CAPNOGRAPHY In Emergency Care

CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care

EDUCATIONAL SERIESEDUCATIONAL SERIES

Part 4:Part 4:Non-intubatedNon-intubated

Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient

CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care

Part 4: The Non-intubated Patient Part 4: The Non-intubated Patient Learning ObjectivesLearning Objectives

• List three non-intubated applicationsList three non-intubated applications• Identify four characteristic patterns Identify four characteristic patterns

seen in seen in – BronchospasmBronchospasm

• AsthmaAsthma• COPDCOPD

– Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low-perfusion statesLow-perfusion states

The Non-intubated PatientThe Non-intubated Patient

CC: CC: ““trouble breathing”trouble breathing”

The Non-intubated Patient The Non-intubated Patient CC: “trouble breathing”CC: “trouble breathing”

Asthma?

Asthma? Emphysema?

Emphysema?

Pneumonia?Pneumonia?Bronchitis?Bronchitis?

CHF?CHF?

PE?PE?

Cardiac ischemia?Cardiac ischemia?

The Non-intubated Patient The Non-intubated Patient CC: “trouble breathing”CC: “trouble breathing”

• Identifying the problem and Identifying the problem and underlying pathogenesis underlying pathogenesis

• Assessing the patient’s statusAssessing the patient’s status• Anticipating sudden changesAnticipating sudden changes

The Non-intubated Patient The Non-intubated Patient Capnography ApplicationsCapnography Applications

• Identify and monitor bronchospasmIdentify and monitor bronchospasm– AsthmaAsthma– COPDCOPD

• Assess and monitor Assess and monitor – Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low-perfusion statesLow-perfusion states

• Capnography reflects changes in Capnography reflects changes in

– VentilationVentilation - movement of gases in and out of - movement of gases in and out of the lungsthe lungs

– Diffusion Diffusion - exchange of gases between the air-- exchange of gases between the air-filled alveoli and the pulmonary circulationfilled alveoli and the pulmonary circulation

– PerfusionPerfusion - circulation of blood through the - circulation of blood through the arterial and venous systemsarterial and venous systems

• VentilationVentilation • Airway obstructionAirway obstruction

– Smooth muscle contractionSmooth muscle contraction– BronchospasmBronchospasm– Airway narrowingAirway narrowing– Uneven emptying of alveoliUneven emptying of alveoli– Mucous plugsMucous plugs

• Diffusion Diffusion • Airway inflammationAirway inflammation• Retained secretionsRetained secretions• Fibrosis Fibrosis • Decreased compliance of alveoli wallsDecreased compliance of alveoli walls• Chronic airway modeling (COPD)Chronic airway modeling (COPD)• Reversible airway disease (Asthma)Reversible airway disease (Asthma)

Capnography in Capnography in Bronchospastic ConditionsBronchospastic Conditions

• Air trapped due to Air trapped due to irregularities in airwaysirregularities in airways

• Uneven emptying of Uneven emptying of alveolar gas alveolar gas – Dilutes exhaled CODilutes exhaled CO22

– Slower rise inSlower rise in COCO2 2

concentration during concentration during exhalationexhalation

Alveoli

Capnography in Capnography in Bronchospastic DiseasesBronchospastic Diseases

• Uneven emptying of Uneven emptying of alveolar gas alters alveolar gas alters emptying on exhalationemptying on exhalation

• Produces changes in Produces changes in ascending phase (II) ascending phase (II) with loss of the sharp with loss of the sharp upslopeupslope

• Alters alveolar plateau Alters alveolar plateau (III) producing a “shark fin”(III) producing a “shark fin”

Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions

Prevalence of AsthmaPrevalence of Asthma

• Asthma is increasing in the USAsthma is increasing in the US– 20.3 million citizens report having asthma20.3 million citizens report having asthma

