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EtCO2_-_Lonnie_Martinez (1).ppt
- 1. Noninvasive CO2 Monitoring Technology& Clinical Applications Lonnie Martinez Director of Respiratory Care Swedish Medical Center
- 2. Objectives Definitions and Parameters Descriptors and Overview Interpretation – Especially Waveform Bedside Application Conscious Sedation CO (mmHg) 2 0 37 50 Real-Time Trend
- 3. Capnography Respiration -The Big Picture 1 Cellular Metabolism of food into energy - O2 consumption & CO2 Production Transport of O2 & CO2 between cells and pulmonary capillaries, & diffusion from/into alveoli. Ventilation between alveoli & atmosphere 2 3
- 4. Monitoring CO2 Elimination =>Patient response to changes in Circulation Diffusion Ventilation Metabolism (CO2 Production) Ventilation CO2 Elimination (VCO2) Transport PaCO2 MTV
- 5. Capnography DepictsRespiration Capnography Metabolism Transport Ventilation CO2 CO2 CO2 ETCO2 RR
- 6.
- 7. Capnography Capnography vs.Capnometry Capnography • Measurement & display of ETCO2 and the (CO2 waveform) Measured by a capnograph Capnometry Measurement & display of the ETCO2 value (no waveform) Measured by a capnometer ETCO2 RR ETCO2 RR
- 8. Capnography Mainstream Technology Sensorplaced in ventilator circuit Measurement made at the patient’s airway Fast response time No water traps or tubing needed - hassle free Non-intubated patient may use Capno Masks Sensor
- 9. Capnography Sidestream Technology Sensor located away from the airway Gas moved to sensor by pump inside the monitor Use with cannula or adapt for ventilator airway Water traps, filters, or dehumidification tubing may be required
- 10. Capnography Quantitative vs.Qualitative ETCO2 Quantitative ETCO2 Provides actual numeric value Found in capnographs and capnometers Qualitative ETCO2 Only provides range of values Colorimetric CO2 detectors ETCO2 RR mmHg ETCO2 0-10 11-20 21-30 31-40 over 40 0-4 5-20 >20
- 11. Normal Capnogram -Phase I 50 0 25 CO2 mmHg Beginning of expiration = anatomical deadspace with no measurable CO2 A B
- 12. Anatomical Dead Space Anatomical Dead Space Internal volume of the upper airways • Nose • Pharynx • Trachea • Bronchi Anatomical Deadspace Conducting Airway - No Gas Exchange
- 13. Normal Capnogram -Phase II 50 0 25 CO2 mmHg Mixed CO2, rapid rise in CO2 concentration B C
- 14. Phase II -Transitional Gas CO2 mmHg Exhaled Volume
- 15. Normal Capnogram -Phase III 50 0 25 CO2 mmHg Time Alveolar Plateau, all exhaled gas took part in gas exchange End Tidal CO2 value C D
- 16. Normal Capnogram -Phase IV 50 0 25 CO2 mmHg Inspiration starts, CO2 drops off rapidly E D
- 17. Capnography • Increased muscularactivity (shivering) • Malignant hyperthermia • Increased cardiac output • Bicarbonate infusion • Tourniquet release • Effective drug therapy for bronchospasm • Decreased minute ventilation • Decreased muscular activity (muscle relaxants) • Hypothermia • Decreased cardiac output (cardiac arrest) • Pulmonary embolism • Bronchospasm • Increased minute ventilation Physiologic Factors Affecting ETCO2 Levels Increase in ETCO2 Decrease in ETCO2
- 18. Capnography Arterial CO2(PaCO2) From Arterial Blood Gas Sample (ABG) ETCO2 from Capnograph Normal Arterial & ETCO2 Values Normal PaCO2 Values: (at sea level) 35- 45 mmHg Normal ETCO2 Values: 30- 43 mmHg 4.0-5.7 kPa 4.0-5.6%
- 19. Understanding why ETCO2doesn’t match the ABG is important, if you don’t understand why it doesn’t match, it erodes confidence in all of the values!!! You may throw the baby out with the bath water!!
