End-tidal carbon dioxide monitoring using a naso-buccal sensor is not appropriate to monitor capnia during non-invasive ventilation

Lise Piquilloud, David Thevoz, Philippe Jolliet, Jean-Pierre Revelly, Lise Piquilloud, David Thevoz, Philippe Jolliet, Jean-Pierre Revelly

Abstract

Background: In acute respiratory failure, arterial blood gas analysis (ABG) is used to diagnose hypercapnia. Once non-invasive ventilation (NIV) is initiated, ABG should at least be repeated within 1 h to assess PaCO2 response to treatment in order to help detect NIV failure. The main aim of this study was to assess whether measuring end-tidal CO2 (EtCO2) with a dedicated naso-buccal sensor during NIV could predict PaCO2 variation and/or PaCO2 absolute values. The additional aim was to assess whether active or passive prolonged expiratory maneuvers could improve the agreement between expiratory CO2 and PaCO2.

Methods: This is a prospective study in adult patients suffering from acute hypercapnic respiratory failure (PaCO2 ≥ 45 mmHg) treated with NIV. EtCO2 and expiratory CO2 values during active and passive expiratory maneuvers were measured using a dedicated naso-buccal sensor and compared to concomitant PaCO2 values. The agreement between two consecutive values of EtCO2 (delta EtCO2) and two consecutive values of PaCO2 (delta PaCO2) and between PaCO2 and concomitant expiratory CO2 values was assessed using the Bland and Altman method adjusted for the effects of repeated measurements.

Results: Fifty-four datasets from a population of 11 patients (8 COPD and 3 non-COPD patients), were included in the analysis. PaCO2 values ranged from 39 to 80 mmHg, and EtCO2 from 12 to 68 mmHg. In the observed agreement between delta EtCO2 and deltaPaCO2, bias was -0.3 mmHg, and limits of agreement were -17.8 and 17.2 mmHg. In agreement between PaCO2 and EtCO2, bias was 14.7 mmHg, and limits of agreement were -6.6 and 36.1 mmHg. Adding active and passive expiration maneuvers did not improve PaCO2 prediction.

Conclusions: During NIV delivered for acute hypercapnic respiratory failure, measuring EtCO2 using a dedicating naso-buccal sensor was inaccurate to predict both PaCO2 and PaCO2 variations over time. Active and passive expiration maneuvers did not improve PaCO2 prediction.

Trial registration: ClinicalTrials.gov: NCT01489150.

Keywords: End-tidal CO2; Hypercapnic respiratory failure; Non-invasive ventilation; Respiratory monitoring.

Figures

Figure 1
Figure 1
Naso-buccal sensor. Illustration of the naso-buccal sensor used in this study. This device is designed to collect expiratory gas immediately at the airway opening both at the nose and mouth levels.
Figure 2
Figure 2
Respiratory circuit. Illustration of the respiratory circuit used in the study. From the patient to the ventilator, the circuit consists of an hermetic nasobuccal mask, the dedicated proximal flow sensor of the V60 ventilator, the additional flow sensor inserted to record insufflated and exuflated flow-time curves, the dedicated whisper swivel to create a calibrated intentional leak to avoid CO2 rebreathing, and the ventilator single-limb pipe.
Figure 3
Figure 3
Bland-Altman plot of agreement between delta PaCO2and delta EtCO2. Bland-Altman plot of agreement between delta PaCO2 and delta EtCO2. PaCO2, CO2 partial pressure in arterial blood; EtCO2, end-tidal CO2; circle markers, COPD patients values; square markers, non-COPD patients values; COPD, chronic obstructive pulmonary disease. The horizontal lines represent the bias and the upper and lower limits of agreement.
Figure 4
Figure 4
Bland-Altman plot of agreement between PaCO2and EtCO2. Bland-Altman plot of agreement between PaCO2 and EtCO2. PaCO2, CO2 partial pressure in arterial blood; EtCO2, end-tidal CO2; circle markers, COPD patients values; square markers, non-COPD patients values; COPD, chronic obstructive pulmonary disease. The horizontal lines represent the bias and the upper and lower limits of agreement.
Figure 5
Figure 5
Evolution over time of PaCO2-EtCO2gradient for all the patients. This figure shows the evolution over time of PaCO2-EtCO2 gradient for all the patients. PaCO2, CO2 partial pressure in arterial blood; EtCO2, end-tidal CO2. Patient numbers 1, 3, 4, 5, 7, 9, 10, and 11 are COPD patients.
Figure 6
Figure 6
Bland-Altman plot of agreement between PaCO2and expired CO2after active and passive maximal expiration maneuvers. A Bland-Altman plot of agreement between PaCO2 and expired CO2 after active maximal expiration maneuver (ExPA). B Bland-Altman plot of agreement between PaCO2 and Expired CO2 after passive maximal expiration maneuver (ExPP). PaCO2, CO2 partial pressure in arterial blood. In both figures, the horizontal lines represent the bias and the upper and lower limits of agreement.

