“Introduction of Volumetric Capnography
One Hospital’s Experience”
Presented By:
Michael Powers, MS, RRT
Director, Lung Ce...
Agenda:
VCO2 Management
Clinical Applications
University of Tennessee Medical Center’s
Experience and Data
Other Hospi...
VCO2 Management
1. Why to use
2. How to use
Monitoring CO2 Elimination
• VCO2 provides continuous feedback regarding
ventilation and perfusion
 Relationship between ...
Metabolism
(CO2 Production)
CO2 Elimination
(VCO2)
PaCO2
VCO2 - A Few
Basics
Things that affect
CO2 elimination
Circulatio...
CO2 Elimination
(VCO2)
Why Measure VCO2?
 Very Sensitive Indicator of
PATIENT STATUS CHANGE
 Early Indicator Future Chan...
Volumetric
Capnography
Integration of Flow & CO2
The integration of CO2 and Flow
provides an easy method to obtain
previously difficult to obtain
parameters
 VCO2 = CO2 E...
Phase I – Airway Gas
The waveform is divided into three phases:
The waveform begins at the onset of expiration. Imagine th...
Phase II – Transitional Gas
Phase II represents gas that is composed partially of airway volume
and partially from early e...
Phase III – Alveolar Gas
Phase III gas is entirely from the alveolar
bed where gas exchange takes place.
Single Breath CO2 Waveform
EtCO2
Exhaled Tidal Volume
VD VALV
Z
Y
X
Clinical Application
Ventilation Management
Customize ventilator settings: VCO2 (CO2
elimination) reflects any changes in ventilation
and/or pe...
Vd/Vt
• Ratio of Total Deadspace (Vd or Vdphys) to Tidal
Volume (Vt)
• Total Deadspace = Airway + Alveolar Deadspace
• Nor...
Decrease in Perfusion
Baseline Perfusion
Decreased Perfusion
 Monitoring trends allows for
detection of sudden and rapid ↓
in VCO2, without change in
Alveolar Minute Volume or Tidal
...
Optimization of PEEP using VCO2/NICO
CASE STUDY:
Profile: 60 Yr. Male, History of COPD and cardiac
problems, Admitted to E...
Alveolar Ventilation
MValv
• Alveolar Ventilation per Minute
• Amount of Vt that Reaches the
Alveoli and is Available for
...
Successful Weaning Trial
 Shows ↑ in spontaneous
alveolar ventilation &
corresponding decrease in
ventilator support.
 ↑...
Unsuccessful Weaning Trial
 SIMV ↓ and patient started to
take over ventilation.
 But patient shows signs of
fatigue at ...
Successful SBT
 Here the patient’s ability to
maintain Alveolar Ventilation
sufficient for CO2 removal during
a T-Piece T...
Unsuccessful SBT
 Initially, patient had a small amount
of ventilatory support, but then was
placed on a T-piece. The ent...
University of Tennessee Medical Center Data
• 600 Bed Hospital
• Designated Level 1 Trauma Center for Adults and Pediatric...
Hospital Constraints
Step Down
Units created
(sub-acute care)
Step Down
Units created
(sub-acute care)
More severe
ICU pat...
University of TN Medical Center
Implementation of Ventilation Management Protocol
3.3
12.5
2.0
11.0
0
5
10
15
VLOS HLOS
Pr...
Re-intubation Rates
Extubation/Reintubation Rates
97939395
0
20
40
60
80
100
120
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
%NotRe-in...
Quickly specific patient population became clear…
 Patients in ALI/ARDS: requiring monitoring for
optimization of PEEP an...
University of TN Medical Center
Difficult to Wean Patients
(Five Months Retrospective)
30.7
17
12
24.7
0
10
20
30
40
VLOS ...
Comparison Data
Reduction of Mechanical Ventilation
Hours Using a Working Protocol with
the Cardiopulmonary Management
System
Mikel W. O'K...
Background:
Genesis Medical Center (GMC) is a 500 bed hospital
with three adult Intensive Care units (ICUs) totaling
45 lC...
