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  • CHF “cardiac asthma” will not present ith shark fin
  • Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate. ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a respiratory rate of 8, but an ETCO2 of 35.
  • Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate. ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a respiratory rate of 8, but an ETCO2 of 35.
  • Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate. ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a respiratory rate of 8, but an ETCO2 of 35.
  • Levels upwards of 100 mmHg are not uncommon.
  • Levels upwards of 100 mmHg are not uncommon.
  • End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the likelihood of resuscitation.
  • Likewise, case studies have shown that patients with a high initial end tidal CO2 reading were more likely to be resuscitated than those who didn 稚 . The greater the initial value, the likelier the chance of a successful resuscitation.
  • Agitated delerium = Increased ETCO2
  • Agitated delerium = Increased ETCO2
  • Get a temp. SHOCK
  • Capnography

    1. 1. Adam Thompson, EMT-P, AS
    2. 2. Objectives Review respiratory system Learn the terms of capnography Learn the uses of capnography Review confirmation of intubation Review ventilatory uses Review circulatory uses Review metabolism uses Practice scenarios
    3. 3. Respiratory System  Exchange O2 for CO2  Air enters nose & mouth Nasal Passages Nasal Passages Roof of the M outh Roof of the M outh  O2 is exchanged for Epiglottis Epiglottis Trachea (w indpipe) Trachea (w indpipe) Esophagus (food tube) Esophagus (food tube) CO2 in alveoliPulm onary VeinPulm onary VeinBronchioleBronchiole Bronchi Bronchi  O2 is transported to the body and exchanged for CO2 Alveoli again Alveoli
    4. 4. Respiratory System The heart pumps the freshly oxygenated blood throughout the body to the cells where oxygen is consumed (metabolism), and carbon dioxide, produced as a byproduct, diffuses out of the cells into the vascular system.
    5. 5. Respiratory System Carbon dioxide rich blood is then pumped through the pulmonary capillary bed where the carbon dioxide diffuses across the alveolar capillary membrane and is exhaled via the nose or mouth.
    6. 6. Terminology Capnometry  The numeric value45mmHg
    7. 7. Terminology Capnometry  The numeric value CO2: 38 40 0
    8. 8. Terminology Capnogram  The waveform 40 B C A D 0
    9. 9. Terminology The capnogram measures expired CO2. The plateau signifies expiration 40 B C A D 0
    10. 10. Terminology ETCO2 (PeCO2) = End-Tidal CO2 CO2 = Carbon Dioxide  Carbondioxide is the by-product of all metabolism, and is eliminated by exhaling. Body Cellular O2 Tissues Metabolism Lungs Carbon Dioxide
    11. 11. Terminology ETCO2 = C on the image below  End-tidal CO2 is measured at the end of expiration.  The highest level of expired CO2 is ETCO2 40 B C A D 0
    12. 12. Capnography CO2 detected with infra Red sensor Side-stream & Main-stream ETCO 2
    13. 13. Use of Capnography ConfirmET-Tube Placement Measure of Ventilation Measure of Cardiac Output Measure of Cellular Metabolism Cir n tio cu la lat nti ion Ve Metabolism
    14. 14. Use of Capnography Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A).  2010 AHA Recommendations
    15. 15. Use of Capnography Studies on wave form capnography "have shown 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement.” Colormetric ETCO2 devices should only be used "when waveform capnography is not available (Class IIa, LOE B)."
    16. 16. Use of Capnography Itis reasonable to consider using quantitative waveform capnography in intubated patients to monitor CPR quality, optimize chest compressions, and detect ROSC during chest compressions or when rhythm check reveals an organized rhythm (Class IIb, LOE C).  2010 AHA Recommendations
    17. 17. Use of Capnography IfPETCO2 abruptly increases to a normal value (35 to 40 mm Hg), it is reasonable to consider that this is an indicator of ROSC (Class IIa, LOE B).  2010 AHA Recommendations
    18. 18. CapnographyCirculation Ventilation Metabolism CO2: 38 40 0
    19. 19. Oxygenation vs.Ventilation Oxygenation VentilationMeasured with pulse oximeter Measured by capnographyChanges take a long time to display Changes display instantlyOxygenation is how we get oxygen to the tissue. Ventilation (the movement of air) is how we get ridOxygen is inhaled into the lungs where gas of carbon dioxide. Carbon dioxide is carried backexchange occurs at the capillary-alveolar through the blood and exhaled by the lungsmembrane. Oxygen is transported to the tissues through the alveoli.through the blood stream.
    20. 20. Capnography vs Oximetery Capnography gives an immediate picture of the patient’s condition. Pulse oximetry is delayed. If you hold your breath…  Capnography will show immediate apnea.  O2 Saturations will remain normal for a prolonged period of time.
