04 capnography hamel

1,242 views

Published on

Published in: Health & Medicine
1 Comment
3 Likes
Statistics
Notes
  • 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
    NB: I write an identical message on each présentation
    PS: I also added you Slidecast to our others group :
    - BANK OF KNOWLEDGE - http://www.slideshare.net/group/bank-of-knowledge
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
1,242
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
56
Comments
1
Likes
3
Embeds 0
No embeds

No notes for slide

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!

×