Capnography- A Review and Renewed Perspective of its Uses and Limitations

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1 Capnography- A Review and Renewed Perspective of its Uses and Limitations Prepared and Presented by: Christine Hardie and Dr. Matt Davis December 2014

2 Learning Objectives Upon completion of this webinar the paramedic should be able to: Recall the physiology of ventilation Recognize the benefits of capnography Identify the role of ETCO2 monitoring in the pre hospital setting Integrate capnography into current practice 1 1

3 Review of Pulmonary Anatomy and Physiology Perfusion Exhalation Oxygenation Metabolism 2 2

4 3 3

5 The Ventilation/Perfusion Relationship 0.8 alveolar ventilation (L/min) 4 L/min cardiac output (L/min) 5 L/min 4 4

6 Short-forms, Terms and Norms PaO2 partial pressure of oxygen in an arterial blood gas sample ( mmhg) PaCO2 partial pressure of carbon dioxide in an arterial blood gas sample (35-45 mmhg) EtCO2/PetCO2 End tidal measurement from expired or exhaled air. (+/- 2-5 mmhg) 5 5

7 What is Capnography? Measurement of exhaled CO2 displayed as a number in millimeters of Mercury (mmhg) or percent It provides the paramedic with a waveform which tracks exhaled CO2 over time called a capnogram End-tidal CO2 (EtCO2) is the partial pressure of CO2 at the end of an exhaled breath mmhg

8 What is Capnography Cont. Indirectly, capnography measures metabolism and circulation. Ex. Increased metabolism will increase the production of carbon dioxide increasing ETCO2 Ex. Decreased cardiac output will lower the delivery of carbon dioxide to the lungs decreasing ETCO2 7 7

9 How do you make a slow reindeer fast? 8 8

10 Pre Hospital Clinical Applications 9 9

Types of Capnography Devices Mainstream placed at the

expired gas to pass directly across the IR light path

gas sample to be continuously aspirated from the

11 Types of Capnography Devices Mainstream placed at the airway of an intubated patient allowing inspired and expired gas to pass directly across the IR light path Sidestream located away from the airway, requiring a gas sample to be continuously aspirated from the breathing circuit and transported to the sensor by pump 10 10

12 ETCO2 Waveform 11 11

13 The Alveolar Plateau V/Q = Low CO2 V/Q = High CO

14 ETCO2 Waveform 13 13

15 Clinical Applications Advanced Airway Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, Level of Evidence (LOE) A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement

16 15 15 Displaced tube or esophageal intubation

17 Clinical Applications - CPR If end-tidal CO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters Serve as an indicator of ROSC by observing an abrupt sustained increase in end-tidal CO

18 Actual CPR Tracings ETCO2 at ROSC ETT tube confirmation 17 17

19 Prognosis in Cardiac Arrest? Some studies have shown that ETCO2 monitoring can confirm the futility of resuscitation as well as forecast the likelihood of resuscitation. CPR Marathon 18 18

20 Cardiac Arrest Consider other factors contributing to Cardiac Arrest when CPR is adequate and cardiac output is declining Hemorrhage Pneumothorax Pulmonary Embolism 19 19

21 Applications for Spontaneously Breathing Patients Hypo/Hyper ventilation DKA Seizure/Post Ictial 20 20

22 Case Study 1 You are called Code 4 for a patient with an altered LOA. You find: 23 y/o female suspected opiate overdose GCS 3 RR 24 ETCO

23 Asthma/COPD 22 22

24 Limitations ETCO2 is most effective when assessing a pure ventilation/perfusion or metabolic problem Mouth breathing patients Sensitivity for esophageal ETT placement in cardiac arrest is uncertain Lack of evidence for use with intermediate a/w 23 23

25 Summary of Key Points Tracheal placement should be confirmed using ETCO2 All ETT should be monitored using ETCO2 Can be helpful to ensure adequate CPR Use to assist with ROSC and loss of spontaneous circulation 24 24

26 Questions? If you have any questions regarding these or any of your Medical Directives, please contact your Regional Paramedic Educator. Christine Hardie Dwayne Cottel Peter Morassutti Jennifer Robson Michael Kennedy 25 25

27 References 7E65 L3017-Capnography-Handbook.final.pdf y_outside_the_operating_rooms.35.aspx 26 26

Don t let your patients turn blue! Isn t it about time you used etco 2?

Don t let your patients turn blue! Isn t it about time you used etco 2? American Association of Critical Care Nurses National Teaching Institute Expo Ed 2013 Susan Thibeault MS, CRNA, APRN, CCRN, EMT-P