16 capnography part3 intubated

CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care

EDUCATIONAL SERIESEDUCATIONAL SERIES

Part 3:Part 3:IntubatedIntubated

Part 3: The Intubated PatientPart 3: The Intubated Patient

CAPNOGRAPHYCAPNOGRAPHYIn Emergency CareIn Emergency Care

Part 3: The Intubated Patient Part 3: The Intubated Patient Learning ObjectivesLearning Objectives

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

seen in: seen in: – Correct ET tube placementCorrect ET tube placement– ET tube displacementET tube displacement– Effective chest compressionEffective chest compression– ROSCROSC

The Intubated PatientThe Intubated Patient

Capnography ApplicationsCapnography Applicationson Intubated Patientson Intubated Patients

• Confirm correct placement of ET tube Confirm correct placement of ET tube • Detect changes in ET tube position immediatelyDetect changes in ET tube position immediately• ResuscitationResuscitation

– Assess adequacy of chest compressionsAssess adequacy of chest compressions– Detect ROSCDetect ROSC– Objective data for decision to cease resuscitationObjective data for decision to cease resuscitation

• Optimize ventilation of patients Optimize ventilation of patients • Document, document, documentDocument, document, document

Confirm ET Tube PlacementConfirm ET Tube Placement

• Traditional methods of confirmationTraditional methods of confirmation– Listen for breath soundsListen for breath sounds– Observe chest movementObserve chest movement– Auscultate stomachAuscultate stomach– Note ET tube cloudingNote ET tube clouding

These methods are subjective and unreliableThese methods are subjective and unreliable


““Standard physical examination methods, Standard physical examination methods, such as auscultation of lungs and such as auscultation of lungs and epigastrium, visualization of chest epigastrium, visualization of chest movement, and fogging in the tube, movement, and fogging in the tube, are not sufficiently reliable to exclude are not sufficiently reliable to exclude esophageal intubation in all situations.” esophageal intubation in all situations.”

Source: Verification of Endotracheal Tube Placement - Approved by the ACEP Board of Directors, October 2001 http://www.acep.org/1,4923,0.html (policy statement)


• “…“…emergency responders must confirm emergency responders must confirm tracheal tube position by using tracheal tube position by using nonphysical examination techniques.” nonphysical examination techniques.” P I-87 P I-87

• Secondary confirmation with an EtCOSecondary confirmation with an EtCO22 or esophageal detection is Class IIa or esophageal detection is Class IIa recommendation recommendation P I-150P I-150

Source: Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care, Circulation 102 (suppl I) 8. August 22,2000


• “…“…end-tidal COend-tidal CO22 monitors can confirm monitors can confirm successful tracheal tube placement within successful tracheal tube placement within seconds of an intubation attempt” seconds of an intubation attempt” P I-101P I-101

• ““The presence of exhaled COThe presence of exhaled CO22 indicates indicates proper tracheal tube placement.” proper tracheal tube placement.” P I-101P I-101



“…“…devices that use capnographic waveforms devices that use capnographic waveforms are so sensitive that the devices can detect are so sensitive that the devices can detect residual COresidual CO22 (during CA) when the tube is in (during CA) when the tube is in the trachea”.the trachea”. P I-383P I-383



• 108 patients intubated in the field108 patients intubated in the field– 52 trauma patients52 trauma patients– 56 medical patients 56 medical patients

• ET tube placement checked on arrival ET tube placement checked on arrival at the EDat the ED

• 27 patients (25%) had improperly 27 patients (25%) had improperly placed ET tubeplaced ET tube– 18 were in the esophagus18 were in the esophagus– 9 in oropharynx with tip above the cords9 in oropharynx with tip above the cords

Source: Falk J., Sayre M.R. 1999. Confirmation of Airway Placement, Prehospital Emergency Care 3: 273-278


