CapnographyCapnography

McHenryMcHenry WesternWestern LakeLake CountyCounty EMSEMS WhatWhat isis Capnography?Capnography?

‰ Capnography is an objective measurement of exhaled CO2 levels. ‰ Capnography measures ventilation. ‰ It can be used to: ‰ Assist in confirmation of intubation. ‰ Continually monitor the ET tube placement during transport. ‰ Assess ventilation status. ‰ Assist in assessment of perfusion. ‰ Assess the effectiveness of CPR. ‰ Predict critical patient outcomes. CAPNOGRAPHYCAPNOGRAPHY

‰‰ TermTerm capnographycapnography comescomes fromfrom thethe GreekGreek workwork KAPNOS,KAPNOS, meaningmeaning smoke.smoke. ‰‰ AnesthesiaAnesthesia context:context: inspiredinspired andand expiredexpired gasesgases sampledsampled atat thethe YY connector,connector, maskmask oror nasalnasal cannula.cannula. ‰‰ GivesGives insightinsight intointo alterationsalterations inin ventilation,ventilation, cardiaccardiac output,output, distributiondistribution ofof pulmonarypulmonary bloodblood flowflow andand metabolicmetabolic activity.activity.

PulmonaryPulmonary PhysiologyPhysiology

‰‰OxygenationOxygenation vsvs VentilationVentilation ‰‰MetabolicMetabolic RespirationRespiration ‰‰TheThe EMSEMS version!version! OxygenationOxygenation –– HowHow wewe getget oxygenoxygen toto thethe tissuestissues

VentilationVentilation (the(the movementmovement ofof air)air) –– HowHow wewe getget ridrid ofof carboncarbon dioxide.dioxide. CellularCellular RespirationRespiration

Glucose (sugar) + Oxygen → Carbon dioxide + Water + Energy (as ATP ) AlveolarAlveolar RespirationRespiration CapnographyCapnography vsvs PulsePulse OximetryOximetry

CapnographyCapnography providesprovides anan immediateimmediate picturepicture ofof patientpatient condition.condition. PulsePulse oximetryoximetry isis delayed.delayed. HoldHold youryour breath.breath. CapnographyCapnography willwill showshow immediateimmediate apnea,apnea, whilewhile pulsepulse oximetryoximetry willwill showshow aa highhigh saturationsaturation forfor severalseveral minutes.minutes. CapnographyCapnography vsvs PulsePulse OximetryOximetry

GoodGood pulsepulse…….good.good Spo2Spo2…….No.No Capnography!Capnography! IntroductionIntroduction toto CapnographyCapnography SummarySummary OxygenationOxygenation andand ventilationventilation PulsePulse oximetryoximetry

–– MeasuresMeasures OO2 saturationsaturation inin bloodblood –– SlowSlow toto indicateindicate changechange inin ventilationventilation CapnographyCapnography

–– MeasuresMeasures COCO2 inin thethe thethe airwayairway –– ProvidesProvides aa breathbreath --toto--breathbreath statusstatus ofof ventilationventilation CapnographicCapnographic WaveformWaveform

CapnographCapnograph detectsdetects onlyonly COCO2 fromfrom ventilationventilation

NoNo COCO2 presentpresent duringduring inspirationinspiration –– BaselineBaseline isis normallynormally zerozero

CD

AB E Baseline CapnogramCapnogram PhasePhase II DeadDead SpaceSpace VentilationVentilation BeginningBeginning ofof exhalationexhalation

NoNo COCO2 presentpresent AirAir fromfrom trachea,trachea, posteriorposterior pharynx,pharynx, mouthmouth andand nosenose –– NoNo gasgas exchangeexchange occursoccurs therethere –– CalledCalled ““deaddead spacespace””

CapnogramCapnogram PhasePhase II BaselineBaseline

A B I Baseline

BeginningBeginning ofof exhalationexhalation CapnogramCapnogram PhasePhase IIII AscendingAscending PhasePhase

COCO2 fromfrom thethe alveolialveoli beginsbegins toto reachreach thethe upperupper airwayairway andand mixmix withwith thethe deaddead spacespace airair – Causes a rapid rise in the amount of CO2 COCO2 nownow presentpresent andand detecteddetected inin exhaledexhaled airair Alveoli CapnogramCapnogram PhasePhase IIII AscendingAscending PhasePhase

