CAPNOGRAPHY- and PULSE OXIMETRY : The Standard of RESPIRATORY Care
CAPNOGRAPHY In Emergency Care
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Transcript of CAPNOGRAPHY In Emergency Care
CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care
EDUCATIONAL SERIESEDUCATIONAL SERIES
Part 4:Part 4:Non-intubatedNon-intubated
Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient
CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care
Part 4: The Non-intubated Patient Part 4: The Non-intubated Patient Learning ObjectivesLearning Objectives
• List three non-intubated applicationsList three non-intubated applications• Identify four characteristic patterns Identify four characteristic patterns
seen in seen in – BronchospasmBronchospasm
• AsthmaAsthma• COPDCOPD
– Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low-perfusion statesLow-perfusion states
The Non-intubated PatientThe Non-intubated Patient
CC: CC: ““trouble breathing”trouble breathing”
The Non-intubated Patient The Non-intubated Patient CC: “trouble breathing”CC: “trouble breathing”
Asthma?
Asthma? Emphysema?
Emphysema?
Pneumonia?Pneumonia?Bronchitis?Bronchitis?
CHF?CHF?
PE?PE?
Cardiac ischemia?Cardiac ischemia?
The Non-intubated Patient The Non-intubated Patient CC: “trouble breathing”CC: “trouble breathing”
• Identifying the problem and Identifying the problem and underlying pathogenesis underlying pathogenesis
• Assessing the patient’s statusAssessing the patient’s status• Anticipating sudden changesAnticipating sudden changes
The Non-intubated Patient The Non-intubated Patient Capnography ApplicationsCapnography Applications
• Identify and monitor bronchospasmIdentify and monitor bronchospasm– AsthmaAsthma– COPDCOPD
• Assess and monitor Assess and monitor – Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low-perfusion statesLow-perfusion states
The Non-intubated Patient The Non-intubated Patient Capnography ApplicationsCapnography Applications
• Capnography reflects changes in Capnography reflects changes in
– VentilationVentilation - movement of gases in and out of - movement of gases in and out of the lungsthe lungs
– Diffusion Diffusion - exchange of gases between the air-- exchange of gases between the air-filled alveoli and the pulmonary circulationfilled alveoli and the pulmonary circulation
– PerfusionPerfusion - circulation of blood through the - circulation of blood through the arterial and venous systemsarterial and venous systems
The Non-intubated Patient The Non-intubated Patient Capnography ApplicationsCapnography Applications
• VentilationVentilation • Airway obstructionAirway obstruction
– Smooth muscle contractionSmooth muscle contraction– BronchospasmBronchospasm– Airway narrowingAirway narrowing– Uneven emptying of alveoliUneven emptying of alveoli– Mucous plugsMucous plugs
The Non-intubated Patient The Non-intubated Patient Capnography ApplicationsCapnography Applications
• Diffusion Diffusion • Airway inflammationAirway inflammation• Retained secretionsRetained secretions• Fibrosis Fibrosis • Decreased compliance of alveoli wallsDecreased compliance of alveoli walls• Chronic airway modeling (COPD)Chronic airway modeling (COPD)• Reversible airway disease (Asthma)Reversible airway disease (Asthma)
Capnography in Capnography in Bronchospastic ConditionsBronchospastic Conditions
• Air trapped due to Air trapped due to irregularities in airwaysirregularities in airways
• Uneven emptying of Uneven emptying of alveolar gas alveolar gas – Dilutes exhaled CODilutes exhaled CO22
– Slower rise inSlower rise in COCO2 2
concentration during concentration during exhalationexhalation
Alveoli
Capnography in Capnography in Bronchospastic DiseasesBronchospastic Diseases
• Uneven emptying of Uneven emptying of alveolar gas alters alveolar gas alters emptying on exhalationemptying on exhalation
• Produces changes in Produces changes in ascending phase (II) ascending phase (II) with loss of the sharp with loss of the sharp upslopeupslope
• Alters alveolar plateau Alters alveolar plateau (III) producing a “shark fin”(III) producing a “shark fin”
A B
C D
EII
III
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Prevalence of AsthmaPrevalence of Asthma
• Asthma is increasing in the USAsthma is increasing in the US– 20.3 million citizens report having asthma20.3 million citizens report having asthma
– Prevalence increased 75% from 1980-1994Prevalence increased 75% from 1980-1994
– Two million ED visits each yearTwo million ED visits each year
– Most common chronic health problem in childrenMost common chronic health problem in children
