Are They Still Breathing? And More: End-tidal CO2

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1 Are They Still Breathing? And More: End-tidal CO2 Robert Katzer MD MBA FACEP FAEMS Associate Professor, Emergency Medicine University of California, Irvine Medical Director, Anaheim City Fire and Rescue Air Medic, San Bernardino County Sheriff

2 Overview Available equipment The science behind it Different applications Interpreting Wave form patterns 2 Department Name Month X, 201X

3 Equipment Types Inline or mainstream Heated to avoid distortion from condensation Sidestream Tubing off of the vent circuit Tubing from a nasal cannula collector Slight delay during travel Calorimetric EtCO2 Detector Purple for < 3 mmhg Tan for 3 to 15 mmhg Yellow for >15 mmhg Image: Rschiedon at Dutch Wikipedia [GFDL ( or CC-BY-SA-3.0 ( via Wikimedia Commons 3 Department Name Month X, 201X

4 Measurement of CO2 Concentration by Quantitative Detectors Sensors look at Infrared (IR) absorption CO2 absorbs a particular wavelength in an exponential fashion 4.3 mu Absence of light waves used to measure CO2 concentration 4 Department Name Month X, 201X

with number Photo: http://www.masimo.co.uk/images/cap nography/one-touch.

5 Capnometry vs. Capnography Capnometry displays a number Capnography displays a waveform with number Photo: nography/one-touch.png Time capnography Volume capnography Photo: 5 Department Name Month X, 201X

6 What End-tidal Tells Us The wave form results from Effectiveness of ventilation Vascular perfusion Aerobic metabolism What lies in the shape? The shape informs of the disease process The magnitude informs of the severity of disease, response to interventions 6 Department Name Month X, 201X

7 Phases of the Waveform: Phase I Expiration has begun Air all from anatomic dead space No CO2 present Image: 7 Department Name Month X, 201X

8 Phases of the Waveform: Phase II Air from alveoli exhaled CO2 concentration rises rapidly Slope determined by uniformity of alveolar ventilation Image: 8 Department Name Month X, 201X

9 It s Time.. To get into the weeds 9 Department Name Month X, 201X Photo:

10 Ventilation(V), Perfusion(Q) Mismatch V/Q mismatch! Areas of perfusion without ventilation are shunts V/Q 0 Shunts do not respond to supplemental O2! Areas of ventilation without perfusion are dead space or V/Q mismatch, V/Q Patients with alveolar dead space (high V/Q) will have a more gradual phase II slope. 10 Department Name Month X, 201X

11 Phases of the Waveform: Phase III Phase III AKA the alveolar plateau Air from nose through alveoli all came from alveoli The point at the end of III is the End-tidal Image: 11 Department Name Month X, 201X

12 We are Back! 12 Department Name Month X, 201X Photo:

13 Phase III and PaCO2 Partial pressure definitions: PACO2: pressure of alveolar CO2 PaCO2: pressure of arterial CO2 PVCO2: pressure of venous CO2 EtCO2 approximates PACO2 and PVCO2, NOT PaCO2 13 Department Name Month X, 201X

14 Phase III and PaCO2 PVCO2 usually around 7 mmhg higher than PaCO2 EtCO2 mirrors PVCO2 when Alveoli are all identical (no dead space) Expiratory time is long Reasons that EtCO2 is lower than PVCO2 Ventilatory rate is fast (gradient not equalized at alveoli V/Q mismatch 14 Department Name Month X, 201X

15 Slope of Phase III Usually close to flat Increased with increased CO2 production Increases naturally through expiration as total alveolar volume decrease Image: 15 Department Name Month X, 201X

16 Phases of the Waveform: Phase IV Inspiration Rapid decline in CO2 concentration Gradual slope results from CO2 being introduced into inhalation Image: 16 Department Name Month X, 201X

17 Angles α: usually 100 degrees. Bronchospasm or obstruction will increase the angle Β: usually 90 degrees. Rebreathing CO2 will increase the angle Image: 17 Department Name Month X, 201X

18 Normal EtCO2 Waveform EtCO2 45 mmhg 0 Time 18 Department Name Month X, 201X

19 What Can I Use This For Anyway? 19 Department Name Month X, 201X Photo:

20 What Esophageal is Going Intubation on? EtCO2 45 mmhg 0 Time 20 Department Name Month X, 201X

21 Sensitivity of End-tidal CO2 for Predicting Tracheal Intubation Patients with spontaneous circulation: 100% sensitive and specific Patients in cardiac arrest: % sensitive 21 Department Name Month X, 201X