C

Ascending Phase Early Exhalation II

A B

COCO2 presentpresent andand increasingincreasing inin exhaledexhaled airair CapnogramCapnogram PhasePhase IIIIII AlveolarAlveolar PlateauPlateau

COCO2 richrich alveolaralveolar gasgas nownow constitutesconstitutes thethe majoritymajority ofof thethe exhaledexhaled airair UniformUniform concentrationconcentration ofof COCO2 fromfrom alveolialveoli toto nose/mouthnose/mouth CapnogramCapnogram PhasePhase IIIIII AlveolarAlveolar PlateauPlateau

Alveolar Plateau C D III

A B

COCO2 exhalationexhalation wavewave plateausplateaus

CapnogramCapnogram PhasePhase IIIIII EndEnd--TidalTidal

EndEnd ofof exhalationexhalation containscontains thethe highesthighest concentrationconcentration ofof COCO2

–– TheThe ““endend--tidaltidal COCO2”” –– TheThe numbernumber seenseen onon youryour monitormonitor

NormalNormal EtCOEtCO2 isis 3535--45mmHg45mmHg –– NormalNormal isis relativerelative NOTNOT absoluteabsolute

CapnogramCapnogram PhasePhase IIIIII EndEnd--TidalTidal

C D End-tidal

A B

EndEnd ofof thethe thethe wavewave ofof exhalationexhalation

CapnogramCapnogram PhasePhase IVIV DescendingDescending PhasePhase InhalationInhalation beginsbegins OxygenOxygen fillsfills airwayairway

COCO2 levellevel quicklyquickly dropsdrops toto zerozero

Alveoli CapnogramCapnogram PhasePhase IVIV DescendingDescending PhasePhase

C D Descending Phase IV Inhalation A B E

InspiratoryInspiratory downstrokedownstroke returnsreturns toto baselinebaseline

CapnographyCapnography WaveformWaveform

Normal Waveform

45

0

NormalNormal rangerange isis 3535--45mm45mm HgHg (5%(5% volvol))

Note: This is Relative NOT absolute CapnographyCapnography WaveformWaveform QuestionQuestion HowHow wouldwould youryour capnogramcapnogram changechange ifif youyou intentionallyintentionally startedstarted toto breathebreathe atat aa raterate ofof 30?30? –– FrequencyFrequency –– DurationDuration –– HeightHeight –– ShapeShape

HyperventilationHyperventilation

RRRR :: EtCOEtCO2

Normal 45

0

Hyperventilation 45

0 CapnographyCapnography WaveformWaveform QuestionQuestion HowHow wouldwould youryour capnogramcapnogram changechange ifif youyou intentionallyintentionally decreaseddecreased youryour respiratoryrespiratory raterate toto 8?8? –– FrequencyFrequency –– DurationDuration –– HeightHeight –– ShapeShape

HypoventilationHypoventilation

RR : EtCO2

Normal 45

0 Hypoventilation

45

0 CapnographyCapnography WaveformWaveform PatternsPatterns Normal 45

0 Hyperventilation 45

0 Hypoventilation

45

0 IntroductionIntroduction toto CapnographyCapnography SummarySummary CapnographicCapnographic waveformwaveform hashas fourfour phasesphases

TheThe highesthighest COCO2 concentrationconcentration isis atat thethe endend ofof alveolaralveolar plateauplateau

–– EndEnd--tidaltidal COCO2

–– NormalNormal EtCOEtCO2 rangerange isis 3535--45mmHg45mmHg SeveralSeveral conditionsconditions cancan bebe immediatelyimmediately detecteddetected withwith capnographycapnography CapnographyCapnography WaveformWaveform PatternsPatterns Normal 45

0 Hyperventilation 45

0 Hypoventilation 45

0 Bronchospasm 45

0 22 TechniquesTechniques forfor MonitoringMonitoring ETCO2ETCO2 ‰‰22 methodsmethods forfor obtainingobtaining gasgas samplesample ofof analysisanalysis ‰Mainstream ‰Sidestream ‰‰MainstreamMainstream (Flow(Flow--throughthrough oror InIn--line)line) ‰Adapter placed in the breathing circuit ‰No gas is removed from the airway ‰Adds bulk to the breathing system ‰Electronics are vulnerable to mechanical damage MainstreamMainstream AnalyzerAnalyzer

