This document discusses advanced capnography techniques. It begins by listing the objectives which include describing the physiology of carbon dioxide monitoring, differentiating between mainstream and sidestream capnography, interpreting normal and abnormal time-based and volume-based capnograms, and discussing several clinical applications of capnography. It then covers the physiology of carbon dioxide, monitoring technologies, key technological issues, differences between mainstream and sidestream sampling, phases of normal time-based and volume-based capnograms, abnormalities, artifacts, and clinical uses including ventilation monitoring, cardiac output measurement, pulmonary embolism detection, and more.
Gas exchange between the alveoli and the pulmonary capillary blood occurs by diffusion, as will be discussed in the next chapter. Diffusion of oxygen and carbon dioxide occurs passively, according to their concentration differences across the alveolar-capillary barrier. These concentration differences must be maintained by ventilation of the alveoli and perfusion of the pulmonary capillaries.
Alveolar ventilation brings oxygen into the lung and removes carbon dioxide from it. Similarly, the mixed venous blood brings carbon dioxide into the lung and takes up alveolar oxygen. The alveolar Image not available. and Image not available. are thus determined by the relationship between alveolar ventilation and pulmonary capillary perfusion. Alterations in the ratio of ventilation to perfusion, called the Image not available., will result in changes in the alveolar Image not available. and Image not available., as well as in gas delivery to or removal from the lung.
Alveolar ventilation is normally about 4 to 6 L/min and pulmonary blood flow (which is equal to cardiac output) has a similar range, and so the Image not available. for the whole lung is in the range of 0.8 to 1.2. Image not available. However, ventilation and perfusion must be matched on the alveolar-capillary level, and the Image not available. for the whole lung is really of interest only as an approximation of the situation in all the alveolar-capillary units of the lung. For instance, suppose that all 5 L/min of the cardiac output went to the left lung and all 5 L/min of alveolar ventilation went to the right lung. The whole lung Image not available. would be 1.0, but there would be no gas exchange because there could be no gas diffusion between the ventilated alveoli and the perfused pulmonary capillaries.
Oxygen is delivered to the alveolus by alveolar ventilation, is removed from the alveolus as it diffuses into the pulmonary capillary blood, and is carried away by blood flow. Similarly, carbon dioxide is delivered to the alveolus in the mixed venous blood and diffuses into the alveolus in the pulmonary capillary. The carbon dioxide is removed from the alveolus by alveolar ventilation. As will be discussed in Chapter 6, at resting cardiac outputs the diffusion of both oxygen and carbon dioxide is normally limited by pulmonary perfusion. Thus, the alveolar partial pressures of both oxygen and carbon dioxide are determined by the Image not available. If the Image not available. in an alveolar-capillary unit increases, the delivery of oxygen relative to its removal will increase, as will the removal ...
Gas exchange between the alveoli and the pulmonary capillary blood occurs by diffusion, as will be discussed in the next chapter. Diffusion of oxygen and carbon dioxide occurs passively, according to their concentration differences across the alveolar-capillary barrier. These concentration differences must be maintained by ventilation of the alveoli and perfusion of the pulmonary capillaries.
Alveolar ventilation brings oxygen into the lung and removes carbon dioxide from it. Similarly, the mixed venous blood brings carbon dioxide into the lung and takes up alveolar oxygen. The alveolar Image not available. and Image not available. are thus determined by the relationship between alveolar ventilation and pulmonary capillary perfusion. Alterations in the ratio of ventilation to perfusion, called the Image not available., will result in changes in the alveolar Image not available. and Image not available., as well as in gas delivery to or removal from the lung.
Alveolar ventilation is normally about 4 to 6 L/min and pulmonary blood flow (which is equal to cardiac output) has a similar range, and so the Image not available. for the whole lung is in the range of 0.8 to 1.2. Image not available. However, ventilation and perfusion must be matched on the alveolar-capillary level, and the Image not available. for the whole lung is really of interest only as an approximation of the situation in all the alveolar-capillary units of the lung. For instance, suppose that all 5 L/min of the cardiac output went to the left lung and all 5 L/min of alveolar ventilation went to the right lung. The whole lung Image not available. would be 1.0, but there would be no gas exchange because there could be no gas diffusion between the ventilated alveoli and the perfused pulmonary capillaries.
