CAPNOGRAPHY-   The New Standard of Care James Pointer, MD, FACEP   Medical Director    Alameda County EMS
CAPNOGRAPHY Why use it?
Capnography &  Pulse Oximetry <ul><li>CO 2 : </li></ul><ul><ul><li>Relects ventilation </li></ul></ul><ul><ul><li>Detects ...
Indications for Use - End-Tidal CO 2  Monitoring   <ul><li>Validation of proper endotracheal tube placement </li></ul><ul>...
ETCO 2  & Cardiac Resuscitation <ul><li>Non-survivors </li></ul><ul><ul><li>Average ETCO 2 :  4-10 mmHg </li></ul></ul><ul...
ETCO 2  & Cardiac Resuscitation <ul><li>If patient is intubated and pulmonary ventilation is consistent with bagging, ETCO...
Capnography What are we measuring?
Respiration–The BIG Picture
Capnography Depicts Respiration
Physiological Factors Affecting ETCO 2  Levels
Normal Arterial &  ETCO 2  Values
Deadspace
CAPNOGRAPHY Theory of Operation
Infrared Absorption <ul><li>A beam of infrared light energy is passed through a gas sample containing CO 2 </li></ul><ul><...
Capnography vs. Capnometry <ul><li>Capnography: </li></ul><ul><li>Measurement and display of both ETCO 2  value and capnog...
Mainstream vs. Sidestream
Quantitative vs. Qualitative ETCO 2 <ul><li>Quantitative ETCO 2 : </li></ul><ul><ul><li>Provides an actual numeric value <...
Colorimetric CO 2  Detectors <ul><li>A “detector” – not a monitor </li></ul><ul><li>Uses chemically treated paper that cha...
CAPNOGRAPHY The Capnogram
Elements of a Waveform <ul><li>Dead Space </li></ul><ul><li>Beginning  of </li></ul><ul><li>exhalation </li></ul>Alveolar ...
Value of the CO 2  Waveform <ul><li>The Capnogram: </li></ul><ul><ul><li>Provides validation of the ETCO 2  value </li></u...
The Normal CO 2  Waveform <ul><ul><li>A – B  Baseline </li></ul></ul><ul><ul><li>B – C  Expiratory Upstroke </li></ul></ul...
Esophageal Tube <ul><li>A normal capnogram is the best evidence that the ETT is correctly positioned </li></ul><ul><li>Wit...
Inadequate Seal Around ETT <ul><li>Possible causes: </li></ul><ul><ul><li>Leaky or deflated endotracheal or tracheostomy c...
Hypoventilation (increase in ETCO 2 ) <ul><li>Possible causes: </li></ul><ul><ul><li>Decrease in respiratory rate </li></u...
Hyperventilation (decrease in ETCO 2 ) <ul><li>Possible causes: </li></ul><ul><ul><li>Increase in respiratory rate </li></...
Rebreathing <ul><li>Possible causes: </li></ul><ul><ul><li>Faulty expiratory valve </li></ul></ul><ul><ul><li>Inadequate i...
Obstruction <ul><li>Possible causes: </li></ul><ul><ul><li>Partially kinked or occluded artificial airway </li></ul></ul><...
Muscle Relaxants <ul><li>“ Curare Cleft”: </li></ul><ul><ul><li>Appears when muscle relaxants begin to subside </li></ul><...
Faulty Ventilator Circuit Valve <ul><li>Baseline elevated </li></ul><ul><li>Abnormal descending limb of capnogram </li></u...
Sudden Loss of Waveform <ul><li>Apnea </li></ul><ul><li>Airway Obstruction </li></ul><ul><li>Dislodged airway (esophageal)...
QUIZ TIME
#1 <ul><li>Normal capnogram </li></ul><ul><ul><li>controlled ventilations </li></ul></ul><ul><ul><li>spontaneous respirati...
#2 <ul><li>Muscle relaxants </li></ul><ul><li>General anesthesia </li></ul><ul><ul><li>The cleft on the alveolar plateau i...