Methods:
We retrospectively measured our MVH for
2003-2004. Next a protocol was
implemented using data from the NICO
monit...
Results:
By incorporating the ventilation management
protocol, the decision process was simplified for
both physician and ...
Conclusion:
By implementing a care protocol
incorporating the Respironics NICO we
observed a decrease of 43.2% in the tota...
Implementation of Care Protocol
Incorporating NICO
Total MVH
72,492
41,144
10,000
30,000
50,000
70,000
90,000
2003 (612 pt...
Implementation of Care Protocol
Incorporating NICO
(MVH per Patient)
118
69
0
50
100
150
2003 (612 pts) 2004 (598 pts)
Dec...
Continuous Monitoring Of Volumetric Capnography
Reduces Length Of Mechanical Ventilation In A
Heterogeneous Group Of Pedia...
Background:
Complications result from mechanical ventilation even
under the best of circumstances; therefore, careful
cons...
Volumetric capnography displays breath-by-breath
measurements of exhaled carbon dioxide during
the entire respiratory cycl...
Hypothesis:
We hypothesized that the management of
patients using continuous volumetric capnography,
including monitoring ...
Methods:
All mechanically ventilated PICU patients (0-18
years of age) were eligible for enrollment in this
prospective, r...
Results:
Both the parametric t-test and the non-parametric
Wilcoxon test reflect a statistically significant
difference in...
Conclusion:
Length of ventilation in a heterogeneous group of
pediatric patients was decreased by 2.25 days, a
clinically ...
Length of Ventilator Hours
(99 patients)
171.4
117.3
0
50
100
150
200
Pre NICO Post NICO
Duke Children's Hospital (cont).
THANK YOU!
Contact Information
Michael Powers, MS, RRT
Director, Lung Center
University of Tennessee Medical Center
1940 Alcoa Highwa...
Presentation 2006 RCSW Volumetric Capnography One Hospitals ...
Presentation 2006 RCSW Volumetric Capnography One Hospitals ...
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  • VCO2 provides continuous feedback regarding both ventilation and perfusion. The relationship between PaCO2 and VCO2 is inverse, if VCO2 is decreasing PaCO2 is increasing. If you decrease the amount of CO2 eliminated from the body, PaCO2 has to go up. This provides instant feedback when making ventilator setting changes:
    Did perfusion change?
    Did ventilation change?
    With PaCO2 from an ABG, you can answer the question, did Vd/Vt change?
  • This simple graphic depicts a machine (arms and gears) that represents metabolism and more importantly CO2 production.
    The blue molecules are filling a beaker (PaCO2) at the rate of 5 drops.
    The beaker has a drain that allows 5 drops out at the same rate that fills the beaker.
    The level of fluid in the beaker remains constant in this configuration.
    There are only three things that affect the elimination of CO2 assuming metabolism remains constant - and they are
    Circulation or perfusion
    Diffusion
    Ventilation
  • CO2 Elimination is very sensitive to any changes in the patient’s ventilatory status.
    If CO2 production remains constant and CO2 Elimination is decreased, what will happen to the level in the beaker (PaCO2)? It will go up.
    Now we can understand what is truly happening to PaCO2 by monitoring CO2 Elimination.
    In most institutions, ABGs are taken at set time intervals, 15-20 min after vent settings have been changed.
    When patient is MV, the “drain” (beaker) is opened, and CO2 pours out.
    Until patient reaches steady state VCO2 level, arterial sample will only reflect values of a patient in acute change
    Remember that the definition of “adequate ventilatory support” is acceptable PaCO2. If the PaCO2 level is evaluated while patient is in a period of acute change then the assessment is mildly valuable.
    It is far better to wait for steady state after ventilatory settings change and get the ABG then.
  • The waveform is divided into three phases:
    The waveform begins at the onset of expiration. Imagine that you are the sensor sitting in the proximal airway. The first gas past the sensor at onset of expiration does not contain any CO2 but does have volume. The graph shows movement along the X-axis (exhaled volume) but no gain in CO2 (Y-axis).
