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14 capnography part1 overview

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14 capnography part1 overview

  1. 1. C A PNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 1: Overview
  2. 2. <ul><li>Program Learning Objectives </li></ul><ul><ul><li>Relate a normal capnogram to the phases of breathing </li></ul></ul><ul><ul><li>List five clinical applications for capnography </li></ul></ul><ul><ul><li>Identify the four most common abnormal capnograms </li></ul></ul><ul><ul><li>Describe how to incorporate capnogram to patient care according to local protocol </li></ul></ul>C A PNOGRAPHY In Emergency Care
  3. 3. Program Parts <ul><li>Part 1: Overview </li></ul><ul><li>Part 2: Introduction to Capnography </li></ul><ul><li>Part 3: Capnography in the Intubated Patient </li></ul><ul><li>Part 4: Capnography in the Non-intubated Patient </li></ul>CAPNOGRAPHY In Emergency Care
  4. 4. Part 1: Overview C A PNOGRAPHY In Emergency Care
  5. 5. Why use capnography? (Corollary: Why should I learn capnography?)
  6. 6. Case Scenario <ul><li>61 year old male </li></ul><ul><li>C/O: “short-of-breath” and “exhausted” </li></ul><ul><li>H/O: > 45 years of smoking 2 packs a day, 3 heart attacks, high blood pressure </li></ul><ul><li>Meds: “too expensive to take every day ” </li></ul><ul><li>Exam: HR 92, RR 18, 160/100, 2+ pitting edema, wheezing, crackles </li></ul>CHF? COPD? <ul><ul><li>What other information would you want in making your assessment? </li></ul></ul>
  7. 7. Capnography Overview <ul><li>A technology that: </li></ul><ul><ul><li>Provides another measurement in assessing your patient </li></ul></ul><ul><ul><li>Gives an objective measure of your patient’s ventilatory status </li></ul></ul><ul><ul><li>Shows a graphic picture of your patient’s ventilatory status </li></ul></ul><ul><ul><li>Presents an early warning of changes in your patient's cardiopulmonary status </li></ul></ul><ul><ul><li>Supplies important documentation on your patient </li></ul></ul>
  8. 8. Capnography Overview <ul><li>Capnography provides an objective measure of ventilation </li></ul><ul><li>Capnography provides </li></ul><ul><ul><li>Numeric value of “End-Tidal CO 2 ” </li></ul></ul><ul><ul><li>Waveform of respiration </li></ul></ul>
  9. 9. Capnography Overview <ul><li>End Tidal CO 2 — what is it? </li></ul><ul><ul><li>Breathing is done in waves </li></ul></ul><ul><ul><li>EtCO 2 is the amount of CO 2 measured at the peak of the wave </li></ul></ul><ul><ul><li>EtCO 2 is measured at the nose, mouth, or hub of the ET tube </li></ul></ul>
  10. 10. Capnography Overview <ul><li>“Capnos” is Greek for smoke </li></ul><ul><ul><li>From the “fire of life” — metabolism </li></ul></ul><ul><ul><li>Metabolism produces carbon dioxide as a waste product </li></ul></ul>
  11. 11. Capnography Overview <ul><li>Carbon Dioxide (CO 2 ) </li></ul><ul><ul><li>Produced by all living cells </li></ul></ul><ul><ul><li>Diffused into the bloodstream </li></ul></ul><ul><ul><li>Transported to the lungs </li></ul></ul><ul><ul><li>Perfused into the alveoli </li></ul></ul><ul><ul><li>Exhaled through the airway </li></ul></ul>
  12. 12. History of Capnography in EMS <ul><li>Initially used for monitoring anesthetized patients in the OR </li></ul><ul><li>New technology now available for EMS in both intubated and non-intubated patients </li></ul>
  13. 13. History of Capnography in EMS <ul><li>Used by anesthesiologists since the 1970s </li></ul><ul><li>Standard of care in the OR since 1991 </li></ul><ul><li>New JCAHO standard now expanding utilization </li></ul>Source: PRACTICE GUIDELINES FOR SEDATION AND ANALGESIA BY NON- ANESTHESIOLOGISTS (Approved by the House of Delegates on October 25, 1995, and last amended on October 17, 2001) 2002. Anesthesiology 96:1004-1017