“ “ Consensus was reached that EtCOConsensus was reached that EtCO22 evaluation evaluation was currently the best method for confirming was currently the best method for confirming correct endotracheal tube placement. The group correct endotracheal tube placement. The group agreed that quantitative capnography was agreed that quantitative capnography was currently the best method for determining currently the best method for determining endotracheal tube position and strongly endotracheal tube position and strongly recommends its use.”recommends its use.” P 295P 295

Turtle Creek Consensus Turtle Creek Consensus

Conference on Prehospital CareConference on Prehospital Care

Source: Wayne M., et al. 1999. Management of Difficult Airways in the Field, Journal of Emergency Medicine 3: 290-296


““ All endotracheal intubations must be All endotracheal intubations must be accompanied by an objective confirmation…accompanied by an objective confirmation…The optimal method of measurement is The optimal method of measurement is quantitative capnography and its use on all quantitative capnography and its use on all intubated patients.”intubated patients.” P 277P 277

Source: Falk J., Sayre M.R. 1999. Confirmation of Airway Placement, Prehospital Emergency Care 3: 273-278


• 108 patients intubated in the field108 patients intubated in the field• Compared to the Falk studyCompared to the Falk study

– 9% had improperly placed ET tube versus 9% had improperly placed ET tube versus 25% in previous study25% in previous study

• No unrecognized misplaced ET tubes No unrecognized misplaced ET tubes in patients with continuous end-tidal in patients with continuous end-tidal COCO22 monitoring monitoring

Source: Silvestri S. J., et al. 2003. Improvement in Misplaced Endotracheal Tube Recognition within a Regional Emergency Medical Services System, Academic Emergency Medicine 10 (5): 445 (Abstract)


• Capnography provides Capnography provides – Objective confirmation of correct Objective confirmation of correct

tube placementtube placement– Documentation of correct placementDocumentation of correct placement


45

0


• ET tube placement in esophagus may ET tube placement in esophagus may briefly detect CObriefly detect CO22 – Following carbonated beverage ingestion Following carbonated beverage ingestion – When gastric distention was produced by When gastric distention was produced by

mouth to mouth ventilation mouth to mouth ventilation

• Residual COResidual CO22 will be washed out after will be washed out after 6 positive pressure breaths6 positive pressure breaths

Detect ET Tube DisplacementDetect ET Tube Displacement

• A properly placed ET A properly placed ET tube can be displaced tube can be displaced out of the trachea out of the trachea without any movement without any movement of the proximal tipof the proximal tip

Source: Matera P. 1998. The Truth About ET Tube Movement, JEMS 23: 34-42


• “…“…risk from a misplaced tube is risk from a misplaced tube is unacceptably high and clinical signs unacceptably high and clinical signs confirming tube placement are not confirming tube placement are not completely reliable” completely reliable” P I-296P I-296

• “…“…animal data shows that detection of a animal data shows that detection of a displaced or obstructed tube using pulse displaced or obstructed tube using pulse oximetry or changes in heart rate or blood oximetry or changes in heart rate or blood pressure may be delayed more than pressure may be delayed more than 3 minutes”3 minutes” P I-296 P I-296



• “…“…use of a device to confirm tracheal tube use of a device to confirm tracheal tube placement in the field, in the transport vehicle, placement in the field, in the transport vehicle, and on arrival to the hospital is desirable and and on arrival to the hospital is desirable and strongly encouraged.” strongly encouraged.” P I-296P I-296

• ““Use of a device to confirm tube placement on Use of a device to confirm tube placement on arrival at the hospital is especially important arrival at the hospital is especially important because displacement of the tube is most likely because displacement of the tube is most likely to occur when the patient is moved into and out to occur when the patient is moved into and out of the transport vehicle.” of the transport vehicle.” P I-296P I-296



““ Continuous capnography detects acute Continuous capnography detects acute airway obstruction and hypopharyngeal airway obstruction and hypopharyngeal extubation more rapidly than does pulse extubation more rapidly than does pulse oximetry or vital sign monitoring in a oximetry or vital sign monitoring in a hyperoxemic porcine model.”hyperoxemic porcine model.”

