Created byCreated by Joshua English, EMT-PJames Pointer, MDMike Jacobs, EMT-P

Objectives

• Understand why we use capnography• Understand the physiology of respiration/

ventilation

• Define normal & abnormal EtCO2 values/ waveforms

• Understand the 4 major applications of EtCO2– intubated applications (mainstream)– non-intubated applications (sidestream)

• Understand why we use capnography• Understand the physiology of respiration/

ventilation

• Define normal & abnormal EtCO2 values/ waveforms

• Understand the 4 major applications of EtCO2– intubated applications (mainstream)– non-intubated applications (sidestream)

Why Capnography?

Advanced Airway Management (Policy #10102)

All devices used to confirm tube placement must be documented on the PCR.• Esophageal Detection Device (EDD)• End tidal CO2 detector (ETCO2) colorimetric or capnography

“Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.[Annals of Emergency Medicine 2005; 45:497-503]”

Advanced Airway Management (Policy #10102)

All devices used to confirm tube placement must be documented on the PCR.• Esophageal Detection Device (EDD)• End tidal CO2 detector (ETCO2) colorimetric or capnography

“Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.[Annals of Emergency Medicine 2005; 45:497-503]”

Why Capnography?

• Verification of proper tube placement

There is simply NO BETTER WAY to confirm proper tube placement

than with waveform capnography…. PERIOD!!!

• Verification of proper tube placement

There is simply NO BETTER WAY to confirm proper tube placement

than with waveform capnography…. PERIOD!!!

Why Capnography?

Because respiration, ventilation and oxygenation are

VERYVERY different concepts.

Because respiration, ventilation and oxygenation are

VERYVERY different concepts.

Why Capnography?

It’s a window into the patient’s ventilatory status

It’s a window into the patient’s ventilatory status

Why Capnography?

Core Concepts• What intubation verification method is most

reliable?• How do oxygenation and ventilation differ?

Core Concepts• What intubation verification method is most

reliable?• How do oxygenation and ventilation differ?

Physiology

Factors that affect CO2 levels:Factors that affect CO2 levels:INCREASE IN ETCO2 DECREASE IN ETCO2

Increased muscular activity Decreased muscular activity

Increased cardiac output(during resuscitation)

Decreased cardiac output(during resuscitation)

Effective drug therapy for bronchospasm

Bronchospasm

Hypoventilation Hyperventilation

Normal EtCO2

Terminology

Capnograma real-time waveform record of theconcentration of carbon dioxide in therespiratory gases

CapnographCapnogram waveform plusnumerical value

Capnograma real-time waveform record of theconcentration of carbon dioxide in therespiratory gases

CapnographCapnogram waveform plusnumerical value

Terminology

EtCO2 – End Tidal CO2

The measurement of exhaled CO2 in the breathNormal Range | 35-45 mmHg

EtCO2 – End Tidal CO2

The measurement of exhaled CO2 in the breathNormal Range | 35-45 mmHg

Normal Waveform

End of inspiration

Beginning of exhalation

End of exhalation

Beginning of new breath

Alveolar plateau

Clearing of anatomic dead space

Normal

Common Waveforms

Hyperventilation

Hypoventilation

Common Waveforms

4 Main Uses of Capnography

• Severity of asthma patients

• Monitoring head injured patients

• Cardiac arrest

• Tube confirmation

• Severity of asthma patients

• Monitoring head injured patients

• Cardiac arrest

• Tube confirmation

Terminology

SidestreamAn indirect method of measuring exhaled CO2 in non-

intubated patients

MainstreamDirect method of measuring exhaled CO2 with intubated

patients

SidestreamAn indirect method of measuring exhaled CO2 in non-

intubated patients

MainstreamDirect method of measuring exhaled CO2 with intubated

patients

Shark Fin

Asthmatic Waveforms

COPD patients have a difficult time exhaling gases

This is represented on the capnogram by a shark fin appearance

Moderate Attack

Mild Attack

EtCO2 & Asthma

Severe Attack

EtCO2 & Asthma

Time To Get MOVING!!!The asthmatic who looks tired and has a shark fin appearance

on the capnogram…IS HEADED FOR RESPIRATORY ARREST

Time To Get MOVING!!!The asthmatic who looks tired and has a shark fin appearance

on the capnogram…IS HEADED FOR RESPIRATORY ARREST

The Head Injured PatientCarbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault and therefore increasing ICP

Recognizing the head injured patient and titrating their CO2 levels to the 30-35 30-35 mmHgmmHg range can help relieve the untoward effects of ICP

Titrate EtCO2

The Head Injured PatientTitration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO2 levels.

Keep them between 30 and 35 mmHg

EtCO2 and Cardiac Arrest

The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output

Increase in CO2 during CPR can be an early indicator of ROSC

Termination of Resuscitation

EtCO2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR

Non-survivors <10 mmHg10 mmHg

Survivors >30 mmHg30 mmHg ((to discharge)

ET Tube Verification

• Verification of proper tube placement

There is simply NO BETTER WAY to confirm proper tube placement

than with waveform capnography…. PERIOD!!!

• Verification of proper tube placement

There is simply NO BETTER WAY to confirm proper tube placement

than with waveform capnography…. PERIOD!!!

4 Main Uses of Capnography

Core Concepts• What is the characteristic shape of a capnogram for a

COPD patient?• Describe how to determine the severity of an asthma

attack using capnography?• What level should you maintain a severe head injured

patient’s CO2 at?• What are two ways that capnography can assist during

CPR?

Core Concepts• What is the characteristic shape of a capnogram for a

COPD patient?• Describe how to determine the severity of an asthma

attack using capnography?• What level should you maintain a severe head injured

patient’s CO2 at?• What are two ways that capnography can assist during

CPR?

Inadequate Seal

Troubleshooting

As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff

Obstruction

Troubleshooting

An obstructed ET tube may have an erratic EtCO2 value with a very irregular waveform

Rebreathing

Troubleshooting

A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO2 through insufficient inspiratory or expiratory flow

QUIZ

Hypoventilation

Rebreathing

Esophageal Tube

Asthma

Normal

Questions?