CAPNOGRAPHY IN EMS
Transcript of CAPNOGRAPHY IN EMS
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Scott Temple
Lake EMS
February 2012
CAPNOGRAPHY
IN
EMS
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What is the difference
Oxygenation
vs.
Ventilation
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• Oxygenation - the ability of the red blood cells to pick up oxygen and move them to the tissues of the body
• Ventilation - the exchange of air between the lungs and the environment, including inhalation and exhalation
Oxygenation vs. Ventilation
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• Oxygen must first be picked up by red blood cells, then dumped off at the tissue level
• The body must then take the O2 and glucose to create energy through cellular metabolism
• This leaves the waste product (CO2) which needs to be discarded through exhalation
Cellular Metabolism
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Pulse oximetry measures oxygenation and can be provided in a waveform
Capnographymeasures ventilation and can also provide a graphical waveform for interpretation
PULSE OXIMETRY AND
CAPNOGRAPHY
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Oxygenation
• Measured with pulse oximetry (SpO2)
• Noninvasive measurement
• Expresses the percentage of oxygen in red blood cells
• Changes in oxygenation may take minutesto be detected (up to 5 minutes at times)
• Affected by motion artifact, poor perfusion nail polish, and some dysrhythmias
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Pulse Oximetry Waveforms
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Ventilation
• Measured by End-Tidal CO2
• Partial pressure (mmHg) or volume
(% vol.) of CO2 in the airway at the end of
exhalation
• Breath-to-breath measurement provides
information within seconds
• Not affected by motion artifact, poor
perfusion or dysrhythmias
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Capnography Waveforms
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• Oxygenation
• Oxygen for
metabolism
• SpO2 measures
% of O2 in RBC
• Reflects change
in oxygenation
within 5 minutes
• Ventilation
• Carbon dioxide from metabolism
• EtCO2 measures exhaled CO2 at the point of exit
• Reflects change in ventilation within 10 seconds
Oxygenation and Ventilation
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Don’t believe me about the time
• Try this:
• Turn on the monitor and put an EtCO2 filter line on and the SpO2 sensor
• Now hold your breath
• You will see that the capnography will show apnea almost immediately
• The SpO2 will continue to show a high saturation
• Because it does not register for several minutes
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Pre-Hospital Use of
Capnography
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Utilizing Capnography
• Immediate information via
breath-to-breath monitoring
• Information on the ABCs
• Airway
• Breathing
• Circulation
• Documentation purposes
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Capnography Uses - Airway
• Airway
• Verification of ET tube placement
• Continuous monitoring of ET tube position
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Capnography Uses - Breathing
• Breathing
• Hyperventilation
• Hypoventilation
• Asthma
• COPD
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Capnography Uses - Circulation
• Circulation
• Checking the effectiveness of compressions during cardiac arrest
• First indicator of ROSC
• Monitors low perfusion states
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Documentation Purposes
• As with all documentation, capnography can be utilized as legal evidence pertaining to the care that a patient received during a call
• The following are examples of the information that capnography provides
• Baseline capnography assessments
• Waveform appearance
• Changes in the waveform with treatment (TRENDING)
• EtCO2 values
• Documenting the actual numbers shown on the monitor – how they change during transport
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Capnography and Intubated
Patients
• Verifies and documents ET tube placement
• Immediately detects changes in ET tube position
• Assesses effectiveness of chest compressions
• Earliest indication of ROSC
• Indicator of probability of successful resuscitation
• Allows crews to adjust manual ventilations in accordance with the patient’s needs
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Research and capnography