Source: Poirier M. P., et al. 1998. Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps: A hyperoxemic animal model, Am J Emerg Med 16: 350-352.


““ ……displacement of the displacement of the tube is most likely to tube is most likely to occur when the patient occur when the patient is moved into and out of is moved into and out of the transport vehicle.” the transport vehicle.” P P I-296I-296



• Traditional methods of monitoring Traditional methods of monitoring tube positiontube position– Periodic auscultation of breath soundsPeriodic auscultation of breath sounds– Gastric distentionGastric distention– Worsening of patient’s colorWorsening of patient’s color

• Late sign of tube displacementLate sign of tube displacement

These methods are subjective and These methods are subjective and unreliableunreliable—and delayed—and delayed


“ “ Continuous capnography monitoring Continuous capnography monitoring devices can identify and signal a fall in devices can identify and signal a fall in exhaled COexhaled CO22 consistent with tracheal tube consistent with tracheal tube dislodgement. This may be very helpful in dislodgement. This may be very helpful in emergencies when clinicians have other emergencies when clinicians have other responsibilities.” responsibilities.” P 140P 140

Source: ACLS-The Reference Textbook, ACLS: Principles and Practice. Ed. 2003 Cummins, R.O. American Heart Association. ISBN 0-87493-341-2


• CapnographyCapnography– Immediately detects Immediately detects

ET tube displacementET tube displacement

45

0Hypopharyngeal Dislodgement

Source: Murray I. P. et. al. 1983. Early detection of endotracheal tube accidents by monitoring CO2 concentration in respiratory gas. Anesthesiology 344-346


• Only capnography provides Only capnography provides – Continuous numerical value of EtCOContinuous numerical value of EtCO22 with with

apnea alarm after 30 secondsapnea alarm after 30 seconds– Continuous graphic waveform for immediate Continuous graphic waveform for immediate

visual recognitionvisual recognition

45

0

Esophageal Dislodgement

Source: Linko K. et. al. 1983. Capnography for detection of accidental oesophageal intubation. Acta Anesthesiol Scand 27: 199-202


• Capnography providesCapnography provides– Documentation of Documentation of

correct placementcorrect placement– Ongoing documentation Ongoing documentation

over time through the over time through the trending printouttrending printout

– Documentation of Documentation of correct position at correct position at ED arrivalED arrival

Capnography in Capnography in Cardiopulmonary ResuscitationCardiopulmonary Resuscitation

• Assess chest compressionsAssess chest compressions• Early detection Early detection

of ROSCof ROSC• Objective data for decision Objective data for decision

to cease resuscitationto cease resuscitation

CPR: Assess Chest CompressionsCPR: Assess Chest Compressions

• Properly done chest compressions Properly done chest compressions provide provide – 25-30% of normal blood supply to the brain25-30% of normal blood supply to the brain– 5%-10% of normal blood supply to the heart5%-10% of normal blood supply to the heart

• Adequate chest compressions promote Adequate chest compressions promote the elimination of metabolic wastesthe elimination of metabolic wastes


• Airway Airway - open with ET tube - open with ET tube • BreathingBreathing - controlled and stable - controlled and stable• Circulation Circulation - cardiac output directly related - cardiac output directly related

to changes in EtCOto changes in EtCO22

• Capnography provides noninvasive method Capnography provides noninvasive method for monitoring blood flow generated by for monitoring blood flow generated by chest compressionschest compressions


• 19 minipigs19 minipigs

• Relationship between EtCORelationship between EtCO22 and cardiac outputand cardiac output

• Measured before cardiac arrest Measured before cardiac arrest and during CPRand during CPR

Source: Weil M. H. 1985. Cardiac Output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909


• Good correlation between EtCOGood correlation between EtCO22 and and cardiac outputcardiac output

• Decrease in EtCODecrease in EtCO22 reflects a critical reflects a critical reduction of cardiac outputreduction of cardiac output

