Capnography guidelines are scattered across a dozen societies, in documents written for different specialties, in different decades, in different countries. Anyone trying to answer a simple question, such as “are we required to use this?”, has to go and find them all.
This page collects them in one place, organised by clinical domain, with links to the primary sources. It also flags the one significant area where the societies genuinely disagree, because that disagreement is more informative than the consensus.
Guidelines are revised periodically. Verify the current version of anything you intend to rely on.
Key takeaways
- Continuous capnography is a minimum monitoring standard for general anaesthesia, across every major anaesthesia body.
- It is the recommended method for confirming and monitoring endotracheal tube placement.
- Consensus is strongest for deep sedation; moderate sedation is where societies differ.
- Dental and oral surgery bodies now require it for moderate and deep sedation.
- Guidance increasingly extends beyond theatre, into recovery, the ward, transport and pre-hospital care.
Anaesthesia
| Body | Position |
|---|---|
| American Society of Anesthesiologists (ASA) | Continuous monitoring of exhaled carbon dioxide is a standard for every patient receiving general anaesthesia, unless invalidated by the patient, procedure or equipment |
| Association of Anaesthetists (UK), 2021 | Capnography is minimum monitoring for general anaesthesia, alongside ECG, pulse oximetry and blood pressure. It begins before induction and continues through transfer into recovery, until the airway device is removed |
| WHO and WFSA, International Standards | Continuous waveform capnography is highly recommended, their term for essential. They have also published minimum capnometer specifications so affordable devices can reach every theatre |
The WHO-WFSA International Standards are worth reading if you work in a resource-limited setting, because they explicitly frame affordable, robust capnography as the route to universal safe anaesthesia rather than a luxury.
See capnography during anaesthesia.
Related, and often missed: the 2023 ASA Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade recommend quantitative neuromuscular monitoring at the adductor pollicis and confirmation of a train-of-four ratio of 0.9 or above before extubation. The European guidance mirrors it. Subjective twitch assessment is no longer considered sufficient on its own.
Airway management and tube confirmation
| Body | Position |
|---|---|
| PUMA consensus, 2022 | Detection of sustained exhaled CO2 by waveform capnography is the mainstay for excluding oesophageal intubation. Confirm across about seven breaths, with a two-person verbal check. If there is no sustained CO2, remove the tube |
| American Heart Association | Continuous waveform capnography, with clinical assessment, is the most reliable method for confirming and monitoring correct endotracheal tube placement (Class I) |
| Royal College of Anaesthetists, 2018 | The “no trace, wrong place” campaign. No sustained CO2 means the tube is misplaced until proven otherwise |
| NAP4 (RCoA and Difficult Airway Society) | Airway deaths outside the operating theatre, many in intensive care, frequently occurred where capnography was not used. A substantial share were judged preventable by it |
The PUMA guideline is the most practical document here. It accepts that following it will occasionally mean removing a correctly placed tube, on the grounds that the cost of leaving one oesophageal tube in place is catastrophic.
See endotracheal tube confirmation.
Cardiac arrest and resuscitation
| Body | Position |
|---|---|
| American Heart Association (ACLS) | Quantitative waveform capnography is recommended in intubated patients during cardiac arrest, to confirm the tube, monitor CPR quality and help detect return of spontaneous circulation |
| AHA, on prognosis | Failure to achieve an EtCO2 above 10 mmHg after 20 minutes of CPR may be considered as one component of a multimodal decision to end efforts. It must never be used in isolation |
That second row is the one most often misquoted. The threshold exists, and it is explicitly not a stopping rule on its own, because poor compressions, a dislodged tube, a disconnected circuit or a pulmonary embolism can all produce the same low reading. See the AHA guidance and capnography in cardiac arrest.
