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- 1. CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 2: Introduction
- 2. Part 2: Introduction to Capnography CAPNOGRAPHY In Emergency Care
- 3. Part 2: Introduction to Capnography Learning Objectives <ul><li>Differentiate between oxygenation and ventilation </li></ul><ul><li>Define end-tidal CO 2 </li></ul><ul><li>Identify phases of a normal capnogram </li></ul><ul><li>Recognize patterns of hypoventilation, hyperventilation and bronchospasm </li></ul>
- 4. Oxygenation and Ventilation <ul><li>What is the difference? </li></ul>
- 5. Oxygenation and Ventilation <ul><li>Two completely different and separate functions </li></ul><ul><ul><li>Oxygenation is the transport of O 2 via the bloodstream to the cells </li></ul></ul><ul><ul><ul><li>Oxygen is required for metabolism </li></ul></ul></ul><ul><ul><li>Ventilation is the exhaling of CO 2 via the respiratory tract </li></ul></ul><ul><ul><ul><li>Carbon dioxide is a byproduct of metabolism </li></ul></ul></ul>
- 6. Oxygenation and Ventilation Oxygenation (oximetry ) Cellular Metabolism Ventilation (capnography) CO 2 O 2
- 7. Oxygenation <ul><li>Measured by pulse oximetry (SpO 2 ) </li></ul><ul><ul><li>Noninvasive measurement </li></ul></ul><ul><ul><li>Percentage of oxygen in red blood cells </li></ul></ul><ul><ul><li>Changes in ventilation take minutes to be detected </li></ul></ul><ul><ul><li>Affected by motion artifact, poor perfusion and some dysrhythmias </li></ul></ul>
- 8. Oxygenation Pulse Oximetry Sensors Pulse Oximetry Waveform
- 9. Ventilation <ul><li>Measured by the end-tidal CO 2 </li></ul><ul><ul><li>Partial pressure (mmHg) or volume (% vol) of CO 2 in the airway at the end of exhalation </li></ul></ul><ul><ul><li>Breath-to-breath measurement provides information within seconds </li></ul></ul><ul><ul><li>Not affected by motion artifact, poor perfusion or dysrhythmias </li></ul></ul>
- 10. Ventilation Capnography waveform Capnography Lines
- 11. Oxygenation versus Ventilation <ul><li>Monitor your own SpO 2 and EtCO 2 </li></ul><ul><li>SpO 2 waveform is in the second channel </li></ul><ul><li>EtCO 2 waveform is in the third channel </li></ul>
- 12. Oxygenation versus Ventilation <ul><li>Now hold your breath </li></ul><ul><li>Note what happens to the two waveforms </li></ul>How long did it take the EtCO 2 waveform to go flat line? How long did it take the SpO 2 to drop below 90%? SpO 2 EtCO 2
- 13. Oxygenation and Ventilation <ul><li>Oxygenation </li></ul><ul><ul><li>Oxygen for metabolism </li></ul></ul><ul><ul><li>SpO 2 measures % of O 2 in RBC </li></ul></ul><ul><ul><li>Reflects change in oxygenation within 5 minutes </li></ul></ul><ul><li>Ventilation </li></ul><ul><ul><li>Carbon dioxide from metabolism </li></ul></ul><ul><ul><li>EtCO 2 measures exhaled CO 2 at point of exit </li></ul></ul><ul><ul><li>Reflects change in ventilation within 10 seconds </li></ul></ul>
- 14. Why Measure Ventilation — Intubated Patients <ul><li>Verify and document ET tube placement </li></ul><ul><li>Immediately detect changes in ET tube position </li></ul><ul><li>Assess effectiveness of chest compressions </li></ul><ul><li>Earliest indication of ROSC </li></ul><ul><li>Indicator of probability of successful resuscitation </li></ul><ul><li>Optimally adjust manual ventilations in patients sensitive to changes in CO 2 </li></ul>
- 15. Why Measure Ventilation — Non-Intubated Patients <ul><li>Objectively assess acute respiratory disorders </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><li>Possibly gauge response to treatment </li></ul>