SidestreamSidestream AnalyzerAnalyzer

‰‰SidestreamSidestream (aspiration)(aspiration) ‰Aspirate gas from an airway sampling site and transport the gas sample through a tube to a remote CO2 analyzer ‰Provides ability to analyze multiple gases ‰Can use in non-intubated patients ‰Potential for disconnect or leak giving false readings ‰Withdrawals 50 to 500ml/min of gas from breathing circuit (most common is 150- 200ml/min) ‰Water vapor from circuit condenses on its way to monitor ‰A water trap is usually interposed between the sample line and analyzer to protect optical equipment SidestreamSidestream AnalyzerAnalyzer MedtronicsMedtronics AnalyzersAnalyzers ZollZoll CapnostatCapnostat SensorSensor

DisplaysDisplays DisplaysDisplays DisplaysDisplays DisplaysDisplays ColorimetricColorimetric Etco2Etco2 SensorSensor ColorimetricColorimetric Etco2Etco2 SensorSensor

Remember!!Remember!!

““GoodGood asas GoldGold”” ““YellowYellow isis SunshineSunshine”” ““YellowYellow isis YESYES!!””

““PurplePurple isis PoopPoop”” LocationLocation ofof SensorSensor

‰‰TheThe locationlocation ofof COCO2 sensorsensor greatlygreatly affectsaffects thethe measurementmeasurement

‰‰MeasurementMeasurement mademade furtherfurther fromfrom thethe alveolusalveolus cancan becomebecome mixedmixed withwith freshfresh gasgas causingcausing aa dilutiondilution ofof COCO2 valuesvalues andand roundingrounding ofof capnogramcapnogram HowHow ETCOETCO22 WorksWorks

‰‰ETCOETCO2 monitoringmonitoring determinesdetermines thethe COCO2 concentrationconcentration ofof exhaledexhaled gasgas ‰‰PhotoPhoto detectordetector measuresmeasures thethe amountamount ofof infraredinfrared lightlight absorbedabsorbed byby airwayairway gasgas duringduring inspirationinspiration andand expirationexpiration ‰CO2 molecules absorb specific wavelengths of infrared light energy ‰Light absorption increases directly with CO2 concentration ‰‰AA monitormonitor convertsconverts thisthis datadata toto aa COCO2 valuevalue andand aa correspondingcorresponding waveformwaveform (capnogram)(capnogram) CapnographyCapnography

‰‰ExpressedExpressed inin numericalnumerical valuevalue inin mmmm Hg.Hg. ‰‰NormalNormal valuevalue betweenbetween ofof 3535 –– 4545 mmmm Hg.Hg. ‰‰ForFor allall ageage groups.groups. CapnographyCapnography

‰‰IfIf thethe numbernumber isis >> 45,45, thethe CO2CO2 isis high.high. ‰‰HypoventilationHypoventilation ‰‰RespiratoryRespiratory AcidosisAcidosis ‰‰IfIf thethe numbernumber isis << 35,35, thethe CO2CO2 isis low.low. ‰‰HyperventilationHyperventilation ‰‰RespiratoryRespiratory Alkalosis.Alkalosis. InterpretingInterpreting CapnographyCapnography

‰‰CapnographyCapnography (Numerical)(Numerical) ‰‰CapnogramCapnogram (Visual)(Visual) ‰‰ROSCROSC ““AA 20052005 studystudy comparingcomparing fieldfield intubationsintubations thatthat usedused continuouscontinuous capnographycapnography toto confirmconfirm intubationsintubations vs.vs. nonnon--useuse showedshowed zerozero unrecognizedunrecognized misplacedmisplaced intubationsintubations inin thethe monitoringmonitoring groupgroup vs.vs. 23%23% misplacedmisplaced tubestubes inin thethe unmonitoredunmonitored group.group.”” ‰ Annals of Emergency Medicine, May 2005 ConfirmConfirm ETET TubeTube PlacementPlacement

CapnographyCapnography providesprovides –– ObjectiveObjective confirmationconfirmation ofof correctcorrect tubetube placementplacement –– DocumentationDocumentation ofof correctcorrect placementplacement

