04 capnography hamel


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04 capnography hamel

  1. 1. 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.
  2. 2. Introduction <ul><li>Technologic advances have led to a myriad of ventilatory modes and flow options. </li></ul><ul><li>Capability to sculpt each breath to meet the specific needs of individual patients. </li></ul><ul><li>Clinicians must now choose from a multitude of options when initiating & managing mechanical ventilation. </li></ul>
  3. 3. Introduction <ul><li>How do we assess the effectiveness of our ventilatory choices? </li></ul><ul><ul><li>Arterial blood gases </li></ul></ul><ul><ul><li>Pulse oximetry </li></ul></ul><ul><ul><li>ETCO 2 monitoring </li></ul></ul><ul><ul><li>Volumetric capnography </li></ul></ul>
  4. 4. What is volumetric capnography? <ul><li>Integration of flow and carbon dioxide. </li></ul><ul><li>Measures, calculates, and displays breath-by-breath measurements throughout the entire respiratory cycle. </li></ul><ul><ul><li>Digital numeric display </li></ul></ul><ul><ul><li>Multiple graphics </li></ul></ul><ul><ul><li>Single breath waveform (SBCO 2 ) </li></ul></ul><ul><li>Multitude of information including VCO 2 </li></ul>
  5. 5. What is VCO 2 <ul><ul><li>Volume of CO 2 eliminated via the lungs. </li></ul></ul><ul><ul><li>Inverse relationship to PaCO 2 </li></ul></ul><ul><ul><li>Affected by ventilation, perfusion, & diffusion </li></ul></ul>
  6. 6. What is VCO 2 <ul><ul><li>Reflects acute clinical changes </li></ul></ul><ul><ul><li>Indicator of pulm capillary blood flow </li></ul></ul><ul><ul><li>Reflects effects of ventilator manipulations </li></ul></ul><ul><ul><li>Most beneficial when used in conjunction with SBCO 2 </li></ul></ul>
  7. 7. SBCO 2 Waveform Expired CO 2 V T
  8. 8. SBCO 2 Waveform Expired CO 2 I V T Phase I = large airway ventilation
  9. 9. SBCO 2 Waveform Expired CO 2 I II V T Phase II = mixed large airway and alveolar ventilation Phase I = large airway ventilation
  10. 10. 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
  11. 11. Phases of SBCO 2 waveform <ul><li>Phase 1: </li></ul><ul><ul><li>represents gas exhaled from the upper airways which generally is void of carbon dioxide </li></ul></ul><ul><li>Phase 2: </li></ul><ul><ul><li>transitional phase from upper to lower airway ventilation and tends to depict changes in perfusion </li></ul></ul><ul><li>Phase 3: </li></ul><ul><ul><li>area of alveolar gas exchange representative of gas distribution </li></ul></ul>
  12. 12. Clinical significance <ul><li>Phase 1 </li></ul><ul><ul><li>↑ depicts an ↑ in airways dead space. </li></ul></ul><ul><li>Phase 2 </li></ul><ul><ul><li>↓ slope depicts reducing perfusion. </li></ul></ul><ul><li>Phase 3 </li></ul><ul><ul><li>↑ slope depicts mal-distribution of gas. </li></ul></ul>
  13. 13. Phase 1 assessment <ul><li>When a change in VCO 2 occurs, assess SBCO 2 </li></ul><ul><li>If ↑ in phase 1 (VD ANA ) </li></ul><ul><ul><li>Assess for appropriate PEEP level </li></ul></ul><ul><ul><ul><li>Excessive PEEP may be present </li></ul></ul></ul><ul><ul><li>Airway obstruction </li></ul></ul><ul><ul><ul><li>Suction? </li></ul></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><ul><li>Bronchodilator tx my be indicated </li></ul></ul></ul>
  14. 14. ↑ phase 1 <ul><li>Phase 1 – relatively short </li></ul><ul><li>Phase 1 - prolonged </li></ul>
  15. 15. Phase 2 assessment <ul><li>If  in phase 2 </li></ul><ul><ul><li>Assure stable minute ventilation </li></ul></ul><ul><ul><li>Assess PEEP level </li></ul></ul><ul><ul><ul><li>↑ intrathoracic pressure may cause  venous return </li></ul></ul></ul><ul><ul><li>Assess hemodynamic status </li></ul></ul><ul><ul><ul><li>Is minute ventilation stable? </li></ul></ul></ul><ul><ul><ul><li>Volume resuscitation or vasopressors may be indicated </li></ul></ul></ul>