• A 2005 study compared field intubations that used capnography to confirm ETT placement vs. intubations that did not use capnography to confirm placement. The study showed:
• That 0% of intubations went unrecognized if misplaced when ETCO2 monitoring was used
• 23% went unrecognized in the non-EtCO2monitored group
That’s why we confirm intubations with waveform capnography
Silverstir, Annals of Emergency Medicine, May 2005
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Capnography and
Non-Intubated Patients
• Assists in the assessment of acute respiratory disorders
• Asthma
• COPD
• Among many others
• Helps in determining a patient’s response to our treatment(s)
• Contributes in the formation of a field diagnosis
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Hypoventilating
Non-intubated Patients
• Capnography can estimate the severity of the condition that leads to hypoventilation
• Stroke
• Head injury
• ETOH intoxication
• Drug overdose
• DKA patients
• Congestive heart failure
• Analgesia and sedation medications
• Great for assessing perfusion status of these patients
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End-tidal CO2 (EtCO2)
• Reflects changes in
• Ventilation - movement of air in and
out of the lungs
• Diffusion - exchange of gases between the
air-filled alveoli and the pulmonary
circulation
• Perfusion - circulation of blood
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What’s occurring in the Lungs
r r
O
2
CO2O
2
VeinA te y
Ventilation
Perfusion
Right
Ventricle
Left
Atrium
Pulmonary Blood Flow
Alveoli
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• The Right Ventricle of the Heart pumps blood into the Pulmonary Artery
• Remember the Pulmonary Artery (P.A.) is the only artery that carries deoxygenated blood
• When in the lungs, the blood will dump CO2 off where it will be diffused into the alveoli
• In return the alveoli will push O2 into the blood, oxygenating the blood
• The Pulmonary Vein (P.V.), the only vein that carries oxygenated blood, then takes the newly oxygenated blood back into the heart, specifically into the Left Atrium
Look at the diagram again
Anatomy and Physiology
P.A P.V.
This is occurring
in the alveoli
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How CO2 gets to the Alveoli
r r
O
2
CO2
O
2
VeinA te y
Ventilation
Perfusion
Right
Ventricle
Left
Atrium
Pulmonary Blood Flow
Alveoli
See how the pulmonary
artery dumps CO2 off
Deoxygenated blood Oxygenated blood
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Oxygenated blood
r r
O
2
CO2
O
2
VeinA te y
Ventilation
Perfusion
Right
Ventricle
Left
Atrium
The pulmonary
vein then picks
up oxygen from
the alveoli and
carries it back to
the heart
Alveoli
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Ventilation
r r
Alveoli
O
2
CO2
O
2
VeinA te y
Now carbon
dioxide (CO2) is
exhaled and we
capture it via the
capnography
filter line
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Changes in EtCO2 Levels
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• Decreased cardiac output
• Cardiac arrest
• Pulmonary embolism
• Bronchospasm
• Decreased muscular activity
• Hypothermia
Why ETCO2 levels decrease
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• Increased cardiac output
• Good compressions during cardiac arrest
• Increased muscular activity
• shivering
• Effective therapy for bronchospasms
Why ETCO2 levels increase
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• The height shows amount of carbon dioxide exhaled
• The length shows the time
• This represents the normal waveform of “one” respiratory cycle
Anatomy of a waveform
TIME
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Phase 1
• Baseline of waveform
• Initial upstroke of the waveform
• Represents exhaled gas from upper airways
• a.k.a. anatomical dead space
Waveform breakdown
Exhalation begins
many reverse this and
believes that it begins
inhalation, it does not
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Dead space area is shaded
orange
• Begins exhalation
• CO2 is absent
• Air is coming from
the mouth, nose,
and pharynx
• Gas exchange
does not occur
here
PHASE 1
“Dead Space” Ventilation
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Define Dead Space
• Ventilated areas that do not take part in the
exchanging of gases:
• Airways leading to the alveoli
and
• Ventilated areas in the lungs without blood
flow
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Phase 2
• Transitions from
upper to lower
airway ventilation
• Shows changes in
the perfusion status
of a patient
Waveform breakdown
CO2 present and increasing in exhaled air
