when pulse oximetry is used in the neonatal intensive care response time of the pulse oximeter (i.e., the time required for the
unit (ICU). Although it is generally used to trend oxygen pulse oximeter to detect a change in central oxygenation level [left-
saturations in neonates, pulse oximetry is not used as a basis for heart PO2]) depends on the location of the probe. The lag time is
prescribing oxygen therapy in neonates; most neonatologists prefer shortest for probes placed on the earlobe; on the finger, the lag time
to base oxygen therapy decisions on PaO2 rather than oxygen is longer by 12 seconds or more than for the earlobe; and probes
saturation.25,26 placed on the toe have the longest lag time.
A review of the relationship between SaO2 and PaO2 (i.e., the As mentioned earlier, pulse oximetry routinely is used to
oxyhemoglobin dissociation curve) is helpful before the use of monitor the oxygenation status of critically ill patients continu-
pulse oximetry to detect hypoxemia is discussed. SaO2 varies with ously with unstable oxygenation status and to monitor oxygen
the PaO2 in a sigmoidal or S-shaped manner. (See Fig. 10-4 for the saturation during surgery and bronchoscopy. Pulse oximetry can
oxyhemoglobin dissociation curve for arterial blood.) For oxygen be particularly useful in the ICU for titrating FIO2 and positive
saturations greater than 90% saturation, PaO2 may rise consider- end-expiratory pressure (PEEP) in mechanically ventilated patients
ably without much change in SaO2. When saturation is less than and for monitoring the oxygenation status of patients undergoing
80%, the PO2 values fall rapidly. Although an SaO2 of 97% is con- chest physical therapy and suctioning.22
sidered normal, maintaining an oxyhemoglobin saturation of at Although pulse oximetry can be effective when prescribing
least 90% is considered acceptable for adult patients. As a result, oxygen therapy in hospitalized patients, it may not be as useful in
many algorithms for oxygen therapy typically use 90% or slightly prescribing oxygen therapy for homecare patients. Carlin and col-
higher as an indication for increasing the fractional inspired leagues25 demonstrated that the use of pulse oximetry only can
oxygen concentration (FIO2). (As mentioned, because dark skin disqualify a significant number of patients applying for reimburse-
pigmentation can lead to erroneously high SpO2, many clinicians ment for oxygen therapy. Under the guidelines of the Centers for
use a threshold of 94% to 95% for these patients as an indication Medicare and Medicaid Services (CMS), a patient must demon-
for adjusting the FIO2.) In the case of hyperoxygenation, pulse strate a PaO2 of 55 Torr or lower or a saturation of 88% or lower to
oximeters can provide limited information about PaO2 values qualify for oxygen therapy.24 It is important to recognize that any
because of the flat portion of the oxyhemoglobin dissociation curve of the aforementioned physiological or technical problems can sig-
above 90%. nificantly affect SpO2 measurements. To resolve this problem, inva-
Several criteria should be met to ensure that pulse oximetry sive ABG analyses should be done in chronically ill patients to
values are meaningful. Box 10-1 contains a summary of the Ameri- establish the need for oxygen therapy. Case Study 10-1 involves
can Association for Respiratory Care (AARC) clinical practice pulse oximetry.
 Assessment of Respiratory Function CHAPTER 10 165

Summary of the American Association

BOX 10-1 for Respiratory Care (AARC) Clinical
Practice Guideline for Pulse Oximetry
Indications
Based on current evidence, pulse oximetry is useful for:
1. Monitoring arterial oxyhemoglobin saturation
2. Quantifying the arterial oxyhemoglobin saturation
response to therapeutic intervention
3. Monitoring arterial oxyhemoglobin saturation during
bronchoscopy
Contraindications
Pulse oximetry may not be appropriate in situations where
measurements of pH, PaCO2, and total hemoglobin are required.
The presence of abnormal hemoglobins may be a relative
contraindication.
Limitations
A number of factors, agents, and situations can affect readings
and limit precision and performance of pulse oximetry. These
include the following: Fig. 10-5 Example of a chemical capnometer. (EasycapII, Nellcor-Puritan-Bennett,
1. Motion artifacts a subsidiary of Covidien, Irvine, Calif.)
2. Abnormal hemoglobins (particularly carboxyhemoglobin
and methemoglobin)
3. Intravascular dyes CAPNOGRAPHY (CAPNOMETRY)
4. Exposure of the measuring sensor to ambient light sources
5. Low perfusion states Capnography is the measurement of carbon dioxide concentra-
6. Skin pigmentation tions in respired gases. Although the terms capnography and
7. Nail polish capnometry often are thought to be synonymous, capnography
8. Low oxyhemoglobin saturations (i.e., below 83%) describes the continuous display of carbon dioxide concentrations
Monitoring as a graphic waveform called a capnogram; capnometry involves
The following information should be recorded during pulse the display of exhaled CO2 numerically without a waveform.27
oximetry:
1. Probe type and site of measurement, date and time of Technical Considerations
measurement, patient position, activity level Both chemical and spectroscopic methods can be used to perform
2. FIO2 and mode of supplemental oxygen delivery capnometry. Chemical devices that rely on a disposable colorimet-
3. Arterial blood gas measurements and CO-oximetry results ric detector provide qualitative estimates of exhaled CO2. Spectro-
that may have been made simultaneously scopic devices (e.g., IR, Raman, acoustic, and mass spectroscopy)
4. Clinical appearance of the patient (presence of cyanosis, provide quantitative data on the concentration of expired CO2.
skin temperature) Because chemical and IR analyzers are most often used for
5. Agreement between pulse oximeter heart rate and heart mechanically ventilated patients in the critical care setting, the
rate determined by palpation or electrocardiographic following discussion will focus on these devices.
recordings
Chemical Methods
(Source: AARC Clinical Practice Guideline: Pulse oximetry, Respir Care
37: 891-897, 1992.) Chemical capnometers are handheld devices composed of specially
treated filter paper in a plastic casing that can be attached to the
patient’s endotracheal tube (ET) (Fig. 10-5). The amount of CO2
present in the patient’s inspired and exhaled gas can be estimated
by noting the color changes in the filter paper. Each device uses a
characteristic series of colors to indicate the approximate CO2 con-
centrations. For example, the Portex CO2 Clip device, which is
Case Study 10-1 manufactured by Smiths Medical Canada (St Paul, Minn.), appears
blue when 0 to less than 1% CO2 is in the respired gas, green when
Causes of Cyanosis
the exhaled gas contains 1% to 2%, green-yellow to indicate a CO2
You are preparing a patient for bronchoscopy. As you are concentration of 2% to 5%, and yellow for CO2 concentrations
administering an aerosol treatment with benzocaine, you over 5.0%.
note that the patient appears to be cyanotic but does not Chemical capnometers are particularly useful in emergency
demonstrate any signs of distress. Pulse oximetry readings situations in assessing airway placement. It is important to under-
indicate that the SpO2 is 85%. You immediately obtain arte- stand that changes in the color of the filter paper are the result of
rial blood gases that demonstrate a pH of 7.36, PCO2 of 42 a chemical reaction that affects the pH of the filter paper. (Note
Torr, and PO2 of 80 Torr. Explain the cause of the cyanosis. that if acidic liquids like regurgitated gastric contents contact the
What diagnostic test would confirm this explanation? filter paper, an irreversible color change will occur and render the
device unusable.28) Proper placement of an ET can be determined
166 CHAPTER 10 Assessment of Respiratory Function

because the color of the paper will change continually as inhaled chamber, which is located in a separate console. In mainstream
and exhaled CO2 levels vary while the patient breathes into and out devices, the sampling chamber attaches directly to the ET and
of the device. In some cases, ET placement in the trachea rather analysis is performed at the airway.
than the stomach may be difficult to determine because the patient’s Sidestream sampling devices show a slight delay between sam-
gastric PCO2 may be elevated after receiving mouth-to-mouth pling and reporting times because of the time required to transport
breathing or if the patient has recently ingested a carbonated the sample from the airway to the measuring chamber. The plastic
beverage. tube that transports the sample of gas to the analyzer is prone to

Infrared Spectroscopy
Infrared spectroscopy is based on the principle that molecules
containing more than one element absorb infrared light in a Monitor
characteristic manner.29 CO2 absorbs IR radiation maximally at
4.26 µm. The concentration of CO2 in a gas sample can be esti-
mated because its concentration is directly related to the amount
of IR light absorbed.30 The presence of other gases (e.g., water
[H2O] and nitrous oxide [N2O]) can adversely affect the accuracy
of CO2 measurements by causing a phenomenon called pressure
broadening. This phenomenon occurs because the peak absorbance
of IR radiation by CO2 lies between the peak absorbencies of H2O
and N2O. The presence of these gases increases the absorption of Sample
infrared radiation and results in erroneously high CO2 readings. port
Pressure broadening can be minimized by removing water vapor
from the gas sample before it is analyzed and by using electronic
filters to subtract the IR absorption by gases other than CO2.21
Figure 10-6 is a schematic of a double beam, positive-filter
capnograph. The gas is drawn into a cuvette inside the sample
chamber. IR radiation is beamed through the cuvette and through
a reference chamber containing CO2-free gas. The CO2 in the
sample chamber absorbs some of the radiation, reducing the
amount of radiation that reaches the detector. The difference
between the radiation transmitted through the sample cell and the
radiation transmitted through the reference is converted into an
electrical signal, which is amplified and displayed. The displayed
value can be displayed in millimeters of mercury (mm Hg) repre- A
senting the partial pressure, or as percent CO2 (% CO2).
Monitor
In clinical practice, IR analyzers are typically classified accord-
ing to the method of sampling of respired gases. Figure 10-7 illus-
trates two methods: sidestream sampling devices and mainstream
sampling devices. In sidestream sampling devices, gas from the
airway is extracted through a narrow plastic tube to the measuring