- 16. Why Measure Ventilation— Non-intubated Patients <ul><li>Gauge severity of hypoventilation states </li></ul><ul><ul><li>Drug and ETOH intoxication </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Sedation and analgesia </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Head injury </li></ul></ul><ul><li>Assess perfusion status </li></ul><ul><li>Noninvasive monitoring of patients in DKA </li></ul>
- 17. Interpreting EtCO 2 and the Capnography Waveform <ul><li>Interpreting EtCO 2 </li></ul><ul><ul><li>Measuring </li></ul></ul><ul><ul><li>Physiology </li></ul></ul><ul><li>Capnography waveform </li></ul>
- 18. End-tidal CO 2 (EtCO 2 ) Ventilation Perfusion Pulmonary Blood Flow Right Ventricle Left Atrium r r O x y g e n O 2 C O 2 O 2 V e i n A t e y
- 19. End-tidal CO 2 (EtCO 2 ) <ul><li>Carbon dioxide can be measured </li></ul><ul><li>Arterial blood gas is PaCO 2 </li></ul><ul><ul><li>Normal range: 35-45mmHg </li></ul></ul><ul><li>Mixed venous blood gas PeCO 2 </li></ul><ul><ul><li>Normal range: 46-48mmHg </li></ul></ul><ul><li>Exhaled carbon dioxide is EtCO 2 </li></ul><ul><ul><li>Normal range: 35-45mmHg </li></ul></ul>
- 20. a-A Gradient r r Alveolus PaCO 2 V e i n A t e y Ventilation Perfusion Arterial to Alveolar Difference for CO 2 Right Ventricle Left Atrium EtCO 2
- 21. End-tidal CO 2 (EtCO 2 ) <ul><li>Normal a-A gradient </li></ul><ul><ul><li>2-5mmHg difference between the EtCO 2 and PaCO 2 in a patient with healthy lungs </li></ul></ul><ul><ul><li>Wider differences found </li></ul></ul><ul><ul><ul><li>In abnormal perfusion and ventilation </li></ul></ul></ul><ul><ul><ul><li>Incomplete alveolar emptying </li></ul></ul></ul><ul><ul><ul><li>Poor sampling </li></ul></ul></ul>
- 22. End-tidal CO 2 (EtCO 2 ) <ul><li>Reflects changes in </li></ul><ul><ul><li>Ventilation - movement of air in and out of the lungs </li></ul></ul><ul><ul><li>Diffusion - exchange of gases between the air-filled alveoli and the pulmonary circulation </li></ul></ul><ul><ul><li>Perfusion - circulation of blood </li></ul></ul>
- 23. End-tidal CO 2 (EtCO 2 ) <ul><li>Monitors changes in </li></ul><ul><ul><li>Ventilation - asthma, COPD, airway edema, foreign body, stroke </li></ul></ul><ul><ul><li>Diffusion - pulmonary edema, alveolar damage, CO poisoning, smoke inhalation </li></ul></ul><ul><ul><li>Perfusion - shock, pulmonary embolus, cardiac arrest, severe dysrhythmias </li></ul></ul>
- 24. Capnographic Waveform <ul><li>Normal waveform of one respiratory cycle </li></ul><ul><li>Similar to ECG </li></ul><ul><ul><li>Height shows amount of CO 2 </li></ul></ul><ul><ul><li>Length depicts time </li></ul></ul>
- 25. Capnographic Waveform <ul><li>Waveforms on screen and printout may differ in duration </li></ul><ul><ul><li>On-screen capnography waveform is condensed to provide adequate information the in 4-second view </li></ul></ul><ul><ul><li>Printouts are in real-time </li></ul></ul><ul><ul><li>Observe RR on device </li></ul></ul>
- 26. Capnographic Waveform <ul><li>Capnograph detects only CO 2 from ventilation </li></ul><ul><li>No CO 2 present during inspiration </li></ul><ul><ul><li>Baseline is normally zero </li></ul></ul>Baseline
- 27. Capnogram Phase I Dead Space Ventilation <ul><li>Beginning of exhalation </li></ul><ul><li>No CO 2 present </li></ul><ul><li>Air from trachea, posterior pharynx, mouth and nose </li></ul><ul><ul><li>No gas exchange occurs there </li></ul></ul><ul><ul><li>Called “dead space” </li></ul></ul>
- 28. Capnogram Phase I Baseline Beginning of exhalation A B I Baseline
- 29. Capnogram Phase II Ascending Phase <ul><li>CO 2 from the alveoli begins to reach the upper airway and mix with the dead space air </li></ul><ul><ul><li>Causes a rapid rise in the amount of CO 2 </li></ul></ul><ul><li>CO 2 now present and detected in exhaled air </li></ul>