• Increasing deaths due to asthmaIncreasing deaths due to asthma– 1987 to 1995, death rate doubled to 56001987 to 1995, death rate doubled to 5600
Sources: Delbridge T., et al. 2003 Prehospital Asthma Management. Prehospital Emergency Care 7(1) 42-47
Asthmatic Statistics. American Academy of Allergies, Asthma and Immunology. http.//www.aaaai.org
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of AsthmaPathology of Asthma
• Acute onset or progressive over weeksAcute onset or progressive over weeks• Airway Airway
– Increased responsiveness (hyper-reactivity)Increased responsiveness (hyper-reactivity)– Bronchospasm Bronchospasm
• Reversible obstructionReversible obstruction– InflammationInflammation
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of AsthmaPathology of Asthma
• Release of inflammatory mediatorsRelease of inflammatory mediators– Histamine, bradykinin, prostaglandinsHistamine, bradykinin, prostaglandins
• Bronchial wall reactionBronchial wall reaction– Spasm of bronchial smooth muscleSpasm of bronchial smooth muscle– Vasodilatation with swelling of bronchial Vasodilatation with swelling of bronchial
mucous membranesmucous membranes– Increased mucous productionIncreased mucous production
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of AsthmaSymptoms of Asthma
• TachycardiaTachycardia• TachypneaTachypnea• WheezingWheezing• Cough Cough • Chest tightnessChest tightness• Use of accessory muscles (retractions)Use of accessory muscles (retractions)• AnxietyAnxiety• DiaphoresisDiaphoresis
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Classification of AsthmaClassification of Asthma
Symptoms Mild Moderate Severe Arrest Imminent
BreathlessBreathless WalkingWalking TalkingTalking RestingResting
Talks inTalks in SentencesSentences PhrasesPhrases WordsWords
AlertnessAlertness Agitated?Agitated? AgitatedAgitated AgitatedAgitated DrowsyDrowsy
Resp RateResp Rate IncreasedIncreased IncreasedIncreased >30/min>30/min
Accessory Accessory NoNo CommonlyCommonly UsuallyUsually ParadoxParadox
WheezeWheeze Mod; EEMod; EE Loud; ExpLoud; Exp Loud: I/ELoud: I/E AbsentAbsent
PulsePulse <100<100 100-120100-120 >120>120 BradyBrady
PaCOPaCO22 <42mmHg<42mmHg <42mmHg<42mmHg >>42mmHg42mmHg
SaCOSaCO22 >95%>95% 91-95%91-95% <91%<91%
PositionPosition Can lie downCan lie down Prefers sittingPrefers sitting Sitting uprightSitting upright
Source: Edmond S. D. 1998. 1997 National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: 579-594
Adopted from the NIH Guidelines for the Diagnosis and Management of AsthmaAdopted from the NIH Guidelines for the Diagnosis and Management of Asthma
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Assessment of AsthmaAssessment of Asthma
• Symptoms and observations are Symptoms and observations are primarily subjectiveprimarily subjective
• Severity of symptoms and your patient’s Severity of symptoms and your patient’s perception may not accurately reflect perception may not accurately reflect severity of conditionseverity of condition
More More objectiveobjective data needed data needed
Source: Teeter J.G., et al. 1998. “Relationship Between Airway Obstruction and Respiratory
Symptoms in Adult Asthmatics. CHEST.113:5:272-277
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
• 28 normal volunteers; 20 asthma 28 normal volunteers; 20 asthma patients in EDpatients in ED
• Correlation between PEFR and Correlation between PEFR and slope of capnogram waveformslope of capnogram waveform
• ConclusionConclusion– Slope value correlated with PEFRSlope value correlated with PEFR
– ““dCOdCO22/dt is an effort independent, rapid noninvasive /dt is an effort independent, rapid noninvasive
measure that indicates significant bronchospasm”measure that indicates significant bronchospasm”
Source: Yaron M. 1996. Utility of the Expiratory Capnogram in the Assessment of Bronchospasm. Annals of Emergency Medicine 28: 4
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
• ““expiratory airflow obstruction affects the expiratory airflow obstruction affects the shape of the COshape of the CO22 time curve due to uneven time curve due to uneven emptying of alveolar gas.”emptying of alveolar gas.” P 312 P 312
• Waveform examples show increasing Waveform examples show increasing change in normal expiratory plateau with change in normal expiratory plateau with increasing obstruction (bronchospasm)increasing obstruction (bronchospasm)
Source: Hall J.B., Acute Asthma, Assessment and Management,McGraw-Hill, New York.