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• CO2 from the alveoli reaches the upper airway and mixes with the dead space air
• Why you see a rise in CO2
• CO2 is now detectable in exhaled air via capnography
PHASE 2
Ascending Phase
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Phase 3
• Shows alveolar gas exchange
• Indicates changes in gas distribution
• Increases in this slope indicates problems with distribution of gas delivery
Waveform breakdown
CO2 exhalation - the wave plateaus
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• CO2 now makes up the
majority of the exhaled
air
• The concentration of
the CO2 remains fairly
constant from alveoli
to the nose/mouth at
this phase
Phase 3
Alveolar Plateau
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• The end of
exhalation contains
the highest
concentration of
CO2
• “End-Tidal CO2”
PHASE 3
END-TIDAL
End-tidal
The star marks the end of
the wave of exhalation
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Phase 4
• Beginning of
inhalation
• CO2 levels drop to
baseline (zero)
• Oxygen is now in
the airway
Waveform breakdown
Descending Phase
Inhalation
Inspiratory down stroke returns
to zero or “baseline”
0
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What is the normal range for a
capnography waveform
45
0
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Answer
45
0
Normal range = 35 - 45mmHg
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• ETCO2 less than 35 mmHg
• Hyperventilation / Hypocapnia
• Hypocapnia – low CO2
• ETCO2 greater than 45 mmHg
• Hypoventilation / Hypercapnia
• Hypercapnia –high CO2
ABNORMAL VALUES
hyperventilation
hypoventilation
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Question
• How would your waveform change if you
intentionally started to breathe at a rate of
40?
• Frequency of waveforms
• Duration of waveforms
• Height of waveforms
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45
0
Hyperventilation
45
0
Normal
Hyperventilation
1) Note how the respirations increase – seen in the increased number of waves
in the bottom capnogram, the duration of each wave is also shorter
2) Notice how the pink waves are under the 45mmHg line – this shows that
the ETCO2 levels have dropped (the patient is blowing CO2 off)
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• Indicates CO2deficiency
�Hyperventilation
�Decreased pulmonary perfusion
�Hypothermia
�Decreased metabolism
• Interventions
�Adjust ventilation rate
�Evaluate for adequate sedation
�Evaluate anxiety
�Conserve body heat
Hyperventilation Waveform
Regular Shape, Plateau Below Normal
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Question
• How would your waveform change
if you intentionally decreased your
respiratory rate to 10?
• Frequency
• Duration
• Height
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Hypoventilation
45
0
45
0
Normal
Hypoventilation
1) Note how the respirations decrease – seen in the decreased number of
waves in the bottom capnogram, the duration of each wave is also longer
2) Notice how the green waves are over the 45mmHg line – this shows that
the ETCO2 levels have increased (the patient is retaining CO2)
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• Indicates increase in ETCO2
�Hypoventilation
�Respiratory depressant drugs
� Increased metabolism
• Interventions
�Adjust ventilation rate
�Decrease respiratory depressant drug dosages
�Maintain normal body temperature
Hypoventilation Waveform
Regular Shape, Plateau Above Normal
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Waveform patterns
0
45
Hypoventilation
45
0
Hyperventilation
45
0
Normal
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What is happening here?
45
0
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Bronchospasm Waveform
• Bronchospasm restrict proper ventilation
• Alveoli unevenly fill during inspiration
• They also empty unevenly during expiration
• Uneven air flow during exhalation dilutes exhaled CO2
• This alters the ascending phase and plateau
• Slower rise in CO2 concentration
• Characteristic pattern for bronchospasm
• “Shark Fin” shape to waveform
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Capnography waveforms
45
0
Hypoventilation
Normal
45
0
45
0
Bronchospasm
Hyperventilation
45
0
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Capnography
and Advanced Airways
“In-line capnography”
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• Utilized to confirm that your tube is in place
• Remember improper placement of the tube will result in the “lack” of a waveform
• This tube is confirmed!