– Prevalence increased 75% from 1980-1994Prevalence increased 75% from 1980-1994

– Two million ED visits each yearTwo million ED visits each year

– Most common chronic health problem in childrenMost common chronic health problem in children

• Increasing deaths due to asthmaIncreasing deaths due to asthma– 1987 to 1995, death rate doubled to 56001987 to 1995, death rate doubled to 5600

Sources: Delbridge T., et al. 2003 Prehospital Asthma Management. Prehospital Emergency Care 7(1) 42-47

Asthmatic Statistics. American Academy of Allergies, Asthma and Immunology. http.//www.aaaai.org

Pathology of AsthmaPathology of Asthma

• Acute onset or progressive over weeksAcute onset or progressive over weeks• Airway Airway

– Increased responsiveness (hyper-reactivity)Increased responsiveness (hyper-reactivity)– Bronchospasm Bronchospasm

• Reversible obstructionReversible obstruction– InflammationInflammation

Pathology of AsthmaPathology of Asthma

• Release of inflammatory mediatorsRelease of inflammatory mediators– Histamine, bradykinin, prostaglandinsHistamine, bradykinin, prostaglandins

• Bronchial wall reactionBronchial wall reaction– Spasm of bronchial smooth muscleSpasm of bronchial smooth muscle– Vasodilatation with swelling of bronchial Vasodilatation with swelling of bronchial

mucous membranesmucous membranes– Increased mucous productionIncreased mucous production

Symptoms of AsthmaSymptoms of Asthma

• TachycardiaTachycardia• TachypneaTachypnea• WheezingWheezing• Cough Cough • Chest tightnessChest tightness• Use of accessory muscles (retractions)Use of accessory muscles (retractions)• AnxietyAnxiety• DiaphoresisDiaphoresis

Classification of AsthmaClassification of Asthma

Symptoms Mild Moderate Severe Arrest Imminent

BreathlessBreathless WalkingWalking TalkingTalking RestingResting

Talks inTalks in SentencesSentences PhrasesPhrases WordsWords

AlertnessAlertness Agitated?Agitated? AgitatedAgitated AgitatedAgitated DrowsyDrowsy

Resp RateResp Rate IncreasedIncreased IncreasedIncreased >30/min>30/min

Accessory Accessory NoNo CommonlyCommonly UsuallyUsually ParadoxParadox

WheezeWheeze Mod; EEMod; EE Loud; ExpLoud; Exp Loud: I/ELoud: I/E AbsentAbsent

PulsePulse <100<100 100-120100-120 >120>120 BradyBrady

PaCOPaCO22 <42mmHg<42mmHg <42mmHg<42mmHg >>42mmHg42mmHg

SaCOSaCO22 >95%>95% 91-95%91-95% <91%<91%

PositionPosition Can lie downCan lie down Prefers sittingPrefers sitting Sitting uprightSitting upright

Source: Edmond S. D. 1998. 1997 National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: 579-594

Adopted from the NIH Guidelines for the Diagnosis and Management of AsthmaAdopted from the NIH Guidelines for the Diagnosis and Management of Asthma

Assessment of AsthmaAssessment of Asthma

• Symptoms and observations are Symptoms and observations are primarily subjectiveprimarily subjective

• Severity of symptoms and your patient’s Severity of symptoms and your patient’s perception may not accurately reflect perception may not accurately reflect severity of conditionseverity of condition

More More objectiveobjective data needed data needed

Source: Teeter J.G., et al. 1998. “Relationship Between Airway Obstruction and Respiratory

Symptoms in Adult Asthmatics. CHEST.113:5:272-277

Capnogram of AsthmaCapnogram of Asthma

• 28 normal volunteers; 20 asthma 28 normal volunteers; 20 asthma patients in EDpatients in ED

• Correlation between PEFR and Correlation between PEFR and slope of capnogram waveformslope of capnogram waveform

• ConclusionConclusion– Slope value correlated with PEFRSlope value correlated with PEFR