ConfirmConfirm ETET TubeTube PlacementPlacement

45

0 ConfirmConfirm ETET TubeTube PlacementPlacement

ETET tubetube placementplacement inin esophagusesophagus maymay brieflybriefly detectdetect COCO2 –– FollowingFollowing carbonatedcarbonated beveragebeverage ingestioningestion –– WhenWhen gastricgastric distentiondistention waswas producedproduced byby mouthmouth toto mouthmouth ventilationventilation

ResidualResidual COCO2 willwill bebe washedwashed outout afterafter 66 positivepositive pressurepressure breathsbreaths DetectDetect ETET TubeTube DisplacementDisplacement

TraditionalTraditional methodsmethods ofof monitoringmonitoring tubetube positionposition –– PeriodicPeriodic auscultationauscultation ofof breathbreath soundssounds –– GastricGastric distentiondistention –– WorseningWorsening ofof patientpatient’’ss colorcolor Late sign of tube displacement

TheseThese methodsmethods areare subjectivesubjective andand unreliableunreliable——andand delayeddelayed

• Connections on sample tubing loose IncreasingIncreasing ETCOETCO22

‰‰HypoventilationHypoventilation (decrease(decrease RRRR oror TV)TV) ‰‰IncreaseIncrease inin metabolicmetabolic raterate ‰‰IncreaseIncrease inin bodybody temperaturetemperature ‰‰SuddenSudden increaseincrease inin bloodblood pressurepressure DecreasingDecreasing ETCOETCO22

‰ Gradual ‰ Hyperventilation (increase RR or TV) ‰ Decrease in metabolic rate ‰ Decrease in body temperature ‰ Rapid ‰ Embolism (air or thrombus) ‰ Sudden hypotension ‰ Circulatory arrest IncreaseIncrease inin InspiredInspired CO2CO2 (Rise(Rise inin Baseline)Baseline)

‰‰ CO2CO2 absorbentabsorbent exhaustedexhausted ‰‰ FaultyFaulty expiratoryexpiratory valvevalve ‰‰ CalibrationCalibration errorerror inin monitormonitor ‰‰ WaterWater inin analyzeranalyzer LossLoss ofof PlateauPlateau // SlopingSloping ofof ETCO2ETCO2 WaveformWaveform

‰‰ObstructionObstruction ofof expirationexpiration (asthma,(asthma, COPD,COPD, bronchospasm)bronchospasm) ‰‰NoNo plateauplateau isis reachedreached priorprior toto nextnext inspirationinspiration ‰‰KinkedKinked endotrachealendotracheal tubetube CleftCleft inin PhasePhase IIIIII ofof WaveformWaveform

‰‰ PatientPatient isis inspiringinspiring duringduring exhalationexhalation phasephase ofof mechanicalmechanical ventilationventilation ‰‰ PaCO2PaCO2 increasingincreasing causecause spontaneousspontaneous respirationrespiration ‰‰ IncreasingIncreasing painpain CardiogenicCardiogenic OscillationsOscillations

‰‰ CausedCaused byby beatingbeating ofof heartheart againstagainst lungslungs DecisionDecision toto CeaseCease ResuscitationResuscitation

CapnographyCapnography providesprovides anotheranother objectiveobjective datadata pointpoint inin makingmaking aa difficultdifficult decisiondecision

25 0 TheThe NonNon--intubatedintubated PatientPatient CC:CC: ““troubletrouble breathingbreathing””

a?? PEPE hmhma EmEmpph ?? AAstst hyysseemmaa?? Bronchitis?Bronchitis? PPnneeuummoonniiaa??

scchheemmiiaa?? CCaarrddiiaacc iis CCHHFF?? TheThe NonNon--intubatedintubated PatientPatient CC:CC: ““troubletrouble breathingbreathing””

IdentifyingIdentifying thethe problemproblem andand underlyingunderlying pathogenesispathogenesis AssessingAssessing thethe patientpatient’’ss statusstatus AnticipatingAnticipating suddensudden changeschanges TheThe NonNon--intubatedintubated PatientPatient CapnographyCapnography ApplicationsApplications IdentifyIdentify andand monitormonitor bronchospasmbronchospasm –– AsthmaAsthma –– COPDCOPD AssessAssess andand monitormonitor –– HypoventilationHypoventilation statesstates –– HyperventilationHyperventilation –– LowLow --perfusionperfusion statesstates