Patient Pump

or
irr
M
Sensor

Sample chamber
Photodetector

Infrared lamp Filter

M
irr
or
Reference chamber
B
Fig. 10-6 Schematic diagram of a double beam positive, infrared capnograph. (From:
Kacmarek RL, Stoller JK, Heurer AJ, editors: Egan’s fundamentals of respiratory care, Fig. 10-7 Schematic illustrating (A) sidestream and (B) mainstream capnographs.
ed 9, St Louis, 2009, Mosby Elsevier.) (From Cairo J: Mosby’s respiratory care equipment, ed 9, St Louis, 2014, Elsevier.)
 Assessment of Respiratory Function CHAPTER 10 167

plugging with water and secretions, which interferes with the deliv- The production of CO2 is primarily determined by the metabolic
ery of gas to the analyzer. Contamination with ambient air, caused rate. Fever, sepsis, hyperthyroidism, and seizures increase meta-
by leaks in the sample line, is also a concern. bolic rate and VCO  2 . Hypothermia, starvation, and sedation
In mainstream sampling devices the analyzer is attached reduce metabolic rate and VCO  2.
directly to the ET; therefore no delay occurs between sampling and The relationship between ventilation and perfusion of the lung
reporting times. However, this type of device adds a small amount and gas exchange (i.e., PACO2) can be expressed using V/Q   rela-
of dead space to the airway. The analyzer must be properly sup- 31  
tionships. Figure 10-9 shows three V/Q relationships that can
ported because the added weight it places on the artificial airway potentially affect the level of alveolar PCO2. In Fig. 10-9, A, ventila-
increases the possibility of dislodgement or complete extubation. tion and perfusion are equally matched. The partial pressure of
Also, because the analyzer is attached directly to the airway, it is arterial CO2 (PaCO2) and PACO2 are nearly equal. The PetCO2 is
handled often and subject to damage from mishandling (e.g., normally about 4 to 6 mm Hg lower than the PaCO2. In Fig. 10-9,
dropping).   The PACO2
B, ventilation decreases relative to perfusion (low V/Q).
eventually equilibrates with the mixed venous PCO2 (PVCO2 ).
Physiological Considerations Clinical situations in which this type of V/Q  relationship can exist
Inspired air contains essentially no carbon dioxide (≈0.3% CO2). throughout the lung (leading to higher than normal PetCO2 values)
Expired air normally contains about 4.5% to 5.5% CO2, which is
primarily the product of cellular metabolism. Figure 10-8 illus-
trates a capnogram for a healthy, resting adult breathing room air.
The waveform, which displays the fractional concentration of Alveolar air plateau
expired CO2 (FECO2) versus time, is divided into four phases. In 3 PetCO2
phase 1, the initial gas exhaled is from the conducting airways, 40

PCO2 (mm Hg)

which contain low levels of CO2 from inspired air. During phase 2,
alveolar gas containing CO2 mixes with gas exhaled from the ana- 2 Inhalation
tomic airways, and the CO2 concentration rises. In phase 3, the
curve plateaus as alveolar gas is exhaled (this phase is often referred 4
to as the alveolar plateau). The concentration of CO2 at the end of Exhalation
the alveolar phase (just before inspiration begins) is referred to as 1
the end-tidal PCO2, or PetCO2. In phase 4 (inspiration), the concen- 0
tration falls to zero. Slow speed Fast speed
The PetCO2 is dependent on the alveolar PCO2 (PACO2), which Time
is ultimately influenced by CO2 production ( VCO  2 ) and the effec-
tiveness of ventilation (i.e., matching of ventilation to perfusion). Fig. 10-8 Capnogram from a normal, healthy, resting subject breathing room air.

A. Normal ventilation and

Inspiration Bronchial tree perfusion
B. Ventilation reduced
C. Perfusion reduced
Expiration

Extraalveolar
shunt

A B

Alveolar shunt
Blood from To
pulmonary C pulmonary
artery Functional veins
dead space

  C, High V/Q.
Fig. 10-9 Ventilation-perfusion relationships: A, Normal. B, Low V/Q.   (Source: Despopoulos A, Silbernagl S: Color
atlas of physiology, ed 4, New York, 1991, Thieme Medical Publishers.)
168 CHAPTER 10 Assessment of Respiratory Function

BOX 10-2 Summary of AARC Clinical Practice Guideline for Capnography/Capnometry During
Mechanical Ventilation
Indications also diminish delivered tidal volume in neonates and small
Based on current evidence, capnography is useful for the patients while using volume-targeted or volume-controlled
following: ventilation.
1. Monitoring the severity of pulmonary disease and evaluating Monitoring
the response to therapy, especially therapy intended to During capnography, the following should be recorded:
  relationships. It
improve VD/V T and ventilation/perfusion V/Q 1. Ventilatory variables, including tidal volume, respiratory rate,
may also provide valuable information about therapy directed positive end-expiratory pressure, inspiratory/expiratory ratios,
at improving coronary blood flow. peak airway pressures, concentrations of respiratory gases.
2. Used as an adjunct to verify that tracheal rather than 2. Hemodynamic variables, including systemic and pulmonary
esophageal intubation has taken place. pressures, cardiac output, shunt, and V/Q  imbalances.
3. Graphic evaluation of the integrity of the patient-ventilatory
Limitations
interface.
Although capnography can provide valuable information about
4. Monitoring the adequacy of pulmonary and coronary blood
the efficiency of ventilation, as well as systemic, pulmonary, and
flow.
coronary perfusion, PaCO2 should be routinely determined
5. Screening patients for pulmonary embolism.
by standard arterial blood gas analysis. Leaks in the ventilator
6. Detection of CO2 rebreathing and the waning effects of
circuit or leaks around the tracheal tube can lead to inaccurate
neuromuscular blockade.
measurements of expired CO2. The reliability of the contour of the
7. Monitoring CO2 elimination.
capnogram can also be affected by the stability of the minute
8. Optimization of mechanical ventilation.
volume, tidal volume, cardiac output, and CO2 body stores. High
Contraindications/Complications breathing frequencies may exceed the response capabilities
There are no absolute contraindications to capnography in of the capnograph and therefore affect the integrity of the
mechanically ventilated adult patients. Mainstream devices capnogram recorded. Low cardiac output may cause a false-
increase the amount of dead space added to the ventilator circuit. negative result when attempting to verify the endotracheal tube
The sampling rate of respired gases when using sidestream ana- (ET) position in the trachea. Positioning the ET in the pharynx, as
lyzers may be high enough to cause autotriggering when flow well as the presence of antacids and carbonated beverage in the
triggering of mechanical breaths is used. The effect is inversely stomach, can lead to false-positive results when assessing ET
proportional to the size of the patient. The gas-sampling rate can placement.

(Source: AARC Clinical Practice Guideline: Capnography/capnometry during mechanical ventilation, 2011, Respir Care 56(4): 503-509, 2011.)

include respiratory center depression, muscular paralysis, and occurs in COPD (Fig. 10-10, A). Hyperventilation is characterized
chronic obstructive pulmonary disease (COPD). In Fig. 10-9, C, by a reduction in PaCO2 and, therefore, PetCO2 (Fig. 10-10, B).
  Physiological dead
ventilation is higher than perfusion (high V/Q). Conversely, hypoventilation is associated with elevated PaCO2 and
space ventilation increases, and the PACO2 approaches inspired air PetCO2 (see Fig. 10-10, B). Figure 10-10, C, is a capnogram of a
 
(0 Torr). Decreased PetCO2 values are found with this type of V/Q patient with Cheyne-Stokes breathing. During bradypnea, phase 4
relationship in patients with pulmonary embolism, excessive PEEP will occasionally show cardiac oscillations resulting from the
(extrinsic or intrinsic), and any disorder marked by pulmonary motion of the beating heart transferred to the conducting airways
hypoperfusion. (Fig. 10-10, D). Failure of the capnogram to return to baseline is
an indicator of rebreathing of exhaled gas (Fig. 10-10, E). Figure
Clinical Applications 10-10, F, shows a capnogram for a paralyzed patient, demonstrat-
Capnography has been shown to be a useful measurement in ing the characteristic “curare cleft” during phase 3. This is a positive
both spontaneously breathing and mechanically ventilated patients. sign that the paralyzed patient is receiving insufficient neuromus-
Box 10-2 summarizes the key points of the AARC’s clinical cular blockade; however, other factors can contribute to this cap-
practice guideline for using capnography/capnometry in ventilated nographic finding, such as patient-ventilator asynchrony.
patients.27 The following section discusses some of the most Capnography can be used to detect pulmonary blood flow ces-
common uses of capnography. sation, such as occurs with pulmonary embolism or during cardiac
arrest. A number of investigators have advocated the use of cap-
Capnograph Contours nography as an adjunct to CPR. Laboratory studies suggest that the
Changes in the contour of the capnogram can be used to detect capnogram can be used as an indication of the progress and success
increases in dead space ventilation, hyperventilation and hypoven- of the event. These studies demonstrated that PetCO2 increases as
tilation, apnea or periodic breathing, inadequate neuromuscular   is restored to normal.
V/Q
blockade in pharmacologically paralyzed patients, and CO2 As mentioned, capnography can also be used to detect
rebreathing. They can also be used to monitor the effectiveness of accidental esophageal intubation. The gastric PCO2 generally is
gas exchange during cardiopulmonary resuscitation (CPR) and to equal to room air; therefore failure to detect the characteristic
detect accidental esophageal intubation. changes in CO2 concentration during ventilation possibly indicates
Phase 3 (i.e., alveolar plateau) becomes indistinguishable from esophageal intubation. However, low perfusion of the lungs is asso-
airway obstruction (i.e., increased physiological dead space) as ciated with low PetCO2 and should not be confused with esophageal
 Assessment of Respiratory Function CHAPTER 10 169

Slow speed
• •
5 ↑V/↓Q
40
% CO2

30

PCO2 (mm Hg)

A 20
Time

Hypoventilation 10
with ↑PaCO2

Hyperventilation
with ↓PaCO2 D Time
Normal
PetCO2

40

0%
Time
40

PCO2 (mm Hg)

PaCO2 (mm Hg)

40

0
0
Time
E
VA L/min

4.5
•

0 “Curare cleft”
B Time
40
PCO2 (mm Hg)

5.3%
% CO2

0
Time
F
C Time

Fig. 10-10 Representative capnograms demonstrating A, chronic obstructive pulmonary disease; B, hypoventilation and
hyperventilation; C, Cheyne-Stokes breathing; D, cardiac oscillations; E, rebreathing exhaled air; F, “curare cleft.” PaCO2, Arterial
carbon dioxide pressure; PCO2, partial pressure of carbon dioxide.
170 CHAPTER 10 Assessment of Respiratory Function

End-tidal
CO2

Normal
5.0
LHF or COPD

% CO2
• •
Pulmonary emboli
V/Q mismatch

Expiratory
reserve
Tidal volume
volume

Normal end of End of End (maximum)

inhalation tidal volume exhalation tidal volume exhalation

Fig. 10-11 P(a-et)CO2 for a normal and a forced expiratory capnogram. (Sources: Darin J: Capnography, Curr Rev Respir Ther
3:146-150, 1981; Erickson L, Wollmer P, Olsson CG, et al: Diagnosis of pulmonary embolism based upon alveolar dead space
analysis, Chest 96:357-362, 1989; Hatle CJ, Rokseth R: The arterial to end expiratory carbon dioxide tension gradient in
pulmonary embolism and other cardiopulmonary diseases, Chest 66:352-357, 1974.)

intubation. Also, the gastric PCO2 may be elevated after mouth-to-

mouth breathing or if the patient recently ingested a carbonated
beverage. Case Study 10-2 gives an example situation of the use of
capnographic data (Key Point 10-2).

Case Study 10-2

Capnography During Intubation
After considerable difficulty, an endotracheal tube is
inserted without visualization of the trachea into a
patient’s airway during CPR. Capnography results show a
PetCO2 of 3 Torr; a standard arterial blood gas measure-
ment demonstrates a PaCO2 of 75 Torr. Explain the cause of
this discrepancy in the capnography and arterial blood
gas results.

Fig. 10-12 A NICO2 capnometer. (Courtesy Respironics, Inc, Murrysville, Pa.)

