Capnography 101

Capnography 101
Why Should We Monitor End tidal CO2?
Continuous quantitative waveform
capnography is now recommended
for intubated patients throughout the
peri-arrest period.
- 2010 AHA guidelines
2010 AHA recommendations
 EtCO2 strongly recommended (ACLS & PALS)
during and after arrest period once airway in
place
 Assures tube remains in place
 Can be guide to effective compressions
 Can alert to ROSC
 Prognostic for outcome (<10=bad outcome)
Why Should We?
 Help determine if/when patient goes into PEA
 Help evaluate effectiveness of bronchodilator
therapy
 Used with oximetry to better evaluate patient’s
respiratory/ventilatory status
 It’s a very accurate RR monitor (patients with
obstructive apnea can still have chest movement
without moving air)
 Real time breath by breath status monitor
Why Should We?
• Recommended as standard practice by
many experts
• Increased liability if it’s not used?
– In August 2008, Chicago dental office paid
$8.5 million to settle a lawsuit over a death
during a routine root canal procedure
– Suit claimed inadequate pt monitoring
– They were using an oximeter and pt. arrested
shortly after oximeter alarmed
Why Should We?
Conclusion: No unrecognized misplaced
intubations were found in patients for whom
paramedics used continuous EtCO2 monitoring.
Failure to use continuous EtCO2 monitoring was
associated with a 23% unrecognized misplaced
intubation rate.
[Annals of Emergency Medicine 2005; 45:497-503]
How does
End-Tidal
CO2 work
and is it
accurate?
Heavy adapter
requires warm-up
then zeroing.
Oridion Microstream® Technology
• Lower sample flow rates
(50ml/min).
– More accurate in low TV &
Flow settings.
– Less likely to suck in
secretions.
• No zeroing, calibrating or
warm-up time required.
• No heavy adapter at ET Tube.
• Can monitor non-intubated
patients.
Nasal Cannula for Non-intubated Patients
Even for those mouth-breathers
Oridion Smart Capnoline®
Filter
• Delivers O2 &
samples CO2
• Works for
mouth or nosebreathers
Nasal Cannula Adapter
 Monitor patients with decreased LOC
 Overdose
 Head Injury
 Postictal
 Monitor asthma/COPD patients response
to therapy
 Monitor patients requiring large doses of
sedation or analgesics
 Great RR monitor
For Intubated Patients
Keep Sample
line facing up
The End-Tidal CO2 Waveform
LifePak 12
The Normal EtCO2 Waveform
34
35
34
Is the ETT in the Right Place?
26
12
3
Respiratory Depression?
39
40
43
Arterial vs. End Tidal CO2
The Arterial/End-Tidal CO2 Gradient
• Arterial CO2 is almost always higher than
ETCO2 (2-8 mmHg average for “healthy”
people)
Anatomic Deadspace & V/Q mismatch
Physiologic Deadspace
CO2 diffuses from
the capillary into
the alveolus to
be exhaled
Physiologic Shunting
Fluid in (or collapse
of) alveolus
interferes with
diffusion
Fluidfilled
alveolus
Physiologic Factors Effecting EtCO2
Causes of Increased PaCO2/PEtCO2 Gradient
• V/Q Mismatching
–
–
–
–
–
–
–
Pneumonia
COPD/Asthma
Atelectasis
The worse your patient’s
lung disease, the greater
P.E.
the gradient.
ARDS
Pulm Edema
Hypotension
Can I Trust The Number I Get?
• Use as a trend
– Obtain a baseline
– Gradient will change as you treat your
patient’s condition
– Don’t make decisions based solely on your
EtCO2 number
– Consider the entire clinical picture
– Analyze the capnography wave form
The “Shark fin” Waveform
40
38
35
Rebreathing CO2
 Causes: Drapes, O2 mask with too little flow,
faulty exhalation valve on ventilator, mechanical
deadspace on ventilator, inadequate exp. time
Practical Use Cases
During CPR….
Monitor response to therapy
COPD or CHF?