  14. 14. History of Capnography in EMS <ul><li>JCAHO January 2001 standard on procedural sedation </li></ul><ul><ul><li>In any hospital or clinic setting </li></ul></ul><ul><ul><li>Monitoring vital signs, continuous monitoring of oxygenation and ventilation </li></ul></ul>Capnography provides the only continuous visual monitoring of ventilation Source: Joint Commission Perspectives, Special Report. July/August 2000
  15. 15. History of Capnography in EMS <ul><li>Pulse oximetry preceded capnography </li></ul><ul><li>Pulse oximetry measures oxygenation </li></ul><ul><li>Capnography measures ventilation </li></ul><ul><ul><li>New technologies now allow use in EMS </li></ul></ul>
  16. 16. History of Capnography in EMS <ul><li>Colorimetric </li></ul><ul><li>Capnometry </li></ul><ul><li>Capnography </li></ul>
  17. 17. History of Capnography in EMS <ul><li>Specially treated litmus paper </li></ul><ul><ul><li>Color changes indicate qualitative amount of CO 2 detected </li></ul></ul><ul><li>For intubated patients only </li></ul><ul><li>Disposable detector fits on ET tube hub </li></ul>Colorimetric:
  18. 18. History of Capnography in EMS <ul><li>Single use </li></ul><ul><li>Easily impaired by moisture or secretions </li></ul><ul><li>False negatives during cardiac arrest </li></ul><ul><li>Equates to checking a pulse on cardiac patient </li></ul><ul><ul><li>Presence </li></ul></ul><ul><ul><li>Strength/amount </li></ul></ul>Colorimetric:
  19. 19. History of Capnography in EMS Colorimetric:
  20. 20. History of Capnography in EMS <ul><li>A numerical value of the EtCO 2 </li></ul><ul><li>For both non-intubated and intubated patients </li></ul><ul><li>Continuous monitoring </li></ul>Capnometry:
  21. 21. History of Capnography in EMS <ul><li>No waveform of the EtCO 2 in the airway </li></ul><ul><li>Equates to monitoring heart rate in cardiac patient </li></ul><ul><ul><li>Present </li></ul></ul><ul><ul><li>Amount or range </li></ul></ul><ul><ul><li>Changes over time </li></ul></ul>Capnometry:
  22. 22. History of Capnography in EMS Capnometer:
  23. 23. History of Capnography in EMS <ul><li>Numeric reading: HR 100 </li></ul><ul><li>Waveform: </li></ul>Capnometry:
  24. 24. History of Capnography in EMS <ul><li>Numeric reading: HR 100 </li></ul><ul><li>Waveform: </li></ul>Capnometry:
  25. 25. History of Capnography in EMS <ul><li>A numerical value of the EtCO 2 </li></ul><ul><li>AND </li></ul><ul><li>A waveform of the concentration of CO 2 present in the airway </li></ul>Capnography:
  26. 26. History of Capnography in EMS <ul><li>For both non-intubated and intubated patients </li></ul><ul><li>Continuous breath-to-breath monitoring </li></ul><ul><li>Equates to ECG monitoring in cardiac patient </li></ul>Capnography:
  27. 27. History of Capnography in EMS Capnography:
  28. 28. History of Capnography in EMS <ul><li>Capnography systems </li></ul><ul><ul><li>Collector of the air sample </li></ul></ul><ul><ul><li>Analyzer detects and measures CO 2 </li></ul></ul><ul><ul><li>Display shows waveform and number </li></ul></ul>
  29. 29. History of Capnography in EMS <ul><li>Conventional high-flow sidestream </li></ul><ul><li>Mainstream </li></ul><ul><li>New low-flow sidestream technology </li></ul>Capnography Technologies: 1980’s Early 1990’s
  30. 30. History of Capnography in EMS <ul><li>Conventional high-flow sidestream capnography </li></ul><ul><ul><li>For both intubated and non-intubated patient </li></ul></ul><ul><ul><li>Analyzer located inside the device for protection </li></ul></ul><ul><ul><ul><li>No added weight on patient’s airway </li></ul></ul></ul>