Confirmation of the tube
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Med-Legal
• Capnography provides
• Documentation of correct placement
• Ongoing documentation over time through the trending printout
• Documentation of correct position at ED arrival
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• Tube dislodgment
is immediately
detected when a
waveform drops
suddenly
• Initially this tube
was confirmed,
then displaced
Dislodgement of tube
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Detect ET Tube Displacement
• This is only provided through the use of capnography
• A continuous numerical value of EtCO2 with apnea alarm after 30 seconds (if you have the alarm set)
and
• A continuous graphic waveform for immediate visual recognition
45
0
Source: Linko K. et. al. 1983. Capnography for detection of accidental oesophageal intubation. Acta Anesthesiol Scand 27: 199-202
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Can Capnography Assist With
CPR?
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Absolutely!
• Determination of how effective your chest compressions are
• Helps to show early detection of ROSC
• Provides data for the decision to cease resuscitation
• i.e. the EtCO2 reading remains under 10mmHg for over 20 minutes of working a code
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Capnography and CPR
Assessment
• When a patient is in cardiac arrest, remember the EtCO2 is going to be low – the patient is not perfusing enough therefore gas exchange is not occurring appropriately
• In cardiac arrest we are hoping to keep the EtCO2 around 10 to 15mmHg. Without a number this high the chances of getting ROSC are very low
• You can increase the EtCO2 by providing better compressions (thus providing better perfusion to the alveoli) during CPR
How does providing better compressions help to raise EtCO2
numbers?
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• Better compressions simply means we are moving blood better
• A patient in cardiac arrest is not circulating blood to the lungs and therefore limits the amount of CO2 being diffused into the alveoli
• When you provide quality compressions it increases the movement of blood to the lungs where CO2 can diffuse into the alveoli and O2 can diffuse into the pulmonary vein
• If you notice your capnogram wave is low during the next code, just compress harder and faster and watch the boxes increase in height
REMEMBER THIS?
r r
O2
CO2O
2
VeinA te y
Ventilation
Perfusion
Right
Ventricle
Left
Atrium
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In 1978
• A scientist, Kalenda,
“reported a decrease in ETCO2 as the
person performing CPR fatigued, followed by
an increase in ETCO2 as a new rescuer took
over, presumably providing better chest
compressions.”
Gravenstein, Capnography: Clinical Aspects,
Cambridge Press, 2004
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Another study suggests
• Reductions in ETCO2 during CPR are
associated with comparable reductions in
cardiac output....The extent to which
resuscitation maneuvers, especially
precordial compression, maintain cardiac
output may be more readily assessed by
measurements of ETCO2 than palpation of
arterial pulses.”
-Max Weil, M.D., Cardiac Output and End-Tidal carbon
dioxide, Critical Care Medicine, November 1985
Yeah it’s old but it still applies today!
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New Guidelines
• With the new American Heart Association Guidelines calling for quality compressions ("push hard, push fast, push deep"), rescuers should switch places every two minutes
• You should be setting the monitor up so the compressors can view the ETCO2 readings as well as the EKG waveform generated by their compressions
• We encourage you to keep the ETCO2 number up as high as possible during CPR
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What is this a sign of?
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What is this a sign of?
This capnogram is a sign that your patient has just had a return of
spontaneous circulation (ROSC)
Note how high the wave is – why does it look this way?
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• The wave is large because the patient in cardiac arrest has been retaining CO2
• When ROSC is achieved the patient, whose heart is now working, is able to perfuse better getting rid of the retained CO2
• This exhalation of retained CO2 is what gives the box such a high appearance
• Remember the box is a representation of an actual figure. In this case the EtCO2
number is about 60mmHg
Retention of CO2
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• Survived to discharge from hospital
• Average EtCO2 : 30mmHg
• Non-survivor
• Average EtCO2:
4-10mmHg
ROSC and ETCO2
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INCREASED INTRACRANIAL
PRESSURE (ICP)
AND
CAPNOGRAPHY
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ICP and EtCO2 Levels
• Capnography should also be utilized in patients with ICP issues
• The following ICP patients are very sensitive to fluctuations in EtCO2 levels:
• Stroke patients (possible bleeds)
• Trauma to the head
• Neoplasms (brain tumors)
• Brain infections
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Question
What do you think will occur to cerebral
vasculature if the patient has high CO2 levels?