Oxygen is delivered to the alveolus by alveolar ventilation, is removed from the alveolus as it diffuses into the pulmonary capillary blood, and is carried away by blood flow. Similarly, carbon dioxide is delivered to the alveolus in the mixed venous blood and diffuses into the alveolus in the pulmonary capillary. The carbon dioxide is removed from the alveolus by alveolar ventilation. As will be discussed in Chapter 6, at resting cardiac outputs the diffusion of both oxygen and carbon dioxide is normally limited by pulmonary perfusion. Thus, the alveolar partial pressures of both oxygen and carbon dioxide are determined by the Image not available. If the Image not available. in an alveolar-capillary unit increases, the delivery of oxygen relative to its removal will increase, as will the removal ...
Capnography is a technique that is used to detect the carbon dioxide concentration in exhalation gases. Capnometer uses infrared light in sensors in order to detect the CO2. Capnography is an important parameter in current day patient monitoring.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. Objectives
• List three indications for capnography.
• Differentiate between mainstream and
sidestream capnography.
• Given a time-based capnogram, identify
and distinguish between the phases.
• Given a time-based capnogram, interpret
any abnormality present.
• Given a volume-based capnogram, identify
and distinguish between the phases.
• Given a volume-based capnogram, state
the significance of each phase.
3. Objectives
• Given a volume-based capnogram,
interpret any abnormality present.
• List two instances where volume-based
capnography can lead to improved patient
management.
• State the formula used for the calculation of
non-invasive cardiac output via the CO2
Partial-Rebreathing method.
• Describe the set-up used to measure
cardiac output via the CO2 Partial-
Rebreathing method.
• List two additional uses for capnography.
4. Physiology of Carbon Dioxide
METABOLISM PERFUSION VENTILATION
ALL THREE ARE IMPORTANT!
10. Phases of the Time Capnogram
• Phase I: Inspiration
• No CO2 detected (hopefully)
• Phase II: Appearance of CO2 in the
system.
• Mixed alveolar and deadspace gas.
• Phase III: Plateau
• Constant emptying of alveolar gas.
• Presence of CO2 through the end of the
breath.
• Phase IV: Washout of CO2 from
subsequent inspiration.
11. Abnormal Waveforms
Sudden loss of PETCO2 to zero or near zero
indicates immediate danger because no
respiration is detected.
•Esophageal intubation
•Complete airway disconnect from ventilator
•Complete ventilator malfunction
•Totally obstructed/kinked endotracheal tube
12. Abnormal Waveforms
Exponential decrease in PETCO2 reflects a
catastrophic event in the patient’s
cardiopulmonary system.
•Sudden Hypotension/massive blood loss
•Circulatory arrest with continued ventilation
•Pulmonary embolism
•Cardiopulmonary Bypass
13. Abnormal Waveforms
Gradual decrease in PETCO2 indicates a
decreasing CO2 production, or decreasing
systemic or pulmonary perfusion.
•Hypothermia
•Sedation
•Hyperventilation
•Hypovolemia
•Decreasing Cardiac Output
20. Checklist for Interpreting a Volume-
Based Capnogram
• Phase I – Deadspace Gas
• Rebreathing? (1)
• Deadspace seem right?
• Phase II – Transitional Phase
• Transition from upper to lower airways.
• Should be steep. (3)
• Represents changes in perfusion.
• Phase III – Alveolar Gas Exchange
• Changes in gas distribution.
• Increased slope = mal-distribution of gas delivery. (5)
• End of Phase III is the PETCO2. (6)
• Area under the curve represents the volume of expired CO2
(VCO2).
• Exhaled volume (8)
25. Phase 2 assessment
If ↓ in phase 2
– Assure stable minute ventilation
• Assess PEEP level
• ↑ intrathoracic pressure may cause ↓ venous return
• Assess hemodynamic status
• Is minute ventilation stable?
• Volume resuscitation or vasopressors may be indicated
27. ↓ Phase 2
• When minute ventilation is stable,
indicative of a ↓ in perfusion.
