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Year : 2011  |  Volume : 6  |  Issue : 4  |  Page : 217-220
Evaluation of a transcutaneous carbon dioxide monitor in patients with acute respiratory failure

1 Department of Respiratory Diseases, Hospital of Sestri Levante, Chiavarese, Italy
2 Department of Public Health, ASL4 Chiavarese, Italy

Date of Submission31-Dec-2010
Date of Acceptance05-May-2011
Date of Web Publication12-Sep-2011

Correspondence Address:
Antonello Nicolini
Department of Respiratory Diseases, Hospital of Sestri, Levante
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1817-1737.84776

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Background: Non-invasive measurement of oxygenation is a routine procedure in clinical practice, but transcutaneous monitoring of PCO 2 (PtCO 2 ) is used much less than expected.
Methods : The aim of our study was to analyze the value of a commercially available combined SpO 2 /PtCO 2 monitor (TOSCA-Linde Medical System, Basel, Switzerland) in adult non-invasive ventilated patients with acute respiratory failure. Eighty critically ill adult patients, requiring arterial blood sample gas analyses, underwent SpO 2 and PtCO 2 measurements (10 min after the probe was attached to an earlobe) simultaneously with arterial blood sampling. The level of agreement between PaCO2 - PtCO 2 and SaO 2 - SpO 2 was assessed by Bland-Altman analyses.
Results : Both, SaO 2 from blood gas analysis and SpO 2 from the transcutaneous monitor, and PaCO 2 and PtCO 2 were equally useful. No measurements were outside of the acceptable clinical range of agreement of ± 7.5 mmHg.
Conclusions : The accuracy of estimation of the TOSCA transcutaneous electrode (compared with the "gold standard" blood sample gas analysis) was generally good. Moreover, TOSCA presents the advantage of the possibility of continuous non-invasive measurement. The level of agreement of the two methods of measurement allows us to state that the TOSCA sensor is useful in routine monitoring of adults admitted to an intermediate respiratory unit and undergoing non-invasive ventilation.

Keywords: Non-invasive measurement, PaCO 2 , PtCO 2 , respiratory failure, SaO 2 , SpO 2 , transcutaneous electrode

How to cite this article:
Nicolini A, Ferrari MB. Evaluation of a transcutaneous carbon dioxide monitor in patients with acute respiratory failure. Ann Thorac Med 2011;6:217-20

How to cite this URL:
Nicolini A, Ferrari MB. Evaluation of a transcutaneous carbon dioxide monitor in patients with acute respiratory failure. Ann Thorac Med [serial online] 2011 [cited 2023 Feb 2];6:217-20. Available from:

Transcutaneous technology for the non- invasive monitoring of oxygen and carbon dioxide has been used for 40 years. It was initially believed that PtCO 2 measurements would not be satisfactory in adults because of their thicker epidermidis. The first transcutaneous electrode consisting of a stow-severinghaus glass electrochemical sensor was modified for transcutaneous use by the incorporation of a thermostatically controlled heater unit. A close correlation between the transcutaneous carbon dioxide tension (PtCO 2 ) and arterial carbon dioxide tension (PaCO 2 )was demonstrated. [1] Transcutaneous measurements of oxygen and carbon dioxide depend on an increased capillary blood flow due to a heating element in the electrode increasing the temperature of underlying tissue: the electrode then measures the gas tension of the underlying tissue. In stable hemodynamic conditions, the two measurements correlate well. [2] In adults there is a greater variation than in pediatric patients from site to site and the suggested locations for optimal results are the forearm, chest, abdomen or earlobe. Recently, a combined sensor has been developed for the measurements of both transcutaneous CO 2 and pulse oximetric saturation: this electrode contains an electrochemical electrode (for PtCO 2 ), a light emitter-sensor (for SpO 2 ), and a heating element to increase local perfusion. The small size of the sensor allows convenient placement on the earlobe. [3] The sensor's measurement directly reflects PaCO 2 and oxygen saturation (SaO 2 ). [3],[4] Arterial blood gas analysis is the gold standard for PaCO 2 measurement, but this method presents major disadvantages because each determination of PaCO 2 requires withdrawal of arterial blood and laboratory analysis. Other disadvantages are that assessment of PaCO 2 is intermittent; relatively expensive; and there is a time delay in obtaining results. In addition, the need for invasive monitoring is not without complications such as infection, hemorrhage, and vessel occlusion. [5] Previous studies of correlation between PaCO 2 and PtCO 2 have had conflicting findings and have not targeted to subgroups with severe ventilatory disturbance such as those requiring non invasive ventilation. [5] Our study was aimed to determine the feasibility of estimating arterial PCO 2 using a combined SatO 2 /PtCO 2 monitor (TOSCA, Linde Medical System, Linde Basel, Switzerland) in patients with acute respiratory failure undergoing non invasive ventilation.