Procedural sedation: where societies disagree
This is the honest complication, and it is worth understanding rather than glossing over.
| Body | Position |
|---|---|
| ASA | During moderate or deep sedation, adequacy of ventilation shall be evaluated by observing clinical signs and monitoring for exhaled carbon dioxide, unless precluded. Its 2018 guideline recommends continual capnography |
| American Dental Association (ADA) | Ventilation for moderate sedation, deep sedation and general anaesthesia must be assisted by capnography. Previously required only for intubated patients |
| AAOMS (oral and maxillofacial surgery) | Has required capnography for moderate and deep sedation in office settings since 2014 |
| ASGE (gastrointestinal endoscopy), 2018 | Capnography during moderate sedation has not been shown to improve safety. Still recommends it be considered for deep sedation |
So the consensus across every body is strongest for deep sedation. For moderate sedation, anaesthesia and dental bodies recommend or require it while the gastroenterology guideline is more cautious.
A neutral summary of these competing positions is in the NCBI evidence brief on capnography for moderate sedation. On the evidence itself, a meta-analysis in JADA pooling sixteen studies of 3,866 adults in moderate sedation found that adding capnography reduced hypoxaemia and increased detection of adverse respiratory events without adding harm.
See capnography in procedural sedation.
Post-operative care and the ward
| Body | Position |
|---|---|
| Anesthesia Patient Safety Foundation (APSF) | Continuous monitoring of oxygen saturation for all hospitalised adults receiving intravenous opioids after surgery. For patients also on supplemental oxygen, continuous monitoring of both oxygen saturation and end-tidal CO2 |
| Association of Anaesthetists | Monitoring, including capnography, continues from theatre through transfer into recovery, until the airway device is removed and the patient is responsive |
The APSF position is the clearest statement anywhere that once supplemental oxygen is in play, capnography becomes the necessary addition, because the pulse oximeter can no longer be relied on as an early warning. See the APSF guidance, patient safety guidance on PCA opioids, and opioid-induced respiratory depression on the ward.
Paediatrics and neonates
| Body | Position |
|---|---|
| ILCOR and American Academy of Pediatrics | Recommend using a carbon dioxide detector to confirm endotracheal tube placement in newborns |
Capnography has been used to confirm tube placement even in extremely low birthweight infants during resuscitation. The practical caveat in this population is apparatus dead space, which is why low-dead-space approaches are often preferred in the smallest patients. See this Acta Paediatrica review and paediatric capnography.
Transport and pre-hospital care
| Body | Position |
|---|---|
| European, Australasian and American guidance | Continuous capnography is recommended as a standard of monitoring for mechanically ventilated ICU patients during transport |
| Intensive Care Society (UK) | Monitoring must be continuous throughout a transfer, with all monitors visible to the transport team at all times |
| AHA | Tube position should be reconfirmed with capnography after any move, not assumed from the last check |
| Brain trauma guidance (via ACEP) | Ventilate at a normal rate targeting an EtCO2 of 35 to 45 mmHg in traumatic brain injury, and avoid hyperventilation |
The head injury target deserves emphasis, because prehospital data show an EtCO2 below 35 mmHg is associated with significantly higher mortality in severe traumatic brain injury, and that finding held even in patients with signs of herniation. See the ACEP summary, EtCO2 monitoring during transport and EtCO2 in trauma.
Regulatory requirements
Distinct from clinical guidance, some jurisdictions have made capnography a legal requirement.
| Body | Position |
|---|---|
| New York State Department of Health | Capnography required for monitoring ventilation in office-based surgery for patients receiving moderate sedation, deep sedation or general anaesthesia |
| CDSCO (India) | All medical devices sold and used in India must be regulated under the Medical Devices Rules, 2017. This applies to capnographs |
See the NY State DOH office-based surgery page, the CDSCO portal, and is your capnograph CDSCO approved.
India-specific standards
| Body | Position |
|---|---|
| ISCCM | The consensus statement on ICU planning and designing, 2020 sets out unit requirements adopted across India and by NABH |
| AIS-125, National Ambulance Code | Issued by MoRTH with the health ministry. Part 2 sets medical equipment requirements by ambulance category |
| NABH | Expects equipment to be maintained and calibrated, with calibration date and status labelled |
What the guidelines agree on
Strip away the specialties and the disagreements, and five points hold across every body above.
- Capnography is the most reliable method of confirming and monitoring endotracheal tube placement.
- It is a minimum monitoring standard for general anaesthesia.
