Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
7/24/2014
1
CAPNOGRAPHY- The New Standard of Care
Introduction
Capnography is a noninvasive method for
monitoring the level of carbon dioxide in
exhaled breath.
Capnography assists clinicians diagnose
specific medical conditions, make
treatment decisions, and assess the
efficacy of resuscitation efforts and
predict outcomes
CAPNOGRAPHY
Why use it????
Applications
Endotracheal Tube Confirmation
Efficacy of CPR
Management of TBI
Assessment of Chronic and Restrictive Airway
Disease
Assessment of Perfusion
V/Q Mismatch
Global Airway Assessment
Ventilator Managment
7/24/2014
2
2010 American Heart Association Guidelines EMBARGOED FOR
RELEASE
for CPR and Emergency Cardiovascular Care Oct. 18, 12:30 a.m. EST
Comparison Chart of Key Changes
Advanced Cardiovascular Life Support (ACLS)
Continuous quantitative waveform capnography is
now recommended for intubated patients throughout
the peri-arrest period. When quantitative waveform
capnography is used for adults, applications now
include recommendations for confirming tracheal
tube placement and for monitoring CPR quality and
detecting return of spontaneous circulation based on
end-tidal carbon dioxide (Petco2) values.
ETCO2 vs. SpO2
CO2:
Relects ventilation
Detects apnea and
hypoventilation
immediately
Should be used with
pulse oximetry
O2 Saturation:
Reflects oxygenation
30 to 60 second lag
in detecting apnea or
hypoventilation
Should be used with
capnography
ETCO2 & Cardiac Resuscitation
Non-survivors
Average ETCO2: 4-10 mmHg
Survivors (to discharge)
Average ETCO2: >30 mmHg
ETCO2 & Cardiac Resuscitation
If patient is intubated and pulmonary
ventilation is consistent with bagging, ETCO2
will directly reflect cardiac output
Flat waveform can establish PEA Increasing ETCO2 can alert to return of spontaneous
circulation
Configuration of waveform will change with
obstruction
7/24/2014
3
Capnography What are we measuring?
Ventilation Physiology
Rule #1 of Life:
“Air must go in and out”
Ventilation
“The movement of air”
(Designed to Eliminate CO2 and intake O2)
Perfusion
Blood Must Circulate
7/24/2014
4
Fick Principle
Oxygen Transport
Requires:
• Adequate number of RBC’s
• Adequate O2
• RBC’s must be able to offload and upload
• Adequate blood pressure
Deadspace
Factors Affecting Tidal Volume
Hyperventilation
•TBI
•DKA
•Metabolic Acidosis
•PE
•STEMI
•Others
Hypoventilation
•CNS Disorders
•Polypharmacy OD
•TBI
•Sedation
•Narcotics
Physiological Factors Affecting
ETCO2 Levels
7/24/2014
5
Normal Arterial &
ETCO2 Values
Arterial – ETCO2 Gradient
In healthy lungs the PaCO2 to ETCO2 gradient is
2-5 mmHg
(Increase indicates V/Q mismatch)
CAPNOGRAPHY
Theory of Operation
Infrared Absorption
A beam of infrared light energy is passed
through a gas sample containing CO2
CO2 molecules absorb specific wavelengths
of infrared light energy.
Light emerging from sample is analyzed.
A ration of the CO2 affected wavelengths to
the non-affected wavelengths is reported as
ETCO2
7/24/2014
6
Capnography vs. Capnometry
Capnography:
Measurement and
display of both ETCO2
value and capnogram
(CO2 waveform)
Measured by a
capnograph
Capnometry:
Measurment and
display of ETCO2 value
(no waveform)
Measured by a
capnometer
Mainstream vs. Sidestream
Quantitative vs. Qualitative ETCO2
Quantitative ETCO2:
Provides an actual numeric
value
Found in capnographs and
capnometers
Qualitative ETCO2:
Only provides a range of values
Termed “CO2 Detectors”
Colorimetric CO2 Detectors
A “detector” – not a
monitor
Uses chemically treated
paper that changes color
when exposed to CO2
Must match color to a
range of values
Requires six breaths
before determination
can be made
7/24/2014
7
CAPNOGRAPHY
The Capnogram
End of
inspiration
Beginning of
exhalation
Alveolar
plateau
End of
exhalation
Beginning of
new breath
Clearing of anatomic dead space
1. Is there a waveform?
2. What's the baseline
3. What does the waveform look like
4. What is the CO2 measurement
7/24/2014
8
45
0
Normal range is 35-45mm Hg
4 5
0
1. Increased Rate &/or VT
2.Decreased Metabolic rate
3.Decrease in core temperature
4.Decreased cardiac output
5.Embolism (Fatty, thrombus or air)
0
4 5
1. Decreased rate &/or VT
2. Increased Metabolic rate or Cardiac Output (Rapid BP)
3. Rise in core temperature
• Malignant Hyperthermia
4. Rhabdomyolysis
5. Neural dysfunction - Widening
45
0
1. Quantitative measurement of CO2
2. Tool of Ventilation, Perfusion, Metabolism
7/24/2014
9
4 5
0
1. Complete Sudden loss of waveform*
2. Dislodgement / Apnea
3. Total obstruction
4. Equipment malfunction
4 5
0
1. Rapid descending waveform
2. Progresses to complete loss of
waveform if not corrected
40
0
1. Loss of expiratory plateau
2. Artificial airway obstruction/kink
3. Expiratory obstruction*
4. FBAO, bronchospasms
5. “Shark fin” appearance
1. Prolonged or Incomplete exhalation
2. COPD, Asthma, Bronchospasm:
• Alveoli unevenly ventilated on inspiration
• Asynchronous emptying during expiration
7/24/2014
10
COPD (Bronchitis/Emphysema), Asthma,
Bronchospasm?
Fatigue, Hypoxia, Hypercapnic =
Respiratory Distress/Arrest
40
16
1. Rebreathing (May show increase in
ETCO2)
2. Inspiratory / expiratory flow inadequate
3. Malfunctioning expiratory component –
Vent
4. Partial Rebreathing
20
16
15
0
Mean ETCO2 <10 mmHg > 20 minutes?
32
20
1.Spontaneous breathing returns
2.Emergence from blockade
3.Look at other vital signs
4. Inversely proportional to degree of blockade or
sedation
7/24/2014
11
40
20
1.Spontaneous breaths during mechanical
ventilation
2.Emergence from blockade
3. “Auto-cycling” Sensitivity setting
End Tidal (Current) x RR (Current)
End Tidal (Desired)
1. Eyes, face, neck
2. Extremities
3. Abdomen
4. Intercostals, glottis
5. Diaphragm
Order of paralysis
Sudden Loss of Waveform
Apnea
Airway Obstruction
Dislodged airway (esophageal)
Airway disconnection
Ventilator malfunction
Cardiac Arrest
7/24/2014
12
Other Methods of Acquisition
QUIZ TIME
Questions?