#3 <ul><li>Normal capnogram </li></ul><ul><ul><li>Spontaneous ventilation in children </li></ul></ul><ul><ul><li>Sampling ...
#4 <ul><li>Esophageal intubation following a mask ventilation </li></ul>
#5 <ul><li>Bronchospasm </li></ul>
#6 <ul><li>Hyperventilation </li></ul>
#7 <ul><li>Esophageal intubation </li></ul>
#8 <ul><li>Contamination of CO 2  sensor </li></ul>
#9 <ul><li>Rebreathing </li></ul>
#10 <ul><li>Flat line </li></ul>
Waveform:  Regular Shape, Plateau  Below  Normal <ul><li>Indicates CO 2  deficiency </li></ul><ul><ul><li>Hyperventilation...
Waveform:  Regular Shape, Plateau   Above   Normal <ul><li>Indicates increase in ETCO 2   </li></ul><ul><ul><li>Hypoventil...
Questions
References <ul><li>Capnography, Bhavani Shankar Kodali, MD </li></ul><ul><li>Capnography in ‘Out of Hospital’ Settings, Ve...
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01 capnography the new standard of care

  1. 1. CAPNOGRAPHY- The New Standard of Care James Pointer, MD, FACEP Medical Director Alameda County EMS
  2. 2. CAPNOGRAPHY Why use it?
  3. 3. Capnography & Pulse Oximetry <ul><li>CO 2 : </li></ul><ul><ul><li>Relects ventilation </li></ul></ul><ul><ul><li>Detects apnea and </li></ul></ul><ul><ul><li>hypoventilation immediately </li></ul></ul><ul><ul><li>Should be used with pulse oximetry </li></ul></ul><ul><li>O 2 Saturation: </li></ul><ul><ul><li>Reflects oxygenation </li></ul></ul><ul><ul><li>30 to 60 second lag in detecting apnea or hypoventilation </li></ul></ul><ul><ul><li>Should be used with capnography </li></ul></ul>
  4. 4. Indications for Use - End-Tidal CO 2 Monitoring <ul><li>Validation of proper endotracheal tube placement </li></ul><ul><li>Detection and Monitoring of Respiratory depression </li></ul><ul><li>Hypoventilation </li></ul><ul><li>Obstructive sleep apnea </li></ul><ul><li>Procedural sedation </li></ul><ul><li>Adjustment of parameter settings in mechanically ventilated patients </li></ul>
  5. 5. ETCO 2 & Cardiac Resuscitation <ul><li>Non-survivors </li></ul><ul><ul><li>Average ETCO 2 : 4-10 mmHg </li></ul></ul><ul><li>Survivors (to discharge) </li></ul><ul><ul><li>Average ETCO 2 : >30 mmHg </li></ul></ul>
  6. 6. ETCO 2 & Cardiac Resuscitation <ul><li>If patient is intubated and pulmonary ventilation is consistent with bagging, ETCO 2 will directly reflect cardiac output </li></ul><ul><li>Flat waveform can establish PEA </li></ul><ul><ul><li>Increasing ETCO 2 can alert to return of spontaneous circulation </li></ul></ul><ul><li>Configuration of waveform will change with obstruction </li></ul>
  7. 7. Capnography What are we measuring?