- Confirmation requires sustained CO2, not a single breath.
- It should be continuous, and should not stop when the patient leaves the room.
- It is not a substitute for clinical assessment, pulse oximetry or arterial blood gas analysis.
For the values these guidelines are all measured against, see the normal EtCO2 range.
A note on our interest
Brainiac Healthcare makes RespiCOz, a portable capnograph, so we have an obvious commercial interest in capnography being widely used. This page exists as a reference, and every position above is linked to its primary source so you can check it rather than take our word for it. Where societies disagree, as they do on moderate sedation, we have said so.
Frequently asked questions
Is capnography mandatory during general anaesthesia? Yes. The ASA makes continuous monitoring of exhaled carbon dioxide a standard for every patient under general anaesthesia, the Association of Anaesthetists lists it as minimum monitoring, and the WHO-WFSA international standards describe continuous waveform capnography as highly recommended, meaning essential.
Is capnography required during procedural sedation? For deep sedation, consensus is strong across all societies. For moderate sedation, the ASA, ADA and AAOMS recommend or require it, while the 2018 gastroenterology guideline is more cautious, holding that benefit in moderate sedation is not established.
What do guidelines say about confirming an endotracheal tube? Waveform capnography detecting sustained exhaled CO2 is the recommended method. The PUMA consensus advises confirming across about seven breaths with a two-person check, and removing the tube if sustained CO2 is absent.
Can a low EtCO2 be used to stop CPR? Not on its own. AHA guidance describes a failure to reach an EtCO2 above 10 mmHg after 20 minutes as one component of a multimodal decision, explicitly not to be used in isolation.
What EtCO2 should be targeted in traumatic brain injury? 35 to 45 mmHg. Prehospital data associate values below 35 mmHg with significantly higher mortality in severe traumatic brain injury, so hyperventilation is avoided.
Conclusion
Capnography guidelines converge far more than they diverge. Across anaesthesia, resuscitation, airway management, sedation, post-operative care, paediatrics and transport, the same conclusions recur: it is the most reliable confirmation of a tracheal tube, it is a minimum standard under general anaesthesia, it must be sustained and continuous, and it complements rather than replaces everything else.
The one genuine disagreement, on moderate sedation, is narrow and well-defined, and even there the direction of travel over the past decade has been towards more capnography rather than less.
If you are building a policy, start with the primary documents linked above rather than any summary, including this one, and check that you have the current version.
Primary sources
- International Standards for a Safe Practice of Anesthesia. WHO and WFSA. wfsahq.org
- Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade. Anesthesiology. 2023;138:13–41. ASA. asahq.org
- Part 8: Adult Advanced Cardiovascular Life Support. AHA. Circulation. ahajournals.org
- Chrimes N, Higgs A, Hagberg CA, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from PUMA and international airway societies. Anaesthesia. 2022;77(12):1395–1415. doi:10.1111/anae.15817
- Klein AA, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021. Anaesthesia. Association of Anaesthetists. onlinelibrary.wiley.com
- Evidence Brief: Capnography for Moderate Sedation in Non-Anesthesia Settings. NCBI Bookshelf. ncbi.nlm.nih.gov
- Benefits and harms of capnography during procedures involving moderate sedation. JADA. 2018. jada.ada.org
- New Practice Guidelines for Neuromuscular Blockade. APSF. apsf.org
- Fatal Patient-Controlled Analgesia Opioid-Induced Respiratory Depression. AHRQ PSNet. psnet.ahrq.gov
- Capnometry during neonatal transport, a mini review. Acta Paediatrica. 2023. onlinelibrary.wiley.com
- Brain Trauma Guidelines for Emergency Medicine. ACEP Now. acepnow.com
- Statement on Use of Capnography in Office-Based Surgery. New York State Department of Health. health.ny.gov
- ISCCM Consensus Statement on ICU Planning and Designing, 2020. pubmed.ncbi.nlm.nih.gov
- AIS-125 (Part 2): Medical Equipment for Road Ambulances. MoRTH. morth.nic.in
- Central Drugs Standard Control Organisation (CDSCO), Government of India. cdsco.gov.in