• Low cardiac output Low cardiac output – Reduces blood flow to the lungsReduces blood flow to the lungs

– Fails to clear COFails to clear CO22 from the bloodstream from the bloodstream

Source: Weil MH. 1985. Cardiac output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909


• Under conditions of constant ventilation, Under conditions of constant ventilation, capnography correlates with the capnography correlates with the circulatory status produced by chest circulatory status produced by chest compressionscompressions

• EtCOEtCO22 has potential value in monitoring has potential value in monitoring effectiveness of CPReffectiveness of CPR

Source: Weil MH. 1985. Cardiac output and end-tidal carbon dioxide, Critical Care Medicine 13 (11): 907-909


• Rescuer fatigue Rescuer fatigue • Ochoa StudyOchoa Study

– Rescuers were not able to maintain adequate Rescuers were not able to maintain adequate chest compressions for more than 1 minutechest compressions for more than 1 minute

– Rescuers did not perceive fatigue even when it Rescuers did not perceive fatigue even when it was measurably presentwas measurably present

Source: Ochoa, F. Javier, et al. 1998. The Effect of Rescuer Fatigue on the Quality of Chest Compressions, Resuscitation April; 37: 149-52


• Increase in EtCOIncrease in EtCO22 has been shown to has been shown to correlate withcorrelate with– A fresh rescuer at a faster compression rateA fresh rescuer at a faster compression rate– A new rescuer during CPR with no change A new rescuer during CPR with no change

in ratein rate– Mechanical compressionsMechanical compressions

Source: White R. D. 1994. Out-of-Hospital Monitoring of End-Tidal Carbon Dioxide Pressure During CPR, Annals of Emergency Medicine 23 (1): 756-761


““ ……measurement of end-tidal carbon dioxide measurement of end-tidal carbon dioxide concentration may be a practical, concentration may be a practical, noninvasive method for monitoring blood noninvasive method for monitoring blood flow generated by compression during flow generated by compression during cardiopulmonary resuscitation and an cardiopulmonary resuscitation and an almost immediate indicator of successful almost immediate indicator of successful resuscitation.”resuscitation.”

Source: Falk J. L. 1988. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation, New England Journal of Medicine 318 (10): 607-611


• Use feedback from Use feedback from EtCOEtCO22 to depth/rate/ to depth/rate/force of chest force of chest compressions compressions during CPRduring CPR

45

0

CPR: Detect ROSCCPR: Detect ROSC

• 90 prehospital patients intubated 90 prehospital patients intubated in the fieldin the field

• 16 survivors16 survivors

• In 13 survivors a rapid rise on COIn 13 survivors a rapid rise on CO22 production was the earliest indicator production was the earliest indicator of ROSCof ROSC– Before a palpable pulse Before a palpable pulse – Prior to blood pressurePrior to blood pressure

Source: Wayne M.A. 1995. Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest. Annals of Emergency Medicine 25 (6): 762-767


• 10 patients on ventilators in ICU10 patients on ventilators in ICU– EtCOEtCO22 increased within 30 seconds of increased within 30 seconds of

ROSC in 7 ROSC in 7

– Rapid rise on CORapid rise on CO22 production was earliest production was earliest indicator of ROSCindicator of ROSC

– “…“…an abrupt increase in the EtCOan abrupt increase in the EtCO22 under under conditions of reasonably constant ventilation conditions of reasonably constant ventilation provides the earliest evidence of successful provides the earliest evidence of successful resuscitation.”resuscitation.”

Source: Falk J. L. 1988. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation, New England Journal of Medicine 318 (10): 607-611125


• Sudden rise in EtCOSudden rise in EtCO22

• Confirm with ECG and capnographyConfirm with ECG and capnography• Questionable pulseQuestionable pulse

– Arterial vasoconstriction may make Arterial vasoconstriction may make pulse difficult to detectpulse difficult to detect


• Briefly stop CPR and Briefly stop CPR and check for organized check for organized rhythm on ECG monitorrhythm on ECG monitor

45

0

Decision to Cease ResuscitationDecision to Cease Resuscitation

• Capnography Capnography – Has been shown to predict probability of Has been shown to predict probability of

outcome following resuscitationoutcome following resuscitation– May be used in the decision to cease May be used in the decision to cease

resuscitation effortsresuscitation efforts

Source: Levine R. L. 1997. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. New England Journal of Medicine 337 (5): 301-306.