    This volume is entirely from the conducting airways - no gas exchange has taken place.
    Phase I represents pure airway gas.
  • Phase II represents gas that is composed partially of airway volume and partially from early emptying alveoli (fast time constant).
    At about generation 17 of the airway tree we find alveolar units that communicate directly with the conducting airway and are considered fast time constant units.
    It is considered transitional gas (from airway to alveoli). An assumption is made here:
    50% of phase II gas belongs to the airway and 50% belongs to the alveoli. Further research is needed to determine if this holds true in all clinical conditions (such as dramatically increasing PEEP).
  • Phase III gas is entirely from the alveolar bed where gas exchange takes place.
  • Now let take a look at some of the research that supports our claims.
  • Volumetric CO2 provides Noninvasive, continuous information about the changes that occur in the patient as a result of our intervention, as described in this paper by Tashkar in Chest 1996.
    VCO2 provides IMMEDIATE PATIENT FEEDBACK to intervention.
    It assists the clinician in answering one of the most important question when evaluating the patient in respiratory failure : has the status of my patient changed ?
    As VCO2 reflects any changes in ventilation and/or perfusion, it is a sensitive indicator of impending trouble or patient change.
  • CO2 Elimination is very sensitive to any changes in ventilation/perfusion relationship.
    Abnormalities in the distribution of ventilation can result from local changes in lung compliance or bronchial narrowing that cause one lung unit to receive only a fraction of the ventilation of the other unit. The VA/Qc of the poorly ventilated but well perfused lung unit is lower as compared to the normal lung unit. The poorly ventilated compartment will have a lower alveolar and capillary PO2 and a higher PCO2 than the unit with a normal VA/QC (in the poorly ventilated unit only a little amount of oxygen flows in with each inspiration, and only a little amount of CO2 is exhaled). If the level of ventilation to the abnormal lung unit were to fall to zero, the capillary PO2 and PCO2 would approximate those in mixed venous blood (there is no O2 delivered during inspiration, and no CO2 is removed from the alveoli). Therefore, the blood gases would pass unchanged from the right heart throughout the lungs to the left heart: right to left shunt. From the gas exchange point of view this blood flow is "wasted". Under this condition, arterial PO2 always decreases. On the other hand, a simultaneous increase in PCO2 is usually compensated by the reflex increase in VA.
     Figure 18 illustrates other examples where the VA/QC ratio is equal to infinity (Fig. 18B) or is increased (Fig. 18C). In both cases, VA will be normal while there is no or a decreased blood flow. At a VA/QC ratio of infinity (Fig. 18B), alveolar PO2 and PCO2 remain unchanged and, therefore, they will approximate those in the inspired air. In the case of an increased VA/QC ratio blood is fully oxygenated and CO2 may diffuse to the alveoli with blood supply (Fig. 18C). However, because of decreased perfusion, part of VA is not used for gas exchange, representing “wasted” ventilation (or alveolar dead space). 
  • Alveolar Ventilation
    Alveolar ventilation is the amount of tidal volume that reaches the alveoli and is made available for gas exchange.
    An acceptable PaCO2 defines adequate alveolar ventilation, so optimizing alveolar minute ventilation provides the most effective CO2 removal.
    Monitoring Spontaneous vs. Mechanical Alveolar Ventilation along with CO2 Elimination verifies a patient’s continued success or impending failure.
  • Not only in the ICU do you have to deal with patients and pathologies, but hospital constraints have to be taken into account.
    Pressure on costs and time lead to the 3 following situations :
    - preference for Noninvasive technologies
    - creation of less specialized units called sub-acute care, or step-down units
    - pressure on overall ventilation time
    The creation of sub-acute care facilities leads to more critical patient population in the ICUs, which again entails a preference for Noninvasive technologies to improve patient outcome.
  • Presentation 2006 RCSW Volumetric Capnography One Hospitals ...