Volumetric Capnometry
Key Point 10-2 Capnography can be a valuable adjunct to verify
tracheal rather than esophageal intubation during CPR. In addition to end-tidal CO2 monitoring, another application that
has been available for about a decade is volumetric capnometry.
End-tidal CO2 monitoring focuses on exhaled CO2 plotted over
time, whereas volumetric capnometry focuses on exhaled CO2
Arterial to Maximum End-Expiratory PCO2 Difference plotted relative to exhaled volume. The Respironics NICO2 is an
The P(a-et)CO2 for tidal breathing should be approximately 4 to example of a capnometer that can provide this type of monitoring
6 mm Hg. It is elevated in patients with COPD, left-sided heart (Fig. 10-12) (The NICO2 monitor [Philips Respironics, Inc., Mur-
failure, and pulmonary embolism caused by an increase in physi- rysville, Pa.] can also be used to estimate cardiac output noninva-
ological dead space.31 Another technique that can be used to sively; see Chapter 11.)
further evaluate the severity of the disease is to compare arterial
PCO2 measurements with maximum expired PCO2 measurements Description of the Single-Breath CO2 Curve
(the arterial to maximum expiratory PCO2 gradient). With this The single-breath CO2 graph (SBCO2) is produced by the integra-
technique, the expired PCO2 recorded at the end of a maximum tion of airway flow and CO2 concentration; it is presented on a
exhalation is compared with the PaCO2. The difference normally is breath-to-breath basis. As shown in Fig. 10-13, the graph can
minimal. Patients with COPD and left-sided heart failure do provide information on anatomic dead space, alveolar dead space
not show an arterial to maximum expired PCO2 difference, (when PaCO2 is known), and CO2 elimination (VCO2) for each
whereas patients with pulmonary embolism do show an increased breath. If a horizontal line is drawn at the top of the curve, repre-
gradient. Figure 10-11 shows the capnographic appearance of these senting %CO2 in arterial blood, three distinct regions of the curve
differences. are established.
 Assessment of Respiratory Function CHAPTER 10 171

% CO2 in arterial blood Reductions in perfusion to the lungs, as occurs with pulmonary
emboli, can lead to changes in the contour of the SBCO2 curve. As
% CO2 perfusion to the lung decreases, the phase 2 portion of the curve
Y shifts to the right, showing increased dead space in the system (i.e.,
less CO2 exhaled). In this situation, physiological dead space
increased. In addition, the area under the curve contains less CO2;

therefore, less VCO 2 per breath is eliminated due to the fact that
Z less CO2 is being delivered to the alveoli. (It is important to recog-
X nize that overall CO2 production is not reduced.)
Application of PEEP can also alter the contour of the volumetric
SBCO2 curve. As PEEP is increased from zero to 15 cm H2O, the
phase 2 portion of the curve shifts to the right because of expand-
Volume (mL)
ing airways (increasing PEEP keeps the airways open) and reduced
Vd V alveolar perfusion. The addition of PEEP can cause compression of the
pulmonary capillaries and a drop in perfusion to the lungs, reduc-
Exhaled tidal volume ing effective perfusion to the ventilated alveoli. This change repre-
sents an increase in alveolar dead space. The slope of phase
Fig. 10-13 Graph of exhaled volume (x axis) versus % CO2 (y axis). A horizontal line 2 decreases as well; this is a result of lower CO2 concentration
drawn at the top of the curve represents the % CO2 in arterial blood. Three distinct occurring at an identical volume point on the x-axis, causing a rise
regions are illustrated: Area X represents actual CO2 exhaled in one breath; area Y is in PaCO2.
the amount of CO2 not eliminated because of alveolar dead space; and area Z is Case Study 10-3 provides an example of how volumetric cap-
the amount of CO2 not eliminated because of anatomic dead space. Vanatomic, nography can be used clinically.
Alveolar volume; Vd, dead space volume. (Redrawn from material from Respironics,
Murryvillle, PA.)
Case Study 10-3

Area X represents the actual amount of CO2 exhaled in the Exercise

breath, assuming that no exhaled air is rebreathed. In other words, Dead Space Ventilation
the area under the SBCO2 curve is the volume of CO2 in a single A 35-year-old 60-kg man is admitted to the ICU following a

breath. Adding all the single breaths in a minute gives the VCO 2,
motor vehicle accident in which he sustained multiple rib
the same results that would occur if exhaled gas were collected fractures. He is receiving volume-targeted mechanical ven-
using a Douglas bag. Thus, the CO2 monitor can provide informa- tilation and is being monitored with pulse oximetry and
tion about the volume of CO2 in one breath (VCO2) and the volume volumetric capnography. You are asked to increase his PEEP
of CO2 produced in one minute (VCO  2 ).
level from +5 cm H2O to +10 cm H2O. After making the
Area Y represents the amount of CO2 that is not eliminated change, you notice that his SpO2 decreases from 93% to
because of alveolar dead space (i.e., ventilated alveoli that are 90%. His SBCO2 curve has shifted to the right and the PetCO2
poorly perfused or receive no perfusion at all). Area Z represents decreased from 30 mm Hg to 25 mm Hg. Briefly describe
the amount of CO2 that was not eliminated because of the anatomic why these changes may have occurred.
dead space.
The relationship of the areas (with the added arterial blood line)
provides some important parameters for analysis. The ratios of the
areas created in the SBCO2 curve are the same as the relationship Single-Breath CO2 Loop of Inspiration and Exhalation
seen in the Enghoff modified Bohr equation: When the SBCO2 graph includes both inspiration and exhalation,
a loop is produced (Fig. 10-14). The net volume of CO2 exhaled in
[Pa CO2 − PE CO2 ] Pa CO2 = (Y + Z) ( X + Y + Z),
one breath is the area between the exhaled and inhaled CO2 of this
where PaCO2 is arterial partial pressure for carbon dioxide, and loop. The net CO2 in one breath is the difference between the
PECO2 is mixed expired partial pressure for CO2. (XYZ were amount of CO2 inhaled (which is typically negligible) and the
defined previously.) Four major factors influence the amount of amount of CO2 exhaled.
CO2 exhaled: CO2 production, perfusion of the lungs, diffusion,
and ventilation. Trending CO2 Production and Alveolar Minute
Altering the production of CO2 or any one of the factors Ventilation Over Time
involved in transport of CO2 without compensation will result in As mentioned, the NICO2 monitor can trend data over time. The
changes in PaCO2 and the volume of CO2 eliminated through the display for this purpose reports the CO2 produced each minute
lungs.32,33 
(VCO 2 ) rather than SBCO2 curves (Fig. 10-15). Trended data can
As previously mentioned, conditions that can alter the volume of be used to monitor a variety of clinical procedures. For example,
CO2 produced are related to changes in metabolic rate. For example, during a recruitment maneuver in a patient with acute respiratory

VCO 2 increases in patients with sepsis, fever, severe burns to the distress syndrome, trended CO2 data will reveal a transient rise in
body, trauma, and with increases in work of breathing (i.e., the respi- CO2 when previously closed alveoli are reopened. This tool can also
ratory muscles produce additional CO2). If metabolic rate increases be used in weaning patients from the ventilator. For example, if the
and ventilation does not increase, PaCO2 rises, and therefore the patient’s respiratory rate increases during a spontaneous breathing
amount of CO2 exhaled during the SBCO2 maneuver increases. trial (SBT), monitoring CO2 can help determine whether the
172 CHAPTER 10 Assessment of Respiratory Function

% CO2 Factors Affecting Levels of Exhaled

BOX 10-3 Nitric Oxide (NO)
Conditions Associated with Reductions of Exhaled NO
Systemic hypertension
Pulmonary hypertension
Insp Cystic fibrosis
Sickle cell anemia
Ciliary dyskinesis
Exp VCO2 Conditions Associated with Elevated Levels
of Exhaled NO
Asthma
Volume (mL)
Bronchiectasis
Airway viral infections
Alveolitis
Fig. 10-14 A single-breath CO2 curve (SBCO2) recorded during inspiration and
Allergic rhinitis
expiration. (Courtesy Ted Tabor, RRT, Paris, France.) Pulmonary sarcoidosis
Chronic bronchitis
Systemic sclerosis
MValv L/m Mech Spont Pneumonia
10
(Courtesy Aerocrine, Solna, Sweden.)

0
•
VCO2 mL/m
250 synthases (NOS), which exist in constitutive and inducible forms.
The constitutive form is associated with endothelial and neural
cells; the inducible NOS is particularly seen in epithelial cells.
Although both forms of NOS are present in the airways, the expres-
50 sion of the inducible NOS appears to correlate with the level of NO
found in exhaled air.
Fig. 10-15 An example of a VCO 2 trended over time (bottom bar graph) compared The most common method used to quantify the level of exhaled
with corresponding VE (top bar graph; L/min). During the successful weaning trial NO is chemiluminescence, which occurs when NO reacts with
illustrated in these graphs, mandatory breaths are reduced (gray area, top graph), and ozone. Exhaled NO (eNO) can be detected in exhaled gas in the
the patient’s spontaneous breath rate increases (dark bars in VE , top graph). At the range of 7.8 to 41.1 parts per billion (ppb). Note that the concentra-
 2 as the expected work of the respiratory
same time a progressive rise occurs in VCO tion of NO can vary with the flow of exhaled air because it is
muscles increases. (Courtesy Philips Respironics, Inc., Murrysville, Pa.) continually formed in the airways. The range of eNO is also affected
by the presence of pathologic conditions, as well as the patient’s
gender, atopic status, smoking habits, and use of medications.33 Box
patient’s metabolic rate is increasing (and thus working the respira- 10-3 provides a list of factors that have been shown to affect the
tory muscles) or whether a change in dead space affects the patient’s levels of eNO.
ability to wean. Exhaled NO is currently used as a marker for airway inflamma-
Trending of CO2 can also be useful for noting the time lag that tion associated with asthma.32 Several studies have shown a posi-
can occur in CO2 removal as a result of CO2 stores (CO2 bound in tive correlation between the eNO and disease severity.33 Monitoring
the cells or through bicarbonate or bound in the blood). Large the level of eNO can also be used to monitor the effectiveness of
stores result in the long time lags, and small stores result in short inhaled corticosteroid in the treatment of asthmatic patients.
time lags. For example, if the alveolar ventilation increases, PaCO2
decreases and the stores of CO2 also begin to decline; however, this TRANSCUTANEOUS MONITORING
second part requires time to happen and can be identified by the
trending of CO2. In this situation, if V E increases, SBCO2 increases Transcutaneous monitoring is another noninvasive method that
and PaCO2 initially declines. After a slight delay, because the pro- can be used to indirectly assess a patient’s oxygenation (PaO2)
duction of CO2 remains constant, the PaCO2 remains low and the and ventilation (PaCO2) status. Unlike pulse oximetry and
monitored exhaled VCO  2 returns to baseline, indicating that a capnography, which rely on spectrophotometric analysis, trans­
balance has returned. Plotting SBCO2 curve trends over time using cutaneous monitoring uses modified blood gas electrodes to
a trending graph is the best way to monitor these types of changes. measure the oxygen and carbon dioxide tensions at the skin surface
(Box 10-4).34,35
EXHALED NITRIC OXIDE MONITORING Transcutaneous PO2
Nitric oxide (NO) has potent dilatory effects on the pulmonary Devices used to monitor the transcutaneous partial pressure of
vessels and airways. It has also been shown to facilitate coordinated oxygen (PtcO2) consist of a servo-controlled, heated (Clark) polaro-
beating of ciliated epithelial cells. The synthesis of NO by the body graphic electrode connected to a central processing unit (Fig.
is mediated through a series of enzymes that are referred to as NO 10-16, A).36-38 The electrode housing, which is covered with a Teflon
 Assessment of Respiratory Function CHAPTER 10 173

