Name:Journa Liza Suyat Regala RTRP.BSRT.BSN

Third QPEM Conference 11-13th of January 2019

Title: Application of Capnography in Pediatric Emergency Department

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

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At the end of the presentation, the attendee will be able to:

Learning Objectives

Understand importance of monitoring end-tidal carbon dioxide and the valuable information it provide for patient assessment and treatment.

Understand importance of capnography in monitoring respiratory status of spontaneous beating patient .

Identify the cause of High and Low ETtCO2 values.

Capnography (End-Tidal Capnography)

Refers to the graphical measurement of the partial pressure of carbon dioxide (EtCO2,PetCO2).First establish in the 1930s,clinical use of EtCO2 measurement become accessible in the 1950s.

More generally end-tidal capnography is used in the following settings:• General anesthesia• Procedural sedation, including sedation with monitored anesthesia care• Analysis of ventilation in mechanical ventilated patient.• Cardiac arrest ,to confirm tracheal intubation and adequacy of chest compression.• Ensure ventilation as to confirm a spontaneously ventilating patient.

The use of Capnography in Spontaneous Breathing Patient

In July 2013, the journal of Emergency medicine published article titled(Capnography for the non-intubated patient in the Emergency setting)

Capnography can be an effective tool for measuring RR and adequacy of ventilation Ex: narcotic, analgesis, benzodiazepines and seizure management.

Hypercabnia can exist in the presence of normal oxygenation.

Capnography gave advanced warning for low oxygenation condition.

Capnography was 100% sensitive for predicting hypoxia.

Using of capnography is cost efficiencies in the ER environment. EX: DKA (fewer blood draws)PE( reducing unnecessary CT scans)

Indication of Capnography in Spontaneous breathing patient

Respiratory distress is one of the most common patient complain. • Waveform capnography is a valuable tool to determine the cause and severity of

respiratory distress. • Monitor the patients response to treatment. • Capnography also detects shocks.

Pathology and the Capnography Cause of High EtCO2 Cause of Low EtCO2

Malignant hyperthermia HypothermiaShivering Low cardiac outputFever Pulmonary EmbolismSepsis Hyperventilation Endocrine diseaseHypoventilation

Normal Capnogram and Phase

Normal Capnogram - Phase I Normal Capnogram - Phase II Normal Capnogram - Phase III Normal Capnogram - Phase IV

Normal Value of PaCO2 vs PETCO2

• PaCO2 Normal Values :

• 35- 45 mmHg

• ETCO2 Normal Values:

30- 43 mmHg4.0-5.7 kPa4.0-5.6%

Note :Arterial - End Tidal CO2 Gradient• In healthy lungs the normal a-ETco2 gradient is 2-5 mmHg

The gradient will increase due to ventilation/perfusion mismatch, decreased cardiac function and decreased pulmonary blood flow

Normal and Abnormal waveform

Absent ETCO2 level and waveform Air way obstruction

Decreasing ETCO2 level towards normal

Reduced ETCO2 level Normal

Increased ETCO2 level from normal Curare cleft Sudden significant increase

in ETCO2

Increased ETCO2 values toward normal

Take home messagesThe shape of the capnography waveform helps determine the cause of the problem.

Think respiratory failure when ETCO2 is high

Think perfusion, metabolic or psychological problem when ETCO2 is low

Capnography provides real-time feedback on response to treatment.

Hyperventilation with a BVM is harmful and capnography can help prevent it.