28. Phase 3 assessment
If ↑ or absent phase 3 mal-distribution of
gas at alveolar level exists
• Assess for appropriate PEEP level
• Inadequate PEEP may be present
• Bronchospasm
• Bronchodilator tx my be indicated
• Structure damage at alveolar level may be
present
• Pnuemothorax?
32. Effective Tidal Volume
• The volume of gas between the end of
Phase I and the end of Phase III.
• Phase I represents the volume of gas
being delivered from the ventilator
which doesn’t participate in gas
exchange.
• Monitoring of the effective tidal volume can
indicate on a breath-by-breath basis when
PaCO2 changes will be occurring before they
actually rise.
33. Area X = Vol CO2
Allows determination of VCO2 in one min. (200 mL/min.)
Exhaled
Volume
% CO2
Volume CO2
(Area X)
34. VCO2
• VCO2 represents the volume of CO2
eliminated.
• This is usually the same as what is produced.
• CO2 balance is dependent on four factors:
• Production
• Transportation (cell to blood & blood to lungs)
• Storage (conversion to CO2 containing substances in the
muscle, fat and bone)
• Elimination
• Monitoring VAand VCO2 allows for evaluation of a
successful weaning process.
35. Waveform Regions
Z = anatomic VD; Y = VD Alveolar
% CO2
VD VALV
%CO2 in Arterial Blood
Z
X
Y
Exhaled Tidal Volume
36. Sum of VDanat (Z) and VDalv (Y) is
Physiologic VD
X
Y
Z
PaCO2 - PeCO2
PaCO2
Y + Z
X + Y + Z
=• Phys VD / VT
• Alveolar
Ventilation
• Min. Vol. CO2
( VCO2 )
37. Uses of Volumetric Capnography
• Assess work of breathing during
weaning trial.
39. Using Vtalv and VCO2 to Recruit
Alveoli in a Postoperative
CABG Patient Suffering from
Hypoxemia
HOSAM M ATEF
40. Using Vtalv and VCO2 to Recruit
Alveoli
• Patient Profile
• 72 yo male, post-op CABG, MV
• Clinical Challenge
• Developed a low SpO2 within 2 hours of
arrival into the ICU
• FIO2 and PEEP increased, no acceptable
change in PaO2 and SpO2
• Clinical Intervention
• Lung recruitment
41. •Clinical Course
•PEEP increased by 2 cm
H2O every 10 minutes
•Observed Vtalv, VCO2 and
SpO2
•Monitoring Data
•Red arrows show PEEP
increases
•No deterioration in VCO2,
oV/Q stable
•Vtalv starts to increase at
16 cm H2O, alveoli are being
recruited
•SpO2 responded at 20
cm H2O
Using Vtalv and VCO2 to Recruit
Alveoli
42. • Summary
• Vtalv is an ideal parameter to show
alveolar recruitment
• VCO2 indicates V/Q status during the
procedure
• SpO2 did not show improvement until
best PEEP
• Vtalv combined with VCO2 were best to
indicate increased PEEP levels were
working
Using Vtalv and VCO2 to Recruit
Alveoli
43. Uses of Volumetric Capnography
• Optimal PEEP
• Overdistension leads to increased
Vdanat and reduced perfusion.
• Increased Vdanatcan be assessed by an
increase in Phase I volume.
• Reduced perfusion can be assessed by a
decrease in Phase II slope combined with
a decrease in VCO2.
45. VCO2 to Determine Optimal PEEP
• Patient Profile
• 25 yo male, motorcycle accident
• Head injury, rib fractures
• Pentobarbital induced coma
• Clinical Challenge
• Developed acute lung injury
• Low PaO2, SpO2
46. • Clinical Intervention
• Maximize lung recruitment
• Determine optimal PEEP
• Without aversely affecting intracranial
pressures
• Clinical Course
• Monitor VCO2 and VA
• Increase PEEP in 2 cm H2O increments
VCO2 to Determine Optimal PEEP
47. •Results
•PEEP increased
from 14 to 20
•Each step increased
VA, VCO2 initially
decreased but
recovered
•At PEEP of 22, VA
did not increase,
VCO2 did not recover
•PEEP reduced to 20,
VCO2 recovered
22 cmH20 Optimal
PEEP
VCO2 to Determine Optimal PEEP
48. • Determining Optimal PEEP
• VA
Showed sharp rises after initial PEEP settings
A result of alveolar recruitment
• VCO2
Initial decrease after PEEP increase,
recovered quickly
Confirmed that pulmonary perfusion was not
compromised
VCO2 to Determine Optimal PEEP
50. Which graph represents ARDS?
•Graphs show
PECO2 vs. Volume
(hatched line).