BOX 10-4 Summary of AARC Clinical Practice Guideline for Transcutaneous Blood Gas Monitoring

Setting Contraindications/Complications
1. Monitoring mechanically ventilated patients (e.g., Transcutaneous monitoring may be relatively contraindicated in
conventional modes of ventilation, high-frequency patients with poor skin integrity and/or adhesive allergy. Compli-
ventilation, and noninvasive ventilation. cations may include thermal injury at the sensor site resulting in
2. Bronchoscopies and procedures requiring sedation or erythema, blisters, burns, and skin tears. Misinterpretation of data
patient-controlled analgesia. may lead to inappropriate treatment of a patient.
3. Sleep studies.
4. Pulmonary function testing (e.g., stress testing, Monitoring
bronchoprovocation). The following should be recorded when monitoring transcutane-
5. Trending HCO3− in patients with diabetic ous measurements:
ketoacidosis. 1. Clinical appearance of the patient, including subjective
6. Apnea testing. assessment of perfusion, pallor, and skin temperature
7. Patient transport. 2. Date and time of the measurement
8. Evaluation of tissue perfusion. 3. Patient position
9. Evaluation of hyperventilation during phonation of patients 4. Respiratory rate
with vocal cord disorders. 5. Physical activity level
10. Titrating long-term oxygen therapy. 6. FIO2 and the type of oxygen delivery device if supplemental
oxygen is being administered
Indications
7. Mode of ventilator support (i.e., ventilator or CPAP settings)
1. Monitoring the adequacy of arterial oxygenation and/or
8. Electrode placement site, electrode temperature, and time of
ventilation.
placement
2. The need to quantify the response to diagnostic and
9. Results of simultaneous measurements of PaO2, PaCO2, and pH
therapeutic interventions (e.g., administering enriched
oxygen mixtures, application of PEEP). Limitations
3. Transcutaneous oxygen index (PtcO2/FIO2) can be used as a Technical and clinical factors may affect the reliability of transcu-
marker of hypoperfusion and mortality. taneous readings and therefore limit the application of transcuta-
4. Tissue perfusion status and revascularization in wound care neous monitoring. Improper calibration, trapped air bubbles, and
(e.g., during hyperbaric oxygen therapy) and peripheral damaged membranes can affect the accuracy of the measure-
vascular disease. ments of PtcO2 and PtcCO2. The presence of hyperoxemia (PaO2 >
5. Monitoring response to therapy in patients with diabetic 100 mm Hg) or a hypoperfused state (e.g., shock) can increase the
ketoacidosis, as PtcCO2 correlates with serum HCO3− levels. difference between PtcO2 and PaO2.

(Source: AARC Clinical Practice Guideline: transcutaneous monitoring of carbon dioxide and oxygen: 2012, Respir Care 57(11):1955-1962, 2012.)

Anode Heater
Heater
Thermistor Thermistor

Cathode

Membrane Electrolyte chamber pH electrode

A Spacer B Membrane Electrolyte

Fig. 10-16 Transcutaneous electrodes. A, Transcutaneous partial pressure of oxygen (PtcO2). B, Transcutaneous partial pressure
of carbon dioxide (PtcCO2). (From Deshpande VM, Pilbeam SP, Dixon RJ: A comprehensive review in respiratory care, East Warwick,
CT, 1988, Appleton & Lange.)

membrane, attaches to the skin surface with a double-sided adhe- altering the structure of the stratum corneum. The stratum
sive ring. The electrode is heated to 42° to 45° C to produce capil- corneum has been described as a mixture of fibrinous tissue within
lary vasodilation below the surface of the electrode. Note that a lipid and protein matrix. It has been suggested that heating the
heating improves diffusion of gases across the skin because it skin to temperatures greater than 41° C melts the lipid layer, thus
increases local blood flow at the site of the electrode, as well as enhancing gas diffusion through the skin.
174 CHAPTER 10 Assessment of Respiratory Function

Although correlation of PtcO2 and PaO2 (PtcO2/PaO2 index) has points, respectively. Electrodes should be calibrated before their
been shown to be good for neonates, it is often unreliable for criti- initial use on a patient. Manufacturers typically suggest that the
cally ill adult patients.39 A decrease in peripheral perfusion caused electrode should be recalibrated each time it is repositioned.
by reductions in cardiac output or by increases in peripheral (cuta- 6. Reports of PtcO2 and PtcCO2 readings should include notation
neous) resistance can significantly affect the accuracy of PtcO2 mea- of the date and time of the measurement, the patient’s activity
surements.40,41 Data indicate that when the cardiac index is greater level and body position, and the site of electrode placement,
than 2.2 L/min/m2, the PtcO2/PaO2 index is 0.5, whereas for a along with the electrode temperature. The inspired oxygen
cardiac index less than 1.5 L/min/m2, it is only 0.1.42 Therefore concentration and the type of equipment used to deliver supple-
hypoperfusion of the cutaneous circulation caused by pathologic mental oxygen should always be included. The clinical appear-
states (e.g., septic shock, hemorrhage, or heart failure) or by ance of the patient, including assessment of peripheral perfusion
increased vascular resistance (e.g., hypothermia or pharmacologic (i.e., pallor, skin temperature), is important data to note. In
intervention) can produce erroneous data. Because the PtcO2 is cases where invasive ABG measurements are available, these
influenced by blood flow to the tissues, as well as by oxygen utiliza- data are recorded for comparison with PtcO2 and PtcCO2
tion by the tissues, changes in this value may be used as an early readings.
indicator of vascular compromise or shock. Burns are probably the most common problem that clinicians
encounter during transcutaneous monitoring. Burns can occur
Transcutaneous PCO2 because the site of measurement must be heated to 42° to 45° C.
Measurement in the transcutaneous CO2 partial pressure (PtcCO2) Repositioning the sensor every 4 to 6 hours can help to avoid
was introduced into clinical practice in the late 1970s after the this problem.41 When transcutaneous monitoring is used with
successful use of PtcO2 monitors in neonatal ICU patients was dem- neonates, the sensor should be repositioned more often (e.g.,
onstrated. Standard devices use a modified Stowe–Severinghaus every 2 hours).
blood gas electrode, which is composed of pH-sensitive glass with A problem can occur with PtcO2 and PtcCO2 readings if the
an Ag/AgCl electrode (Fig. 10-16, B). As with the PtcO2 electrode, electrode is applied improperly. A leak-proof seal must be main-
the PtcCO2 electrode is heated to 42° to 45° C. PtcCO2 values are tained at the skin surface for the readings to be meaningful. A leak
slightly higher than PaCO2, primarily because of the higher meta- allows room air to contact the sensor and results in higher than
bolic rate at the site of the electrode caused by heating the skin. actual PtcO2 and lower than actual PtcCO2 readings even though the
Most commercial instruments incorporate correction factors into patient’s clinical condition has not changed.
their system’s software to remove this discrepancy between PtcCO2 When combined O2/CO2 electrodes are used, hydroxyl (OH−)
and PaCO2. ions produced at the PO2 cathode may interfere with PtcCO2 read-
ings. This problem has been reduced by stoichiometric consump-
Technical Considerations tion of OH− by an anodized anode.24
Some simple rules apply when using transcutaneous monitors.
These relate to care, placement, and calibration of the electrodes.
Establishing a set routine for these three tasks will help to ensure Indirect Calorimetry and Metabolic
accurate and useful measurements41: Measurements
1. The transcutaneous monitor manufacturer should have vali-
dated transcutaneous monitor, electrodes, calibration gases,
OVERVIEW OF INDIRECT CALORIMETRY
and supplies, using accepted quality control procedures and
clinical reliability studies. Indirect calorimetry allows the clinician to estimate energy
2. Transcutaneous electrodes are bathed by an electrolyte solution expenditure from measurements of oxygen consumption ( VO  2)
(see Fig. 10-16). This solution can easily evaporate because of and carbon dioxide production ( VCO  2 ). 43
This technique is based
the heat applied to the electrode. The electrolyte and the sen- on the theory that all the energy that a person uses is derived from
sor’s membrane should be changed weekly or whenever the the oxidation of carbohydrates, fats, and proteins and that the ratio
respiratory care practitioner notices a signal drift during cali- of carbon dioxide produced to oxygen consumed (i.e., the respira-
bration. Because silver can become deposited on the cathode, 
tory quotient or VCO 
2 / VO2 ) is characteristic for the fuel being
periodic cleaning of the electrode is suggested, using the manu- burned (Box 10-5).44 Although the use of metabolic measurements
facturer’s recommendations. varies considerably, many clinicians are becoming comfortable
3. Before placing an electrode on the patient’s skin, the site should with this emerging technology and recognize that metabolic mea-
be cleansed using an alcohol swab. In cases where hair may be surements can provide valuable information for designing nutri-
present, the site should be shaved to ensure good contact tional support regimens.
between the electrode and the skin. Before applying the elec-
trode to the skin, a drop of electrolyte gel or deionized water Technical Considerations
should be placed on the electrode’s surface to enhance gas dif- The most commonly used devices for indirect calorimetry are
fusion between the skin and the electrode. open-circuit gas exchange monitors (Fig. 10-17). They are often
4. PtcO2 monitors are calibrated using a two-point calibration in referred to as metabolic monitors or metabolic carts. A typical meta-
which room air (PO2 of about 150 mm Hg) serves as the high bolic monitor includes analyzers for measuring the concentration
PO2 of the calibration and an electronic zeroing of the system of inspired and expired gases, as well as a sensor for measuring the
serves as the low PO2 of the calibration. volume and/or flow of respired gases. The O2 analyzer is a rapid
5. PtcCO2 monitors are also calibrated with a two-point calibration responding polarographic or zirconium oxide oxygen analyzer. The
procedure. In this calibration, a 5% CO2 calibration gas and a CO2 analyzer is a nondispersive, infrared analyzer. Volume and
10% CO2 calibration gas are used for low and high calibration flow measurements can be obtained using pneumotachometers,
 Assessment of Respiratory Function CHAPTER 10 175

Gas sample from inspired limb of ventilator

FIO2
FICO2 FECO2, FEO2
O2 and CO2
analyzers
G S G S
A A A A
S M S M
P P
L L
E E

Expired gas from ventilator

Constant
•
flow (V)
Constant Mixing chamber
flow
generator
Room air

Deltatrac

Fig. 10-17 Major components of a metabolic monitoring system. (Source: Weissman CM, Sadar A, Kemper MA: In vivo
evaluation of a compact metabolic measurement instrument, J Parenter Enteral Nutr 14:216-221, 1990. Redrawn from Levine RL,
Fromm RE: Critical care monitoring, St Louis, 1995, Mosby.)