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
Source: Krauss B., et al. 2003. FEV1 in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA
Changes in dCOChanges in dCO22/dt seen with increasing bronchospasm/dt seen with increasing bronchospasm
Bronchospasm
Normal
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnography in AsthmaCapnography in Asthma
• Research is underway on the correlation Research is underway on the correlation of capnographic changes to patient’s of capnographic changes to patient’s respiratory statusrespiratory status
• Anticipating clinical trials on the impact Anticipating clinical trials on the impact on patient care, outcomes and on patient care, outcomes and healthcare costs healthcare costs
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Asthma Case ScenarioAsthma Case Scenario
• 16 year old female16 year old female• C/O “having difficulty breathing”C/O “having difficulty breathing”• Visible distressVisible distress• History of asthma, physical exertion, “a cold”History of asthma, physical exertion, “a cold”• Patient has used her “puffer” 8 times over the Patient has used her “puffer” 8 times over the
last two hourslast two hours• Pulse 126, BP 148/86, RR 34Pulse 126, BP 148/86, RR 34• Wheezing noted on expirationWheezing noted on expiration
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
AsthmaAsthma Case ScenarioCase Scenario
Initial Initial
After therapyAfter therapy
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Prevalence of COPDPrevalence of COPD
• COPD is increasing in the U.S.COPD is increasing in the U.S.– Fourth leading cause of death in adultsFourth leading cause of death in adults– 16 million cases in 199616 million cases in 1996
• Increasing deaths due to COPDIncreasing deaths due to COPD– 1999 estimated 110,0001999 estimated 110,000– Number of deaths doubled in the past 25 yearsNumber of deaths doubled in the past 25 years
Source: Boyle, A.H. 2000. Recommendations of the National Lung Health Education Program,Heart & Lung 29: 6: 446-449
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
• Chronic, progressive disease processChronic, progressive disease process– Major risk factors: smoking, exposure to Major risk factors: smoking, exposure to
dusts and fumes, history of frequent dusts and fumes, history of frequent respiratory infectionsrespiratory infections
• Spectrum of diseasesSpectrum of diseases– Chronic bronchitisChronic bronchitis– EmphysemaEmphysema– AsthmaAsthma– BronchiectisisBronchiectisis
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
• Progressive Progressive • Partially reversiblePartially reversible• Airways obstructedAirways obstructed
– Hyperplasia of mucous glands Hyperplasia of mucous glands and smooth muscleand smooth muscle
– Excess mucous productionExcess mucous production– Some hyper-responsivenessSome hyper-responsiveness
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
• Small airways Small airways – Main sites of airway obstructionMain sites of airway obstruction– InflammationInflammation– Fibrosis and narrowingFibrosis and narrowing– Chronic damage to alveoliChronic damage to alveoli– Hyper-expansion due to Hyper-expansion due to