- 20. Capnography Arterial -End Tidal CO2 Gradient In healthy lungs the normal a-ETCO2 gradient is 2-5 mmHg In diseased lungs, the gradient will increase due to ventilation/perfusion mismatch. Decreased cardiac function will also reduce the ETCO2 value, due to decreased pulmonary blood flow
- 21. Capnography Deadspace Ventilatedareas which do not participate in gas exchange Anatomic Deadspace (airways leading to the alveoli Total Deadspace Alveolar Deadspace (ventilated areas in the lungs) Mechanical Deadspace (artificial airways including ventilator circuits) + +
- 22. Normal V/Q CO2 O2 ETCO2/ PaCO2 Gradient = 2 to 5 mmHg . .
- 23. Shunt Perfusion –Low V/Q No exchange of O2 or CO2 ETCO2 / PaCO2 Gradient = 4 to 10 mmHg . .
- 24. Dead Space Ventilation HighV/Q Perfusion is the problem No exchange of O2 or CO2 occurs ETCO2 / PaCO2 Gradient is large May exceed 60 torr Ventilation is not the problem! . .
- 25. Dead Space Ventilation 00 0 0 0 0 0 PaCO2 = 53 mmHg ETCO2 = 33 mmHg 53 53 53 Alveoli that do not take part in gas exchange will still have no CO2 – Therefore they will dilute the CO2 from the alveoli that were perfused The result is a widened ETCO2 to PaCO2 Gradient
- 26. Capnography Clinical Application of Capnography CO(mmHg) 2 0 37 50 Real-Time Trend
- 27. Capnography Value ofthe CO2 Waveform Provides validation of ETCO2 value Visual assessment of patient airway integrity Verification of proper ET tube placement ASA, JCAHO guidelines Recent CMS recommendation Assessment of ventilator, breathing circuit integrity
- 28. Capnogram – ValuableTool CO2 (mmHg) 0 25 50 Alveolar Plateau established No Alveolar Plateau
- 29.
- 30. Capnography Endotracheal Tube inEsophagus Possible Causes: Missed Intubation A normal capnogram is the best evidence that the ET tube is correctly positioned. When the ET tube is in the esophagus, little or no CO2 is present CO (mmHg) 2 0 37 50 Real-Time Trend
- 31. Capnography Inadequate Seal AroundET Tube Possible Causes: Leaky of deflated endotracheal or tracheostomy cuff Artificial airway that is too small for patient Tube could be at the vocal cords CO (mmHg) 2 0 37 50 Real-Time Trend
- 32. Capnography Obstruction in Airwayor Breathing Circuit Possible Causes: Partially kinked or occluded artificial airway Presence of foreign body in the airway Obstruction in expiratory limb of breathing circuit Bronchospasm CO (mmHg) 2 0 37 50 Real-Time Trend
- 33. CO2 Exhaled Volume Day 1 Day5 Patient with Asthma
- 34. Capnography Hypoventilation - Increasein ETCO2 Possible Causes: Decrease in respiratory rate Decrease in tidal volume Increase in metabolic rate Rapid rise in body temperature (hyperthermia) CO (mmHg) 2 0 37 50 Real-Time Trend
- 35. Capnography Hyperventilation - Decreasein ETCO2 Possible Causes: Increase in respiratory rate Increase in tidal volume Decrease in metabolic rate Fall in body temperature CO (mmHg) 2 0 37 50 Real-Time Trend
- 36. • Based onsimple O2 delivery style mask • Allows measurement of EtCO2 and delivery of O2 on non- intubated patients • Effective Capnogram to verify data • Excellent Choice for Conscious Sedation CAPNO2 Mask O2 Delivery/CO2 Mainstream Mask
- 37. Cannula O2 Delivery/CO2 Sidestream
- 38. Procedural Sedation Capnographyis the logical device to monitor ventilation during procedural sedation Why? Airway problems are primary causes of morbidity associated with sedation/analgesia Drug induced respiratory depression Airway obstruction
- 39. Procedural Sedation withO2 Capnography is a valuable monitoring tool to to detect respiratory events that could culminate in hypoxia Why? Patients in the ED are often on supplemental oxygen Increased FIO2 may mask the decrease in ventilation early on if you are only observing pulse oximetry
- 40. Procedural Sedation Capnographyoffers a safety net A decrease in ventilation during procedural sedation almost always precedes a drop in saturation The decrease in ETCO2, or a change in the shape of the capnogram will indicate a change in ventilation or airway integrity This safety net can facilitate early intervention and avoid subsequent hypoxemia
- 41.
- 42. A cool story…VentilatorDyssynchrony
- 43. Conclusion Improved PatientMonitoring It’s not just about the Number Waveform Interpretation Helps with Differential DX Clinical Application