- 30. Capnogram Phase II Ascending Phase CO 2 present and increasing in exhaled air II A B C Ascending Phase Early Exhalation
- 31. Capnogram Phase III Alveolar Plateau <ul><li>CO 2 rich alveolar gas now constitutes the majority of the exhaled air </li></ul><ul><li>Uniform concentration of CO 2 from alveoli to nose/mouth </li></ul>
- 32. Capnogram Phase III Alveolar Plateau <ul><li>CO 2 exhalation wave plateaus </li></ul>Alveolar Plateau A B C D I I I
- 33. Capnogram Phase III End-Tidal <ul><li>End of exhalation contains the highest concentration of CO 2 </li></ul><ul><ul><li>The “end-tidal CO 2 ” </li></ul></ul><ul><ul><li>The number seen on your monitor </li></ul></ul><ul><li>Normal EtCO 2 is 35-45mmHg </li></ul>
- 34. Capnogram Phase III End-Tidal <ul><li>End of the the wave of exhalation </li></ul>A B C D End-tidal
- 35. Capnogram Phase IV Descending Phase <ul><li>Inhalation begins </li></ul><ul><li>Oxygen fills airway </li></ul><ul><li>CO 2 level quickly drops to zero </li></ul>
- 36. Capnogram Phase IV Descending Phase <ul><li>Inspiratory downstroke returns to baseline </li></ul>A B C D E I V Descending Phase Inhalation
- 37. Capnography Waveform <ul><li>Normal range is 35-45mm Hg (5% vol) </li></ul>Normal Waveform
- 38. Capnography Waveform Question <ul><li>How would your capnogram change if you intentionally started to breathe at a rate of 30? </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Height </li></ul></ul><ul><ul><li>Shape </li></ul></ul>
- 39. Hyperventilation <ul><li>RR : EtCO 2 </li></ul>4 5 0 Normal Hyperventilation
- 40. Capnography Waveform Question <ul><li>How would your capnogram change if you intentionally decreased your respiratory rate to 8? </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Height </li></ul></ul><ul><ul><li>Shape </li></ul></ul>
- 41. Hypoventilation RR : EtCO 2 Normal Hypoventilation 4 5 0 4 5 0
- 42. Capnography Waveform Patterns 0 4 5 Hypoventilation 4 5 0 Hyperventilation Normal
- 43. Capnography Waveform Question <ul><li>How would the waveform shape change during an asthma attack? </li></ul>
- 44. Bronchospasm Waveform Pattern <ul><li>Bronchospasm hampers ventilation </li></ul><ul><ul><li>Alveoli unevenly filled on inspiration </li></ul></ul><ul><ul><li>Empty asynchronously during expiration </li></ul></ul><ul><ul><li>Asynchronous air flow on exhalation dilutes exhaled CO 2 </li></ul></ul><ul><li>Alters the ascending phase and plateau </li></ul><ul><ul><li>Slower rise in CO 2 concentration </li></ul></ul><ul><ul><li>Characteristic pattern for bronchospasm </li></ul></ul><ul><ul><li>“Shark Fin” shape to waveform </li></ul></ul>
- 45. Capnography Waveform Patterns Norma l Bronchospasm 4 5 0
- 46. Part 2: Introduction to Capnography Summary <ul><li>Oxygenation and ventilation </li></ul><ul><li>Pulse oximetry </li></ul><ul><ul><li>Measures O 2 saturation in blood </li></ul></ul><ul><ul><li>Slow to indicate change in ventilation </li></ul></ul><ul><li>Capnography </li></ul><ul><ul><li>Measures CO 2 in the the airway </li></ul></ul><ul><ul><li>Provides a breath-to-breath status of ventilation </li></ul></ul>
- 47. Part 2: Introduction to Capnography Summary <ul><li>Capnographic waveform has four phases </li></ul><ul><li>The highest CO 2 concentration is at the end of alveolar plateau </li></ul><ul><ul><li>End-tidal CO 2 </li></ul></ul><ul><ul><li>Normal EtCO 2 range is 35-45mmHg </li></ul></ul><ul><li>Several conditions can be immediately detected with capnography </li></ul>
- 48. Capnography Waveform Patterns Hypoventilation Normal Bronchospasm Hyperventilation 4 5 0 4 5 0 4 5 0
- 49. Part 2: Introduction to Capnography We’re off to a running start!

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