Capnography: The Ventilation Vital Sign

1. Capnography: The Ventilation Vital Sign Prepared By: Bill Milan NREMT-P, FP-C

2. Objectives Define Capnography Discuss Respiratory Cycle Discuss ways to collect ETCO2 information Discuss Non-intubated vs. intubated patient uses Discuss different waveforms and treatments of them.

3. So what is Capnograhy? Capnography- Continuous analysis and recording of Carbon Dioxide concentrations in respiratory gases ( I.E. waveforms and numbers) Capnometry- Analysis only of the gases no waveforms

4. Respiratory Cycle Breathing- Process of moving oxygen into the body and CO2 out can be passive or non-passive. Metabolism-Process by which an organism obtains energy by reacting O2 with glucose to obtain energy. Aerobic- glucose+O2 = water vapor, carbon dioxide, energy (2380 kJ) Anaerobic- glucose= alcohol, carbon dioxide, water vapor, energy (118 kJ)

5. Respiratory Cycle con�t Ventilation- Rate that gases enters and leaves the lungs Minute ventilation- Total volume of gas entering lungs per minute Alveolar Ventilation- Volume of gas that reaches the alveoli Dead Space Ventilation- Volume of gas that does not reach the respiratory portions ( 150 ml)

6. The Respiratory Cycle. A common myth is that oxygenation is the complete Respiratory Cycle. However, that is not so. The Respiratory Cycle is comprised of Oxygenation, Metabolism and Ventilation.The Respiratory Cycle. A common myth is that oxygenation is the complete Respiratory Cycle. However, that is not so. The Respiratory Cycle is comprised of Oxygenation, Metabolism and Ventilation.

7. Respiratory Cycle Important to note that CO2 plays a role in metabolic, cardiovascular and respiratory systems. By monitoring CO2 concentration, the clinician has an indication of subtle pathological disturbances of metabolic, cardiovascular and respiratory systems. Important to note that CO2 plays a role in metabolic, cardiovascular and respiratory systems. By monitoring CO2 concentration, the clinician has an indication of subtle pathological disturbances of metabolic, cardiovascular and respiratory systems.

8. How is ETCO2 Measured? Semi-quantitative capnometry Quantitative capnometry Wave-form capnography

9. Semi-Quantitative Capnometry Relies on pH change Paper changes color from Purple to Brown to Yellow

10. Quantitative Capnometry Absorption of infra-red light Gas source Side Stream In-Line Factors in choosing device: Warm up time Cost Portability

11. Waveform Capnometry Adds continuous waveform display to the ETCO2 value. Additional information in waveform shape can provide clues about causes of poor oxygenation.

13. Hyperventilation Kills

15. Physiology Relationship between CO2 and RR ?RR ? ?CO2 Hyperventilation ? RR ? ? CO2 Hypoventilation There is an inverse relationship between your respiratory rate and your CO2 level. As you breath faster your RR goes up, your body is unable to hold onto CO2 and therefore blows it off faster so those levels go down. As you breath more slowly, your RR goes down, your body is holding more CO2 due to the lack of breaths taken and the CO2 level goes up. It is important to keep a healthy balance. There is an inverse relationship between your respiratory rate and your CO2 level. As you breath faster your RR goes up, your body is unable to hold onto CO2 and therefore blows it off faster so those levels go down. As you breath more slowly, your RR goes down, your body is holding more CO2 due to the lack of breaths taken and the CO2 level goes up. It is important to keep a healthy balance.

