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Capnography : The Window Into Your Patient

Capnography : The Window Into Your Patient. Talk Code 682. Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic Surgical ICUs – Albany Medical Ctr EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering Magazine

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Capnography : The Window Into Your Patient

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  1. Capnography:The Window Into Your Patient Talk Code 682 Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic Surgical ICUs – Albany Medical Ctr EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering Magazine EMS Director – New York State Association of Fire Chiefs

  2. mikemcevoy.com

  3. SpO2 versus EtCO2

  4. Physiology Oxygen lungs  alveoli  blood Oxygen breath CO2 muscles + organs lungs Oxygen CO2 cells energy blood Oxygen + Glucose CO2

  5. Contrasting Pulse Ox with Capnography Pulse oximetry measure oxygen going OUT from the heart Capnography measures what is coming BACK from the periphery Two Different Concepts

  6. Oxygenation (Pulse Ox) O2 for metabolism SpO2 measures % of O2 in RBCs Reflects changes in oxygenation within 5 minutes Ventilation (Capnography) CO2 from metabolism EtCO2 measures exhaled CO2 at point of exit Reflects changes in ventilation within 10 seconds Oxygenation and Ventilation

  7. What is Capnography? • “Capnos” = Greek for smoke • From the “fire of life”  metabolism • CO2 is the waste product of metabolism • Carbon Dioxide is a compound molecule • 2 oxygen + 1 carbon • Odorless; heavier than atmospheric air • Green plants scavenge excess CO2 • 0.03% concentration in room air • Resting adults produce 2.5 mg/kg/min

  8. Capnography Basics Carbon Dioxide (CO2) • Produced by all living cells • Diffused into the bloodstream • Transported to the lungs • Perfused into the alveoli • Exhaled through the airway

  9. Measuring Exhaled CO2 Colorimetric Capnometry Capnography

  10. Measuring Exhaled CO2 Colorimetric Capnometry Capnography

  11. Measuring Exhaled CO2 Colorimetric Capnometry Capnography

  12. Waveform Capnography • Available for spontaneously breathing and for intubated patients

  13. Capnography is the window INTO the patient

  14. Normal Capnography Waveform • Normal range is 35-45 mmHg • Height = total CO2 • Length = time/rate

  15. Capnogram Phases Inhale D C End-tidal A B E

  16. Capnogram Phases Exhale (dead space) D C End-tidal A B E

  17. Capnogram Phases Exhale (rapid rise) D C End-tidal A B E

  18. Capnogram Phases Exhale (plateau) D C End-tidal A B E

  19. Capnogram Phases End of the wave of exhalation D C End-tidal A B E

  20. How Capnography Can Help • Airway • Breathing • Circulation

  21. What Happened? The endotracheal tube became dislodged!

  22. Apnea • Airway Obstruction • Displaced airway (esophageal) • Airway or vent disconnection • Vent malfunction • Cardiac Arrest

  23. What about the Pulse Ox? Sp02 98

  24. Normal: Esophageal tube:

  25. Breathing

  26. Capnography Waveforms Normal Hyperventilation 45 0 Hypoventilation 45 0

  27. Rebreathing • Possible causes: • Faulty expiratory valve • Inadequate inspiratory flow • Breath stacking (wrong mode, undersedated) • Malfunction of CO2 absorber system

  28. What’s the SHAPE?

  29. The Shark Fin • Possible causes: • Partially kinked or occluded artificial airway • Presence of foreign body in the airway • Obstruction in expiratory limb of vent circuit • Bronchospasm

  30. Bronchospasm (asthma) Mild Moderate

  31. Marked bronchospasm

  32. Airway:Leaking tube cuff

  33. “Curare Cleft” • Appears when NMBAs begin to wear off • Depth of cleft inversely proportional to degree of blockade

  34. Circulation The lungs and the heart are inextricably tied together

  35. CO2 clearance reflects perfusion In other words: CO2 production is largely dependent on oxygen consumption!

  36. Cardiac Arrest Little O2delivery or consumption Little CO2production or venous return …Little Need to Ventilate!

  37. Use EtCO2 as guide to avoid overventilation during resuscitation: < 20: slooooow down > 40: increase breaths Increased CO2 may = ROSC

  38. Decision to Call the Code • 120 prehospital patients in nontraumatic cardiac arrest • EtCO2 had 90% sensitivity in predicting ROSC • Maximal level of <10mmHg during the first 20 minutes after intubation was never associated with ROSC Source: Canitneau J. P. 1996. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole, Critical Care Medicine 24: 791-796

  39. What about other shock states? “These data suggest that respiratory rate alone cannot be used to predict measured capnography levels.” R. Fowler, P. Pepe September, 2007

  40. ? Wide a-A gradient: EtCO2 = 11 PaCO2 = 28

  41. Something is blocking gas exchange: • Pulmonary embolism • PNA, ALI or ARDS • Shunting • Low CO state • Very low HCO3

  42. Test: your patient is seizing

  43. Thank You ! Talk Code: 682

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