  8. 8. Respiration–The BIG Picture
  9. 9. Capnography Depicts Respiration
  10. 10. Physiological Factors Affecting ETCO 2 Levels
  11. 11. Normal Arterial & ETCO 2 Values
  12. 12. Deadspace
  13. 13. CAPNOGRAPHY Theory of Operation
  14. 14. Infrared Absorption <ul><li>A beam of infrared light energy is passed through a gas sample containing CO 2 </li></ul><ul><li>CO 2 molecules absorb specific wavelengths of infrared light energy. </li></ul><ul><li>Light emerging from sample is analyzed. </li></ul><ul><li>A ration of the CO 2 affected wavelengths to the non-affected wavelengths is reported as ETCO 2 </li></ul>
  15. 15. Capnography vs. Capnometry <ul><li>Capnography: </li></ul><ul><li>Measurement and display of both ETCO 2 value and capnogram (CO 2 waveform) </li></ul><ul><li>Measured by a capnograph </li></ul><ul><li>Capnometry: </li></ul><ul><li>Measurment and display of ETCO 2 value (no waveform) </li></ul><ul><li>Measured by a capnometer </li></ul>
  16. 16. Mainstream vs. Sidestream
  17. 17. Quantitative vs. Qualitative ETCO 2 <ul><li>Quantitative ETCO 2 : </li></ul><ul><ul><li>Provides an actual numeric value </li></ul></ul><ul><ul><li>Found in capnographs and capnometers </li></ul></ul><ul><li>Qualitative ETCO 2 : </li></ul><ul><ul><li>Only provides a range of values </li></ul></ul><ul><ul><li>Termed “CO 2 Detectors” </li></ul></ul>
  18. 18. Colorimetric CO 2 Detectors <ul><li>A “detector” – not a monitor </li></ul><ul><li>Uses chemically treated paper that changes color when exposed to CO 2 </li></ul><ul><li>Must match color to a range of values </li></ul><ul><li>Requires six breaths before determination can be made </li></ul>
  19. 19. CAPNOGRAPHY The Capnogram
  20. 20. Elements of a Waveform <ul><li>Dead Space </li></ul><ul><li>Beginning of </li></ul><ul><li>exhalation </li></ul>Alveolar gas mixes with dead space Alveolar Gas End of exhalation Inspiration
  21. 21. Value of the CO 2 Waveform <ul><li>The Capnogram: </li></ul><ul><ul><li>Provides validation of the ETCO 2 value </li></ul></ul><ul><ul><li>Visual assessment of patient airway integrity </li></ul></ul><ul><ul><li>Verification of proper ETT placement </li></ul></ul><ul><ul><li>Assessment of ventilator/breathing circuit integrity </li></ul></ul>
  22. 22. The Normal CO 2 Waveform <ul><ul><li>A – B Baseline </li></ul></ul><ul><ul><li>B – C Expiratory Upstroke </li></ul></ul><ul><ul><li>C – D Expiratory Plateau </li></ul></ul><ul><ul><li>D ETCO 2 value </li></ul></ul><ul><ul><li>D – E Inspiration begins </li></ul></ul>
  23. 23. Esophageal Tube <ul><li>A normal capnogram is the best evidence that the ETT is correctly positioned </li></ul><ul><li>With an esophageal tube little or no CO 2 is present </li></ul>
  24. 24. Inadequate Seal Around ETT <ul><li>Possible causes: </li></ul><ul><ul><li>Leaky or deflated endotracheal or tracheostomy cuff </li></ul></ul><ul><ul><li>Artificial airway too small for the patient </li></ul></ul>
  25. 25. Hypoventilation (increase in ETCO 2 ) <ul><li>Possible causes: </li></ul><ul><ul><li>Decrease in respiratory rate </li></ul></ul><ul><ul><li>Decrease in tidal volume </li></ul></ul><ul><ul><li>Increase in metabolic rate </li></ul></ul><ul><ul><li>Rapid rise in body temperature (hypothermia) </li></ul></ul>
  26. 26. Hyperventilation (decrease in ETCO 2 ) <ul><li>Possible causes: </li></ul><ul><ul><li>Increase in respiratory rate </li></ul></ul><ul><ul><li>Increase in tidal volume </li></ul></ul><ul><ul><li>Decrease in metabolic rate </li></ul></ul><ul><ul><li>Fall in body temperature (hyperthermia) </li></ul></ul>