 2 and VCO
VO  2 are calculated by comparing the fractional con-
BOX 10-5 Variations in Respiratory Quotient (RQ) centrations of O2 and CO2 of inspired and expired air. For patients
breathing room air, the FIO2 can be assumed to be 0.209 and the
Substrate RQ
FICO2, 0.03. For patients receiving enriched oxygen mixtures, the
Carbohydrate oxidation 1.0
FIO2 must be measured by the system.46,47 Fluctuations in FIO2 can
Fat oxidation 0.7
be caused by air leaks in the patient-ventilator-metabolic monitor
Protein oxidation 0.8
Lipogenesis >1.0
system and also by varying gas volumes and pressure demands,
such as occur during intermittent mandatory ventilation (IMV).
Unstable air–oxygen blending systems within the ventilator circuit
may also contribute to unstable FIO2 values (this problem can be
turbine flow meters, or ultrasonic vortex flow meters. Barometric prevented with the use of an external air–oxygen blender). Clinical
pressure and expired gas temperatures are monitored with studies have shown that some systems may not provide accurate
temperature-sensitive, solid-state (integrated circuit) transducers. and reproducible VO  2 measurements for patient breathing FIO2
values greater than 0.5.46 Box 10-6 provides a summary of the
Obtaining Indirect Calorimetry Measurements AARC Clinical Practice Guideline for using indirect calorimetry
A spontaneously breathing patient who is breathing room air can during mechanical ventilation.
be connected to the system by having the patient breathe through
a mouthpiece or a mask that is attached to a nonrebreathing valve. Clinical Applications of Metabolic Measurements
Specially designed canopies and hoods can also be used for spon- Indirect calorimetry can provide information on energy expendi-
taneously breathing patients who are not receiving ventilatory ture (EE) and the pattern of substrate utilization. EE represents an
support. individual’s caloric expenditure calculated from measured VO  2
Patients with ETs or tracheostomy tubes who are being mechan- 
and VCO 2 values. EE can be calculated with the deWeir equation
ically ventilated can be connected to the system by placing the shown in Box 10-7. Note that the urinary nitrogen (UN) is deter-
nonrebreathing valve directly onto the airway opening and direct- mined separately by the clinical laboratory using a 24-hour urine
ing the expired gases into the system. It is important to inflate the sample. The UN is one of the end products of protein metabolism;
cuffs of ETs and tracheostomy tubes when measuring inspired and therefore the number of grams of nitrogen excreted in the urine is
expired gases. Failure to inflate the cuff will result in loss of expired directly related to the amount of protein used by the individual. If
air around the tube (system leak) and erroneous measurements of nitrogen excretion data are not available, EE can be calculated
 2 and VCO
VO  2 . For patients receiving a continuous flow of gas using the modified deWeir equation. In this latter equation, it is
during ventilatory support, such as occurs when an external flow assumed that protein represents 12% to 15% of the total energy
from a flow meter is used to power a small volume nebulizer inline, expenditure.
an isolation valve must be used to ensure that only the patient’s Energy expenditure can be expressed in kilocalories per
exhaled gases are delivered to the system.45-47 day (kcal/day) or relative to the individual’s body surface area
176 CHAPTER 10 Assessment of Respiratory Function

BOX 10-6 Summary of AARC Clinical Practice Guideline for Metabolic Measurement Using Indirect
Calorimetry During Mechanical Ventilation
Indications 4. Inspiratory reserves may cause a reduction in alveolar
1. Metabolic measurements may be indicated in patients with ventilation due to increased compressible volume of the
known nutritional deficits and derangements. Multiple breathing circuit.
nutritional risk and stress factors that may skew predictions Inaccurate measurements of REE and RQ during open circuit
made using the Harris-Benedict equation (e.g., neurologic measurements may be caused by:
trauma, COPD, acute pancreatitis, multiple trauma, severe 1. Instability of FIO2 within a breath or breath to breath due to
sepsis, extreme obesity, severe hypermetabolic or changes in the source gas pressure and ventilator blender
hypometabolic patients). characteristics.
2. To measure O2 cost of breathing in patients who fail attempts 2. FIO2 >0.60.
at liberation from mechanical ventilation. 3. Inability to separate inspired and expired gases due to bias
3. To measure VO  2 and cardiac output by the Fick equation for flow and flow-triggering systems, IMV systems, or specific
patients requiring hemodynamic monitoring. ventilator characteristics.
Contraindications/Complications 4. Presence of anesthetic gases or gases other than O2, CO2, and
1. Manipulation of the ventilator circuit for connection of nitrogen in the patient-ventilator circuit.
measurement lines may cause leaks that may lower alveolar 5. Presence of water vapor resulting in sensor malfunction.
ventilation and result in hypoxemia, bradycardia, or other 6. Inadequate length of the measurement.
adverse connections. Assessment of Test Quality and Outcome
2. Inappropriate calibration or system setup may result in 1. RQ is consistent with the patient’s nutritional intake.
erroneous results leading to incorrect patient management. 2. RQ at rest is in the normal physiological range (0.67 to 1.3).
3. Isolation valves may increase circuit resistance and cause  2 and VCO
3. Variability of VO  2 measurements should be within a
increased work of breathing and/or dynamic hyperinflation physiological range (0.7 to 1.0).
(auto-PEEP).

(Source: AARC Clinical Practice Guideline: Metabolic measurement using indirect calorimetry during mechanical ventilation—2004 revision and update,
Respir Care 49(9):1073-1079, 2004.)

Formulas Used During Indirect (kcal/h/m2). A normal, healthy adult uses about 1500 to 3000 kcal/
BOX 10-7 Calorimetry day or about 30 to 40 kcal/h/m2.48
Another method used to express the level of energy metabolism
Harris-Benedict Equations*
is to compare the measured EE to predicted EE, which is based on
Men: Energy expenditure (EE) = 66.5 + (13.75 × weight)
the individual’s age, weight, and height. (The Harris-Benedict
+ (5.003 × height) − (6.775 × age)
equations shown in Box 10-7 are examples of reference equations
Women: EE = 655.1 + (9.563 × weight) + (1.85 × height)
− (4.676 × age) used in clinical practice.) If the measured EE is greater than 120%
where weight is measured in pounds, height is measured in of the predicted EE, a hypermetabolic state exists. Conversely,
inches, and age is determined in years. when the measured EE is less than 80% of the predicted EE, a
hypometabolic state exists.
Energy Expenditure†
 2 ) + 1.106 ( VCO
 2 )] × 1.44 Numerous factors can influence the metabolic rate, including
deWeir equation: EE = [3.941 ( VO
the type and rate of nutrition that is ingested; the time of day the
− [2.17 UN]
 2 ) + 1.1 ( VCO
Modified deWeir equations: EE = [3.9 ( VO  2 )] × 1.44 measurement is made; the patient’s level of physical activity; and
whether he or she is recovering from infection, surgery, or trauma.49
Substrate Utilization‡ The presence of chronic gastrointestinal, hepatic, renal, endocrine,
 2 − 2.909 VO
Carbohydrates: dS = 4.115 VCO  2 − 2.539 UN
 2 − VCO
 2) − 1.943 UN cardiovascular, and pulmonary diseases can also influence the
Fats: dF = 1.689 ( VO
metabolic rate.50 Box 10-8 lists several conditions that are associ-
Proteins: dP = 6.25 UN
ated with hypermetabolic and hypometabolic states.
dS, dF, and dP represent grams of carbohydrate, fat, and protein, Prolonged starvation is associated with a decreased metabolic
respectively, for a fasting individual. rate. Feeding raises metabolic rate through a mechanism referred
*Harris JA, Benedict FG, eds: Standard basal metabolism constants for to as specific dynamic action. It is thought that specific dynamic
physiologists and clinicians: a biometric study of basal metabolism in
man, Philadelphia, 1991 Lippincott Williams & Wilkins.
action is related to the digestion and absorption of food. EE can
†
Weir JB: A new method for calculating metabolic rate with special show diurnal variation; it usually is lowest on awakening in the
reference to protein metabolism, J Physiol 109:1-9, 1949. morning and increases 10% to 15% by late afternoon.50,51 This
‡
Burszein S, Saphar S, Singer P, et al: A mathematical analysis of increase in energy expenditure may be related to hormonal changes
indirect calorimetry measurement in acutely ill patients, Am J Clin Nutr that occur during the day.
50:227-230, 1980.
Sleep is associated with a reduction in metabolic rate, whereas
even the slightest exertion is associated with increases in metabolic
rate. Changes in body temperature, as occur with bacterial and
viral infections, can profoundly affect the metabolic rate. For
example, an increase in body temperature of 1°C will cause 10%
 Assessment of Respiratory Function CHAPTER 10 177