   Methods Top

The study was approved by the Local Research Ethics Committee. Eighty patients were enrolled after giving their informed consent: they were hemodynamically stable and admitted to the Intermediate respiratory care unit of the Respiratory Diseases Division of the Hospital of Sestri Levante. Each subject had acute respiratory failure needing non-invasive ventilation. The principal disease causing respiratory failure was chronic obstructive pulmonary disease (COPD) (sixty four patients), cardiogenic pulmonary edema (five patients), neuromuscular diseases (eleven patients: three with Steinert myotonic, one with spinal muscular atrophy type 2, three with cyphoscoliosis, and four with amiotrophic lateral sclerosis).

All patients were monitored for PtCO 2 and SpO 2 and all patients underwent non-invasive ventilation. The sensor probe, cleaned with alcohol and dried before each application, was applied to the skin of the earlobe using one drop of contact gel. After 5 minutes calibration period before placement of the monitor, and an additional 10 minutes equilibration period (as indicated by manufacturers),[6],[7] PtCO 2 /SaO 2 was recorded simultaneously with arterial blood sampling gas analysis in the usual way (Bayer Rapid Point 405). [8] The primary outcome of this study was to investigate the agreement between PaCO 2 and PtCO 2 , and between SaO 2 and SpO 2 ; and the second outcome was to evaluate the skin irritations caused by heating-up the sensor. A measurement was considered acceptable if it was in a clinical range of agreement of ±7.5 mmHg or 1 KPa.[8].

Statistical analyses

The level of agreement between the two measurements was assessed by Bland-Altman analysis. [9] The statistical analysis of the results was performed using R-project program (R 2.12.02 version, 2010).

   Results Top

Eighty comparisons were analyzed. Median age was 70.88 ± 7.56 (Interquartile range IQR 44-82); 48 (60%) patients were male, while 32 (40%) were female. Median PaCO 2 was 56.97 ± 9.98 (IQR 42-89), median O 2 saturation was 90.89 ± 4.82(IQR 79-98). Median pH was 7.308 ± 0.02 (IQR 7.25-7.35) and median systolic blood pressure was 132.58 ± 17.22 mmHg (IQR 104-169) [Table 1].
Table 1: Characteristics of the patients

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Standard blood gas SaO 2 analysis and TOSCA SpO 2 were studied over a range of 79% to 98%. Standard blood gas analysis PaCO 2 and TOSCA PtCO 2 were studied over a range of 42 to 89 mmHg. There was a close correlation between the oxygen saturation from blood gas analysis and transcutaneous SpO2 , PaCO 2 and transcutaneous PtCO 2 and limits of correlation lower than ±7 mmHg.[4],[6],[7],[8] No measurement was outside the acceptable clinical range of agreement of ±7.5 mmHg.[7],[10] A scatter plot of the relationship between SatO 2 /PtSatO 2 and PaCO 2 /PtCO 2 was shown in [Figure 1]a and b and average difference and 95% limits of agreement was shown in [Figure 2]. None of the patients experienced adverse effects due to skin irritation caused by heating-up the sensor clipped to the earlobe.
Figure 1: Bland-Altman plot of difference between two estimation of (a) PO2 and their average (b) PCO2 and their average

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Figure 2: SatO2 and PCO2: Averages and 95% confidence limits

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   Discussion Top

It is widely known that the value of pulse-oximetry to detect only hypoventilation is limited in the presence of supplemental oxygen. Carbon dioxide monitoring, which is a more accurate measure of the respiratory function, appears to be used much less than expected, outside the operation theater or intensive care unit. [8]