    1. 1. “Introduction of Volumetric Capnography One Hospital’s Experience” Presented By: Michael Powers, MS, RRT Director, Lung Center University of Tennessee Medical Center Knoxville, Tennessee
    2. 2. Agenda: VCO2 Management Clinical Applications University of Tennessee Medical Center’s Experience and Data Other Hospital’s Outcome Data
    3. 3. VCO2 Management 1. Why to use 2. How to use
    4. 4. Monitoring CO2 Elimination • VCO2 provides continuous feedback regarding ventilation and perfusion  Relationship between PaCO2 and VCO2 is inverse and consistent  Instant feedback when making ventilator setting changes: • Did perfusion change? • Did ventilation change? • With PaCO2 from an ABG, you can answer the question, “Did Vd/Vt change?”
    5. 5. Metabolism (CO2 Production) CO2 Elimination (VCO2) PaCO2 VCO2 - A Few Basics Things that affect CO2 elimination Circulation Diffusion Ventilation 1 2
    6. 6. CO2 Elimination (VCO2) Why Measure VCO2?  Very Sensitive Indicator of PATIENT STATUS CHANGE  Early Indicator Future Changes in PaCO2  Another Tool to Assist in Determining When to Draw a Blood Gas  Reduces the # of ABGs VCO2 - A Few Basics 3
    7. 7. Volumetric Capnography Integration of Flow & CO2
    8. 8. The integration of CO2 and Flow provides an easy method to obtain previously difficult to obtain parameters  VCO2 = CO2 Elimination  Airway Deadspace, Physiologic VD/VT  Alveolar Ventilation  Cardiac Output Integration of Flow & CO2 EtCO2 Capnogram Respiratory Rate Capnography Volumetric CO2 CO2 Elimination Airway Deadspace Alveolar Ventilation Physiologic Vd/Vt
    9. 9. Phase I – Airway Gas The waveform is divided into three phases: The waveform begins at the onset of expiration. Imagine that you are the sensor sitting in the proximal airway. The first gas past the sensor at onset of expiration does not contain any CO2 but does have volume. The graph shows movement along the X-axis (exhaled volume) but no gain in CO2 (Y-axis). This volume is entirely from the conducting airways - no gas exchange has taken place. Phase I represents pure airway gas.
    10. 10. Phase II – Transitional Gas Phase II represents gas that is composed partially of airway volume and partially from early emptying alveoli (fast time constant). At about generation 17 of the airway tree we find alveolar units that communicate directly with the conducting airway and are considered fast time constant units. It is considered transitional gas (from airway to alveoli). An assumption is made here: 50% of phase II gas belongs to the airway and 50% belongs to the alveoli. Further research is needed to determine if this holds true in all clinical conditions (such as dramatically increasing PEEP).
    11. 11. Phase III – Alveolar Gas Phase III gas is entirely from the alveolar bed where gas exchange takes place.
    12. 12. Single Breath CO2 Waveform EtCO2 Exhaled Tidal Volume VD VALV Z Y X
    13. 13. Clinical Application
    14. 14. Ventilation Management Customize ventilator settings: VCO2 (CO2 elimination) reflects any changes in ventilation and/or perfusion; it indicates instantly how patient gas exchange responds to ventilator setting changes Customize ventilator settings: VCO2 (CO2 elimination) reflects any changes in ventilation and/or perfusion; it indicates instantly how patient gas exchange responds to ventilator setting changes VCO2 Vd/Vt MValv “Noninvasively monitored VCO2 provides an instantaneous indication of the change in alveolar ventilation in mechanically ventilated patients. It allows instant, cheap and noninvasive determination of effective gas exchange.” Dynamics of Carbon Dioxide Elimination Following Ventilator Resetting. Varsha Taskar, MD ; Joseph John, MD ; Anders Larsson, MD,PhD ; Torbjörn Wetterberg, MD, PhD ; Björn Jonson, MD, PhD – Chest 108/1/July 1995 . .