  27. 27. Rebreathing <ul><li>Possible causes: </li></ul><ul><ul><li>Faulty expiratory valve </li></ul></ul><ul><ul><li>Inadequate inspiratory flow </li></ul></ul><ul><ul><li>Insufficient expiratory flow </li></ul></ul><ul><ul><li>Malfunction of CO 2 absorber system </li></ul></ul>
  28. 28. Obstruction <ul><li>Possible causes: </li></ul><ul><ul><li>Partially kinked or occluded artificial airway </li></ul></ul><ul><ul><li>Presence of foreign body in the airway </li></ul></ul><ul><ul><li>Obstruction in expiratory limb of the breathing circuit </li></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul>
  29. 29. Muscle Relaxants <ul><li>“ Curare Cleft”: </li></ul><ul><ul><li>Appears when muscle relaxants begin to subside </li></ul></ul><ul><ul><li>Depth of cleft is inversely proportional to degree of drug activity </li></ul></ul>
  30. 30. Faulty Ventilator Circuit Valve <ul><li>Baseline elevated </li></ul><ul><li>Abnormal descending limb of capnogram </li></ul><ul><li>Allows patient to rebreath exhaled gas </li></ul>
  31. 31. Sudden Loss of Waveform <ul><li>Apnea </li></ul><ul><li>Airway Obstruction </li></ul><ul><li>Dislodged airway (esophageal) </li></ul><ul><li>Airway disconnection </li></ul><ul><li>Ventilator malfunction </li></ul><ul><li>Cardiac Arrest </li></ul>
  32. 32. QUIZ TIME
  33. 33. #1 <ul><li>Normal capnogram </li></ul><ul><ul><li>controlled ventilations </li></ul></ul><ul><ul><li>spontaneous respirations </li></ul></ul>
  34. 34. #2 <ul><li>Muscle relaxants </li></ul><ul><li>General anesthesia </li></ul><ul><ul><li>The cleft on the alveolar plateau is due to spontaneous respiratory effort </li></ul></ul>
  35. 35. #3 <ul><li>Normal capnogram </li></ul><ul><ul><li>Spontaneous ventilation in children </li></ul></ul><ul><ul><li>Sampling from nasal cannula or O 2 mask in adults </li></ul></ul>
  36. 36. #4 <ul><li>Esophageal intubation following a mask ventilation </li></ul>
  37. 37. #5 <ul><li>Bronchospasm </li></ul>
  38. 38. #6 <ul><li>Hyperventilation </li></ul>
  39. 39. #7 <ul><li>Esophageal intubation </li></ul>
  40. 40. #8 <ul><li>Contamination of CO 2 sensor </li></ul>
  41. 41. #9 <ul><li>Rebreathing </li></ul>
  42. 42. #10 <ul><li>Flat line </li></ul>
  43. 43. Waveform: Regular Shape, Plateau Below Normal <ul><li>Indicates CO 2 deficiency </li></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Decreased pulmonary perfusion </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Decreased metabolism </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Adjust ventilation rate </li></ul></ul><ul><ul><li>Evaluate for adequate sedation </li></ul></ul><ul><ul><li>Evaluate anxiety </li></ul></ul><ul><ul><li>Conserve body heat </li></ul></ul>
  44. 44. Waveform: Regular Shape, Plateau Above Normal <ul><li>Indicates increase in ETCO 2 </li></ul><ul><ul><li>Hypoventilation </li></ul></ul><ul><ul><li>Respiratory depressant drugs </li></ul></ul><ul><ul><li>Increased metabolism </li></ul></ul><ul><ul><li>Fever, pain, shivering </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Adjust ventilation rate </li></ul></ul><ul><ul><li>Decrease respiratory depressant drug dosages </li></ul></ul><ul><ul><li>Assess pain management </li></ul></ul><ul><ul><li>Conserve body heat </li></ul></ul>
  45. 45. Questions
  46. 46. References <ul><li>Capnography, Bhavani Shankar Kodali, MD </li></ul><ul><li>Capnography in ‘Out of Hospital’ Settings, Venkatesh Srinivasa, MD, Bhavani Shankar Kodali, MD </li></ul><ul><li>Capnography, Novametrix Systems, Inc. </li></ul><ul><li>Clinical Physiology of Capnography, Oridion Emergency Medical Services </li></ul><ul><li>Evolutions/Revolutions: Respiratory Monitoring, RN/MCPHU Home Study Program CE Center </li></ul><ul><li>End-Tidal Carbon Dioxide, M-Series, Zoll Medical Corporation </li></ul>
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