Applying Capnography in the Clinical Setting

Applying Capnography in the
Clinical Setting
Paula Burke Brockenbrough BSEd,
CRT
NeuroCritical Care Respiratory Therapist, VCUHS NSICU and
MDA/ALS Clinic
EVERY BREATH
YOU TAKE I’LL BE
WATCHING YOU
Sting
Oxygenation and Ventilation
• Oxygenation
– Oxygen for
metabolism
– SpO2 measures
% of O2 in RBC
– Reflects change in
oxygenation within
5 minutes
• Ventilation
– Carbon dioxide
from metabolism
– EtCO2 measures
exhaled CO2 at
point of exit
– Reflects change in
ventilation within
10 seconds
I want all my patients to have a pulse
ox on….
SHOULD YOU BELIEVE YOUR
GREAT SATS???
• Reflects changes in
Oxygenation within 5
MINUTES!!!
• NOT ACCURATE when sat
is > than70
• Grossly inaccurate when a
finger probe is placed on
the ear or forehead
• Inaccurate readings can occur if
patient is:
–
–
–
–
–
–
–
–
–
Hypotensive
Hypovolemic
Hypothermic
Has Sickling red cells
Wears Nail polish, esp blue, beige,
purple and white
Treated w vasoactive drugs
Has Cardiac Failure/arrythmias
Has PVD
Under bright lights
Wouldn’t You Rather Have an ETCO2
Monitor?
• First hypoventilation then
apnea, then comes hypoxia
• Capnography can recognize
hypoventilation, airway
obstruction or apnea,
• Enables caregiver to take
corrective measures prior to
critical events
Results of National Audit Project to Identify and
Study Serious Airway Complications
•
• 310 NHS hospitals:
anesthesia, ICU&ED
• 80% intubations
performed by anesthesia
•
or critical care MDS
• Events: Pts who died, had
brain damage or needed a•
surgical airway
emergently or had
prolonged ICU stay
20% of reported critical
events came from ICU but
counted for 50% of deaths in
the study
O.R.: 130 cases 14% led to
death or brain damage
Occurred after hours, mostly
to junior residents
National Audit Project to Identify and Study
Serious Airway Complications
• More males then females,
young, multi organ failure,
more than 60% FiO2 needs at
time of event
• 50% were obese
• Obese pts in ICU worse
outcome
• Failure to use ETCO2 caused
74% of death and brain
damage
Results of National Audit Project to Identify and
Study Serious Airway Complications
• Problems with intubations:
– Failed or delayed or misplaced
intubations
• Loss of airway in pt
dependent on it, most were
tracheostomies
• Almost 50% were misplaced
trach tubes
• 36 intensive care
events…only 1/4 of true
events were captured…
Results of National Audit Project to Identify and
Study Serious Airway Complications
•
•
•
•
AT RISK:
Fresh trachs
In for 3-4 days
Adjustable phalange changed
to speaking trach. Trach
displaced with turns,
sedation hold
• Delay in diagnosis of
displacement, few had
ETCO2
Physiological Factors Affecting ETCO2
Levels
CAPNOGRAPHY
• MUST USE IN TRANSPORT / ER/ICU/ CPR
• PCO2 is usually 2- 5 mmHg higher than ETCO2
• Significant difference in PCO2 to ETCO2 if:
–
–
–
–
multiple trauma
severe chest trauma
hypotension, and heavy blood loss.
due to increased dead space secondary to decreased
alveolar perfusion or disruptions in pulmonary blood flow
USE OF ETCO2 in INTUBATED PATIENTS
• Verify and document ETT or
tracheostomy placement
• Detect changes in ETT during
traveling or patient position
changes immediately
• Detect changes in
tracheostomy placement
immediately
• Adjust rate and/or tidal
volume in head injury
patients
• Identify obstruction in ETT
or Trach
• Provides optimal ventilation pre
hospital
• Predictive of outcome in trauma
resuscitation
• Assess effectiveness of chest
compressions
• Earliest indication of ROSC
• Helps predict whether CPR will
have been successful in
resuscitation
Only capnography provides Numerical as well as
Continuous graphic waveform for immediate visual
recognition of ETT placement. ACLS Standard
45
0
ACLS POST INTUBATION
GUIDELINES
• Colormetric ETCO2 devices
should only be used when
waveform capnography is not
available.