air trappingair trapping– Impaired gas exchangeImpaired gas exchange Alveoli
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation
• Increase in chronic symptomsIncrease in chronic symptoms– SOB SOB – CoughCough– WheezingWheezing– Use of accessory musclesUse of accessory muscles– Sputum - increased volume, tenacity Sputum - increased volume, tenacity
and purulenceand purulence– AnxietyAnxiety– DiaphoresisDiaphoresis– Chest tightnessChest tightness
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation
• May also have May also have – Fever - underlying infectionFever - underlying infection– Co-morbidity Co-morbidity
• Congestive heart failureCongestive heart failure• Acute coronary syndromeAcute coronary syndrome• Diabetes mellitusDiabetes mellitus• HypertensionHypertension
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Assessment of COPDAssessment of COPD
• Symptoms and observations are Symptoms and observations are primarily subjectiveprimarily subjective
• Severity of symptoms and your patient’s Severity of symptoms and your patient’s perception may not accurately reflect perception may not accurately reflect severity of conditionseverity of condition
More objective data neededMore objective data needed
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnography in COPDCapnography in COPD
• Arterial COArterial CO22 in COPD in COPD– PaCOPaCO22 increases as disease progresses increases as disease progresses
– Requires frequent arterial punctures for ABGsRequires frequent arterial punctures for ABGs
• Correlating capnograph to patient statusCorrelating capnograph to patient status– Ascending phase and plateau are altered by Ascending phase and plateau are altered by
uneven emptying of gasesuneven emptying of gases
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
COPD Case ScenarioCOPD Case Scenario
• 72 year old male72 year old male• C/O difficulty breathingC/O difficulty breathing• History of CAD, CHF, smoking History of CAD, CHF, smoking
and COPD and COPD • Productive cough, recent Productive cough, recent
respiratory infectionrespiratory infection• Pulse 90, BP 158/82 RR 27 Pulse 90, BP 158/82 RR 27
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
COPD Case ScenarioCOPD Case Scenario
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Initial Capnogram AInitial Capnogram A
Initial Capnogram BInitial Capnogram B
Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of CHFCapnogram of CHF
• 207 patients in pulmonary function lab207 patients in pulmonary function lab– 61 with obstructive disease (OD); 34 with restrictive 61 with obstructive disease (OD); 34 with restrictive
disease (RD) disease (RD) – Correlation of slope of exhalation plateau Correlation of slope of exhalation plateau
• C/O severe difficulty breathing (FEV1<50%)C/O severe difficulty breathing (FEV1<50%)– 97% of OD had elevations >4°; 5% of RD had elevations >4°97% of OD had elevations >4°; 5% of RD had elevations >4°– P<0.0001P<0.0001
• ConclusionConclusion– Changes in shape of capnogram in OD confirmedChanges in shape of capnogram in OD confirmed– Changes in capnogram in RD did not occurChanges in capnogram in RD did not occur
Source: Krauss B., et al. 2003. FEV1in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA.