References

    1. Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374:250–9. doi: 10.1016/S0140-6736(09)60496-7.
    1. Ferrer M, Esquinas A, Arancibia F, Bauer TT, Gonzalez G, Carrillo A, et al. Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. Am J Respir Crit Care Med. 2003;168:70–6. doi: 10.1164/rccm.200209-1074OC.
    1. Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287:3238–44. doi: 10.1001/jama.287.24.3238.
    1. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350:2452–60. doi: 10.1056/NEJMoa032736.
    1. Takki S, Aromaa U, Kauste A. The validity and usefulness of the end-tidal pCO 2 during anaesthesia. Ann Clin Res. 1972;4:278–84.
    1. Whitesell R, Asiddao C, Gollman D, Jablonski J. Relationship between arterial and peak expired carbon dioxide pressure during anesthesia and factors influencing the difference. Anesth Analg. 1981;60:508–12. doi: 10.1213/00000539-198107000-00008.
    1. Moon RE, Camporesi EM. Respiratory monitoring. In: Miller DR, editor. Miller’s anesthesia. Volume 4th edition. 4. New York: Churchill Livingtone; 1994. pp. 1253–91.
    1. Hoffman RA, Krieger BP, Kramer MR, Segel S, Bizousky F, Gazeroglu H, et al. End-tidal carbon dioxide in critically ill patients during changes in mechanical ventilation. Am Rev Respir Dis. 1989;140:1265–8. doi: 10.1164/ajrccm/140.5.1265.
    1. Fletcher R, Jonson B, Cumming G, Brew J. The concept of deadspace with special reference to the single breath test for carbon dioxide. Br J Anaesth. 1981;53:77–88. doi: 10.1093/bja/53.1.77.
    1. Raheem MS, Wahba OM. A nasal catheter for the measurement of end-tidal carbon dioxide in spontaneously breathing patients: a preliminary evaluation. Anesth Analg. 2010;110:1039–42. doi: 10.1213/ANE.0b013e3181d365fd.
    1. Jabre P, Jacob L, Auger H, Jaulin C, Monribot M, Aurore A, et al. Capnography monitoring in nonintubated patients with respiratory distress. Am J Emerg Med. 2009;27:1056–9. doi: 10.1016/j.ajem.2008.08.017.
    1. Delerme S, Freund Y, Renault R, Devilliers C, Castro S, Chopin S, et al. Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED. Am J Emerg Med. 2010;28:711–4. doi: 10.1016/j.ajem.2009.04.028.
    1. Johnson DC, Batool S, Dalbec R. Transcutaneous carbon dioxide pressure monitoring in a specialized weaning unit. Respir Care. 2008;53:1042–7.
    1. Takano Y, Sakamoto O, Kiyofuji C, Ito K. A comparison of the end-tidal CO2 measured by portable capnometer and the arterial PCO2 in spontaneously breathing patients. Respir Med. 2003;97:476–81. doi: 10.1053/rmed.2002.1468.
    1. Gancel PE, Roupie E, Guittet L, Laplume S, Terzi N. Accuracy of a transcutaneous carbon dioxide pressure monitoring device in emergency room patients with acute respiratory failure. Intensive Care Med. 2011;37:348–51. doi: 10.1007/s00134-010-2076-1.
    1. Kelly AM, Klim S. Agreement between arterial and transcutaneous PCO2 in patients undergoing non-invasive ventilation. Respir Med. 2011;105:226–9. doi: 10.1016/j.rmed.2010.11.010.

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