22 Quantitative CO2 in the Field Without continuous quantitative CO2 in field 23 % of intubations end up unrecognized nontracheal location With continuous quantitative CO2 in the field 0% end up unrecognized nontracheal location 22 Department Name Month X, 201X

23 How Your patient about now? may have just coded EtCO2 45 mmhg 0 Time 23 Department Name Month X, 201X

24 End-Tidal CO2 and Effective Compressions During CPR EtCO2 directly correlates with cardiac output EtCO2 > 20 mmhg is indicative of high quality compressions EtCO2 < 10 after 20 minutes of ACLS associated with a very remote likelihood of achieving ROSC (intubated patients only!) EtCO2 of ROSC average of 25 mmhg EtCO2 > 40 mmhg indicative of ROSC 24 Department Name Month X, 201X

25 End-Tidal CO2 and Effective Compressions 20 mmhg < EtCO2 < 25 mmhg Quality compressions EtCO2 > 40 mmhg Likely ROSC Average EtCO2 at ROSC 25 mmhg < 10 mmhg after 20 minutes CPR Exceedingly low likelihood of survival 25 Department Name Month X, 201X

26 Should We be Doing Pulse Checks? After a 20 second pause in compressions it takes 1 minute of compressions to achieve coronary perfusion again Odds of survival by perishock pause. Compared to patients with perishock pause < 10 sec and postshock pause < 20 seconds Preshock pause > 20 seconds had odds ratio of survival 0.47 Postshock pause > 40 seconds had odds ratio of survival Department Name Month X, 201X

27 Good News? EtCO2 45 mmhg 0 Time 27 Department Name Month X, 201X

28 ETCO2 and Metabolic Acidosis Serum HCO3 decreases in metabolic acidosis Physiologic response is compensatory respiratory alkalosis Increase respiratory rate decreases EtCO2 28 Department Name Month X, 201X

29 EtCO2, Hyperglycemia, and Diabetic Ketoacidosis In pediatric population: EtCO2 >36mmHg rules out DKA In adult population with blood glucose > 550 EtCO2 < 21 mmhg rules in DKA EtCO2 > 35 mmhg rules out DKA 29 Department Name Month X, 201X

30 Hyperventilation What is the Subtle Process Here? EtCO2 45 mmhg 0 Time 30 Department Name Month X, 201X

31 EtCO2 and Seizures Unlike pulse oximetry and cardiac monitoring, EtCO2 unaffected by motion artifact Provided detector is not displaced, it will measure the exhaled CO2 Lack of waveform indicates apnea Slowed waveform with greater magnitude indicates inadequate ventilation Normal waveform indicates adequate ventilation 31 Department Name Month X, 201X

32 Trending CapnometricValue with Treatment In patients with obstructive respiratory process Increasing EtCO2 over time indicates worsening respiratory status Stable EtCO2 over time indicates stable respiratory status Decreasing EtCO2 over time indicates improving respiratory status 32 Department Name Month X, 201X

33 Asthma, Bronchospasm, Other Obstruction EtCO2 45 mmhg 0 Time 33 Department Name Month X, 201X

34 Hyperventilation EtCO2 45 mmhg 0 Time 34 Department Name Month X, 201X

35 Normal etco2 Waveform EtCO2 45 mmhg 0 Time 35 Department Name Month X, 201X

36 ETCO2 and Procedural Sedation Delay exists between apnea and hypoxia on pulse oximeter EtCO2 can identify apnea earlier General belief: use of continuous EtCO2 will allow earlier airway intervention before disaster 36 Department Name Month X, 201X

37 Does Continuous EtCO2 During Procedural Sedation Save Lives? It is estimated that implementing continuous end tidal CO2 monitoring for all Emergency Department procedural sedation would save 6 lives every 5 five years throughout the US. $2,830,326 to prevent each catastrophic event Cochrane review: There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. 37 Department Name Month X, 201X

38 ETCO2, Sepsis, and Lactate EtCO2 inversely correlated with lactate levels 38 Department Name Month X, 201X

39 EtCO2 Flatline With chest movement Equipment failure Obstruction Without chest movement Apnea 39 Department Name Month X, 201X

40 Leak Huh? in the Vent Circuit EtCO2 45 mmhg 0 Time 40 Department Name Month X, 201X

41 Volumetric Capnography Harder to obtain and interpret than time capnography Concentration of CO2 within the total volume of expired air Gives greater insite into dead space The lower the percentage of volume that is CO2, the greater amount of lung that is ventilated, but no perfused. 41 Department Name Month X, 201X

Not your Grand Daddy s Back Yard Photo: https://somacolorado.