• Complications come during
ongoing care of patient not just
one brief picture….DO YOU
TAKE OFF PULSE OX AFTER ONE
LOOK AT SATS ???
Traveling with the Intubated Patient
• ALL intubated patients should
be transported on ventilators
with pulse oximetry and ETCO2
• Mechanical Ventilation and
ETCO2
– Provides strict control of PCO2
– Prevents episodes of CBF
fluctuations in TBI
– Maintains ventilator settings
that ABG’s were obtained on
– Ability to maintain set PaO2
Detect ET Tube Displacement During
Transport, Position Changes, Taping, XRay ETC…..
• Immediately detects
ET tube or trach tube
displacement
45
0
ETT or trach tube Dislodgement
ETCO2 Waveform of Obstruction
Is there a foreign body in the airway?
Is there a partial or complete obstruction in the airway?
Did the expiratory side of the vent circuit get kinked?
Is the patient starting to get bronchospastic?
ETCO2 IS A FUNDAMENTAL COMPONENT
OF CARE OF THE TBI PATIENT
•
•
•
•
Hyperventilation causes
hypocapnia
Hypocapnia causes
vasoconstriction and decreases
CBF
Hypocapnia reduces cerebral
blood volume and lowers ICP
Hyperventilation associated with
cerebral ischemia
Muizelaar vasoconstriction
effects last >24 hours
Optimize Ventilation with ETCO2
• Use capnography to titrate EtCO2 levels
in patients sensitive to fluctuations
• Patients with suspected increased intracranial pressure (ICP)
– Head trauma
• Critically important in preventing low cerebral blood flow. First
24 hours post injury TBI have 50% less blood flow than normal
patients.
• Low ETCO2 shown to increase mortality and disability (ETCO2
<20mmHg, pre hospital)
– Stroke
– Brain tumors
Sudden Loss of Waveform
•
Fully obstructed Airway
•
Esophageal Intubation
•
Airway dislodged
•
Paralytics given to spontaneously breathing patient
•
Ventilator circuit disconnect
•
Ventilator failure
•
Apnea
•
Cardiac Arrest
Capnography in
Cardiopulmonary Resuscitation
• Assess chest compressions
• Early detection
of ROSC
• Objective data for decision to
cease resuscitation
CPR: Assess Chest Compressions
• Use waveforms from EtCO2 to
depth/rate/
force of chest compressions
during CPR
45
0
CPR: Detect ROSC
• Briefly stop CPR and check for
organized rhythm on ECG monitor
• ETCO2 can detect presence of
pulmonary blood flow even in
absence of major pulses
45
0
ETCO2 & Cardiac Resuscitation
• Non-survivors
– Average ETCO2:
4-10 mmHg
• Survivors (to discharge)
– Average ETCO2:
>30 mmHg
ETCO2 and Trauma Resuscitation
• 191 patients J Trauma study 2004
ETCO2< 10 mm Hg only 5%
survived to discharge
Use of ETCO2 In Non Intubated Patients
• Identify and monitor
bronchospasm
– Asthma
• Can be used to Assess
and monitor
– Hypoventilation states
– Hyperventilation
• Weaning, CHF, exercise
– Low-perfusion states
• CHF
Capnography in
Bronchospastic Diseases
• Uneven emptying of
alveolar gas alters
emptying on exhalation
• Produces changes in
ascending phase (II)
with loss of the sharp
upslope
• Alters alveolar plateau
(III) producing a “shark fin”
C
A
B
D
II
E
III
Hypoventilation
45
0
Hypoventilation
• Neuromuscular diseases
monitoring
– ALS,MD, MG
• Titrating optimal settings
on non invasive
ventilation
• SCI patients
• Obstructive sleep apnea
• Procedures
• PCA infusions
SUMMARY
• Capnography is standard of care for approx 15 years
in O.R. equipment is in hospitals already
• Respiratory Therapists and Nurses should have it set
up in the ER or ICU room ready to go
– Non-Invasive, Quick set up
• Capnography use in hospitals, and in the field, is a
patient safety issue
– It has been shown to prevent critical events
SUMMARY
• Capnography should be used on all intubations
– ACLS guidelines mandate
• Capnography should be used on intubated patients in
pre hospital / ER /ICU / transport
• Capnography should be used on trach patients:
– spontaneous breathing patient had marked de sats then arrest
• Capnography should be used to confirm trach changes
• Capnography should be used in code situations
• Capnography should be used in conscious sedation
procedures and PCA infusions
Tips to improve accuracy
• Position monitor higher than patient.