TheThe NonNon--intubatedintubated PatientPatient CapnographyCapnography ApplicationsApplications CapnographyCapnography reflectsreflects changeschanges inin –– VentilationVentilation -- movementmovement ofof gasesgases inin andand outout ofof thethe lungslungs –– DiffusionDiffusion -- exchangeexchange ofof gasesgases betweenbetween thethe airair --filledfilled alveolialveoli andand thethe pulmonarypulmonary circulationcirculation –– PerfusionPerfusion -- circulationcirculation ofof bloodblood throughthrough thethe arterialarterial andand venousvenous systemssystems TheThe NonNon--intubatedintubated PatientPatient CapnographyCapnography ApplicationsApplications VentilationVentilation Airway obstruction – Smooth muscle contraction – Bronchospasm – Airway narrowing – Uneven emptying of alveoli – Mucous plugs

TheThe NonNon--intubatedintubated PatientPatient CapnographyCapnography ApplicationsApplications DiffusionDiffusion Airway inflammation Retained secretions Fibrosis Decreased compliance of alveoli walls Chronic airway modeling (COPD) Reversible airway disease (Asthma) CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions

AirAir trappedtrapped duedue toto irregularitiesirregularities inin airwaysairways UnevenUneven emptyingemptying ofof alveolaralveolar gasgas

–– DilutesDilutes exhaledexhaled COCO2

–– SlowerSlower riserise inin COCO2 concentrationconcentration duringduring Alveoli exhalationexhalation CapnographyCapnography inin BronchospasticBronchospastic DiseasesDiseases

UnevenUneven emptyingemptying ofof C D alveolaralveolar gasgas altersalters II emptyingemptying onon exhalationexhalation A B E ProducesProduces changeschanges inin ascendingascending phasephase (II)(II) III withwith lossloss ofof thethe sharpsharp upslopeupslope AltersAlters alveolaralveolar plateauplateau (III)(III) producingproducing aa ““sharkshark finfin”” CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions CapnogramCapnogram ofof AsthmaAsthma

Normal

Bronchospasm

Changes in CO2 seen with increasing bronchospasm 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 CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions AsthmaAsthma CaseCase ScenarioScenario 1616 yearyear oldold femalefemale C/OC/O ““havinghaving difficultydifficulty breathingbreathing”” VisibleVisible distressdistress HistoryHistory ofof asthma,asthma, physicalphysical exertion,exertion, ““aa coldcold”” PatientPatient hashas usedused herher ““pufferpuffer”” 88 timestimes overover thethe lastlast twotwo hourshours PulsePulse 126,126, BPBP 148/86,148/86, RRRR 3434 WheezingWheezing notednoted onon expirationexpiration CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions AsthmaAsthma CaseCase ScenarioScenario

InitialInitial

AfterAfter therapytherapy CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions PathologyPathology ofof COPDCOPD ProgressiveProgressive PartiallyPartially reversiblereversible AirwaysAirways obstructedobstructed –– HyperplasiaHyperplasia ofof mucousmucous glandsglands andand smoothsmooth musclemuscle –– ExcessExcess mucousmucous productionproduction –– SomeSome hyperhyper--responsivenessresponsiveness

Hyperplasia: An abnormal increase in the number of cells in an organ or a tissue with consequent enlargement. CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions PathologyPathology ofof COPDCOPD SmallSmall airwaysairways –– MainMain sitessites ofof airwayairway obstructionobstruction –– InflammationInflammation –– FibrosisFibrosis andand narrowingnarrowing –– ChronicChronic damagedamage toto alveolialveoli –– HyperHyper --expansionexpansion duedue toto airair trappingtrapping –– ImpairedImpaired gasgas exchangeexchange Alveoli

CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions CapnographyCapnography inin COPDCOPD

ArterialArterial COCO2 inin COPDCOPD

–– PaCOPaCO2 increasesincreases asas diseasedisease progressesprogresses –– RequiresRequires frequentfrequent arterialarterial puncturespunctures forfor ABGsABGs CorrelatingCorrelating capnographcapnograph toto patientpatient statusstatus –– AscendingAscending phasephase andand plateauplateau areare alteredaltered byby unevenuneven emptyingemptying ofof gasesgases

