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Prolonged "phantom" square wave capnograph tracing after patient disconnection or extubation. Potential hazard
1Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Hebrew University of Jerusalem, Israel.
Background:
The authors report on the appearance of misleading square wave "phantom" capnograph tracings for approximately 3 min after disconnection from the Siemens Servo 900c ventilator. A series of experiments are described to examine the mechanism of this phenomenon.
Methods:
Patients were ventilated using the Siemens Servo 900c ventilator with the following settings: minute volume, 5 1/min; respiratory rate, 8 breaths/min; PEEP, 0 cm H2O; trigger sensitivity, 20 cm H2O. The ventilator was connected to the Siemens Servo Evac 180 evacuation system (25 1/min on evacuation flowmeter). Airway pressure and capnography were recorded at the Y piece during ventilation and after disconnection. A back-up ventilator was used to support the patient during disconnection of the ventilator being studied.
Results:
Initially, the "phantom" capnograph tracing closely resembled the square wave capnograph tracing before disconnection, but the amplitude and shape of the waveform gradually decayed. Based on experiments described in this article, the authors show that the carbon dioxide for the "phantom" capnograph tracing comes from the gas exhaled by the patient in the last breaths before disconnection and which is present in both the expiratory tubing and in the evacuation system. The small pressure gradient between the exhaust reservoir and the atmosphere causes reverse flow of expired gas after disconnection, when both the nonreturn flap valve at the exhaust outlet is open (due to minimal valve incompetence) and when the expiratory servo valve is open (in the absence of positive end-expiratory pressure). This continuous reverse flow is detected by the capnograph but is interrupted intermittently by each attempted positive pressure ventilation, thereby creating a "phantom" capnograph.
Conclusions:
After accidental disconnection of the patient from the breathing system, or after accidental extubation of the trachea, the "phantom" capnograph is likely to confuse even an experienced anesthesiologist into the mistaken belief that his rapidly deteriorating patient is being ventilated adequately. Several potential mechanisms to eliminate this phenomenon are outlined, including the avoidance of zero positive end-expiratory pressure. "Phantom" capnography provides an illustration of the dangers of using monitoring techniques, however reliable, as a substitute for vigilant clinical observation.