Capnography in CHFCapnography in CHF
Case ScenarioCase Scenario
• 88 year old male 88 year old male • C/O: Short of breathC/O: Short of breath• H/O: MI X 2, on oxygen at 2 L/mH/O: MI X 2, on oxygen at 2 L/m• Pulse 66, BP 114/76/p, RR 36 labored and Pulse 66, BP 114/76/p, RR 36 labored and
shallow, skin cool and diaphoretic, shallow, skin cool and diaphoretic, 2+ pedal edema2+ pedal edema
• Initial SpOInitial SpO22 69%; EtCO 69%; EtCO22 17mmHG 17mmHG
Capnography in CHFCapnography in CHF
Case ScenarioCase Scenario
• Placed on non-rebreather mask with 100% Placed on non-rebreather mask with 100% oxygen at 15 L/m; IV diuretic and SL nitroglycerin oxygen at 15 L/m; IV diuretic and SL nitroglycerin as per local protocolas per local protocol
• Ten minutes after treatment:Ten minutes after treatment:
SpOSpO22 69% 99% 69% 99%
EtCOEtCO22 17mmHG 35 mmHG 17mmHG 35 mmHG
4 5
3 5
0
2 5
Time condensed Time condensed to show changesto show changes
Capnography in Capnography in Hypoventilation StatesHypoventilation States
• Altered mental statusAltered mental status– SedationSedation– Alcohol intoxicationAlcohol intoxication– Drug IngestionDrug Ingestion– StrokeStroke– CNS infectionsCNS infections– Head injuryHead injury
• Abnormal breathing Abnormal breathing
• COCO22 retention retention – EtCOEtCO22 >50mmHg >50mmHg
Capnography in Capnography in Hypoventilation StatesHypoventilation States
• EtCOEtCO22 is above 50mmHG is above 50mmHG
• Box-like waveform shape is unchangedBox-like waveform shape is unchanged
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Time condensed; actual rate is slowerTime condensed; actual rate is slower
Capnography in Hypoventilation StatesCapnography in Hypoventilation States Case ScenarioCase Scenario
• Observer called 911Observer called 911• 76 year old male sleeping and 76 year old male sleeping and
unresponsive on sidewalk, “gash unresponsive on sidewalk, “gash on his head”on his head”
• Known history of hypertension, Known history of hypertension, EtOH intoxication EtOH intoxication
• Pulse 100, BP 188/82, RR 10, SpOPulse 100, BP 188/82, RR 10, SpO22 96% 96% on room airon room air
Capnography in Hypoventilation StatesCapnography in Hypoventilation States HypoventilationHypoventilation
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Time condensed; actual rate is slowerTime condensed; actual rate is slower
Capnography in Hypoventilation StatesCapnography in Hypoventilation States HypoventilationHypoventilation
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Hypoventilation in shallow Hypoventilation in shallow breathingbreathing
Capnography in Low PerfusionCapnography in Low Perfusion
• Capnography reflects changes in Capnography reflects changes in • PerfusionPerfusion
– Pulmonary blood flow Pulmonary blood flow – Systemic perfusionSystemic perfusion– Cardiac outputCardiac output
Capnography in Low PerfusionCapnography in Low Perfusion
Case ScenarioCase Scenario
• 57 year old male 57 year old male • Motor vehicle crash with injury to chestMotor vehicle crash with injury to chest• History of atrial fib, anticoagulantHistory of atrial fib, anticoagulant• UnresponsiveUnresponsive• Pulse 100 irregular, BP 88/pPulse 100 irregular, BP 88/p• Intubated on sceneIntubated on scene
Capnography in Low PerfusionCapnography in Low Perfusion
Case ScenarioCase Scenario
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Low EtCOLow EtCO22 seen in seen in
low cardiac outputlow cardiac output
Ventilation controlledVentilation controlled
Capnography ApplicationsCapnography Applicationson Non-intubated Patientson Non-intubated Patients
• New applications now being reportedNew applications now being reported– Pulmonary emboliPulmonary emboli– CHFCHF– DKADKA– BioterrorismBioterrorism– Others? Others?
r r O xy g e n
O 2
V e inA t e y
Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus
Case ScenarioCase Scenario
• 72 year old female 72 year old female • CC: Sharp chest pain, short of breath CC: Sharp chest pain, short of breath • History: Legs swollen and pain in right History: Legs swollen and pain in right
calf following flight from Alaska calf following flight from Alaska • Pulse 108 and regular, RR 22, BP 158/88 Pulse 108 and regular, RR 22, BP 158/88
SpOSpO22 95% 95%
Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus
Case ScenarioCase Scenario
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Strong radial pulseStrong radial pulse
Low EtCOLow EtCO22 seen in seen in
decreased alveolar perfusiondecreased alveolar perfusion
Part 4: Part 4: The Non-intubated Patient SummaryThe Non-intubated Patient Summary
• Identify and monitor bronchospasmIdentify and monitor bronchospasm– AsthmaAsthma– COPDCOPD
• Assess and monitor Assess and monitor – Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low perfusionLow perfusion– Many others now being reportedMany others now being reported
Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient
Ready to take capnography for a run?Ready to take capnography for a run?