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Cerebral Vasodilation
• High CO2 levels cause
cerebral vasodilatation
• The Good: It increases
cerebral blood flow (CBF) to
counter cerebral hypoxia
• The Bad: Increased CBF
increases ICP and may
increase brain edema
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Question
What do you think will occur to cerebral
vasculature if the patient has low CO2 levels?
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Cerebral Vasoconstriction
• Low CO2 levels lead to cerebral vasoconstriction
• The Good: It lowers CO2 levels that can cause mild cerebral vasoconstriction which may decrease ICP
• The Bad: Although low CO2 levelsdecrease ICP it may cause or increasecerebral hypoxia
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Pearls
• Hypoventilation increases CO2 levels
• Not blowing off the CO2
• Results in cerebral vasodilation
• Hyperventilation decreases CO2 levels
• Blowing off too much CO2
• Results in cerebral vasoconstriction
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Treatment Goals
• Avoid cerebral hypoxia
• Maintain adequate cerebral blood flow
• Monitor oxygen saturation with pulse oximetry
• Utilize the capnography in conjunction with pulse oximetry
• Your target should be an EtCO2 of 35mmHg
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Warning when
hyperventilating patients
• “Recent evidence suggests hyperventilation
leads to ischemia almost immediately...current
models of both ischemic and Traumatic Brain
Injury (TBI) suggest an immediate period during
which the brain is especially vulnerable to
secondary insults. This underscores the
importance of avoiding hyperventilation in the
pre-hospital environment.”
--Capnography as a Guide to Ventilation in the Field, D.P. Davis,
Gravenstein, Capnography: Clinical Perspectives, Cambridge Press,
2004
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The Dyspnea Patient
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Other Patients Needing CO2
Monitoring
• COPD
• Emphysema
• Chronic Bronchitis
• Asthma
• CHF/Pulmonary Edema
• Pneumonia
• Possible Pulmonary Embolism
• Cardiac Ischemia
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Why you should use
capnography for these patients
• To assess and trend your patients’
• Low-perfusion status
• Hyperventilation status
• Hypoventilation status
• To identify changes in capnography waveforms
• i.e. bronchospasms in COPD and Asthma patients
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Capnography and
Bronchospasms
• Produces changes in
ascending phase (2)
with loss of the sharp
upslope
• Alters alveolar plateau
(3) producing a “shark fin”
A B
C D
E
2
3
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Normal vs. 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
Bronchospasm
Normal
Bronchospasm
Normal
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What you should see
after treatment
Prior to therapy
After therapy
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• In COPD patients the PaCO2 or the partial pressure of carbon dioxide in the arterial blood INCREASES
• This is the waveform that you will probably see
• Notice how the ascending phase and plateau look abnormal
• This is because there is an uneven emptying of gases
Role of capnography with COPD
45
0
Normal patient presentation
45
0
Abnormal patient presentation
Do you see the COPD patient is retaining CO2?
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Scenario
• 70 year old female
• C.C.: Dyspnea, with moderate chest pain
• History: MI, CABG X 3, on oxygen at 2 l/m
• Pulse 60, BP 144/70, RR 38 labored and
shallow, skin cool and diaphoretic,
some pedal edema
• Initial SpO2 79%; EtCO2 20mmHG
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You….
• Place the patient on NRBM 15L (100% O2)
• Administer 1 inch nitro paste
• During transport you trend her vitals, this is what you
see:
• SpO2 99%
• EtCO2 35mmHg4 5
3 5
0
2 5
In order to see documented improvement in your patients you
must TREND!