Transcutaneous measurement of CO 2 is based on the observation that this gas has a high tissue solubility and diffusion through the skin and that application of the local heat dilates blood vessels, and to enhance skin permeability. This permits the non-invasive measurement of the arterial PCO 2 . [10],[11],[12],[13],[14] We have evaluated the accuracy of a transcutaneous sensor for non-invasive evaluation of arterial carbon dioxide in adult patients with acute respiratory failure, compared with the "gold standard" arterial blood sample analysis. The results showed an acceptable level of correlation between SaO 2 and SpO 2 , as well as between PaCO 2 and PtCO 2 , as reported in previous studies. [3],[4],[7],[15],[16],[17],[18],[19],[20],[21],[22] The agreement between the two methods is independent of the level of PaCO 2 . [7] The monitor is simple to use and offers the advantage of the possibility of continuous non- invasive measurement. Therefore, it can allow to reduce the number of invasive sampling of arterial blood sampling, [3] saving money and decreasing discomfort. Our study was made only in hemodynamically stable patients, like subjects undergoing non-invasive ventilation, having a pH from 7.25 to 7.35 and monitored with TOSCA. Another study demonstrated that the use of both vasopressors and vasodilators had no significant effects on PtCO 2 measurements. [2],[11],[14] The TOSCA sensor is able to detect the desaturation events significantly earlier than the finger sensors of other devices. [4] It is well tolerated: no adverse events such as skin lesions have been observed following the removal of the sensor after an application time of up to eight hours. [7] Other complimentary studies have been published in recent years. These have looked at critically ill children, [15] emergency room patients with acute respiratory failure, [16] patients during cardiopulmonary exercise testing, [17] or healthy individuals. [18] Two previous studies have evaluated critically illness patients: [4,7] the first one [4] looked at eighteen patients, among whom, nine had hemodynamic instability treated with inotropic or vasoactive drugs; the second study [7] evaluated 69 critically ill patients admitted to the surgical intensive care unit for major surgery, multiple trauma, or septic shock. Of this group, 39 were placed on mechanical ventilation.Only three further studies have evaluated transcutaneous monitoring in patients undergoing non-invasive ventilation: the first two [16],[17] (with a small number of patients) had a good agreement between PaCO 2 and PtCO 2 , the third, [5] instead, reported a sub-optimal result.

Our study selected 80 patients affected by respiratory failure that were hemodynamically stable (no inotropic or vasoactive agents used). We found a good correlation between PaCO 2 /PtCO 2 . Our study presents some limitations: it is a single center study and the acceptable limits of agreement of 7.5 mmHg were chosen based on previous studies.[7],[10],[16] In conclusion, the placement of the probe is technically easy and rapid. The device can used continuously even for eight hours. [20],[21] We found that the TOSCA sensor is useful in adult routine monitoring practice in an intermediate respiratory unit, where patients have no hemodynamic instability and are completely awake. The device measurements allow real time estimation of CO 2 level over a prolonged period and facilitates proactive (rather than reactive) ventilator manipulation. [22] Moreover, the device may help in deciding the timing of arterial sampling and may therefore considerably reduce, as reported by a previous study, [20],[22] the frequency of painful invasive arterial sampling.

   Acknowledgments Top

The authors would like to acknowledge the contributor, Dr. Cornelius Barlascini, in reviewing the manuscript.

