CCAAPNOGRAPHYPNOGRAPHYIn Emergency CareIn Emergency Care

EDUCATIONAL SERIESEDUCATIONAL SERIES

Part 1:Part 1:OverviewOverview

• Program Learning ObjectivesProgram Learning Objectives– Relate a normal capnogram to the Relate a normal capnogram to the

phases of breathingphases of breathing– List five clinical applications for capnographyList five clinical applications for capnography– Identify the four most common abnormal Identify the four most common abnormal

capnogramscapnograms– Describe how to incorporate capnogram to Describe how to incorporate capnogram to

patient care according to local protocolpatient care according to local protocol

CCAAPNOGRAPHYPNOGRAPHYIn Emergency CareIn Emergency Care

Program PartsProgram Parts

Part 1:Part 1: Overview Overview

Part 2:Part 2: Introduction to CapnographyIntroduction to Capnography

Part 3: Part 3: Capnography in the Intubated PatientCapnography in the Intubated Patient

Part 4:Part 4: Capnography in the Non-intubated PatientCapnography in the Non-intubated Patient

CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care

Part 1: OverviewPart 1: Overview

CCAAPNOGRAPHYPNOGRAPHYIn Emergency CareIn Emergency Care

Why use capnography?Why use capnography?

(Corollary: Why should I learn capnography?)(Corollary: Why should I learn capnography?)

Case ScenarioCase Scenario

• 61 year old male61 year old male• C/O: “short-of-breath” and “exhausted”C/O: “short-of-breath” and “exhausted”• H/O: > 45 years of smoking 2 packs a day, H/O: > 45 years of smoking 2 packs a day,

3 heart attacks, high blood pressure3 heart attacks, high blood pressure• Meds: “too expensive to take every day ”Meds: “too expensive to take every day ”• Exam: HR 92, RR 18, 160/100, 2+ pitting Exam: HR 92, RR 18, 160/100, 2+ pitting

edema, wheezing, cracklesedema, wheezing, crackles

CHF?CHF? COPD?COPD?What other information would you What other information would you

want in making your assessment?want in making your assessment?

Capnography Overview Capnography Overview

• A technology that:A technology that:– Provides another measurement in assessing Provides another measurement in assessing

your patient your patient – Gives an objective measure of your patient’s Gives an objective measure of your patient’s

ventilatory statusventilatory status– Shows a graphic picture of your patient’s Shows a graphic picture of your patient’s

ventilatory statusventilatory status– Presents an early warning of changes in your Presents an early warning of changes in your

patient's cardiopulmonary status patient's cardiopulmonary status – Supplies important documentation on Supplies important documentation on

your patientyour patient

Capnography Overview Capnography Overview

• Capnography provides an objective Capnography provides an objective measure of ventilationmeasure of ventilation

• Capnography providesCapnography provides– Numeric value of “End-Tidal CONumeric value of “End-Tidal CO22””

– Waveform of respirationWaveform of respiration

Capnography Overview Capnography Overview

• End Tidal COEnd Tidal CO22——what is it? what is it? – Breathing is done in wavesBreathing is done in waves

– EtCOEtCO22 is the amount of CO is the amount of CO22 measured measured at the peak of the wave at the peak of the wave

– EtCOEtCO22 is measured at the nose, mouth, is measured at the nose, mouth, or hub of the ET tubeor hub of the ET tube

Capnography OverviewCapnography Overview

• ““Capnos” is Greek for smoke Capnos” is Greek for smoke – From the “fire of life”From the “fire of life”——metabolismmetabolism– Metabolism produces carbon dioxide Metabolism produces carbon dioxide

as a waste productas a waste product

Capnography OverviewCapnography Overview

• Carbon Dioxide (COCarbon Dioxide (CO22))– Produced by all living cellsProduced by all living cells– Diffused into the bloodstreamDiffused into the bloodstream– Transported to the lungsTransported to the lungs– Perfused into the alveoli Perfused into the alveoli – Exhaled through the airwayExhaled through the airway

History of Capnography in EMSHistory of Capnography in EMS

• Initially used for monitoring anesthetized Initially used for monitoring anesthetized patients in the ORpatients in the OR

• New technology now available for EMS in New technology now available for EMS in both intubated and non-intubated patientsboth intubated and non-intubated patients

History of Capnography in EMSHistory of Capnography in EMS

• Used by anesthesiologists Used by anesthesiologists since the 1970ssince the 1970s