16. Why ETCO2 I Have my Pulse Ox? Pulse Oximetry Oxygen Saturation Reflects Oxygenation SpO2 changes lag when patient is hypoventilating or apneic Should be used with Capnography Capnography Carbon Dioxide Reflects Ventilation Hypoventilation/ Apnea detected immediately Should be used with Pulse Oximetry

17. What does it really do for me? Non-Intubated Applications Bronchospasms: Asthma, COPD, Anaphlyaxis Hypoventilation: Drugs, Stroke, CHF, Post-Ictal Shock & Circulatory compromise Hyperventilation Syndrome: Biofeedback Intubated Applications Verification of ETT placement ETT surveillance during transport Control ventilations during CHI and increased ICP CPR: compression efficacy, early signs of ROSC, survival predictor

18. The Normal Wave Form The Shape of a �Normal� Capnogram. During inhalation there is no CO2 present. The body is taking in Oxygen. As the body begins to exhale the first air out of the system is that which is in the upper airway. That air contents little to no CO2. As the body continues to exhale the rush of air carries the CO2 up and out from the lungs. You will see a sharp rise in CO2 as this process continues. At the end of the breath, there is an equal amount of CO2 in the system and you will see the wave form flatten out. It is also at this point that the measurement is taken, the End-tidal CO2 value is that point when CO2 is at the maximum amount. Then you will see a sharp decline in CO2 as the next breath is taken. When the airway is obstructed or constricted, you will see definite changes to all aspects of the waveform. The Shape of a �Normal� Capnogram. During inhalation there is no CO2 present. The body is taking in Oxygen. As the body begins to exhale the first air out of the system is that which is in the upper airway. That air contents little to no CO2. As the body continues to exhale the rush of air carries the CO2 up and out from the lungs. You will see a sharp rise in CO2 as this process continues. At the end of the breath, there is an equal amount of CO2 in the system and you will see the wave form flatten out. It is also at this point that the measurement is taken, the End-tidal CO2 value is that point when CO2 is at the maximum amount. Then you will see a sharp decline in CO2 as the next breath is taken. When the airway is obstructed or constricted, you will see definite changes to all aspects of the waveform.

19. Normal Wave Form Square box waveform ETCO2 35-45 mm Hg Management: Monitor Patient

20. Dislodged ETT Loss of waveform Loss of ETCO2 reading Management: Replace ETT

21. Esophageal Intubation Absence of waveform Absence of ETCO2 Management: Re-Intubate

22. CPR Square box waveform ETCO2 10-15 mm Hg (possibly higher) with adequate CPR Management: Change Rescuers if ETCO2 falls below 10 mm Hg

23. Obstructive Airway Shark fin waveform With or without prolonged expiratory phase Can be seen before actual attack Indicative of Bronchospasm( asthma, COPD, allergic reaction) Management: Bronchodilators (albuterol, atrovent, or Epinephrine)

24. ROSC (Return of Spontaneous Circulation) During CPR sudden increase of ETCO2 above 10-15 mm Hg Management: Check for pulse

25. Rising Baseline Patient is re-breathing CO2 Management: Check equipment for adequate oxygen flow If patient is intubated allow more time to exhale

26. Hypoventilation Prolonged waveform ETCO2 >45 mm Hg Management: Assist ventilations or intubate as needed

27. Hyperventilation Shortened waveform ETCO2 < 35 mm Hg Management: If conscious gives biofeedback. If ventilating slow ventilations If ventilations are high and ETCO2 is high consider other causes (DKA, sepsis, TCA overdose, acute renal failure, methanol ingestion, salicylate poisioning)

28. Patient breathing around ETT Angled, sloping down stroke on the waveform In adults may mean ruptured cuff or tube too small In pediatrics tube too small Management: Assess patient, Oxygenate, ventilate and possible re-intubation

29. Curare cleft Curare Cleft is when a neuromuscular blockade wears off The patient takes small breaths that causes the cleft Management: Consider neuromuscular blockade re-administration

30. Now what does all this mean to me? ETCO2 is a great tool to help monitor the patients breath to breath status. Can help recognize airway obstructions before the patient has signs of attacks Helps you control the ETCO2 of head injuries Can help to identify ROSC in cardiac arrest

31. Now we are finished Questions Comments Concerns Snide Remarks Now who was the guy that made this and bored you to death?