  16. 16.  Phase 2 <ul><li>When minute ventilation is stable, indicative of a  in perfusion. </li></ul>
  17. 17. Phase 3 assessment <ul><li>If ↑ or absent phase 3 mal-distribution of gas at alveolar level exists </li></ul><ul><ul><li>Assess for appropriate PEEP level </li></ul></ul><ul><ul><ul><li>Inadequate PEEP may be present </li></ul></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><ul><li>Bronchodilator tx my be indicated </li></ul></ul></ul><ul><ul><li>Structure damage at alveolar level may be present </li></ul></ul><ul><ul><ul><li>Pnuemothorax? </li></ul></ul></ul>
  18. 18. ↑ or absent phase 3 <ul><li>Slope of phase 3 present and level </li></ul><ul><li>Phase 3 absent </li></ul>
  19. 19. Optimizing PEEP VCO 2 & SBCO 2 <ul><li>A ↓ in VCO 2 may be indicative of inappropriate PEEP level. </li></ul><ul><li>To determine appropriate action evaluate SBCO 2 waveform. </li></ul><ul><li>Look for changes from baseline. </li></ul>
  20. 20. Slope 1: anatomic deadspace <ul><li>Excessive PEEP can be quickly recognized </li></ul><ul><ul><li>Decrease in VCO 2 </li></ul></ul><ul><ul><li>Increase from baseline in slope 1 of waveform </li></ul></ul>
  21. 21. ↑ Phase 1
  22. 22. Slope 2: pulmonary perfusion <ul><li>A ↓ in pulmonary perfusion may result from excessive PEEP. </li></ul><ul><li>Generally created by ↑in intrathoracic pressure resulting in: </li></ul><ul><ul><li>↓ Systemic venous return </li></ul></ul><ul><ul><li>↑ Pulmonary vascular resistance </li></ul></ul>
  23. 23. Slope 2: pulmonary perfusion <ul><li>Quickly recognized by: </li></ul><ul><ul><li>Decrease in VCO 2 </li></ul></ul><ul><ul><li>Decrease from baseline in slope 2 of waveform </li></ul></ul>
  24. 24.  Phase 2 Decreased Perfusion Baseline
  25. 25. Slope 3: gas distribution <ul><li>Depicts gas distribution at alveolar level. </li></ul><ul><li>Mal-distribution of gas can be a result of inappropriate PEEP level. </li></ul><ul><li>When PEEP levels inadequate, alveolar collapse can occur. </li></ul>
  26. 26. Mal-distribution of gas <ul><li>Quickly recognized by: </li></ul><ul><ul><li>Decrease in VCO 2 </li></ul></ul><ul><ul><li>Increase from baseline in slope 3 of waveform </li></ul></ul>
  27. 27. ↑ Phase 3 CO 2 Exhaled Volume increased phase 3
  28. 28. PEEP determination <ul><li>A ↓ in slope 1 indicates excessive PEEP </li></ul><ul><ul><li>↓ PEEP should improve MV ALV </li></ul></ul><ul><li>A ↓ in slope 2 in the presence of a stable MV indicates a reduction in pulmonary perfusion. </li></ul><ul><ul><li>If volume status is optimal excessive PEEP may be impeding venous return. </li></ul></ul><ul><ul><li>↓ PEEP should ↓ intrathoracic pressure. </li></ul></ul>
  29. 29. PEEP determination <ul><li>↑ in slope 3 represents mal-distribution of gas. </li></ul><ul><ul><li>↑ PEEP level may prevent de-recruitment of alveoli and improve gas exchange. </li></ul></ul><ul><ul><li>Consider recruitment maneuver with subsequent ↑ PEEP. </li></ul></ul>
  30. 30. What is volumetric capnography? <ul><li>Very sensitive indicator of change in pt’s cardio-respiratory status </li></ul><ul><li>Signals future changes in PaCO 2 & SaO 2 </li></ul><ul><li>Provides instant feedback of how gas exchange responds to vent changes </li></ul>
  31. 31. Why VCO 2 ? <ul><li>Rapid indicator of changes in patient status as well as responses to ventilator parameter adjustments. </li></ul><ul><li>Watch for changes from baseline. </li></ul><ul><li>Familiarize yourself with the SBCO 2 waveform. </li></ul><ul><li>It is as easy as 1,2,3! </li></ul>
  32. 32. Conclusion <ul><li>Monitoring with volumetric capnography will most likely not change clinical practice. </li></ul><ul><li>What it will do is provide information that will enhance clinical practice. </li></ul><ul><li>Management strategies can be based on objective data. </li></ul>
  33. 33. Thank You!