•VAE represents
the “alveolar
ejection volume”
(true alveolar gas
mixing volume).
51. Uses of Volumetric Capnography
• Pulmonary Embolism
• 650,000 cases/year in US
• 50,000 to 200,000 die.
• Most deaths occur within first hour.
• Prompt therapy can reduce mortality from 30% to 2.5 to
10%.
• 70% of deaths from PE identified by autopsy were not
identified before death.
• Methods of PE detection
• Evaluation of Vd/Vt
• PaCO2-PETCO2 gradient with maximum exhalation.
• Late deadspace fraction (Fdlate)
52.
53. Uses of Volumetric Capnography
•Non-Invasive Cardiac Output
•Fick Principle (1870)
OR
22
2
OvCCaO
OV
QC
−
=
•
22
2
CaCOCOvC
COV
QC
−
=
•
57. Other uses for Capnography
• During Apnea Testing in Brain-dead patients.
• Eur J Anaesthesia Oct 2007, 24(10):868-75
• Evaluating DKA in children.
• No patients with a PETCO2 >30 had DKA.
• J Paeditr Child Health Oct 2007, 43(10):677-680
• Vd/Vt ratio and ARDS Mortality
• Elevated Vd/Vt early in the course of ARDS was
correlated with increased mortality.
• Chest Sep 2007, 132(3): 836-842
• PCA Administration
• “Continuous respiratory monitoring is optimal for
the safe administration of PCA, because any RD
event can progress to respiratory arrest if
undetected.”
• Anesth Analg Aug 2007, 105(2):412-8
Editor's Notes
Summarize the phases
…the slope of phase II is eliminated and a clear separation of deadspace is established.
Area under the SBCO2 curve IS the volume of CO2 in a single breath. Sum all the Co2 volumes in a minute and you get the same results as a Douglas Bag collection
If we add a horizontal line representing %CO2 in arterial blood, 4 distinct regions of the curve are established:
1 – Area X represents the actual amount of CO2 exhaled in the breath.
2 – Area Y represents the amount of CO2 that was NOT eliminated because we have some alveolar deadspace
3 – Area Z represents the amount of CO2 that was NOT eliminated because we have a certain anatomic structure
4 – Area X, Y and Z in total represent the maximum volume of CO2 possible to exhale in a single breath IF we have no airway deadspace AND no alveolar deadspace (or shunt). This would represent the perfect situation.
The relationship between the areas (with the added Arterial Blood line) gives us some very important parameters for analysis.
Three very important ventilation assessment parameters emerge and mimic the action of the douglas bag…
The ratios of the areas created in the SBCO2 curve are the same as the relationship seen in the Enghoff modified Bohr equation.
Keep in mind here that the elimination of CO2 volume (VCO2) is necessary to balance CO2 produced in the metabolism process. Alveolar ventilation details how much ventilation is required to eliminate the CO2 volume that is presented to the alveoli by perfusion.
P R O F I L E
This is a 72-year-old male patient, status post open heart surgery for four vessel CABG. The patient was taken to the Open Heart Cardiac Surgery Intensive Care Unit post procedure.
Ventilator settings:
SIMV 12, DP 22 cmH2O, IT 1.1 seconds, FIO2 40%, PEEP 5 cmH2O, PS 5 cmH2O. The ventilator settings were based on protocol
and the anesthesia settings.
Clinical problem:
The patient developed a low SpO2 within two hours of arrival into the ICU. FIO2 was increased to 60%, PEEP increased to 10 cmH2O, DP increased to 28 cmH2O. A subsequent blood gas revealed a PaO2 of 61 mmHg. The patient’s compliance was 41 cmH2O/mL.
Clinical intervention:
The Health Care Team (HCT) decided to utilize the NICO2 monitor to optimize PEEP and maximize lung recruitment.
