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End Tidal CO2 and Pulse Oximetry

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End Tidal CO2 and Pulse Oximetry 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
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