– PaC02 is the (P)artial pressure of (a)rterial (C02) in the human body. In other words, it is a calculation of the amount of carbon dioxide present in the artery of a person. The normal level is 35 -45 mmHg. An amount greater than 45 is dangerous, even life-threatening. CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions COPDCOPD CaseCase ScenarioScenario 7272 yearyear oldold malemale C/OC/O difficultydifficulty breathingbreathing HistoryHistory ofof CAD,CAD, CHF,CHF, smokingsmoking andand COPDCOPD ProductiveProductive cough,cough, recentrecent respiratoryrespiratory infectioninfection PulsePulse 90,90, BPBP 158/82158/82 RRRR 2727 CapnographyCapnography inin BronchospasticBronchospastic ConditionsConditions COPDCOPD CaseCase ScenarioScenario

45 Initial Capnogram A 0

Initial Capnogram B 45 0 CapnographyCapnography inin CHFCHF CaseCase ScenarioScenario 8888 yearyear oldold malemale C/O:C/O: ShortShort ofof breathbreath H/O:H/O: MIMI XX 2,2, onon oxygenoxygen atat 22 L/mL/m PulsePulse 66,66, BPBP 114/76/p,114/76/p, RRRR 3636 laboredlabored andand shallow,shallow, skinskin coolcool andand diaphoretic,diaphoretic, 2+2+ pedalpedal edemaedema

InitialInitial SpOSpO2 69%;69%; EtCOEtCO2 17mmHG17mmHG

CapnographyCapnography inin CHFCHF CaseCase ScenarioScenario PlacedPlaced onon nonnon--rebreatherrebreather maskmask withwith 100%100% oxygenoxygen atat 1515 L/m;L/m; IVIV FentanylFentanyl andand SLSL NitroglycerinNitroglycerin asas perper locallocal protocolprotocol TenTen minutesminutes afterafter treatment:treatment:

SpOSpO2 69%69% 99%99% EtCOEtCO2 17mmHG17mmHG 3535 mmHGmmHG

4 5 3 5 Time condensed 2 5 to show changes 0 CapnographyCapnography inin HypoventilationHypoventilation StatesStates AlteredAltered mentalmental statusstatus – Sedation – Alcohol intoxication – Drug Ingestion – Stroke – CNS infections – Head injury AbnormalAbnormal breathingbreathing

COCO2 retentionretention

– EtCO 2 >50mmHg

CapnographyCapnography inin HypoventilationHypoventilation StatesStates

45

0 Time condensed; actual rate is slower

EtCOEtCO2 isis aboveabove 50mmHG50mmHG BoxBox--likelike waveformwaveform shapeshape isis unchangedunchanged CapnographyCapnography inin HypoventilationHypoventilation StatesStates CaseCase ScenarioScenario ObserverObserver calledcalled 911911 7676 yearyear oldold malemale sleepingsleeping andand unresponsiveunresponsive onon sidewalk,sidewalk, ““gashgash onon hishis headhead”” KnownKnown historyhistory ofof hypertension,hypertension, EtOHEtOH intoxicationintoxication

PulsePulse 100,100, BPBP 188/82,188/82, RRRR 10,10, SpOSpO2 96%96% onon roomroom airair CapnographyCapnography inin HypoventilationHypoventilation StatesStates HypoventilationHypoventilation

65 55 45 35 25 0

Time condensed; actual rate is slower CapnographyCapnography inin HypoventilationHypoventilation StatesStates HypoventilationHypoventilation

45

0 HypoventilationHypoventilation inin shallowshallow breathingbreathing CapnographyCapnography inin LowLow PerfusionPerfusion

CapnographyCapnography reflectsreflects changeschanges inin PerfusionPerfusion –– PulmonaryPulmonary bloodblood flowflow –– SystemicSystemic perfusionperfusion –– CardiacCardiac outputoutput

CapnographyCapnography inin LowLow PerfusionPerfusion CaseCase ScenarioScenario

5757 yearyear oldold malemale MotorMotor vehiclevehicle crashcrash withwith injuryinjury toto chestchest HistoryHistory ofof atrialatrial fib,fib, anticoagulantanticoagulant UnresponsiveUnresponsive PulsePulse 100100 irregular,irregular, BPBP 88/p88/p IntubatedIntubated onon scenescene CapnographyCapnography inin LowLow PerfusionPerfusion CaseCase ScenarioScenario