    15. 15. Vd/Vt • Ratio of Total Deadspace (Vd or Vdphys) to Tidal Volume (Vt) • Total Deadspace = Airway + Alveolar Deadspace • Normal = 0.25 to 0.30 • Estimates the Overall (In)efficiency of the CardioRespiratory System Why Measure Vd/Vt ? • Helps Understand what is Happening at the Alveolar Capillary Interface • Measures Effectiveness of Ventilation • Get Baseline Vd/Vt Defines Severity of Insult
    16. 16. Decrease in Perfusion Baseline Perfusion Decreased Perfusion
    17. 17.  Monitoring trends allows for detection of sudden and rapid ↓ in VCO2, without change in Alveolar Minute Volume or Tidal Volumes.  Drop in VCO2 suggests change in blood flow to the lungs.  ↓ VCO2 may be due to ↓ in C.O. or blood loss.  ↑ VCO2 may be due to ↑ in C.O. or malignant hyperthermia.  Coupled with Alveolar Ventilation and Deadspace measurements, this allows for quick patient assessment. Monitoring trend screens
    18. 18. Optimization of PEEP using VCO2/NICO CASE STUDY: Profile: 60 Yr. Male, History of COPD and cardiac problems, Admitted to ED with severe respiratory distress, elevated temperature and semi-comatose. Patient intubated and placed on control ventilation and monitored with NICO. Tidal Volume (6ml/kg)= 600 ml, Respiratory Rate=10, I:E=1:2, PEEP= 8 FiO2 = 40%. Baseline CO = 4 L/min, Over time SpO2 decreases from 94 to 88%. Flow/Volume loop and capnogram exhibit severe airway obstruction and increased work of breathing. Bronchodilator treatment administered and PEEP increased to 15 CmH2O. SpO2 = 95%. Observed a decrease in VCO2 (150 mL/m) and CO (2.5 L/m) due to increased intrathoracic pressure and decreased venous return. PEEP reduced to 8 cmH2O. Both cardiac output (3.4 L/m) and VCO2 (225 mL/m) returns to baseline levels. Discussion: Use of NICO provided immediate and continuous feedback on the appropriateness of the ventilator strategy, and also allowed expeditious optimization of cardiac performance. PEEP=0 PEEP lowered to 4 cmH2O PEEP increased to 8 cmH2O
    19. 19. Alveolar Ventilation MValv • Alveolar Ventilation per Minute • Amount of Vt that Reaches the Alveoli and is Available for Gas Exchange (Effective Ventilation) Why Measure MValv ?  To provides the Most Effective CO2 Removal  To manage alveolar ventilation and not Vt
    20. 20. Successful Weaning Trial  Shows ↑ in spontaneous alveolar ventilation & corresponding decrease in ventilator support.  ↑ VCO2 suggests ↑ metabolic activity due to additional task of breathing by the patient.  Delivered mechanical tidal volume has not changed & spontaneous tidal volume is increasing (SIMV rate ↓).  Shows PATIENT RESPONSE to the trial allowing for better management of the weaning process.
    21. 21. Unsuccessful Weaning Trial  SIMV ↓ and patient started to take over ventilation.  But patient shows signs of fatigue at early stage (↓ VCO2 followed by ↓ in spontaneous tidal volume).  Leads to ↑ in PaCO2 & EtCO2.  Return to mechanical ventilation.  Assists clinicians in determining PATIENT RESPONSE.  When used effectively, these utilities may help reduce costly ventilator days.
    22. 22. Successful SBT  Here the patient’s ability to maintain Alveolar Ventilation sufficient for CO2 removal during a T-Piece Trial is proven.  Spontaneous Tidal Volumes have remained constant and have even shown slight increases over time.  Trends also show that the patient has been off mechanical support throughout the trial (no Vte MECH trend bars).
    23. 23. Unsuccessful SBT  Initially, patient had a small amount of ventilatory support, but then was placed on a T-piece. The entire task of breathing was placed on the patient.  Within minutes trends showed that the patient was unable to support the required level of ventilation (VCO2 decreasing since total Alveolar Ventilation is decreasing).  Spontaneous Tidal Volume trend also shows inadequate ventilation.  Removal of mechanical support, increased Vd/Vt, reducing ventilatory efficiency and the patient’s ability to remove CO2. This resulted in a pattern of rapid shallow breaths requiring the patient to be placed back on full mechanical support.