  31. 31. History of Capnography in EMS <ul><li>Conventional high-flow sidestream capnography </li></ul><ul><ul><li>Requires 150-200ml of air to measure a CO 2 level </li></ul></ul><ul><ul><ul><li>Air aspirating system </li></ul></ul></ul><ul><ul><ul><li>Requires frequent calibration </li></ul></ul></ul><ul><ul><ul><li>Frequent occlusion of tubing by moisture and secretions </li></ul></ul></ul><ul><ul><ul><li>Inaccurate in neonates, infants, and young children </li></ul></ul></ul>
  32. 32. History of Capnography in EMS <ul><li>Conventional high-flow sidestream capnography system </li></ul>A i r S a m p l e W a t e r T r a p E n d - t i d a l C O 2 m o n i t o r w i t h analyzer inside S a m p l e P o r t B a g
  33. 33. History of Capnography <ul><li>Mainstream Capnography </li></ul><ul><ul><li>Developed for intubated patient </li></ul></ul><ul><ul><li>Analyzer on the hub of ET tube </li></ul></ul><ul><ul><ul><li>Not disposable </li></ul></ul></ul><ul><ul><ul><li>Weight on the ET tube </li></ul></ul></ul><ul><ul><ul><li>Adaptors attach to analyzer for non-intubated patients </li></ul></ul></ul>
  34. 34. History of Capnography <ul><li>Mainstream Capnography </li></ul>E l e c t r o n i c C a b l e Analyzer E n d - t i d a l C O 2 m o n i t o r B a g
  35. 35. History of Capnography <ul><li>New low-flow sidestream capnography </li></ul><ul><ul><li>Newer technology requires 50ml of air for sampling </li></ul></ul><ul><ul><ul><li>Occlusions uncommon </li></ul></ul></ul><ul><ul><ul><li>Accurate in all age groups </li></ul></ul></ul><ul><ul><ul><ul><li>neonates to large adults </li></ul></ul></ul></ul>
  36. 36. History of Capnography <ul><li>New low-flow sidestream capnography </li></ul><ul><ul><li>For intubated and non-intubated patients </li></ul></ul><ul><ul><li>No calibration required between patients </li></ul></ul><ul><ul><li>Disposable tubing and cannulas </li></ul></ul><ul><ul><li>New in-line filters exclude contaminants </li></ul></ul><ul><ul><li>Central collector system in tubing </li></ul></ul><ul><ul><li>Durable for EMS environment </li></ul></ul>
  37. 37. History of Capnography <ul><li>New low-flow sidestream technology </li></ul>
  38. 38. Using Capnography <ul><li>Immediate information via breath-to-breath monitoring </li></ul><ul><li>Information on the ABCs </li></ul><ul><ul><li>Airway </li></ul></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Circulation </li></ul></ul><ul><li>Documentation </li></ul>
  39. 39. Using Capnography <ul><li>Airway </li></ul><ul><ul><li>Verification of ET tube placement </li></ul></ul><ul><ul><li>Continuous monitoring of ET tube position </li></ul></ul><ul><li>Circulation </li></ul><ul><ul><li>Check effectiveness of cardiac compressions </li></ul></ul><ul><ul><li>First indicator of ROSC </li></ul></ul><ul><ul><li>Monitor low perfusion states </li></ul></ul>Airway <ul><ul><li>Circulation </li></ul></ul>
  40. 40. Using Capnography <ul><li>Breathing </li></ul><ul><ul><li>– Hyperventilation </li></ul></ul><ul><ul><li>– Hypoventilation </li></ul></ul><ul><ul><li>– Asthma </li></ul></ul><ul><ul><li>– COPD </li></ul></ul>
  41. 41. Using Capnography <ul><li>Documentation </li></ul><ul><ul><li>Waveforms </li></ul></ul><ul><ul><ul><li>Initial assessment </li></ul></ul></ul><ul><ul><ul><li>Changes with treatment </li></ul></ul></ul><ul><ul><li>EtCO 2 values </li></ul></ul><ul><ul><ul><li>Trends over time </li></ul></ul></ul><ul><ul><li>Waveforms </li></ul></ul>Trends
  42. 42. Part 1: Capnography Overview Summary <ul><li>The only visual objective measure of ventilation </li></ul><ul><li>Provides breath-to-breath readings </li></ul><ul><li>For intubated and non-intubated patients </li></ul><ul><li>Information and documentation of patient’s ABCs </li></ul><ul><li>New technology for use in EMS </li></ul>
  43. 43. Part 1: Capnography Overview Okay, let’s get started.

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