Examples of Hypermetabolic and approach 0.7) and reduces the CO2 load to the lungs. It is reason-
BOX 10-8 Hypometabolic States able to suggest that this change would enhance the potential for a
successful weaning outcome. See Critical Care Concept 10-1 for a
Hypermetabolic States discussion of the advantages of using indirect calorimetry in the
Pancreatitis
management of critically ill patients.
Hyperthyroidism
Pregnancy
Drugs (e.g., stimulants)
Hyperthermia (fever) Key Point 10-3 The types of substrates ingested and the ability of
Seizures an individual to use various foods influence substrate utilization.
Burns
Hypometabolic States
Starvation CRITICAL CARE CONCEPT 10-1
Hypothyroidism
Anesthesia Indirect Calorimetry
Sedation Prediction equations used by clinicians to determine
Hypothermia energy needs for hospitalized patients are derived from
Coma studies of healthy subjects. Clinicians generally agree that
using standard prediction equations to estimate energy
needs for critically ill patients provides values that compare
increase in metabolic rate. Burns, long-bone fractures, and surgery poorly with measured values, such as those reported from
can increase the metabolic rate by as much as 200%.50 indirect calorimetry. The energy needs of these patients
The substrate utilization pattern is the proportion of carbohy- tend to be quite diverse and can lead to over- or under-
drates, fats, and proteins that contribute to the total energy metab- nutrition. Although stress factors can be added to the cal-
olism. The percentage of the total energy that a substrate contributes culation of predicted caloric intake, these factors may be
can be derived from measurements of the RQ (the ratio of VCO  2 misleading, particularly in those patients demonstrating
 2 ). The RQ levels for the various foods are known; when pure
to VO multisystem problems.
fat is burned, the RQ equals 0.7. The RQ for pure carbohydrate is
1.0, and the RQ for protein is approximately 0.8. RQ levels greater
than 1.0 are associated with lipogenesis (fat synthesis) and hyper-
ventilation. RQ levels less than 0.7 are associated with ketosis.
A healthy adult consuming a typical American diet derives 45%
Assessment of Respiratory System Mechanics
to 50% of his or her calories from carbohydrates, 35% to 40% from
lipids, and 10% to 15% from proteins. The resultant RQ will range The assessment of respiratory system mechanics for patients
from 0.80 to 0.85. Note that proteins normally contribute only receiving ventilatory support begins with measurements of pres-
minor amounts to energy metabolism. The percentage of protein sure, volume, and flow events. Once these measurements have been
used represents the normal turnover rate for replenishing struc- made, the clinician can calculate derived values for respiratory
tural and functional proteins in the body. Proteins may contribute system compliance, airway resistance, and the work of breathing.54
significantly to EE in cases of starvation. For this reason, a nonpro- Chapter 1 discusses the physiological concepts required for an
tein RQ is usually reported to indicate the contribution to RQ understanding of respiratory mechanics in mechanically ventilated
made by carbohydrates and lipids. patients. The following is a brief description of the devices
The types of substrates ingested and the ability of the individual and techniques that are used to measure airway pressures, volumes,
to use various foods determine substrate utilization. For example, and flows.
feeding large amounts of glucose will raise the RQ to about 1.0,
suggesting that carbohydrates are providing most of the EE. Pro- MEASUREMENTS
longed starvation will lower the RQ to about 0.7, indicating that
the individual is relying almost completely on fats for energy. Many Airway Pressure Measurements
systemic diseases will adversely affect an individual’s ability to use Mechanical ventilators have traditionally allowed for measure-
various substrates. For example, several studies have shown that ments of airway pressures by incorporating an aneroid manometer
patients with severe sepsis demonstrate RQ levels of approximately into the ventilator circuit. With this arrangement, the manometer
0.7 because of reliance on lipid metabolism for energy and their records pressure changes within the ventilator, which includes con-
inability to use carbohydrates. tributions from ventilator resistance. Measuring airway pressure
Monitoring of substrate utilization patterns also can assist the near the airway opening can minimize the effects associated with
clinician who is trying to wean patients with limited ventilatory ventilator resistance. Thus, in the current generation of adult and
reserve from mechanical ventilation (Key Point 10-3). It has been neonatal ventilators, airway pressure is measured using electrome-
demonstrated that feeding these patients diets containing a high chanical transducers (e.g., piezoelectric, variable capacitance,
percentage of carbohydrates will raise their VCO  2 to a greater strain gauge) that connect to pressure sampling ports that are
extent than their VO  2 (RQ approaches 1.0).52,53 The added CO2 located near the airway opening (i.e., measurements can be made
load placed on these patients (remember they have limited ventila- on the inspiratory limb of the ventilator circuit, the expiratory side
tory reserve) is greater than their own ventilatory capacity, and of the circuit, or directly at the ET).
they fail to wean. Switching their diet to one that has a higher An alternative method of recording airway pressures during
fat/carbohydrate ratio lowers their VCO  
2 / VO2 ratio (RQ levels mechanical ventilation is to use a strain gauge pressure transducer
178 CHAPTER 10 Assessment of Respiratory Function

inspiratory pause control incorporated into the ventilator system

PIP
that closes the inspiratory and expiratory valves at the end of inspi-
ration so that Pplateau measurement can be obtained. As illustrated
30 Resistive in Fig. 10-18, Pplateau measurements require the establishment of a
work
Pressure (cm H2O)

period of zero flow for 1 to 2 seconds to allow pressure equilibra-

Pplateau
tion to occur across the airway. This delay in pressure equilibration
and establishment of the Pplateau is the result of redistribution of the
tidal volume and stress relaxation. True Pplateau measurements can
15 be obtained only during a passive inspiration, and failure to estab-
lish a stable Pplateau can result from patient breathing activity or a
Elastic
work leak in the ventilator circuit.55,56

Flow Measurements
0
Gas flow during mechanical ventilation can be monitored with a
1.0 2.0 3.0 number of different types of flow meters, including vortex ultra-
sonic flow meters, variable orifice pneumotachometers, thermal
Time (sec)
flow meters, and turbine flow meters. With these devices,
Fig. 10-18 Airway pressure tracing for a patient on mechanical ventilation. PIP, Peak volume changes can be calculated by integrating the flow signal
inspiratory pressure; Pplateau, plateau pressure. relative to time.57,58
Vortex ultrasonic flow meters and variable orifice pneumotach-
ometers use resistive elements to create a pressure drop that is
that is normally used for measuring systemic and pulmonary arte- proportional to the flow of gas through them.57 Vortex ultrasonic
rial pressures. These transducers can be adapted for respiratory flow meters use struts to create a partial obstruction to gas flow. As
pressure measurements because respiratory pressures are similar gases flow past these struts, whirlpools or vortices are produced.
in magnitude to those found in the systemic or pulmonary arterial The frequency at which these whirlpools are produced is related to
vasculature.24,55 There are several points to remember when using the flow of gas through the struts. These devices are not affected
these types of pressure transducers. Hemodynamic pressures are by the viscosity, density, or temperature of the gas being measured.
recorded in millimeters of mercury (mm Hg) and respiratory pres- They are unidirectional devices and therefore cannot be used to
sures are recorded in centimeters of water (cm H2O); to convert measure inspiratory and expiratory flow simultaneously.57 The
from millimeters of mercury to centimeters of H2O, the mm Hg Servo-i (Maquet, Bridegewater, N.J.) uses ultrasonic transducer
value is multiplied by 1.36. Second, the transducer needs not be technology to measure expiratory gas flow. Rather than struts, two
filled with fluid for making airway pressure measurements. Third, ultrasonic transducers that alternate function are used. One acts as
the same transducer should not be used to obtain both airway the transmitting device and the other the receiver (Fig. 10-19). The
pressure and hemodynamic measurements, to avoid the possibility ultrasonic waves detect the expiratory gas flow characteristics as
of introducing an air embolus into the circulation. the patient’s exhaled air moves through the expiratory cassette and
The most common airway pressure measurements are peak provide a measure of exhaled tidal volumes and flows.
inspiratory pressure (PIP) and static, or plateau, pressure (Pplateau) Variable orifice pneumotachometers are disposable, bidirec-
(Fig. 10-18). As discussed in Chapter 1, PIP is the maximum pres- tional flow measuring devices that use a variable area, flexible
sure generated during inspiration. During volume-targeted venti- obstruction for measuring flow as a function of the pressure dif-
lation, PIP is determined by the tidal volume, peak flow, and ferential generated by the obstruction. They contain minimal dead
inspiratory flow. It is also influenced by the resistance and compli- space (about 10 mL), and they can measure flow from 0.02 to 3.0 L/
ance of the patient’s lungs and chest wall and by ET resistance and sec.59 Although the flow-pressure characteristics of these devices
the compliance of the ventilator circuit. During pressure-targeted are nonlinear, nonlinearity is typically compensated electronically.
ventilation, the target pressure set on the ventilator determines the Variable orifice pneumotachometers are used in the Bicore CP-100
PIP. Patient-triggering efforts can increase or decrease the PIP, pulmonary monitor, the Novametrics Ventrak monitoring system,
depending on the patient-ventilator synchrony.55 and the Hamilton Galileo ventilator (Fig. 10-20).
Pplateau is the amount of pressure that is required to maintain the Thermal flow meters (“hot wire” anemometers) use sensors that
tidal volume within the patient’s lungs during a period of no gas are temperature-sensitive, resistive elements (e.g., thermistor beads
flow. As such, Pplateau reflects that alveolar pressure (Palv), and it is or heated wires). These devices operate on the principle that as gas
ultimately influenced by the tidal volume, the lung and thorax passes over the thermistor bead or the heated wire, the sensor cools
compliance, circuit elastance, and the total measured PEEP (includ- and its resistance changes in proportion to the gas flow. Note that
ing applied and auto-PEEP) (Key Point 10-4). the amount of cooling depends on the viscosity and the thermal
conductivity of the gas measured. With thermistor beads, cooling
increases resistance, whereas with a heated platinum wire, cooling
Key Point 10-4 Pplateau reflects alveolar pressure, and it is ulti- decreases resistance. The wire is typically heated above 37° C and
mately influenced by the tidal volume, the lung and thorax compliance, circuit protected by a low-resistance screen to prevent moisture accumula-
elastance, and the total measured PEEP. tion and debris impaction on the wire. The gas flow can be calcu-
lated because the amount of power needed to maintain the
temperature of the heating element above the temperature (e.g.,
Pplateau can be measured by occluding the expiratory valve at the end 37° C) is related to the log of the velocity of gas flow, and therefore
of a tidal inspiration. Many current ICU ventilators have an must be linearized. Thermal flow meters are unidirectional devices
 Assessment of Respiratory Function CHAPTER 10 179

Fig. 10-19 Ultrasonic flow transducers within the Servo-i expiratory cassette. (Courtesy Maquet, Inc, Wayne, N.J.)

Pressure measured electronically using a light beam that is interrupted each

tubes time the vane turns. Rotating vane devices are portable and easy
to use; however, they are slow to respond to flow changes resulting
from inertia and as such are inaccurate for measuring bidirectional
flows. As discussed in Chapter 8 (Figure 8-2), portable turbine flow
meters can be used during patient-ventilator checks when a flow
meter has not been incorporated into the ventilator’s design.
Airflow Orifice
Clinical Applications
Respiratory systems mechanics data can provide valuable informa-
tion for the clinician caring for a mechanically ventilated patient.
These data are generally divided into measured and derived vari-
ables. Measured variables include airway pressures, volumes, and
airflow. Derived variables, which are calculated from measured
Fixed Variable values, include respiratory system compliance, airway resistance,
orifice orifice and work of breathing. The following is a brief description of how
pathophysiological events and conditions can affect respiratory
Fig. 10-20 A pneumotachograph illustrating a fixed orifice and a variable orifice system mechanics.
(contains a moveable flap). (Redrawn from Sullivan WJ, Peters GM, Enright PL:
Pneumotachographs: theory and clinical application, Respir Care 29:736-749, 1984.) Measured Variables
As mentioned previously, PIP reflects the total force that must be
applied to overcome elastic and frictional forces offered by patient-
and cannot be used for measuring bidirectional flows during ventilator systems, and Pplateau represents that portion of the total
breathing. It is important to recognize that the density and viscos- pressure required to overcome only elastic forces. Increases in the
ity of the gas being measured can affect the accuracy and precision elastance of the respiratory system (i.e., decreases in compliance of
of the flow measurement. Correction factors for various gases can the lung and/or chest wall) will increase both peak and plateau
be applied through computer software.4 Thermal anemometers are pressures. Increases in respiratory system compliance will lower
available with the Covidien PB 840 ventilator and Dräger Oxylog both PIP and Pplateau. Increases in airway resistance increase PIP
3000 ventilators. without concomitant increases in Pplateau. Decreases in airway resis-
Turbine flow meters use a rotating vane that is placed in the tance (Raw) will lower PIP but not affect Pplateau. It is important to
path of gas flow. As gas flows through the device, the vane turns at recognize that changes in inspiratory flow or tidal volume should
a rate that is dependent on the flow rate of the gas. Gas flow there- not be made when monitoring Raw by this method. Also, the addi-
fore can be measured by counting the number of times the vane tion of PEEP (i.e., applied and auto-PEEP) will affect both PIP and
turns. This can be done mechanically by linking the vane to a Pplateau and should be taken into account (see the discussion on Raw
needle attached to a calibrated display. The rate of gas flow can be later in this chapter) (Key Point 10-5).
180 CHAPTER 10 Assessment of Respiratory Function