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Pulmonary Embolism and
Capnography
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Ventilation/Perfusion Mismatch(V/Q Mismatch)
• This is when the amount of ventilation or
perfusion is altered
• In pulmonary embolism patients there is a
decrease in perfusion when compared to
ventilation
• This increases deadspace
• Remember deadspace is the parts of the
airway that are unable to take part in gas
exchange due to the lack of perfusion
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• P.E. patients
therefore show a
reduction in
exhaled CO2 on
your capnography
due to the
increased
deadspace
INCREASED DEADSPACE
45
35
0
25
The green line represents the normal level of
CO2. See how this PE patient is way under
it?
Low EtCO2 due to increased deadspace
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Why use capnography in P.E.
• We should utilize capnography in these
patients because it can assist us in forming a
field diagnosis
• Most of us know what to look for in these
patients. Give me some examples of how
P.E. patients present
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• Sudden dyspnea
• Tachycardia
• RR > 20
• Chest pain
• Hypoxia
• Anxiety
• Feeling of doom
• Hemoptysis
• Syncope
• And if you were paying attention
• A sudden decrease in EtCO2
Presentation of pulmonary embolism
patients
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Scenario
• 25 year old female
• C.C. – shortness of breath and sharp pain in chest
• History: healthy no issues
• Meds: Chantix (smoking cessation), Yasmin (birth control)
• Sound like a possible P.E. candidate?
YUP!
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Patient begins to hyperventilate
• You place her on capnography and see this
• Without warning you see a marked decrease
in EtCO2 and patient mental status
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So what caused the drop in
EtCO2
• Typically hyperventilation alone does not cause a sudden rapid drop in EtCO2
• Pulmonary Embolisms however DO!
• Remember a P.E. will increase the deadspace of the lung
• The increased deadspace will produce a decrease in exhaled CO2
• Now put the P.E. signs and symptoms together with the EtCO2 information and you have just made an excellent field diagnosis
Having the tools are nice,
but knowing when to use them is key!
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Using Capnography for
Hypoventilatory States
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First of all, think of some
differential diagnosis that can
cause a patient’s breathing to be
slow
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Differentials
• Patients with altered mental status
• Head injury
• CVA
• Drug overdose
• Heavily sedated
• ETOH
• Sepsis/Infection (specifically CNS in nature)
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Which of these is a patient
hypoventilating
45
0
45
0
45
0
A
B
C
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Answer
In this case the patient is retaining too much CO2
Note: the EtCO2 is above 45mmHg
45
0
C
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What is this patient doingHint: he is still hypoventilating
4 5
0
This patient is actually breathing very shallow which causes most
of the waveforms to be small and uneven.
However when the patient lets out a larger exhale you note the
height increase of one of the boxes. This shows he was breathing
shallow then exhaled a high amount of retained CO2
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You are called to a nursing home. As you approach your patient you note that the patient is on a O2 mask and lying semi fowlers (his chin is nearly touching his chest)
You place him on capnography and this is what you see…..
WHAT IS OCCURRING HERE?
45
0
Tell me what is going on based on this
waveform?
Observe this one carefully,
something is not right
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• Note that the baseline is elevated
• This is a situation that many patients experience and we often don’t recognize
• Patient “Rebreathing”
DID YOU SEE IT?
45
0
The baseline never comes back to
zero because of the poor positioning
of the patient. Also because he is
wearing a mask that allows him to
“rebreath” his own CO2
He is not clearing the dead space that
would allow a return to “0”
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DKA PATIENTS
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What is occurring in DKA
• Diabetic Ketoacidosis (DKA)
• The issue with a Insulin Dependent Diabetic Mellitus (IDDM) and some Non-Insulin Dependent Diabetic Mellitus (NIDDM) patients is that they do not have insulin available to breakdown glucose (a.k.a. sugar) for energy creation
• Instead the IDDM (type 1) diabetic and in some case NIDDM (type 2) patients will sometimes have no choice but to utilize fat stores for energy production (termed Gluconeogenesis)
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Fat for energy
• When fat stores are used for energy, acids called Ketones begin to build up in the blood and urine
• Ketones become toxic in high levels – this is what we call ketoacidosis
• In many cases people find out that the have diabetes because they initially had a DKA experience
• These are the patients with very high blood sugar levels and whose breath smells sweet or some say like acetone
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Buffering
• Eventually the body turns to the bicarbonate buffering system in order to balance the acid build up
• bicarbonate is a base that opposes acid, decreasing acid levels
• The problem is this system is quickly overwhelmed and other mechanisms must work to compensate for the acidosis
• So what does the body do?