Advanced Lung Recruitment Technology (ALuRT)
CLINICAL COURSE
Patient was set up on the NICO2 monitor and baseline Vtalv, VCO2, and SpO2 was measured. PEEP was increased by 2 cmH2O every 10 minutes to observe increases in Vtalv and SpO2. If the lung overdistends, VCO2 will drop significantly (greater than 20%). At a PEEP level of 14 cmH2O, Vtalv, VCO2, and SpO2 did not change significantly. PEEP was increased by 2 cmH2O up to 20 cmH2O. Within 15 minutes, Vtalv, VCO2 and SpO2 increased. Subsequent PaO2 increased to 151 mmHg. Compliance increased to 81 cmH2O/ml. The DP and IT was decreased to maintain the same minute ventilation. FIO2 was decreased to 40%. Over the next 24-36 hours, the patient’s PEEP was weaned utilizing the Vtalv parameter.
DISCUSSION
Most patients undergoing heart/lung bypass have adequate lung re-expansion from aggressive manual bagging by the clinician in the operating
room prior to transfer to the ICU. If the procedure is not adequate, the patient can suffer from alveolar collapse and poor ventilation in the hours after the surgery. Using NICO2 to monitor Vtalv, VCO2, and SpO2 served two purposes:
1) increase the PEEP while monitoring for over distension
2) continuous monitoring of Vtalv to demonstrate the alveolar recruitment moment.
In this case, the lung was never “over distended” at anytime, no cardiac compromise was noted.
The reduction in DP, IT, and FIO2 facilitated a minimal support ventilation strategy.
Additional note:
Notice as the PEEP levels increased there was no deterioration in VCO2 indicating that V/Q was maintained. Vtalv was most sensitive to showing that alveoli were being recruited. SpO2 lagged until optimal PEEP was achieved.
Another example is in this increasing PEEP model…phase II shifts right due to expanding airways (increasing PEEP stints the airways open more). Notice that slope of phase II decreases as well. This is a result of lower CO2 concentration occurring at a identical volume point (in a less/more PEEP setting).
This demonstrates the need to manage alveolar volume in changing PEEP conditions…you must compensate for the loss of gas exchange volume
P R O F I L E
A 25-year-old male motorcycle operator struck a tree head-on. He sustained a massive head injury requiring ventriculostomy and eventually a pentobarbital-induced coma to control intracranial pressures. Patient rapidly
developed acute lung injury due to multiple rib fractures and bilateral lung contusions. Ventilator settings were PCV-AC, RR of 14 breaths/minute, DP of 25 cmH2O, FIO2 80%, PEEP 14 cmH2O. The patient’s arterial PO2 was 78 mmHg.
In light of the patient’s lung injury, the Health Care Team sought to maximize lung recruitment and determine the
patient’s optimal PEEP without adversely affecting intracranial pressures.
C L I N I CA L C O U R S E
A baseline VCO2 trend was gathered. The NICO® Monitor was utilized to trend •VCO2 while PEEP was increased in 2 cmH2O increments. VCO2 was monitored for approximately five to seven minutes after each increase in PEEP. A decrease in VCO2 occurred immediately when PEEP was increased to 16 cmH2O. Over the next two minutes, sharp rises in MValv occurred and the VCO2 returned to baseline.
An increase in PEEP to 18 cmH2O resulted in a decrease in VCO2 and no change in MValv. Over the next two minutes, sharp rises in MValv occurred and the VCO2 returned to baseline. The trial continued until the PEEP level reached 22 cmH2O. At this point, VCO2 decreased by over 40 ml/min and did not rise. PEEP was decreased to 20 cmH2O and VCO2 increased. The subsequent blood gas resulted in an arterial PO2 of 120 mmHg. The FIO2 was decreased over the next hour to 50%. The NICO Monitor was utilized over the next 24 to 48 hours to assist in weaning PEEP.
The NICO Monitor was instrumental in determining optimal PEEP. The sharp rises in MValv and VCO2 after the initial two PEEP changes were a result of lung recruitment. Once the patient was receiving 22 cmH2O of PEEP, the alveoli were over-distended and pulmonary capillaries were compressed preventing adequate CO2 diffusion across
the alveolar-capillary membrane. Determining optimal PEEP and fully recruiting the alveoli dramatically reduced
the FIO2 requirement.