For mechanically ventilated patients, the compliance of the ventila-

Key Point 10-5 Addition of PEEP (applied and auto-PEEP) tor circuit (CT)* must be included in the calculation, so the formula
affects both PIP and Pplateau and should be taken into account when assessing is more accurately stated as:
changes in Raw.
Dynamic compliance = VT − [(PIP − PEEP) × C T ] (PIP − PEEP)

Static compliance is calculated by dividing the delivered tidal

Sudden increases in PIP should alert the clinician to a potential volume by the Pplateau minus the total PEEP (i.e., applied PEEP plus
problem like bronchospasm or mucus plugging. Other factors that auto-PEEP):
should be checked when determining the cause of increased airway
Static compliance = adjusted VT (Pplateau − PEEP)
resistance include partially blocked heat and moisture exchanger
(HME), incorrect ET size, water in ventilator tubing, and malfunc- As with dynamic compliance, the compliance of the ventilator
tioning expiratory valves. Increases in PIP can also be associated circuit must be included in the calculation. The resultant formula
with barotrauma or ventilator-induced lung injury; if these condi- is therefore
tions are suspected, Pplateau should be monitored because alveolar
Static compliance = VT − [(Pplateau − PEEP) × C T ]/ (Pplateau − PEEP)
overdistension and rupture are associated with high Palv, which in
turn results in a higher Pplateau. Static compliance in healthy adult subjects is approximately
Airflow monitoring can also alert the clinician to significant 100 mL/cm H2O; it is lower in adult patients receiving positive
changes in the resistance or compliance (or both) of the patient’s pressure ventilation. It ranges from 40 to 50 mL/cm H2O (men) or
respiratory system. For example, high-frequency ripples on the 35 to 45 mL/cm H2O (women) to as high as 100 mL/cm H2O in
inspiratory flow tracing can indicate turbulent flow caused by the either sex. (Static compliance is approximately 40 to 50 mL/cm
presence of secretions in the airway or water in the ventilator H2O in pediatric patients and 10 to 20 mL/cm H2O in neonates.)
circuit.54,59 Expiratory flow limitations should be suspected if the Pathophysiological conditions, such as pulmonary interstitial
decay in expiratory flow is linear rather than exponential (see fibrosis, pleural effusion, hyperinflation, consolidation, respiratory
Chapter 9). Flow measurements can also be used to detect the distress syndrome, and pulmonary vascular engorgement, are
presence of auto-PEEP because flow will still be present at the end associated with decreases in lung compliance. Conditions such as
exhalation. This approach to detecting auto-PEEP is more of a kyphoscoliosis and myasthenia gravis are also associated with
qualitative assessment and does not provide an accurate measure- increased chest wall elastic recoil and decreases in chest wall
ment of the level of auto-PEEP (see Fig. 9-7). compliance.
Serial measurements of dynamic and static compliance provide
Derived Variables considerably more information than single measurements can
Mean airway pressure. The mean airway pressure (Paw ) repre- provide. For example, congestive heart failure will lead to pulmo-
sents the average pressure recorded during the respiratory cycle. It nary vascular engorgement and a reduction in both static and
is influenced by peak inspiratory pressure, PEEP, inspiratory time dynamic compliance. Diuretics therapy reduces the level of
(TI), and total cycle time (TCT). It can be calculated using the engorgement and improves static and dynamic compliance. Bron-
following equation: chospasm causes a decrease in dynamic compliance but does not
always affect static compliance (static compliance may decrease if
1 air trapping occurs). If bronchodilator therapy resolves the bron-
Paw = [(PIP − PEEP) × (TI TCT)] + PEEP
2 chospasm, dynamic compliance returns to normal.

Paw can also be obtained by integrating the area under the pressure– Airway resistance. Airway resistance (Raw) is the opposition to
time curve. In most ICU ventilators, microprocessors incorporated airflow from nonelastic forces of the lung. Raw for the respiratory
into their electronic circuitry perform this calculation and provide system in a ventilated patient is about 5 to 7 cm H2O/L/sec. As
a continuous display of Paw. Oxygenation status can be significantly mentioned in Chapter 1, Raw is calculated by dividing the difference
improved by increases in Paw , and the application of PEEP has between PIP and Pplateau by the airflow (constant flow with volume
the greatest effect. However, excessive increases in Paw can also ventilation), or
adversely affect cardiac performance and lead to significant reduc-  (L sec)
R aw = (PIP − Pplateau ) V
tions in cardiac output (see Chapter 11).
Airway resistance is primarily determined by the diameter of the
Dynamic and static compliances. Compliance can be simply airway. A twofold decrease in airway diameter will result in a
defined as the lung volume achieved for a given amount of applied 16-fold increase in airway resistance (Poiseuille’s law).† Retention
pressure.60 Two types of compliance calculations can be used to of secretions, peribronchiolar edema, bronchoconstriction, or
describe this pressure–volume relationship: dynamic compliance dynamic compression of the airways results in increased airway
and static compliance. Dynamic compliance takes into account the resistance. Bronchodilation results in reduced Raw.
total impedance to volume changes (i.e., flow resistive and elastic
characteristics of the patient-ventilator interface); static compli-
ance is only influenced by the elastic characteristics of the lung- *Ventilator tubing compliance varies depending on the type and diameter
thorax unit. of tubing used. It is typically 2 to 3 mL/cm H2O.
Dynamic compliance is calculated by dividing the tidal volume
†
Poiseuille’s law describes the factors that affect laminar flow through a
smooth tube with a constant diameter. ΔP = V  × [(8ηl)/(πr4)], where ΔP =
by the PIP minus the PEEP, or
driving pressure (dynes/cm2), η = coefficient of viscosity of the gas, l = tube
length (cm), V  = gas flow (mL/sec), r = radius of tube (cm) (π and 8 are
Dynamic compliance = Exhaled VT (PIP − Pplateau ) constants).
 Assessment of Respiratory Function CHAPTER 10 181

Exhalation loop
E Inspiration loop
B
0.5

Volume (L)
D

Elastic resistance

Nonelastic resistance
C

FRC
5 10
A Transpulmonary pressure
(cm H2O)

Fig. 10-21 Pressure/volume changes that occur in a patient receiving controlled ventilation with a constant flow ventilator.

Work of breathing. The normal work of breathing (WOB) is that the accuracy of the calculation still needs to be studied. The
related to the energy required to take in a breath. WOB normally amount of work expended during a respiratory cycle can be esti-
is associated with nonelastic forces from gas moving through the mated by multiplying the pressure changes associated with a given
airway and inertial forces to move structures in the thorax. Intrin- volume change, or W = P × V. Alternatively, WOB can be calculated
sic work is a result of work done to overcome these normal elastic as W = (PIP − 0.5 × Pplateau)/100 × VT to estimate WOB during
and resistive forces and work to overcome a disorder or disease constant flow passive inflation of the lungs.63 A pressure–volume
process affecting normal workloads in the lungs and thorax. For curve can be used to make this estimate.63 Figure 10-21 illustrates
example, abnormal (increased) intrinsic work occurs in chronic the pressure and volume changes that occur in a patient receiving
bronchitis, in which the resistance to gas flow through the conduc- controlled mechanical ventilation (CMV) with a constant flow
tive airways increases. In fibrotic diseases of the lung, compliance with the ventilator doing the resistive and elastic work of breath-
is reduced and alveolar movement is restricted. This reduced ing.64 Contrast this to Fig. 10-22, which shows WOB required
movement impedes the ability of the lungs to expand, thus increas- during continuous positive airway pressure (CPAP). In this figure,
ing intrinsic work. WOB is the integral of airway pressure and VT; the greater the area
Extrinsic work is work imposed (WOBi) by systems that are of the loop, the greater the WOB. Loop A is an example of a free-
added to the patient. Common examples are the ET, trigger sensi- standing CPAP system. Spontaneous breaths occur clockwise—
tivity, demand valve systems, the humidifying device, and the inspiration to expiration. Loop B is CPAP through a ventilator
patient circuit.61 Expiratory work is increased by the resistance demand valve system and shows an increased WOBi. The area to
offered by the exhalation valve or PEEP valve. the left of the vertical lines (baseline pressure of 5 cm H2O) is the
WOBi during inspiration. The area to the right of the line repre-
Work of breathing defined. In physics, work (W) is defined as sents WOBi during expiration.
the product of force (F) acting on a mass to move it through a Figure 10-23 shows the components of a spontaneous breath
distance (d), or W = F × d. In fluid systems, such as the respiratory and a ventilator breath. It distinguishes those parts of the breath
system, we say that work is performed when an applied force or that the patient must do and those parts that the ventilator
pressure causes a volume to displace, as in inspiration and expira- provides.64
tion. The WOB is the integral of the product of pressure and Figure 10-24 compares the components of a normal spontane-
volume (W = ∫PV). That is, work is the amount of pressure that ous breath with a spontaneous breath with high impedance to
must be generated to result in the movement of a certain volume breathing (ET in place), and with a mandatory controlled breath.65
of gas. Work is reported in kilogram-meters (kg·m) or joules (J; Curve A represents breathing through an ET by a patient with
0.1 kg·m = 1 J). In healthy individuals, the WOB is about 0.5 J/L, high impedance (increased Raw or decreased compliance, or
 2 or 0.35 to 1.0 mL/L
which represents only 2% to 5% of the total VO both). This occurs during T-tube trials for ventilator liberation or
of ventilation. Oxygen consumption by the respiratory muscles during spontaneous breathing through a continuous flow system.
may be as high as 35% to 40% of total VO  2 in patients with COPD. Curve B represents the work done by the ventilator during a
WOB is sometimes described by the amount of oxygen consumed volume-controlled breath. The ventilator is doing all the work of
by the working respiration muscles, although this is difficult to breathing. A spontaneous breath under normal conditions is rep-
measure.61,62 WOB can also be defined as the pressure–time product resented by curve C.
when intrapleural pressure is monitored. Some have suggested that measuring the work of breathing in
this way may underestimate the total amount of work that a patient
Graphic representation of WOB. The WOB can now be moni- expends during assisted ventilation.66 Measurements of transdia-
tored through the use of graphic displays and calculated data pro- phragmatic pressures and pressure–time products may provide
vided by newer microprocessor-controlled ventilators and by accurate estimates of the work of breathing and the metabolic cost
special monitoring devices (esophageal pressure monitors). Note of breathing in mechanically ventilated patients.67
182 CHAPTER 10 Assessment of Respiratory Function

A B
500 500

Volume in mLs

Volume in mLs
0 5 0 5
Pressure in cm H2O Pressure in cm H2O

Fig. 10-22 Work of breathing (WOB) during continuous positive airway pressure (CPAP). WOB in this figure is the integral of
airway pressure and tidal volume. Loop A is an example of a freestanding CPAP system. Spontaneous breaths occur clockwise,
inspiration to expiration. Loop B is CPAP through a ventilator demand valve system. (Sources: Hirsch C, Kacmarek RM, Stankek K:
Work of breathing during CPAP and PSV imposed by the new generation mechanical ventilators: a lung model study, Respir Care
36:815-828, 1991; Kacmarek RM: The role of pressure support ventilation in reducing the work of breathing, Respir Care
33:99-120, 1988; Kirby RR, Banner MJ, Downs JB: Clinical applications of ventilatory support, New York, 1990,
Churchill-Livingstone.)