• 120 prehospital patients in nontraumatic 120 prehospital patients in nontraumatic cardiac arrestcardiac arrest

• EtCOEtCO22 had 90% sensitivity in had 90% sensitivity in predicting ROSC predicting ROSC

• Maximal level of <10mmHg during the Maximal level of <10mmHg during the first 20 minutes after intubation was first 20 minutes after intubation was never associated with ROSCnever associated with ROSC

Source: Canitneau J. P. 1996. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole, Critical Care Medicine 24: 791-796


• 27 out-of-hospital patients in cardiac arrest 27 out-of-hospital patients in cardiac arrest looked at EtCOlooked at EtCO22 at 3 points at 3 points– 1 and 2 minutes post intubation 1 and 2 minutes post intubation – Maximum EtCOMaximum EtCO22 during CPR during CPR

• EtCOEtCO22 in ROSC was higher at each point in ROSC was higher at each point ROSCROSC No ROSCNo ROSC1 min1 min 23.023.0++ 7 7 13.213.2++14.7 14.7 P =.0002P =.00022 min2 min 26.826.8++10.810.8 15.415.4++5.7 5.7 P =.0019P =.0019MaximumMaximum 30.830.8++9.59.5 22.722.7++8.8 8.8 P =.0022P =.0022

Source: Asplin BR. 1995. Prognostic Value of End-tidal Carbon Dioxide Pressures During Out-of-Hospital Cardiac Arrest, Annals of Emergency Medicine 25 (6): 756-761


• 90 victims of prehospital cardiac arrest with PEA90 victims of prehospital cardiac arrest with PEA

ROSCROSC No ROSCNo ROSCInitialInitial 10.910.9++4.94.9 11.711.7++6.6 6.6 P =.672 (NS)P =.672 (NS)

20 min20 min 31.031.0++5.35.3 3.93.9++2.8 2.8 P <=.0001P <=.0001

• 100% mortality if unable to achieve an EtCO100% mortality if unable to achieve an EtCO22 of of 10mmHg after 20 minutes10mmHg after 20 minutes

Source: Wayne M. A. 1995. Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest, Annals of Emergency Medicine 25 (6): 762-767


• Capnography provides Capnography provides another objective data another objective data point in making a point in making a difficult decisiondifficult decision

0

25

Optimize VentilationOptimize Ventilation

• Monitor ventilation efforts and carbon Monitor ventilation efforts and carbon dioxide levels with capnography dioxide levels with capnography

• Carbon dioxide has a profound affect on Carbon dioxide has a profound affect on cerebral blood flow (CBF)cerebral blood flow (CBF)– Influences intracranial pressure (ICP)Influences intracranial pressure (ICP)


• Use capnography to titrate EtCOUse capnography to titrate EtCO22 levels levels in patients sensitive to fluctuationsin patients sensitive to fluctuations

• Patients with suspected increased Patients with suspected increased intracranial pressure (ICP)intracranial pressure (ICP)– Head traumaHead trauma– StrokeStroke– Brain tumorsBrain tumors– Brain infectionsBrain infections


• Intracranial pressureIntracranial pressure– Tissue and fluid contained within a Tissue and fluid contained within a

rigid compartmentrigid compartment– Affected by changes in any componentAffected by changes in any component

• Treatment goalTreatment goal– Maintain stability Maintain stability – Avoid raising intracranial pressuresAvoid raising intracranial pressures


• Treatment of patients with head injuries Treatment of patients with head injuries and ICPand ICP

Hyperventilate the patient?Hyperventilate the patient?