• It triggers hyperventilation to lower the blood CO2
levels
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So how do DKA patients
breathe?
• Remember what is occurring in these patients
• Ketones are building up (causing acidosis)
• This means that there is a high level of
CO2 in the blood
• Therefore what type of waveform will you
see?
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• When patients are
in (DKA) the body
attempts to correct
acidosis
• High levels of CO2
in the body creates
an acidotic
environment
DKA and Capnography
45
0
In this waveform you are seeing a patient
whose body is attempting to correct the
acidosis
Note how the EtCO2 is above 45mmHg
showing an acidotic state
This is why a patient breathes fast in DKA –
initially, they are trying to blow off the CO2
and therefore lessen the acidosis that may
kill them
Be sure to utilize end-tidal with suspected DKA patients
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However!
• Just like in the case of fast heart rates, a patient breathing this fast cannot keep it up, so what occurs?
• The patient begins a pattern of labored and deep breathing
• Remember in metabolic acidosis (in this case DKA) breathing is first rapid and shallow
BUT…
• As acidosis worsens breathing becomes deep, labored and gasping (Kussmaul respirations)
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Shock Patients
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Perfusing warning!
• Capnography 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
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Another Pig Study
• 5 pigs had hemorrhagic shock induced by
bleeding, 5 pigs had septic shock induced by
infusion of e-coli, and 6 pigs had cardiogenic
shock induced by repeated episodes of v-fib.
The pigs' cardiac output was continuously
measured as well as their PETCO2.
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Results
• “A patient with low cardiac output caused by cardiogenic shock or hypovolemia resulting from hemorrhage won’t carry as much CO2 per minute back to the lungs to be exhaled
• Therefore this patient’s ETCO2 will be reduced
• This doesn’t necessarily mean the patient is hyperventilating or that their arterial CO2 level will be reduced. Reduced perfusion to the lungs alone causes this phenomenon. The patient’s lung function may be perfectly normal
Baruch Krauss, M.D, JEMS, November 2003
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When to use capnography
• Capnography is not cheap yet the benefits for
the medic and the patient outweigh the cost
• However we still want to be selective when
utilizing the filter lines
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• Altered mental states
• CNS infections
• Sepsis
• Drug/ETOH intoxication
• Hyperglycemia
• DKA
• Patients with potential increased ICP issues
Utilize capnography for these
patients
• STEMIs
• Cardiac arrest
• Respiratory
patients
• Patients on
sedation and
analgesic meds
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Capnography is just another tool in your arsenal of equipment that can be utilized to further confirm your field diagnosis. Remember that the your “field diagnosis” assists to lead you in your treatments.
As stated previously the placement of EtCO2 filter lines are not intended for every patient. Instead it should be used only for those patients who can benefit from it’s information. If utilized please trend your findings after every treatment and document accordingly.
Thank you for you attention!
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Post-Test
Please complete the post test and return to administration via interoffice mail or fax to: 352-735-4475 attention Scott Temple
This program is worth 3 CEUs in the Airway, Medical, Operations, or Electives categories
Please specify on your post test where you would like the CEUs to be inserted.
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References• D.P. Davis, Gravenstein Capnography as a Guide to Ventilation in the
Field,, Capnography: Clinical Perspectives, Cambridge Press, 2004
• 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
• Max Weil, M.D., Cardiac Output and End-Tidal carbon dioxide, Critical Care
• Linko K. et. al. Capnography for detection of accidental oesophageal intubation. Acta Anesthesiol Scand 27: 199-202 Medicine
• Silverstir, Annals of Emergency Medicine, May 2005