    21. 21. Circulation & Metabolism While capnography is a direct measurement of ventilation in the lungs, it also indirectly measures metabolism and circulation.  Increased Cardiac Output = Increased ETCO2  Decreased Cardiac Output = Decreased ETCO 2“O2 is the smoke from the flames of metabolism.” -Ray Fowler, M.D. Dallas, Street Doc’s Society
    22. 22. PaCO2 vs. PeTCO2 PaCO2= Partial Pressure of Carbon Dioxide in arterial blood gases.  The PaCO2 is measured by drawing the ABGs, which also measure the arterial PH. If ventilation and perfusion are stable PaCO2 should correlate to PetCO2.
    23. 23. V/Q Mismatch Ifventilation or perfusion are unstable, a Ventilation/Perfusion (V/Q) mismatch can occur. This will alter the correlation between PaC02 and PetCO2. This V/Q mismatch can be caused by blood shunting.
    24. 24. Normal ETCO2 Normal ETCO2  35 to 45 mmHg *Alterations in nasopharyngeal anatomy, and device obstruction may alter the ETCO2 reading.
    25. 25. ETCO2 A is the start of alveolar expiration  A-B is the exhalation upstroke where dead space gas mixes with lung gas40 B C B C A D A D 0
    26. 26. ETCO2  B-C is the continuation of exhalation, or the plateau(all the gas is alveolar now, rich in C02)40 B C B C A D A D 0
    27. 27. ETCO2 C is the end-tidal value - the peak concentration40 B C B C A D A D 0
    28. 28. ETCO2  C-D is the inspiration washout  D-A is post inspiration/dead space exhalation40 B C B C A D A D 0
    29. 29. Abnormal ETCO2 ETCO2 Less Than 35 mmHg  "Hypocapnia”  Respiratory Alkalosis ETCO2 Greater Than 45 mmHg  "Hypercapnia”  Respiratory Acidosis “End-Tidal CO2 reading without a waveform is like a heart rate without an ECG recording.” -Bob Page, Riding the Waves
    30. 30. Intubation There is no better indicator of proper ET-Tube placement than waveform capnography. The presence of a waveform indicates a tube is correctly placed in the trachea. Good Tube Bad Tube
    31. 31. Intubation ETCO2 = 0 mmHg  The tube is in the esophagus!!!  Cardiac arrest with prolonged downtime  Spontaneous apnea
    32. 32. Intubation Intubated patient  with ETCO2 of 0 mmHg DOPE Pneumonic D - Dislodgement  O - Obstruction  P - Pneumothorax  E - Equipment
    33. 33. Intubation Intubated patient  with ETCO2 of 0 mmHg DOPE Pneumonic D - Dislodgement - check the tube!  O - Obstruction - suction  P - Pneumothorax - check lung sounds  E - Equipment - check the vent
    34. 34. Intubation Intubation Trick  Attach the ETCO2 detector to the ET-tube prior to attempting intubation.  You should see some waveforms as you get close to the vocal cords with the spontaneously breathing patient.  May be useful if CPR is in progress as well.
    35. 35. Intubation Capnography can be used with supraglottic airway devices Paramedics should document the use of capnography  Thisbenefits the paramedic!!!  There is no dispute when a waveform is present.
    36. 36. Intubation
    37. 37. Intubation Waveform vs. Colorimetric Capnography In colorimetric capnography a filter attached to an ET tube changes color from purple to yellow when it detects carbon dioxide  It is not continuous  has no waveform  no number  no alarms  is easily contaminated  is hard to read in dark  can give false readings.
    38. 38. Monitoring Ventilation Hyperventilationdecreases ETCO2 Other causes of decreased ETCO 2  Cardiac arrest  Decreased cardiac output  Hypotension  Cold  Severe pulmonary edema
    39. 39. Monitoring Ventilation Hyperventilation Ventilation Hypothermia Metabolism
    40. 40. Monitoring Ventilation Ventilation  equals tidal volume x respiratory rate.A patient taking in a large tidal volume can still hyperventilate with a normal respiratory rate just as a person with a small tidal volume can hypoventilate with a normal respiratory rate.
    41. 41. Monitoring Ventilation Hypoventilationcauses an increased ETCO2 (hypocapnia) Other causes of increased ETCO 2:  Increased cardiac output  Fever  Pain  severe difficulty breathing  depressed respirations  chronic hypercapnia
    42. 42. Monitoring Ventilation Hypoventilation Ventilation Malignant Hyperthermia Metabolism
    43. 43. Monitoring Ventilation Monitor The Trend!  A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic anticipate when a patient may soon require assisted ventilations or intubation.