– Water and secretions then will not drain into
monitor and block the filter
• Position sampling line upright
– Water, patient secretions and neb rain out can
contaminate the sampling tube and increase
resistance in the tubing
References
• Cook, T, et al Major complications of airway management in the
UK: results of the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society. Part 2:
intensive care and emergency., Br Journal of Anes.
2011;106[5]:632-642
• Bhavani Shankar K. A method to prevent occlusion of CO2
sampling tubes. Can J Anaesth 1997:44.
• C. W. Perry & B. J. Phillips : GSW To The Face: "Hunting Camp" .
The Internet Journal of Rescue and Disaster Medicine. 2001
Volume 2 Number 2
• HS Cicek, et al. Effect of nail polish and henna on oxygen
saturation determined by pulse oximetry in healthy young adult
females. Emerg Med J 2011;28:783-785.
References
• Deiorio NM. Continuous end-tidal carbon dioxide monitoring for
confirmation of endotracheal tube placement is neither widely available
nor consistently applied by emergency physicians. Emerg Med J. 2005
Jul;22(7);490-3.
• Li J. A prospective multicenter trial testing the SCOTI device for
confirmation of endotracheal tube placement. J Emerg Med. 2001
Apr;20(3) 231-9.
• Murray I. P. et. al. 1983. Early detection of endotracheal tube accidents by
monitoring CO2 concentration in respiratory gas. Anesthesiology 344-346
• Raheem MS, Wahba OM. A nasal catheter for measurement of end-tidal
carbon dioxide in spontaneously breathing patients: A preliminary evaluation.
Anaesth Analg 2010;110(4):1039-42.
•
•
•
www.braintrauma.org
www.capnography.com
www.heart.org
References
 Hiller J, et al. A retrospective observational study examining
admission arterial to end-tidal carbon dioxide gradient in intubated
major trauma patients. Anaesth Intensive Care 2010;38(2) 302-6.
 Cacho G, et al. Capnography is superior to pulse oximetry for the
detection of respiratory depression during colonoscopy. Rev Enferm
Dig. 2010;102(2):86-9.
 Gerogiou AP, et al. The use of capnography and the availability of
airway equipment on intensive care units in the UK and the republic
of Ireland. Anaesthesia 2010;65(5):242-7.
 Deakin, CD et al. Prehospital end-tidal carbon dioxide concentration and
outcome in major trauma. J Trauma 2004;57(1):65-8.
References
• Bouma GJ,et al. Ultra-early evaluation of regional blood flow in severe
head injured patients using xenon-enhanced computerized
tomography. J Neurosurg 1992;77:360-8.
• MuizzelaarJP, Marmarou A. et al. Adverse effects of prolonged
hyperventilation in patients with severe head injury: a randomized
clinical trial. J Neurosurg 1991;75:731-9. Helm, M, et al, Tight Control
of pre-hospital ventilation by capnography in major trauma victims.
Br. J. Anaesth. (2003 )
90(3) ;327-332.
• Repetto JE et al. Use of Capnography in the delivery room for
assessment of endotraceal tube placement. J Perinatol, 2001 JulAug;21(5):284-7.
• Grmec S. Comparison of three different methods to confirm tracheal
tube placement in emergency intubation. Intensive Care Med. 2002
Jun;28(6):701-4.
• Special thanks to Tommy Leonard RRT, Remote Monitoring
Product Manager, Covidien