   References Top

1.Hutchinson DC, Rocca G, Honeybourne D. Estimation of arterial oxygen tension in adult subjects using transcutaneous electrode. Thorax 1981;36:473-7.  Back to cited text no. 1
2.Janssens JP, Howarth-frey C, Chrevolet JC, Abajo B, Rochat T. Transcutaneous PCO2 to monitor noninvasive mechanical ventilation in adults. Assessment of a new transcutaneous PCO 2 device. Chest 1998;113:768-73.  Back to cited text no. 2
3.Parker SM, Gibson GJ. Evaluation of a transcutaneous carbon dioxide monitor (TOSCA) in adult patients in routine respiratory practice. Resp Med 2007;101:261-4.  Back to cited text no. 3
4.Senn O, Clarenbach CF, Kaplan V, Maggiorini M, Bloch KE. Monitoring carbon dioxide tension and arterial oxygen saturation by a single earlobe sensor in patients with critical illness or sleep apnea. Chest 2005;128:1291-6.  Back to cited text no. 4
5.Bollinger D, Steiner LA, Kasper J, Aziz OA, Filipovic M, Seeberger MD. The accuracy of non-invasive carbon dioxide monitoring: A clinical evaluation of two transcutaneous systems. Anaesthesia 2007;62:394-9.  Back to cited text no. 5
6.Kelly AM, Klim S. Agreement between arterial and transcutaneous PCO2 in patients undergoing non-invasive ventilation. Resp Med 2011;105:226-9.  Back to cited text no. 6
7.De Oliveira GS Jr, Ahmad S, Fitzgerald PC, McCarthy RJ. Detection of hypoventilation during deep sedation in patients undergoing ambulatory gynaecological hysteroscopy: A comparison between transcutaneous and nasal end-tidal carbon dioxide measurements. Br J Anaest 2010;104:774-8.  Back to cited text no. 7
8.Sarrazin F, Tessler M, Kardash K, McNamara E, Holcroft C. Blood gas measurements using the Bayer Point 405: Are we basing our decision on accurate data? J Clin Monit comput 2007;21:253-6.  Back to cited text no. 8
9.Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307-10.  Back to cited text no. 9
10.Bendjelid K, Schutz N, Stolz M, Gerard I, Suter PM, Romand JA. Transcutaneous PCO 2 monitoring in critically adults: Clinical evaluation of a new sensor. Crit Care Med 2005;33:2203-6.  Back to cited text no. 10
11.Kopka A, Wallace E, Reilly G, Binning A. Observational study of perioperative PtCO 2 and SpO 2 in non-ventilated patients receiving epidural infusion or patient-controlled analgesia using a single earlobe monitor (TOSCA). Brit J Anaesth 2007;99:567-71.  Back to cited text no. 11
12.Eberhard P, Mindt W, Schafer R. Cutaneous blood gas monitoring in the adult. Crit Care Med 1981;9:702-5.  Back to cited text no. 12
13.Severinghaus JW, Astrup P, Murray JF. Blood gas analysis and critical care medicine. Am J Resp Crit Care Med 1998;157: S114-22.  Back to cited text no. 13
14.Palmisano BW, Severinghaus JW. Transcutaneous PCO 2 and PO 2 : A multicenter study of accuracy. J Clin Monit 1990;6:189-95.  Back to cited text no. 14
15.Urbano J, Cruzado V, Lopez-Herce J, del Castillo J, Bellon JM, Carrillo A. Accuracy of three transcutaneous carbon dioxide monitors in critically ill children. Pediatr Pulmonol 2010;45:481-6.  Back to cited text no. 15
16.Gancel PE, Rouple 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.  Back to cited text no. 16
17.Stege G, van den Elshout FJ, Heijdra YF, van den Ven MJ, Dekhuijzen PN, Vos PJ. Accuracy of transcutaneous carbon dioxide tension measurements during cardiopulmonary exercise testing. Respiration 2009;78:147-53.  Back to cited text no. 17
18.Randerath WJ, Stieglitz S, Galetke W, Anduleit N, Treml M, Schafer T. Evaluation of a system for transcutaneous long-term capnometry. Respiration 2010;80:139-45.  Back to cited text no. 18
19.Storre JH, Steurer B, Kabitz HJ, Dreher M, Windisch W. Transcutaneous PCO 2 monitoring during initiation of noninvasive ventilation. Chest 2007;132:1810-6.  Back to cited text no. 19
20.Cox M, Kemp R, Anwar S, Athey V, Aung T, Moloney ED. Non-invasive monitoring of CO 2 levels in patients using NIV for AECOPD. Thorax 2006;61:363-4.  Back to cited text no. 20
21.Storre JH, Magnet FS, Dreher M, Windisch W. transcutaneous monitoring as a replacement for arterial PCO 2 monitoring during nocturnal non-invasive ventilation. Resp Med 2011;105:143-50.  Back to cited text no. 21
22.Hazenberg A, Zijstra JG, Kerstijens HAM, Wijkstra PJ. Validation of a transcutaneous CO 2 monitor in adult patients with chronic respiratory failure. Respiration 2011;81:242-6.  Back to cited text no. 22


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  [Table 1]

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