EtCO2 (End-Tidal Carbon Dioxide) Monitoring and Capnography Waveforms
End-tidal CO2 (etCO2) monitoring and
capnography have been
a valuable tool in a clinical setting (emergency medicine) for many decades (see medical reviews: Bhende MS, LaCovey, 2001; Cambra & Pons, 2003; Zwerneman, 2006). It has been
also applied for breathing retraining. It provides additional information about
the progress of a person in their breathing normalization. Sometimes,
however, etCO2 monitoring is used as a feedback or biofeedback mechanism.
Can capnometers improve the effectiveness of breathing exercises or could it
worsen the outcomes? What is the scope of correct application of capnometers
and capnography in breathing retraining?
First, let us consider expected arterial, alveolar, and end-tidal CO2
values in people with normal breathing and those who suffer from chronic diseases.
Since nearly 100% of people with chronic diseases suffer from chronic
hyperventilation (alveolar hyperventilation), they should have reduced CO2 levels in the expired air since metabolism in all groups of people is about the same. CO2 production rate in all groups of people is the same. Hence, CO2 levels in the expired gas is a parameter that accurately reflects minute ventilation.
Capnography waveforms, etCO2, and breathing patterns
Capnography can be used to measure end-tidal CO2. In conditions of normal breathing (6 L/min, 12 breaths/min, 500 ml for tidal volume) etCO2 is very close
to alveolar CO2. Since problems with lungs are not common and gas exchange
between alveoli and the blood is very fast and effective, alveolar CO2
reflects arterial CO2. Hence, for normal breathing parameters, capnography can be used to define CO2 level in the alveoli and arterial
blood. What about etCO2 in those people who have increased minute ventilation?
first problem with etCO2 monitoring relates to chest breathing. During
normal diaphragmatic breathing (shown by the capnography waveforms graph), we get a nice alveolar
plateau. As a result, it is easy to find the alveolar CO2 pressure that
corresponds to the top of this plateau. (In this case, the alveolar CO2 is
about 5% or 38 mm Hg, which is common for some modern normals.)
Chest breathing leads to a tricky effect that is described in 2 paragraphs of the bonus content right below here.
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Capnography waveforms and end tidal CO2
biofeedback monitoring during breathing exercises
If a person breath holds, his etCO2
reading is going to show zero (no CO2 exhaled). Obviously, his
alveolar and arterial CO2 values increase during breath holding.
person has a very shallow breathing pattern (with the tidal volume as his dead
space or about 200-250 ml), there would be almost no gas exchange (very
limited gas exchange will take place due to diffusion). Hence, his capnography
end-tidal CO2 pressure will be small, but the alveolar and arterial CO2
pressures will be much greater and increasing in time.
This effect could be also understood from the viewpoint of CO2 accumulation.
If a person holds his breath, his body accumulates CO2 and etCO2 is going to be
zero. If a person performs a
Buteyko reduced breathing exercise (breathing about 15-20 % less air with
reduced minute ventilation), it will take several minutes before stable CO2 values will be
shown by the capnometer since large amounts of CO2 can be dissolved in the blood, and
intra- and extra-cellular fluids. Hence, it will take several minutes (up to
5-7 min) for the stable waveforms to appear. Would etCO2 represent
arterial CO2 then?
Let us look in more detail. If the person practices Buteyko reduced breathing
exercise with strong air hunger (both minute ventilation and tidal volume are
reduced about 2 times), end tidal CO2 monitoring is not going to reflect the
alveolar CO2 concentration. Physiological studies have also found that people
with larger tidal volume and reduced respiratory frequency have abnormally high
etCO2 values. Since reduced breathing in the sick (those with less than 20 s for the body
oxygen test or more than 12 L/min for minute ventilation at rest) is done with
increased respiratory frequency and reduced tidal volume, they can get low etCO2 numbers,
while in reality their alveolar and arterial CO2 will be increasing during
the whole session (e.g., 10-15 minutes).
Vice versa, if a person starts a deep breathing exercise with increased
minute ventilation with deliberate extended
exhalations (to push all high-CO2 air out from the lungs), their etCO2
capnography monitoring will show increased etCO2 levels, while alveolar and arterial
CO2 concentrations will be less and less.
Western medical doctors also observed these effects during anesthesia.
A large review of medical literature resulted in an article " Misleading
end-tidal CO2 tensions" (Wahba & Tessler, 1996). In the abstract of the study, the authors wrote, "RESULTS:
(1) Patients with systemic disease, or when placed in the lateral position, or with haemodynamic instability have an increased Pa-PETCO2 gradient... (4) The magnitude and direction of change in PaCO2 and PETCO2 can be disproportionate and in the opposite direction.".
Finally, there are purely psychological factors that can seriously distort
etCO2 capnography results. When someone holds a capnometer under your nose, it
is difficult to maintain the automatic breathing pattern. Our breathing
parameters undergo large changes as soon as we pay attention to our
For example, most Buteyko breathing students, since they know that hyperventilation is
not good and they practiced the reduced breathing hundreds of times in the past, may
start reducing breathing as soon as there is something under their nose.
(Many Buteyko teachers even say to their students, "Japanese samurai had a
feather under their nose for 1 hour every day to train their breath.
The goal was to have this feather motionless." Hence, the capnometer could
immediately trigger this image.)
people may have a fantasy about the importance of deep breathing and they
may start practicing deep breathing as soon as someone holds a device under
The effects will be opposite: the Buteyko student will get abnormally low
etCO2 (and higher arterial CO2), while a "deep breather" will
get abnormally high etCO2 with reduced arterial CO2 concentrations.
Hence, etCO2 monitoring and capnography are not useful as biofeedback, but
can be used in the long run (e.g., once per day or once per week), as an additional tool for breathing retraining
control. This is how Dr. Buteyko viewed and described capnography.
The situation with the application of breathing devices (such as the Frolov
breathing or the DIY breathing device) is different since the practicing person
has to have large diaphragmatic inhalations and exhalations, while the capnometer
can be used to measure CO2 inside the breathing device or near the
place where air leaves the device. In this application (e.g.,
for the Frolov breathing device therapy), the results will show real CO2 values
in the container at the end of exhalations and etCO2 monitoring and capnography
waveforms can be used as