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04 capnography hamel
 

04 capnography hamel

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  • Hello, I discovered your very interesting presentations in the Slideshare group 'HEALT AND MEDICINE' (http://www.slideshare.net/group/healt-and-medicine ). I take this opportunity to referencer some of your presentations. Thank for sharing. Greetings from France. Good day. Kate
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    04 capnography hamel 04 capnography hamel Presentation Transcript

    • The Use of Volumetric Capnography in Optimizing Mechanical Ventilation Donna Hamel, RRT, RCP, FAARC Pediatric Critical Care Medicine Duke Children’s Hospital Durham, N.C.
    • Introduction
      • Technologic advances have led to a myriad of ventilatory modes and flow options.
      • Capability to sculpt each breath to meet the specific needs of individual patients.
      • Clinicians must now choose from a multitude of options when initiating & managing mechanical ventilation.
    • Introduction
      • How do we assess the effectiveness of our ventilatory choices?
        • Arterial blood gases
        • Pulse oximetry
        • ETCO 2 monitoring
        • Volumetric capnography
    • What is volumetric capnography?
      • Integration of flow and carbon dioxide.
      • Measures, calculates, and displays breath-by-breath measurements throughout the entire respiratory cycle.
        • Digital numeric display
        • Multiple graphics
        • Single breath waveform (SBCO 2 )
      • Multitude of information including VCO 2
    • What is VCO 2
        • Volume of CO 2 eliminated via the lungs.
        • Inverse relationship to PaCO 2
        • Affected by ventilation, perfusion, & diffusion
    • What is VCO 2
        • Reflects acute clinical changes
        • Indicator of pulm capillary blood flow
        • Reflects effects of ventilator manipulations
        • Most beneficial when used in conjunction with SBCO 2
    • SBCO 2 Waveform Expired CO 2 V T
    • SBCO 2 Waveform Expired CO 2 I V T Phase I = large airway ventilation
    • SBCO 2 Waveform Expired CO 2 I II V T Phase II = mixed large airway and alveolar ventilation Phase I = large airway ventilation
    • SBCO 2 Waveform Expired CO 2 I II V T Phase II = mixed large airway and alveolar ventilation Phase I = large airway ventilation III Phase III = exhaled volume of alveolar gas
    • Phases of SBCO 2 waveform
      • Phase 1:
        • represents gas exhaled from the upper airways which generally is void of carbon dioxide
      • Phase 2:
        • transitional phase from upper to lower airway ventilation and tends to depict changes in perfusion
      • Phase 3:
        • area of alveolar gas exchange representative of gas distribution
    • Clinical significance
      • Phase 1
        • ↑ depicts an ↑ in airways dead space.
      • Phase 2
        • ↓ slope depicts reducing perfusion.
      • Phase 3
        • ↑ slope depicts mal-distribution of gas.
    • Phase 1 assessment
      • When a change in VCO 2 occurs, assess SBCO 2
      • If ↑ in phase 1 (VD ANA )
        • Assess for appropriate PEEP level
          • Excessive PEEP may be present
        • Airway obstruction
          • Suction?
        • Bronchospasm
          • Bronchodilator tx my be indicated
    • ↑ phase 1
      • Phase 1 – relatively short
      • Phase 1 - prolonged
    • Phase 2 assessment
      • If  in phase 2
        • Assure stable minute ventilation
        • Assess PEEP level
          • ↑ intrathoracic pressure may cause  venous return
        • Assess hemodynamic status
          • Is minute ventilation stable?
          • Volume resuscitation or vasopressors may be indicated
    •  Phase 2
      • When minute ventilation is stable, indicative of a  in perfusion.
    • Phase 3 assessment
      • If ↑ or absent phase 3 mal-distribution of gas at alveolar level exists
        • Assess for appropriate PEEP level
          • Inadequate PEEP may be present
        • Bronchospasm
          • Bronchodilator tx my be indicated
        • Structure damage at alveolar level may be present
          • Pnuemothorax?
    • ↑ or absent phase 3
      • Slope of phase 3 present and level
      • Phase 3 absent
    • Optimizing PEEP VCO 2 & SBCO 2
      • A ↓ in VCO 2 may be indicative of inappropriate PEEP level.
      • To determine appropriate action evaluate SBCO 2 waveform.
      • Look for changes from baseline.
    • Slope 1: anatomic deadspace
      • Excessive PEEP can be quickly recognized
        • Decrease in VCO 2
        • Increase from baseline in slope 1 of waveform
    • ↑ Phase 1
    • Slope 2: pulmonary perfusion
      • A ↓ in pulmonary perfusion may result from excessive PEEP.
      • Generally created by ↑in intrathoracic pressure resulting in:
        • ↓ Systemic venous return
        • ↑ Pulmonary vascular resistance
    • Slope 2: pulmonary perfusion
      • Quickly recognized by:
        • Decrease in VCO 2
        • Decrease from baseline in slope 2 of waveform
    •  Phase 2 Decreased Perfusion Baseline
    • Slope 3: gas distribution
      • Depicts gas distribution at alveolar level.
      • Mal-distribution of gas can be a result of inappropriate PEEP level.
      • When PEEP levels inadequate, alveolar collapse can occur.
    • Mal-distribution of gas
      • Quickly recognized by:
        • Decrease in VCO 2
        • Increase from baseline in slope 3 of waveform
    • ↑ Phase 3 CO 2 Exhaled Volume increased phase 3
    • PEEP determination
      • A ↓ in slope 1 indicates excessive PEEP
        • ↓ PEEP should improve MV ALV
      • A ↓ in slope 2 in the presence of a stable MV indicates a reduction in pulmonary perfusion.
        • If volume status is optimal excessive PEEP may be impeding venous return.
        • ↓ PEEP should ↓ intrathoracic pressure.
    • PEEP determination
      • ↑ in slope 3 represents mal-distribution of gas.
        • ↑ PEEP level may prevent de-recruitment of alveoli and improve gas exchange.
        • Consider recruitment maneuver with subsequent ↑ PEEP.
    • What is volumetric capnography?
      • Very sensitive indicator of change in pt’s cardio-respiratory status
      • Signals future changes in PaCO 2 & SaO 2
      • Provides instant feedback of how gas exchange responds to vent changes
    • Why VCO 2 ?
      • Rapid indicator of changes in patient status as well as responses to ventilator parameter adjustments.
      • Watch for changes from baseline.
      • Familiarize yourself with the SBCO 2 waveform.
      • It is as easy as 1,2,3!
    • Conclusion
      • Monitoring with volumetric capnography will most likely not change clinical practice.
      • What it will do is provide information that will enhance clinical practice.
      • Management strategies can be based on objective data.
    • Thank You!