    24. 24. University of Tennessee Medical Center Data • 600 Bed Hospital • Designated Level 1 Trauma Center for Adults and Pediatrics • Associated with University of Tennessee Graduate School of Medicine • 50+ Bed Level 3 NICU • 70+ Bed Adult Critical Care • Operate Aggressive Therapist Driven Protocols on All Modalities of RC
    25. 25. Hospital Constraints Step Down Units created (sub-acute care) Step Down Units created (sub-acute care) More severe ICU patient population More severe ICU patient population Prefer Noninvasive technologies Prefer Noninvasive technologies Pressure on hospital budgets Human resources limited Pressure on hospital budgets Human resources limited Need to keep ventilator- time as minimal as possible Need to keep ventilator- time as minimal as possible Need to be efficient and ↓ costsNeed to be efficient and ↓ costs
    26. 26. University of TN Medical Center Implementation of Ventilation Management Protocol 3.3 12.5 2.0 11.0 0 5 10 15 VLOS HLOS Pre-Protocol (585 pts) Post-Protocol (643 pts) Decrease of 39% Decrease of 12%
    27. 27. Re-intubation Rates Extubation/Reintubation Rates 97939395 0 20 40 60 80 100 120 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr %NotRe-intubated Extubation/Reintubation Goal *Less than 6%
    28. 28. Quickly specific patient population became clear…  Patients in ALI/ARDS: requiring monitoring for optimization of PEEP and other ventilator settings  Patients with ventilator dysynchrony or other respiratory pattern issues that require differentiation of etiologies, prevention of exhaustive failures, etc. – Patients with failures to get to SBT, or appearances of failures, such as RSBI, GCS, etc. – Differentiating Tachypnea vs Dyspnea – Early detection of exhaustion prior to signs/symptoms
    29. 29. University of TN Medical Center Difficult to Wean Patients (Five Months Retrospective) 30.7 17 12 24.7 0 10 20 30 40 VLOS HLOS Pre NICO (43 pts) Post NICO (25 pts) Decrease of 29% Decrease of 20%
    30. 30. Comparison Data
    31. 31. Reduction of Mechanical Ventilation Hours Using a Working Protocol with the Cardiopulmonary Management System Mikel W. O'Klock RRT, Dennis Harker RRT, Aksay Mahadevia MD, FCCP Genesis Medical Center, Davenport, IA. Reference: Respiratory Care, Dec 2005, Vol 50, Number 12, Page 95 Genesis Medical Center, Davenport, IA.
    32. 32. Background: Genesis Medical Center (GMC) is a 500 bed hospital with three adult Intensive Care units (ICUs) totaling 45 lCU beds. Mechanical Ventilation Hours (MVH) for fiscal year 2003 totaled 84,000 with an average of 123 hours per patient. We adopted a Mechanical Ventilation Management Strategy Protocol incorporating the Respironics Cardiopulmonary Management System (NICO) in an attempt to effectively reduce MVH. Genesis Medical Center (cont).
    33. 33. Methods: We retrospectively measured our MVH for 2003-2004. Next a protocol was implemented using data from the NICO monitor (SBCO2, VCO2, EtCO2, CO and Vd/Vt) and a decision template. After 12 months of managing patients using the protocol, MVH were again measured. Genesis Medical Center (cont).
    34. 34. Results: By incorporating the ventilation management protocol, the decision process was simplified for both physician and therapist. This resulted in a significant reduction (p=0.001) in mechanical ventilation hours per patient. Ventilator Hours Statistical Analysis Year Number of Patients Total MVH MVH/pt 2003 612 72,492 118 2004 598 41,144 69 Genesis Medical Center (cont).
    35. 35. Conclusion: By implementing a care protocol incorporating the Respironics NICO we observed a decrease of 43.2% in the total number of ventilator hours, and a 42% decrease in the number of hours per patient. Genesis Medical Center (cont).