• Standard of care in the Standard of care in the OR since 1991OR since 1991

• New JCAHO standard New JCAHO standard now expanding utilizationnow expanding utilization

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

History of Capnography in EMSHistory of Capnography in EMS

• JCAHO January 2001 standard JCAHO January 2001 standard on procedural sedationon procedural sedation– In any hospital or In any hospital or

clinic settingclinic setting– Monitoring vital signs, Monitoring vital signs,

continuous monitoring continuous monitoring of oxygenation and of oxygenation and ventilationventilation

Capnography provides the Capnography provides the onlyonlycontinuous visual monitoring of ventilationcontinuous visual monitoring of ventilation

Source: Joint Commission Perspectives, Special Report. July/August 2000

History of Capnography in EMSHistory of Capnography in EMS

• Pulse oximetry preceded capnographyPulse oximetry preceded capnography• Pulse oximetry measures oxygenationPulse oximetry measures oxygenation• Capnography measures ventilationCapnography measures ventilation

– New technologies now allow use in EMSNew technologies now allow use in EMS

History of Capnography in EMSHistory of Capnography in EMS

ColorimetricColorimetric

Capnometry Capnometry

Capnography Capnography

History of Capnography in EMSHistory of Capnography in EMS

• Specially treated litmus paperSpecially treated litmus paper– Color changes indicate qualitative Color changes indicate qualitative

amount of COamount of CO22 detected detected

• For intubated patients onlyFor intubated patients only• Disposable detector fits on ET tube hubDisposable detector fits on ET tube hub

Colorimetric:Colorimetric:

History of Capnography in EMSHistory of Capnography in EMS

• Single useSingle use• Easily impaired by moisture or secretionsEasily impaired by moisture or secretions• False negatives during cardiac arrestFalse negatives during cardiac arrest• Equates to checking a pulse on Equates to checking a pulse on

cardiac patientcardiac patient– PresencePresence– Strength/amountStrength/amount

Colorimetric:Colorimetric:

History of Capnography in EMSHistory of Capnography in EMS

Colorimetric CO2 Indicator

Breathing Circuit

ET Tube

Colorimetric:Colorimetric:

History of Capnography in EMSHistory of Capnography in EMS

• A numerical value of the EtCOA numerical value of the EtCO22

• For both non-intubated and For both non-intubated and intubated patientsintubated patients

• Continuous monitoringContinuous monitoring

Capnometry:Capnometry:

History of Capnography in EMSHistory of Capnography in EMS

• No waveform of the EtCONo waveform of the EtCO22 in the airway in the airway

• Equates to monitoring heart rate in Equates to monitoring heart rate in cardiac patientcardiac patient– PresentPresent– Amount or rangeAmount or range– Changes over timeChanges over time

Capnometry:Capnometry:

History of Capnography in EMSHistory of Capnography in EMS

Capnometer:Capnometer:

History of Capnography in EMSHistory of Capnography in EMS

• Numeric reading: HR 100Numeric reading: HR 100• Waveform:Waveform:

Capnometry:Capnometry:

History of Capnography in EMSHistory of Capnography in EMS

• Numeric reading: HR 100Numeric reading: HR 100• Waveform:Waveform:

Capnometry:Capnometry:

History of Capnography in EMSHistory of Capnography in EMS

• A numerical value of the EtCOA numerical value of the EtCO22

ANDAND• A waveform of the concentration A waveform of the concentration

of COof CO22 present in the airway present in the airway

Capnography:Capnography:

History of Capnography in EMSHistory of Capnography in EMS

• For both non-intubated and For both non-intubated and intubated patientsintubated patients

• Continuous breath-to-breath monitoring Continuous breath-to-breath monitoring • Equates to ECG monitoring in Equates to ECG monitoring in

cardiac patientcardiac patient

Capnography:Capnography:

History of Capnography in EMSHistory of Capnography in EMS

Capnography:Capnography:

History of Capnography in EMSHistory of Capnography in EMS

• Capnography systemsCapnography systems– Collector of the air sample Collector of the air sample

– Analyzer detects and measures COAnalyzer detects and measures CO22

– Display shows waveform and numberDisplay shows waveform and number

History of Capnography in EMSHistory of Capnography in EMS

Conventional high-flow sidestreamConventional high-flow sidestream

MainstreamMainstream

New low-flow sidestream technologyNew low-flow sidestream technology

Capnography Technologies:Capnography Technologies:

1980’s1980’s

Early 1990’sEarly 1990’s

History of Capnography in EMSHistory of Capnography in EMS

• Conventional high-flow sidestream Conventional high-flow sidestream capnographycapnography– For both intubated and non-intubated patientFor both intubated and non-intubated patient– Analyzer located inside the device Analyzer located inside the device

for protectionfor protection• No added weight on patient’s airwayNo added weight on patient’s airway

History of Capnography in EMSHistory of Capnography in EMS

• Conventional high-flow sidestream Conventional high-flow sidestream capnographycapnography– Requires 150-200ml of air to measure Requires 150-200ml of air to measure

a COa CO22 level level• Air aspirating systemAir aspirating system• Requires frequent calibrationRequires frequent calibration• Frequent occlusion of tubing by moisture Frequent occlusion of tubing by moisture

and secretionsand secretions• Inaccurate in neonates, infants, and Inaccurate in neonates, infants, and

young childrenyoung children

History of Capnography in EMSHistory of Capnography in EMS

Conventional high-flow sidestream Conventional high-flow sidestream capnography systemcapnography system

Air Sample

Water TrapEnd-tidal CO2monitor withanalyzer inside

SamplePort

Bag

History of CapnographyHistory of Capnography

• Mainstream CapnographyMainstream Capnography– Developed for intubated patientDeveloped for intubated patient– Analyzer on the hub of ET tubeAnalyzer on the hub of ET tube

• Not disposableNot disposable

• Weight on the ET tubeWeight on the ET tube

• Adaptors attach to analyzer for Adaptors attach to analyzer for non-intubated patientsnon-intubated patients

History of CapnographyHistory of Capnography

Mainstream CapnographyMainstream Capnography

Electronic CableAnalyzer

End-tidalCO2 monitorBag

History of CapnographyHistory of Capnography

• New low-flow sidestream capnographyNew low-flow sidestream capnography– Newer technology requires 50ml of Newer technology requires 50ml of

air for samplingair for sampling• Occlusions uncommonOcclusions uncommon

• Accurate in all age groupsAccurate in all age groups– neonates to large adultsneonates to large adults

History of CapnographyHistory of Capnography

• New low-flow sidestream capnographyNew low-flow sidestream capnography– For intubated and non-intubated patientsFor intubated and non-intubated patients– No calibration required between patientsNo calibration required between patients– Disposable tubing and cannulasDisposable tubing and cannulas– New in-line filters exclude contaminantsNew in-line filters exclude contaminants– Central collector system in tubingCentral collector system in tubing– Durable for EMS environmentDurable for EMS environment

History of CapnographyHistory of Capnography

• New low-flow sidestream technologyNew low-flow sidestream technology

Using CapnographyUsing Capnography

• Immediate information via Immediate information via breath-to-breath monitoring breath-to-breath monitoring

• Information on the ABCsInformation on the ABCs– AirwayAirway– BreathingBreathing– CirculationCirculation

• DocumentationDocumentation

Using CapnographyUsing Capnography

• AirwayAirway– Verification of ET tube Verification of ET tube

placementplacement– Continuous monitoring of Continuous monitoring of

ET tube positionET tube position

• CirculationCirculation– Check effectiveness of Check effectiveness of

cardiac compressionscardiac compressions– First indicator of ROSCFirst indicator of ROSC– Monitor low perfusion statesMonitor low perfusion states

AirwayAirway

CirculationCirculation

Using CapnographyUsing Capnography

• BreathingBreathing–– HyperventilationHyperventilation

–– HypoventilationHypoventilation

–– AsthmaAsthma

–– COPD COPD

Using CapnographyUsing Capnography

• DocumentationDocumentation– WaveformsWaveforms

• Initial assessmentInitial assessment• Changes with treatmentChanges with treatment

– EtCOEtCO22 values values

• Trends over timeTrends over time

WaveformsWaveforms

TrendsTrends

Part 1: Capnography Overview Part 1: Capnography Overview SummarySummary

• The only visual objective measure The only visual objective measure of ventilationof ventilation

• Provides breath-to-breath readingsProvides breath-to-breath readings• For intubated and non-intubated patientsFor intubated and non-intubated patients• Information and documentation of Information and documentation of

patient’s ABCs patient’s ABCs • New technology for use in EMSNew technology for use in EMS

Part 1: Capnography OverviewPart 1: Capnography Overview

Okay, let’s Okay, let’s get started.get started.