Work done by
ventilator B
Tidal volume

20
C
15
Pressure (cm H2O)

10
Work done by A
patient to trigger
5 demand valve
Muscle tension Ventilator pressure
0
Work Fig. 10-24 Pressure–volume loops under various conditions. A, Patient breathing
done by through an endotracheal tube with high impedance (increased resistance
5 patient to Work done and/or decreased compliance). B, Patient receiving a controlled volume breath.
overcome by patient C, Spontaneous breath under normal circumstances. (Sources: Kacmarek RM:
CL  Raw to trigger
10 The role of pressure support ventilation in reducing the work of breathing, Respir Care
the ventilator
33:99-120, 1988; MacIntyre NR: Weaning from mechanical ventilatory support:
Time volume-assisting intermittent breaths versus pressure-assisting every breath, Respir
Care 33:121-125, 1988.)
Fig. 10-23 Pressure requirements for a spontaneous (left) and an assisted breath
(right). The imposed work of breathing (WOBi) can occur during triggering of the
breath. In the spontaneous breath, the patient performs work to overcome elastic and
resistive forces, while in the assisted breath, the ventilator provides the work. CL, Lung product, which is an assessment of transdiaphragmatic pressure
compliance. (From Branson RD: Enhanced capabilities of current ICU ventilators: do during the inspiratory portion of the breathing cycle, is one method
they really benefit patients? Respir Care 36:362-376, 1991.) of estimating the contributions of the diaphragm during inspira-
tion. It is probably a better indication of a patient’s effort to breathe
than measurement of work derived from pressure–volume curves.
Figure 10-25, A, shows the positioning of the two balloon-
Pressure–time product. Measurement of the maximum inspira- tipped catheters used to measure transdiaphragmatic pressures
tory pressure (MIP) and the maximum expiratory pressure (MEP) and thus the pressure–time product. The catheters are inserted
provides nonspecific information about the strength of the respira- through the nose; one is positioned in the stomach (below the
tory muscles. It is possible to obtain more specific information diaphragm), and the other is positioned in the lower third of the
about the contributions of diaphragmatic contractions on breath- esophagus (above the diaphragm). Gastric (PGA) and esophageal
ing by measuring transdiaphragmatic pressure and the pressure– (Pes) pressures are measured during the respiratory cycle. The
time product.68,69 Transdiaphragmatic pressure is a measure of electronic difference between these two pressures is referred to as
the forcefulness of diaphragmatic contractions. The pressure–time the transdiaphragmatic pressure. When the transdiaphragmatic
 Assessment of Respiratory Function CHAPTER 10 183

Pes PGA

To pneumotachometer PGA

Pes

(cm H2O)
Pressure
TI TE

TTOT
A B

Fig. 10-25 A, Apparatus for measuring transdiaphragmatic pressures and the pressure–time product. B, Pressure–time curve
for a spontaneous breath. The waveforms illustrate pleural pressure changes during a breath. A variety of waveforms can be
displayed with the current respiratory mechanics software. Pes, Esophageal pressure; PGA, gastric pressure; TE, expiratory time;
TI, inspiratory time; TTOT, total time.

pressure is plotted over time, it provides a pressure–time curve that • Exhaled NO measurements can be used to assess the severity
can be used to estimate the activity of the diaphragm (Fig. 10-25, of a patient’s asthma exacerbation.
B). Thus, diaphragmatic activity during inspiration can be esti- • Transcutaneous O2 and CO2 measurements provide a noninva-
mated by integrating the area within the curve during inspiration; sive method of assessing oxygenation and ventilation status.
the resultant value is called the pressure–time product. Increases in • Indirect calorimetry provides new insights about the nutri-
the pressure–time product indicate a greater force of contraction tional status of spontaneously breathing and mechanically ven-
by the diaphragm. Conversely, decreases in the pressure–time tilated patients.
product are associated with less muscular force.69-71 • Several factors can influence the metabolic rate, including the
Although some clinicians consider the pressure–time product type and rate of food ingested, the time of day the measure-
a useful measurement for determining the effectiveness of dia- ments are made, the patient’s level of physical activity, and
phragm function during weaning from mechanical ventilation, its whether the person is recovering from surgery or an acute or
use is limited in the clinical setting.69,70 chronic illness.
• The substrate utilization pattern is the proportion of carbohy-
Occlusion pressure measurements. The occlusion pressure drates, fats, and proteins that contribute to the total energy
(P0.1s or P100) is the airway pressure measured after occluding the expenditure.
airway during the first 100 msec of a patient’s spontaneous inspira- • Bedside mechanics testing is an invaluable resource for opti-
tion. Clinical data suggest that P0.1 provides a useful index of ven- mizing mechanical ventilatory support.
tilatory drive and may be used as a predictor of weaning success • Current ICU mechanical ventilators incorporate microproces-
(i.e., elevated P0.1 is associated with weaning failure). For ventilator- sors that can provide breath-by-breath and summative reports
dependent patients, the P0.1 has also been shown to correlate with of pressure and flow events along with calculations of airways
the work of breathing during pressure support ventilation.17 (See resistance, respiratory compliance, and work of breathing.
Chapter 20 for additional information on P0.1.) • Dynamic compliance takes into account flow resistive
and elastic characteristics of the patient-ventilator interface,
whereas static compliance is influenced only by elastic charac-
teristics of the lung-thorax unit.
• Airway resistance is primarily determined by the diameter of
SUMMARY the airway.
• The work of breathing is influenced by intrinsic and extrinsic
• Noninvasive monitoring has become common practice in the factors. Intrinsic factors include the elastic and resistive forces
care of mechanically ventilated patients. that must be overcome during inspiration and expiration.
• Pulse oximeters, capnographs, and transcutaneous monitors Extrinsic factors are related to the work imposed by systems
have greatly improved the respiratory care practitioner’s ability that are added to the patient, such as endotracheal tubes,
to monitor changes in patients’ ABG levels. demand valve systems, the humidifying devices, and exhalation
• The presence of abnormal hemoglobin, such as carboxyhemo- valve or PEEP valve.
globin (smoke inhalation), produces an erroneously high SpO2 • The pressure–time product uses transdiaphragmatic pressure
and CO-oximetry should be performed to determine the true measurements to estimate the contributions of the diaphragm
oxygen saturation. during inspiration.
184 CHAPTER 10 Assessment of Respiratory Function

REVIEW QUESTIONS (See Appendix A for answers.)

1. Draw and label the normal components of the capnogram. 10. Which of the following conditions is associated with
hypermetabolism?
2. What is the pressure–time product? How can this variable be
A. Starvation
used in the management of mechanically ventilated patients?
B. Hypothyroidism
3. Which of the following conditions will adversely affect pulse C. Pregnancy
oximeter readings? D. Anesthesia
1. Hypovolemia
11. The following data were obtained from a mechanically
2. Methemoglobinemia
ventilated patient: V T = 600 mL, PIP = 30 cm H2O, PPlat = 20 cm
3. Anemia
H2O. What is this patient’s static compliance?
4. Hyperbilirubinemia
A. 20 mL/cm H2O
A. 1 and 2
B. 25 mL/cm H2O
B. 1 and 3
C. 30 mL/cm H2O
C. 1, 2, and 3
D. 60 mL/cm H2O
D. 2, 3, and 4
12. Which of the following conditions will cause a decrease in
4. Which of the following actions is indicated when there is
static and dynamic compliance?
disparity between SpO2, SaO2, and the clinical presentation of
1. Bronchospasm
a patient?
2. Congestive heart failure
A. Moving the probe to an alternative site to check for SpO2
3. Partial occlusion of the endotracheal tube
B. Replacing the pulse oximeter probe
4. Atelectasis
C. Measuring arterial oxygen saturation by CO-oximetry
A. 1 and 2
D. Disregarding the SaO2
B. 1 and 4
5. Which of these parameters is measured to obtain a functional C. 2 and 3
hemoglobin saturation? D. 2 and 4
1. O2Hb
13. What is associated with an increase in the work of breathing
2. HHb
in mechanically ventilated patients?
3. COHb
A. Bronchodilation
4. MetHb
B. Decreased spontaneous breathing frequency
A. 1 and 2
C. Switching from controlled mechanical ventilation to
B. 1 and 3
assisted ventilation
C. 2 and 3
D. Using a larger endotracheal tube
D. 3 and 4
14. Phase 3 of an SBCO2 curve represents which of the following?
6. An indistinct phase 3 on a patient’s capnogram is most often
A. Dead space
associated with:
B. Alveolar dead space
A. Rebreathing exhaled gas
C. A mixture of airway and alveolar gas
B. Anemia
D. Alveolar gas
C. Chronic obstructive pulmonary disease
D. Cheyne-Stokes breathing 15. The PEEP is increased on a patient receiving mechanical
ventilation. The SBCO2 curve shows a simultaneous shift to
7. In the clinical setting, the P(a-et)CO2 is normally:
the right and an increase in the area of zone Y. This would
A. −2 to −5 mm Hg
indicate which of the following?
B. 1 to 3 mm Hg
A. Lung recruitment and emptying of previously collapsed
C. 4 to 6 mm Hg
alveoli
D. 10 to 15 mm Hg
B. Increased alveolar dead space from reduced pulmonary
8. Which of the following data should be recorded when making perfusion
transcutaneous measurements? C. Decreased PaCO2 from improvement in oxygenation
1. Date and time of the measurement D. Increase in rebreathed volume
2. Clinical appearance of the patient
16. Which of the following will affect the level of exhaled NO in
3. Site of electrode placement on the patient
exhaled gas?
4. Type of oxygen delivery device and the FIO2
1. Presence of a pathologic condition
A. 1 only
2. Smoking habits
B. 2 and 4 only
3. Atopic status
C. 1 and 3 only
4. Patient’s gender
D. 1, 2, 3, and 4
A. 1 and 3 only
9. Which of the following conditions could lead to an elevated B. 2 and 4 only
RQ (>1.0)? C. 1, 2, and 4 only
A. Hyperventilation D. 1, 2, 3, and 4
B. Starvation
C. Diabetes mellitus
D. Sepsis