Help differentiate between obstructive airway
wheezing (COPD or Asthma) and CHF
Patient with Insp. Crackles & Esp. Wheezes
28 y.o. Intubated Asthma Pt
Your Capnograph is displayed below:
48
28 y.o. Intubated Asthma Pt.
48
What is this showing?
What do you want to do about it?
A. Increase ventilation rate
B. Decrease ventilation rate
C. Administer bronchodilator
D. Nothing. This technology is worthless
Hypotensive & Bradycardic Pt
• 73 y.o. female MI
•
Bradycardic & Hypotensive
•
•
Pt. intubated, being bagged
Placed EtCO2=
7
3 possibilities:
A. ETT in esophagus
B. Pt. in PEA
C. EtCO2 Monitor is worthless
62 y.o. COPD/CHF




62 year old with history of COPD & CHF
Chief complaint: Respiratory distress & cough
HR 116, RR28, BP 78/50 T 102
BS: Decreased with coarse rhonchi & exp.
Wheezes
 He’s coughing up thick green sputum
 You place an End Tidal CO2 nasal cannula that
reads 48
62 y.o. COPD/CHF
• You administer an SVN and the EtCO2
increases from 48 to 55. HR 104, RR 24
What happened?
A. Bronchospasm has worsened
B. Bronchospasm has improved
C. Oxygenation is improving
D. EtCO2 monitor is worthless
62 y.o. COPD/CHF
• Your EtCO2 monitor reads 50 when an ABG
sample is drawn at the receiving ER. The
PaCO2 from the ABG comes back 72.
• Why?
A. Air bubble in ABG sample
B. Extensive V/Q mismatching
C. EtCO2 monitor is worthless
62 y.o. COPD/CHF
• Discussion point:
• Knowing that this type of patient has a
higher than usual PaCo2/EtCO2 gradient
what number should you shoot for if
ventilating this patient?
22 y.o. trauma
• 22 y.o. intubated head trauma pt. is being
ventilated by an EMT while you start a second
IV. Once you get the IV secured you notice the
EtCO2 monitor reads 18. What’s going on?
A. Pt is being appropriately hyperventilated
B. Pt is being inappropriately hyperventilated
C. Extensive V/Q mismatching is present
D. EtCO2 monitor is worthless
22 y.o. trauma
Discussion Point:
What EtCO2 range is your goal for this
patient?
Titration IS NOT hyperventilation. Intubating a head
injured patient and using capnography gives a means to
closely monitor CO2 levels.
Keep them between 30 and 35 mmHg
Titrate EtCO2
Full arrest monitoring
You resume compressions after defibrillating a
patient and notice this waveform…..
Return of spontaneous circulation
Full arrest monitoring
You arrive at the receiving hospital ER, unload
your patient and notice this waveform…..
The ET Tube has likely become dislodged
COPD Pt-vent transport
85 y. o. female (h/o COPD) found unresponsive
at nursing home. On your arrival, she is
intubated/ventilated at CMV 20, Vt 500, Flow
40, I:E 1:2.5 (weight 66 kg)
COPD Pt-vent transport
After experimenting with different settings to decrease the
EtCO2 (which stayed in the low 90’s), pt. is now on
CMV 28, Vt 450, Flow 65 I:E 1:4
95
COPD Pt-vent transport
Causes of baseline not returning to 0
Patient is rebreathing CO2
AutoPEEP-increase exhalation time
Increased mechanical deadspace in circuit
Malfunctioning exhalation valve
Check valve for leaks during inspiration
Troubleshooting
You have intubated a trauma patient with bloody
secretions and your EtCO2 portion of the monitor is
alarming “Filter Line Blockage”
What is the problem?
A. Monitor needs calibrated.
B. CO2 sensor needs to warm-up.
C. Sensor tubing is clogged.
D. The monitor’s worthless
Troubleshooting
You connect your intubated pt. to the LifePak CO2 monitor
and XXX appears in place of the EtCO2 value.
What is the problem?
A. Monitor needs calibrated.
B. CO2 sensor needs to warm-up.
C. Sensor tubing is clogged.
D. The monitor’s worthless
Thank You For Your Attention
On-line Capnography Reference sites:
www.oridion.com
www.capnography.com
www.physio-control.com