Do Do NOTNOT hyperventilate the patient? hyperventilate the patient?

Optimize Ventilation Optimize Ventilation

• Hyperventilation is very effective Hyperventilation is very effective at lowering ICPat lowering ICP

• Prophylactic hyperventilation once Prophylactic hyperventilation once mainstay therapymainstay therapy

• New guidelines recommend against New guidelines recommend against prophylactic hyperventilation prophylactic hyperventilation

• Avoid hypoventilating patients with Avoid hypoventilating patients with suspected high ICPsuspected high ICPSource: Huizenga J.E. 2000. Guidelines for the Management of Severe Head Injury: Are Emergency Physicians Following Them? Academic Emergency Medicine 9 (8): 806-812


• Treatment goalsTreatment goals– Maintain stability of EtCOMaintain stability of EtCO22 levels levels

– Maintain adequate blood flow to the brainMaintain adequate blood flow to the brain– Avoid secondary injury as a result of inducing Avoid secondary injury as a result of inducing

or increasing cerebral edemaor increasing cerebral edema


• Treatment goalsTreatment goals• Avoid cerebral hypoxia Avoid cerebral hypoxia

– Monitor blood oxygen Monitor blood oxygen levels with pulse oximetry levels with pulse oximetry

– Maintain adequate CBF Maintain adequate CBF


• High COHigh CO22 levels induce levels induce cerebral vasodilatationcerebral vasodilatation– Positive: Increases CBP to Positive: Increases CBP to

counter cerebral hypoxiacounter cerebral hypoxia– Negative: Increased CBP, Negative: Increased CBP,

increases ICP and may increase increases ICP and may increase brain edema brain edema

• Hypoventilation retains COHypoventilation retains CO22 which increases levelswhich increases levels

COCO22


• Low COLow CO22 levels lead to cerebral levels lead to cerebral vasoconstrictionvasoconstriction– Positive: EtCOPositive: EtCO22 of 25-30mmHG of 25-30mmHG

causes a mild cerebral causes a mild cerebral vasoconstriction which may vasoconstriction which may decrease ICPdecrease ICP

– Negative: Decreased ICP but Negative: Decreased ICP but may cause or increase in may cause or increase in cerebral hypoxiacerebral hypoxia

• Hyperventilation decreases Hyperventilation decreases COCO22 levels levels

COCO22


• ““In summary, after either cardiac arrest In summary, after either cardiac arrest or head trauma, ventilate the comatose or head trauma, ventilate the comatose

patient to achieve normocarbia patient to achieve normocarbia (Class IIa).” (Class IIa).” P 168P 168

• ““Routine hyperventilation may be Routine hyperventilation may be detrimental and should be avoided detrimental and should be avoided

(Class III).” (Class III).” P 168P 168



• Monitor ventilations with Monitor ventilations with capnography to maintain capnography to maintain appropriate and stable appropriate and stable COCO22 levels levels

• Follow local protocols Follow local protocols and medical directionand medical direction

Part 3: The Intubated PatientPart 3: The Intubated PatientSummarySummary

• Capnography can be used in Capnography can be used in intubated patients forintubated patients for– Verification and documentation of Verification and documentation of

ET tube placementET tube placement– Immediate identification of Immediate identification of

ET tube displacementET tube displacement– Confirmation of adequate Confirmation of adequate

chest compressionschest compressions– Early indication of ROSCEarly indication of ROSC

Part 3: The Intubated PatientPart 3: The Intubated PatientSummarySummary

• Capnography can be used in Capnography can be used in intubated patients tointubated patients to– Detect cardiac output when no pulse palpableDetect cardiac output when no pulse palpable– Help in the decision to cease resuscitationHelp in the decision to cease resuscitation

– Maintain COMaintain CO22 levels in patients sensitive levels in patients sensitive to changesto changes

Part 3: The Intubated PatientPart 3: The Intubated Patient

Now you’re catching on!Now you’re catching on!

Health & Medicine

16 capnography part3 intubated