– ““dCOdCO22/dt is an effort independent, rapid noninvasive /dt is an effort independent, rapid noninvasive

measure that indicates significant bronchospasm”measure that indicates significant bronchospasm”

Source: Yaron M. 1996. Utility of the Expiratory Capnogram in the Assessment of Bronchospasm. Annals of Emergency Medicine 28: 4

• ““expiratory airflow obstruction affects the expiratory airflow obstruction affects the shape of the COshape of the CO22 time curve due to uneven time curve due to uneven emptying of alveolar gas.”emptying of alveolar gas.” P 312 P 312

• Waveform examples show increasing Waveform examples show increasing change in normal expiratory plateau with change in normal expiratory plateau with increasing obstruction (bronchospasm)increasing obstruction (bronchospasm)

Source: Hall J.B., Acute Asthma, Assessment and Management,McGraw-Hill, New York.

Source: Krauss B., et al. 2003. FEV1 in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA

Changes in dCOChanges in dCO22/dt seen with increasing bronchospasm/dt seen with increasing bronchospasm

Bronchospasm

Normal

Capnography in AsthmaCapnography in Asthma

• Research is underway on the correlation Research is underway on the correlation of capnographic changes to patient’s of capnographic changes to patient’s respiratory statusrespiratory status

• Anticipating clinical trials on the impact Anticipating clinical trials on the impact on patient care, outcomes and on patient care, outcomes and healthcare costs healthcare costs

Asthma Case ScenarioAsthma Case Scenario

• 16 year old female16 year old female• C/O “having difficulty breathing”C/O “having difficulty breathing”• Visible distressVisible distress• History of asthma, physical exertion, “a cold”History of asthma, physical exertion, “a cold”• Patient has used her “puffer” 8 times over the Patient has used her “puffer” 8 times over the

last two hourslast two hours• Pulse 126, BP 148/86, RR 34Pulse 126, BP 148/86, RR 34• Wheezing noted on expirationWheezing noted on expiration

AsthmaAsthma Case ScenarioCase Scenario

Initial Initial

After therapyAfter therapy

Prevalence of COPDPrevalence of COPD

• COPD is increasing in the U.S.COPD is increasing in the U.S.– Fourth leading cause of death in adultsFourth leading cause of death in adults– 16 million cases in 199616 million cases in 1996

• Increasing deaths due to COPDIncreasing deaths due to COPD– 1999 estimated 110,0001999 estimated 110,000– Number of deaths doubled in the past 25 yearsNumber of deaths doubled in the past 25 years

Source: Boyle, A.H. 2000. Recommendations of the National Lung Health Education Program,Heart & Lung 29: 6: 446-449

Pathology of COPDPathology of COPD

• Chronic, progressive disease processChronic, progressive disease process– Major risk factors: smoking, exposure to Major risk factors: smoking, exposure to

dusts and fumes, history of frequent dusts and fumes, history of frequent respiratory infectionsrespiratory infections

• Spectrum of diseasesSpectrum of diseases– Chronic bronchitisChronic bronchitis– EmphysemaEmphysema– AsthmaAsthma– BronchiectisisBronchiectisis

• Progressive Progressive • Partially reversiblePartially reversible• Airways obstructedAirways obstructed

– Hyperplasia of mucous glands Hyperplasia of mucous glands and smooth muscleand smooth muscle

– Excess mucous productionExcess mucous production– Some hyper-responsivenessSome hyper-responsiveness

• Small airways Small airways – Main sites of airway obstructionMain sites of airway obstruction– InflammationInflammation– Fibrosis and narrowingFibrosis and narrowing– Chronic damage to alveoliChronic damage to alveoli– Hyper-expansion due to Hyper-expansion due to

air trappingair trapping– Impaired gas exchangeImpaired gas exchange Alveoli

Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation

• Increase in chronic symptomsIncrease in chronic symptoms– SOB SOB – CoughCough– WheezingWheezing– Use of accessory musclesUse of accessory muscles– Sputum - increased volume, tenacity Sputum - increased volume, tenacity

and purulenceand purulence– AnxietyAnxiety– DiaphoresisDiaphoresis– Chest tightnessChest tightness

Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation

• May also have May also have – Fever - underlying infectionFever - underlying infection– Co-morbidity Co-morbidity

• Congestive heart failureCongestive heart failure• Acute coronary syndromeAcute coronary syndrome• Diabetes mellitusDiabetes mellitus• HypertensionHypertension

Assessment of COPDAssessment of COPD

• Symptoms and observations are Symptoms and observations are primarily subjectiveprimarily subjective

• Severity of symptoms and your patient’s Severity of symptoms and your patient’s perception may not accurately reflect perception may not accurately reflect severity of conditionseverity of condition

More objective data neededMore objective data needed

Capnography in COPDCapnography in COPD

• Arterial COArterial CO22 in COPD in COPD– PaCOPaCO22 increases as disease progresses increases as disease progresses

– Requires frequent arterial punctures for ABGsRequires frequent arterial punctures for ABGs

• Correlating capnograph to patient statusCorrelating capnograph to patient status– Ascending phase and plateau are altered by Ascending phase and plateau are altered by

uneven emptying of gasesuneven emptying of gases

COPD Case ScenarioCOPD Case Scenario

• 72 year old male72 year old male• C/O difficulty breathingC/O difficulty breathing• History of CAD, CHF, smoking History of CAD, CHF, smoking

and COPD and COPD • Productive cough, recent Productive cough, recent

respiratory infectionrespiratory infection• Pulse 90, BP 158/82 RR 27 Pulse 90, BP 158/82 RR 27

COPD Case ScenarioCOPD Case Scenario

Initial Capnogram AInitial Capnogram A

Initial Capnogram BInitial Capnogram B

Capnogram of CHFCapnogram of CHF

• 207 patients in pulmonary function lab207 patients in pulmonary function lab– 61 with obstructive disease (OD); 34 with restrictive 61 with obstructive disease (OD); 34 with restrictive

disease (RD) disease (RD) – Correlation of slope of exhalation plateau Correlation of slope of exhalation plateau

• C/O severe difficulty breathing (FEV1<50%)C/O severe difficulty breathing (FEV1<50%)– 97% of OD had elevations >4°; 5% of RD had elevations >4°97% of OD had elevations >4°; 5% of RD had elevations >4°– P<0.0001P<0.0001

• ConclusionConclusion– Changes in shape of capnogram in OD confirmedChanges in shape of capnogram in OD confirmed– Changes in capnogram in RD did not occurChanges in capnogram in RD did not occur

Source: Krauss B., et al. 2003. FEV1in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA.

Capnography in CHFCapnography in CHF

Case ScenarioCase Scenario

• 88 year old male 88 year old male • C/O: Short of breathC/O: Short of breath• H/O: MI X 2, on oxygen at 2 L/mH/O: MI X 2, on oxygen at 2 L/m• Pulse 66, BP 114/76/p, RR 36 labored and Pulse 66, BP 114/76/p, RR 36 labored and

shallow, skin cool and diaphoretic, shallow, skin cool and diaphoretic, 2+ pedal edema2+ pedal edema

• Initial SpOInitial SpO22 69%; EtCO 69%; EtCO22 17mmHG 17mmHG

Capnography in CHFCapnography in CHF

• Placed on non-rebreather mask with 100% Placed on non-rebreather mask with 100% oxygen at 15 L/m; IV diuretic and SL nitroglycerin oxygen at 15 L/m; IV diuretic and SL nitroglycerin as per local protocolas per local protocol

• Ten minutes after treatment:Ten minutes after treatment:

SpOSpO22 69% 99% 69% 99%

EtCOEtCO22 17mmHG 35 mmHG 17mmHG 35 mmHG

Time condensed Time condensed to show changesto show changes

Capnography in Capnography in Hypoventilation StatesHypoventilation States

• Altered mental statusAltered mental status– SedationSedation– Alcohol intoxicationAlcohol intoxication– Drug IngestionDrug Ingestion– StrokeStroke– CNS infectionsCNS infections– Head injuryHead injury

• Abnormal breathing Abnormal breathing

• COCO22 retention retention – EtCOEtCO22 >50mmHg >50mmHg

Capnography in Capnography in Hypoventilation StatesHypoventilation States

• EtCOEtCO22 is above 50mmHG is above 50mmHG

• Box-like waveform shape is unchangedBox-like waveform shape is unchanged

Time condensed; actual rate is slowerTime condensed; actual rate is slower

Capnography in Hypoventilation StatesCapnography in Hypoventilation States Case ScenarioCase Scenario

• Observer called 911Observer called 911• 76 year old male sleeping and 76 year old male sleeping and

unresponsive on sidewalk, “gash unresponsive on sidewalk, “gash on his head”on his head”

• Known history of hypertension, Known history of hypertension, EtOH intoxication EtOH intoxication

• Pulse 100, BP 188/82, RR 10, SpOPulse 100, BP 188/82, RR 10, SpO22 96% 96% on room airon room air

Capnography in Hypoventilation StatesCapnography in Hypoventilation States HypoventilationHypoventilation

Time condensed; actual rate is slowerTime condensed; actual rate is slower

Capnography in Hypoventilation StatesCapnography in Hypoventilation States HypoventilationHypoventilation

Hypoventilation in shallow Hypoventilation in shallow breathingbreathing

Capnography in Low PerfusionCapnography in Low Perfusion

• Capnography reflects changes in Capnography reflects changes in • PerfusionPerfusion

– Pulmonary blood flow Pulmonary blood flow – Systemic perfusionSystemic perfusion– Cardiac outputCardiac output

• 57 year old male 57 year old male • Motor vehicle crash with injury to chestMotor vehicle crash with injury to chest• History of atrial fib, anticoagulantHistory of atrial fib, anticoagulant• UnresponsiveUnresponsive• Pulse 100 irregular, BP 88/pPulse 100 irregular, BP 88/p• Intubated on sceneIntubated on scene

Low EtCOLow EtCO22 seen in seen in

low cardiac outputlow cardiac output

Ventilation controlledVentilation controlled

Capnography ApplicationsCapnography Applicationson Non-intubated Patientson Non-intubated Patients

• New applications now being reportedNew applications now being reported– Pulmonary emboliPulmonary emboli– CHFCHF– DKADKA– BioterrorismBioterrorism– Others? Others?

r r O xy g e n

V e inA t e y

Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus

• 72 year old female 72 year old female • CC: Sharp chest pain, short of breath CC: Sharp chest pain, short of breath • History: Legs swollen and pain in right History: Legs swollen and pain in right

calf following flight from Alaska calf following flight from Alaska • Pulse 108 and regular, RR 22, BP 158/88 Pulse 108 and regular, RR 22, BP 158/88

SpOSpO22 95% 95%

Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus

Strong radial pulseStrong radial pulse

Low EtCOLow EtCO22 seen in seen in

decreased alveolar perfusiondecreased alveolar perfusion

Part 4: Part 4: The Non-intubated Patient SummaryThe Non-intubated Patient Summary

• Identify and monitor bronchospasmIdentify and monitor bronchospasm– AsthmaAsthma– COPDCOPD

• Assess and monitor Assess and monitor – Hypoventilation statesHypoventilation states– HyperventilationHyperventilation– Low perfusionLow perfusion– Many others now being reportedMany others now being reported

Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient

Ready to take capnography for a run?Ready to take capnography for a run?

CAPNOGRAPHY In Emergency Care

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