    36. 36. Implementation of Care Protocol Incorporating NICO Total MVH 72,492 41,144 10,000 30,000 50,000 70,000 90,000 2003 (612 pts) 2004 (598 pts) Decrease of 42.2% Pre-NICO Post-NICO Genesis Medical Center (cont).
    37. 37. Implementation of Care Protocol Incorporating NICO (MVH per Patient) 118 69 0 50 100 150 2003 (612 pts) 2004 (598 pts) Decrease of 42% Pre-NICO Post-NICO Genesis Medical Center (cont).
    38. 38. Continuous Monitoring Of Volumetric Capnography Reduces Length Of Mechanical Ventilation In A Heterogeneous Group Of Pediatric ICU Patients Donna Hamel,RRT, RCP,FAARC Ira Cheifetz, MD, FAARC; Pediatric Critical Care Medicine. Duke Children's Hospital, Durham, North Carolina Reference: Respiratory Care, Dec 2005, Vol 50, Number 12, Page 107 Duke Children's Hospital, Durham, North Carolina
    39. 39. Background: Complications result from mechanical ventilation even under the best of circumstances; therefore, careful consideration must be provided for optimal management strategies on a continual basis. Recent advances in technology provide clinicians access to noninvasive monitoring devices with the ability to display measurable and consistent data, thus, allowing for a more objective approach to total ventilator management. Duke Children's Hospital (cont).
    40. 40. Volumetric capnography displays breath-by-breath measurements of exhaled carbon dioxide during the entire respiratory cycle. Additionally, the integration of flow and carbon dioxide elimination over time enables the capnograph to calculate and display alveolar minute ventilation (MVALV) and deadspace ventilation (Vd/Vt). Therefore, volumetric capnography should be a better marker for monitoring dynamic changes in gas exchange during mechanical ventilation than standard time-based capnometry alone. Duke Children's Hospital (cont).
    41. 41. Hypothesis: We hypothesized that the management of patients using continuous volumetric capnography, including monitoring of the deadspace to tidal volume ratio, alveolar minute ventilation, and carbon dioxide elimination (VCO2) would reduce the length of ventilation (LOV) in infants and children. Duke Children's Hospital (cont).
    42. 42. Methods: All mechanically ventilated PICU patients (0-18 years of age) were eligible for enrollment in this prospective, randomized study. Intervention patients were placed on a NICO Respiratory Profile Monitor (Respironics, Inc.) on initiation of mechanical ventilation in our Pediatric lCU. These patients remained on the NICO Monitor until extubation. Control patients received all standard care and monitoring including intermittent use of volumetric capnography at the discretion of the PICU team. Duke Children's Hospital (cont).
    43. 43. Results: Both the parametric t-test and the non-parametric Wilcoxon test reflect a statistically significant difference in average length of ventilation with LOV being significantly reduced for the NICO group. Patients managed with continuous volumetric capnography (n=99) had a significantly shorter LOV than control patients (n=99) (117.3 vs. 171.4 hrs; P = 0.002). Extubation failure rates were similar for both groups. Duke Children's Hospital (cont).
    44. 44. Conclusion: Length of ventilation in a heterogeneous group of pediatric patients was decreased by 2.25 days, a clinically significant 32%, with the use of Vd/Vt, MVALV and VCO2 monitoring. Such a significant decrease in LOV should corre-late with a reduction in length of lCU admission cost, complications and morbidity as well as improved patient and family satisfaction. Duke Children's Hospital (cont).
    45. 45. Length of Ventilator Hours (99 patients) 171.4 117.3 0 50 100 150 200 Pre NICO Post NICO Duke Children's Hospital (cont).
    46. 46. THANK YOU!
    47. 47. Contact Information Michael Powers, MS, RRT Director, Lung Center University of Tennessee Medical Center 1940 Alcoa Highway, Suite E-110 Knoxville, TN 37920 Phone: 865-544-9274 Fax: 865-544-6607 E-mail: mpowers@mc.utmck.edu
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