    44. 44. Monitoring Ventilation Capnography should be used to monitor any patients receiving pain management or sedation (enough to alter their mental status) for evidence of hypoventilation and/or apnea. Sign of Overdose
    45. 45. Monitoring Ventilation Capnography is also essential in sedated, intubated patients. A small notch in the wave form indicates the patient is beginning to arouse from sedation, starting to breathe on their own, and will need additional medication to prevent them from "bucking" the tube.  Called “curare cleft”
    46. 46. Monitoring Ventilation “Curare cleft”
    47. 47. Monitoring Ventilation  “Curare cleft”40 B C B C A D A D 0
    48. 48. Monitoring Ventilation End-tidalCO2 monitoring on non- intubated patients is an excellent way to assess the severity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce a characteristic “Shark fin” wave form, as the patient has to struggle to exhale
    49. 49. Monitoring Ventilation Bronchospasm “Shark Fin”
    50. 50. Monitoring Ventilation  Bronchospasm “Shark Fin” A40 B 0
    51. 51. Monitoring Ventilation Drug Overdoses  Some EMS systems permit medics to administer Narcan only to unresponsive patients with suspected opiate overdoses with respiratory rates less than 10.
    52. 52. Monitoring Ventilation Emphysema  Down-slopingdue to destruction of alveolar capillary membranes & reduced gas exchange
    53. 53. Monitoring Ventilation Rebreathing  Sometimes called “stacking breaths”  Troubleshoot mechanical ventilator
    54. 54. Monitoring Circulation Cardiac Arrest  A higher ETCO2 reading indicates a higher quality of CPR.  Pulseless patients generally present with ETCO2 readings from 10 to 15 mmHg  A spike in ETCO2 indicates return of spontaneous circulation (ROSC). *ALWAYS SUSPECT A POSSIBLE PERFUSABLE RHYTHM WITH ELEVATED ETCO2 LEVELS!
    55. 55. Monitoring Circulation Circulation VentilationWith cardiacarrest wehave acirculatorycompromise Metabolism
    56. 56. Monitoring Circulation
    57. 57. Monitoring Circulation  The O2 in the cells is metabolized, and CO2 is present, but stagnant in the body.  The return of circulation causes a washout of this CO2; which shows up asCO2 a spike in ETCO2 levels. 40 0
    58. 58. Monitoring Circulation A sudden drop in ETCO2 may be an indication to check for a pulse.CO2 40 0
    59. 59. Monitoring Circulation "An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patients.” -Levine R, End-tidal Carbon Dioxide and Outcome of Out-of- Hospital Cardiac Arrest, New England Journal of Medicine, July 1997
    60. 60. Monitoring Circulation “No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived. Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital signs....The difference between survivors and nonsurvivors in 20 minute end- tidal carbon dioxide levels is dramatic and obvious.” -ibid.
    61. 61. Monitoring Circulation Asphyxic vs. Cardiac Arrest  Cardiac Arrest caused by asphyxia shows a higher ETCO2 reading initially on the monitor.  This number should come down within the first minute of CPR.
    62. 62. Monitoring Circulation End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless of any change in breathing. This has implications for trauma patients, cardiac patients - any patient at risk for shock.
    63. 63. Monitoring Circulation Pulmonary Embolus  Pulmonary embolus will cause an increase in the dead space in the lungs decreasing the alveoli available to offload carbon dioxide.  The ETCO2 will go down.
    64. 64. Monitoring Metabolism DKA - Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation causes their PACO2 to go down.  Kussmal’s respirations are rapid & deep.
    65. 65. Monitoring Metabolism Water + Carbon dioxide = Carbonic Acid Carbonic Acid = Hydrogen + Bicarbonate H2O + CO2 H2CO3 H + HCO3
    66. 66. Monitoring Metabolism Hyperthermia  Metabolism is on overdrive in fever, which may cause ETCO2 to rise. Observing this phenomena can be live-saving in patients with malignant hyperthermia, a rare side effect of RSI (Rapid Sequence Induction).
    67. 67. Monitoring Metabolism Sepsis  ETCO2: 31-34 = Increased survivability  ETCO2: Less than 30 = Increased morbidity End-Tidal Carbon Dioxide Levels Are Associated with Mortality In Emergency Department Patients with Suspected Sepsis -Hunter CL, et al. Orlando Regional Medical Center, Orlando, FL
    68. 68. Abnormal ETCO2 Increased Decreased ETCO2 ETCO2Ventilation Hypoventilation Hyperventilation Bronchoconstriction Dislodged ET-Tube Drug overdoseCirculation Good CPR Apnea Return of pulse (ROSC) CardiacArrest Increased cardiac output Pulmonary Edema Pulmonary EmbolismMetabolism Fever/Hyperthermia DKA Seizure Sepsis Burns Hypothermia Muscle use
    69. 69. Scenarios Youjust intubated a patient that had severe dyspnea using RSI successfully  BP: 142/90 ETCO2: 55  HR: 140 40  RR: Assisted  BGL: 170 0Malignant Hyperthermia
    70. 70. Scenarios You have a 88 y/o male who has fallen on the ground, and is currently unconscious. ETCO2: 25  BP: 114/70 40  HR: 50  RR: 10  BGL: 90 0Hypothermia
    71. 71. Scenarios You have a 75 y/o female patient with altered mental status  BP: 100/40 ETCO2: 25  HR: 130 40  RR: 30  BGL: 100 0SEPSIS
    72. 72. The End This concludes this course on capnography. Questions or feedback  Email