42 Not your Grand Daddy s Back Yard Photo: 42 Department Name Month X, 201X

43 Normal etco2 Waveform EtCO2 45 mmhg 0 Time 43 Department Name Month X, 201X

44 Hyperventilation EtCO2 45 mmhg 0 Time 44 Department Name Month X, 201X

45 Asthma, Bronchospasm, Other Obstruction EtCO2 45 mmhg 0 Time 45 Department Name Month X, 201X

46 Hypoventilation EtCO2 45 mmhg 0 Time 46 Department Name Month X, 201X

47 Rebreathing CO2 EtCO2 45 mmhg 0 Time 47 Department Name Month X, 201X

48 Leak in the Vent Circuit EtCO2 45 mmhg 0 Time 48 Department Name Month X, 201X

49 Esophageal Intubation EtCO2 45 mmhg 0 Time 49 Department Name Month X, 201X

50 CPR with ROSC EtCO2 45 mmhg 0 Time 50 Department Name Month X, 201X

51 Pericoding Patient EtCO2 45 mmhg 0 Time 51 Department Name Month X, 201X

52 References Mohr NM, Stoltze A, Ahmed A, Kiscaden E, Shane. Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis. Intern Emerg Med Dec 28. Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation.. Bhende MS, Thompson AE. Pediatrics. 1995;95(3):395. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection..macleod BA, Heller MB, Gerard J, Yealy DM, Menegazzi JJ. Ann Emerg Med. 1991;20(3):267. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. Ann Emerg Med. 2005;45(5):497. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. Garnett AR, Ornato JP, Gonzalez ER, Johnson EB JAMA. 1987;257(4):512. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. Falk JL, Rackow EC, Weil MH. N Engl J Med. 1988;318(10):607. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. Levine RL, Wayne MA, Miller CC. N Engl J Med. 1997;337(5):301. Highlights of the 2015 AHA Guidelines Update for CPR ane ECC 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Cirvulstion. Vol. 132 Number Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Cheskes S, Schmicker RH, Christenson J, Salcido DD, Rea T, Powell J, Edelson DP, Sell R, May S, Menegazzi JJ, Van Ottingham L, Olsufka M, Pennington S, Simonini J, Berg RA, Stiell I, Idris A, Bigham B, Morrison L, Resuscitation Outcomes Consortium (ROC) Investigators. Circulation. 2011;124(1):58. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial.. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Ann Emerg Med. 2010;55(3):258. A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. Hunter CL, Silvestri S, Ralls G, Stone A, Walker A, Papa L. Am J Emerg Med May;34(5): Epub 2016 Jan 21. Capnography during cardiopulmonary resuscitation: Current evidence and future directions Bhavani Shankar Kodali, Richard D. Urman J Emerg Trauma Shock Oct-Dec; 7(4): Pokorna M, Necas E, Kratochvil J, Skripsky R, Andrlik M, Franek O. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010;38: Wall BF, Magee K, Campbell SG, Zed PJ. Capnography versus standard monitoring for emergency department procedural sedation and analgesia. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. Bou Chebl et al. Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. BMC Emergency Medicine (2016) 16:7 Boulos S. Nassar, MD; and Gregory A. Schmidt, MD, FCCP. Capnography During Critical Illness. Chest. 2016; 149(2): Hartmann SM1, Farris RW2, Di Gennaro JL2, Roberts JS2.. Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.. J Intensive Care Med Oct;30(7): Suarez-Sipmann F1, Bohm SH, Tusman G.. Volumetric capnography: the time has come. Curr Opin Crit Care Jun;20(3): Department Name Month X, 201X

Capnography: Not just for confirmation

Capnography: Not just for confirmation Pennsylvania DOH ALS Protocol 2032-ALS Ernest Yeh, M.D. Division of EMS Department of Emergency Medicine Temple University Hospital and School of Medicine Medical