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Capnography in ems.ppt
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  1. 1. Re-appropriated from the internet by Diane J. Morris
  2. 2. Objectives • Understand why we use capnography • Understand the physiology of respiration/ ventilation • Define normal & abnormal EtCO2 values/ waveforms • Understand the 4 major applications of EtCO2 – intubated applications (mainstream) – non-intubated applications (sidestream)
  3. 3. Why Capnography? Advanced Airway Management All devices used to confirm tube placement must be documented on the PCR. • Esophageal Detection Device (EDD) • End tidal CO2 detector (ETCO2) colorimetric or capnography “Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate. [Annals of Emergency Medicine 2005; 45:497-503]”
  4. 4. Why Capnography? • Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!!
  5. 5. Why Capnography? Because respiration, ventilation and oxygenation are VERYVERYdifferent concepts.
  6. 6. Why Capnography? It’s a window into the patient’s ventilatory status
  7. 7. Why Capnography? Core Concepts • What intubation verification method is most reliable? • How do oxygenation and ventilation differ?
  8. 8. Physiology
  9. 9. Factors that affect CO2 levels: INCREASE IN ETCO2 DECREASE IN ETCO2 Increased muscular activity Decreased muscular activity Increased cardiac output (during resuscitation) Decreased cardiac output (during resuscitation) Effective drug therapy for bronchospasm Bronchospasm Hypoventilation Hyperventilation
  10. 10. Normal EtCO2
  11. 11. Terminology Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value
  12. 12. Terminology EtCO2 – End Tidal CO2 The measurement of exhaled CO2 in the breath Normal Range 35-45 mmHg
  13. 13. Normal Waveform End of inspiration Beginning of exhalation End of exhalation Beginning of new breath Alveolar plateau Clearing of anatomic dead space
  14. 14. Normal Common Waveforms
  15. 15. Hyperventilation Hypoventilation Common Waveforms
  16. 16. 4 Main Uses of Capnography • Severity of asthma patients • Monitoring head injured patients • Cardiac arrest • Tube confirmation
  17. 17. Terminology Sidestream An indirect method of measuring exhaled CO2 in non-intubated patients Mainstream Direct method of measuring exhaled CO2 with intubated patients
  18. 18. Shark Fin Asthmatic Waveforms COPD patients have a difficult time exhaling gases This is represented on the capnogram by a shark fin appearance
  19. 19. Moderate Attack Mild Attack EtCO2 & Asthma
  20. 20. Severe Attack EtCO2 & Asthma Time To Get MOVING!!! The asthmatic who looks tired and has a shark fin appearance on the capnogram… IS HEADED FOR RESPIRATORY ARREST
  21. 21. The Head Injured Patient Carbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault and therefore increasing ICP Recognizing the head injured patient and titrating their CO2 levels to the 30-3530-35 mmHgmmHg range can help relieve the untoward effects of ICP
  22. 22. Titrate EtCO2 The Head Injured Patient Titration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO2 levels. Keep them between 30 and 35 mmHg
  23. 23. EtCO2 and Cardiac Arrest The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output Increase in CO2 during CPR can be an early indicator of ROSC
  24. 24. Termination of Resuscitation EtCO2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR Non-survivors <10 mmHg10 mmHg Survivors >30 mmHg30 mmHg ((to discharge)
  25. 25. ET Tube Verification • Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!!
  26. 26. 4 Main Uses of Capnography Core Concepts • What is the characteristic shape of a capnogram for a COPD patient? • Describe how to determine the severity of an asthma attack using capnography? • What level should you maintain a severe head injured patient’s CO2 at? • What are two ways that capnography can assist during CPR?
  27. 27. Inadequate Seal Troubleshooting As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff
  28. 28. Obstruction Troubleshooting An obstructed ET tube may have an erratic EtCO2 value with a very irregular waveform
  29. 29. Rebreathing Troubleshooting A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO2 through insufficient inspiratory or expiratory flow
  30. 30. QUIZ
  31. 31. Hypoventilation
  32. 32. Rebreathing
  33. 33. Esophageal Tube
  34. 34. Asthma (bronchospasm)
  35. 35. Normal
  36. 36. Questions?

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