45 35 25 0

Low EtCO2 seen in low cardiac output

Ventilation controlled CapnographyCapnography inin PulmonaryPulmonary EmbolusEmbolus CaseCase ScenarioScenario

7272 yearyear oldold femalefemale CC:CC: SharpSharp chestchest pain,pain, shortshort ofof breathbreath History:History: LegsLegs swollenswollen andand painpain inin rightright calfcalf followingfollowing flightflight fromfrom AlaskaAlaska PulsePulse 108108 andand regular,regular, RRRR 22,22, BPBP

158/88158/88 SpOSpO2 95%95%

CapnographyCapnography inin PulmonaryPulmonary EmbolusEmbolus CaseCase ScenarioScenario

45 35 25 0

Strong radial pulse

Low EtCO2 seen in decreased alveolar perfusion CapnographyCapnography inin SeizingSeizing PatientsPatients

OnlyOnly accurateaccurate andand reliablereliable modalitymodality forfor assessmentassessment ofof ventilatoryventilatory statusstatus HelpsHelps toto distinguishdistinguish betweenbetween CentralCentral apneaapnea IneffectiveIneffective ventilationsventilations EffectiveEffective ventilationsventilations CapnographyCapnography inin DKADKA

TheThe moremore acidoticacidotic thethe patient,patient, thethe lowerlower thethe HCO3HCO3 andand thethe higherhigher thethe respiratoryrespiratory raterate andand lowerlower thethe EtCO2EtCO2

HelpsHelps isis distinguishingdistinguishing DKADKA vsvs HHNKHHNK

CapnographyCapnography useuse withwith aa HeadHead InjuredInjured PatientPatient

HelpsHelps toto avoidavoid hyperventilationhyperventilation

TargetTarget valuevalue ofof 35mmHG35mmHG isis recommendedrecommended TheThe NonNon--intubatedintubated PatientPatient SummarySummary IdentifyIdentify andand monitormonitor bronchospasmbronchospasm –– AsthmaAsthma –– COPDCOPD AssessAssess andand monitormonitor –– HypoventilationHypoventilation statesstates –– HyperventilationHyperventilation –– LowLow perfusionperfusion –– ManyMany othersothers nownow beingbeing reportedreported

CapnographyCapnography FactFact oror Myth?Myth?

Capnography will detect a tracheal intubation, every time. MYTH!MYTH!

Carbonated Beverages!

‰‰DonDon’’tt forgetforget youryour timetime testedtested assessments.assessments. ‰‰WillWill notnot detectdetect aa rightright mainmain stemstem intubation.intubation. CapnographyCapnography FactFact oror Myth?Myth?

I saw the tube go through the cords, and my capnometer reads zero. I must have missed. MYTH!MYTH!

‰‰NEVERNEVER forgetforget youryour timetime testedtested assessments!assessments! ‰‰WhatWhat ifif thethe bodybody isis notnot makingmaking CO2?CO2? ‰‰CellularCellular DeathDeath ‰‰ExtremeExtreme HypothermiaHypothermia ‰‰ExtendedExtended downdown timetime withoutwithout CPRCPR CapnographyCapnography FactFact oror Myth?Myth?

Capnography is just another confusing thing I don’t need to know about and doesn’t need to be on the ambulance! MYTH!MYTH!

‰‰AirwayAirway ManagementManagement posesposes thethe 22nd highesthighest riskrisk ofof liabilityliability forfor EMS.EMS. ‰‰WhatWhat isis thethe riskiest?riskiest? ‰‰ItsIts easyeasy toto use!use! ‰‰JustJust looklook forfor thethe littlelittle boxes!boxes! ‰‰MuchMuch betterbetter indicatorindicator thanthan pulsepulse oximetry.oximetry. ‰‰PulsePulse oximetryoximetry isis oxygenationoxygenation…….ETC02.ETC02 isis ventilation!ventilation! ReviewReview

The normal value of ETCO2 and for what ages? ReviewReview

35 – 45 mm HG for all ages

ReviewReview

The clear plastic piece is disposable or reusable? ReviewReview

DISPOSABLE! ReviewReview

Can capnography be used on the King Tube? ReviewReview

YES! ReviewReview

HowHow longlong cancan CapnographyCapnography bebe used?used? ReviewReview

CapnographyCapnography isis usedused asas longlong asas EMSEMS feelsfeels itit providesprovides benefitbenefit forfor thethe patient.patient. ReviewReview

DoesDoes CapnographyCapnography hurt?hurt? ReviewReview

TheThe devicedevice isis harmlessharmless andand causescauses nono painpain oror discomfortdiscomfort toto thethe patient.patient. CaseCase StudyStudy

YouYou havehave oneone ofof youryour fellowfellow crewcrew membersmembers ventilatingventilating aa cardiaccardiac arrestarrest victim.victim. CapnographyCapnography hashas beenbeen appliedapplied afterafter thethe tubetube (ET(ET oror King)King) hashas beenbeen insertedinserted andand aa EtCo2EtCo2 ofof 1919 hashas beenbeen found.found. WhatWhat shouldshould youyou dodo next?next? CaseCase StudyStudy

YourYour crewcrew wouldwould wantwant toto slowslow thethe respiratoryrespiratory raterate toto bringbring thethe EtCo2EtCo2 upup toto aa normalnormal levellevel ofof 3535 –– 45.45. ContinueContinue toto monitormonitor thethe patientspatients Spo2Spo2 andand EtCo2EtCo2 readingsreadings duringduring transport.transport. Question?Question?

YouYou havehave oneone ofof youryour crewcrew ventilatingventilating aa TraumaticTraumatic HeadHead InjuryInjury patientpatient andand thethe initialinitial EtCo2EtCo2 readingreading thatthat youyou obtainobtain isis 49.49. ThisThis readingreading indicatesindicates thatthat youyou willwill needneed to:to: – A) Slow the respiratory rate – B) Increase the respiratory rate – C) Does not matter what this is. We need 100% on the Sp02 – D) Increase the flow of 02 into the BVM

YouYou havehave oneone ofof youryour crewcrew ventilatingventilating aa TraumaticTraumatic HeadHead InjuryInjury patientpatient andand thethe initialinitial EtCo2EtCo2 readingreading thatthat youyou obtainobtain isis 49.49. ThisThis readingreading indicatesindicates thatthat youyou willwill needneed to:to: – A) Slow the respiratory rate – B) Increase the respiratory rate – C) Does not matter what this is. We need 100% on the Sp02 – D) Increase the flow of 02 into the BVM

CaseCase StudyStudy

YouYou areare treatingtreating aa fullfull arrestarrest andand havehave hookedhooked upup youryour capnographycapnography toto youryour advancedadvanced airway.airway. YouYou havehave aa readingreading ofof 00 andand nono wavewave form.form. IsIs thisthis reasonreason toto removeremove youryour airway?airway? WhatWhat shouldshould youyou dodo…….. CaseCase StudyStudy

ListenListen toto lunglung soundssounds LookLook forfor symmetricalsymmetrical chestchest riserise VaporVapor inin thethe tubetube ChangeChange inin patientpatient colorcolor AbsentAbsent abdominalabdominal soundssounds ReRe--visualizevisualize placementplacement ofof tubetube EIDDEIDD CaseCase StudyStudy

66 yearyear oldold hashas overdosedoverdosed onon parentsparents painpain medications.medications. AgonalAgonal respirationsrespirations ofof 77 werewere notednoted onon youryour arrival.arrival. YouYou havehave insertedinserted anan appropriateappropriate sizedsized KingKing TubeTube andand youyou seesee thethe followingfollowing wavewave form.form.

LeakingLeaking oror inadequateinadequate inflationinflation ofof airwayairway cuffcuff IsIs thisthis colorcolor goodgood oror bad?bad? PurplePurple isis Poop!Poop! SourcesSources

‰ Paramedic Care: Principles and Practice. Bledsoe, Bryan E. Brady Publishers. 2003. ‰ Emergency Care. 10th Edition. Limmer, Daniel. Brady Publishers. 2005. ‰ Capnography for Paramedics. http://emscapnography.blogspot.com ‰ Capnography in EMS. Kraus, Baruch EdM. JEMS. January 2003. ‰ Medtronic ERS SpecialSpecial ThanksThanks Staci Rivas, CRNA, MSN KU Nurse Anesthesia Department Jeff Lesniak, EMT-P Woodstock Fire Rescue District & Medtronics Corporation for the use of their materials in this presentation NowNow letlet’’ss play!!play!!

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