8/12/2009

Why Capnography?

ETCO2 Monitoring in the
Pediatric ED





Randolph Cordle FAAEM
Medical Director: Division of Pediatric Emergency Medicine
Program Director: Pediatric Emergency Medicine Fellowship
Levine Children’s Hospital
Carolinas Medical Center

Great deal of information from the shape of the curve
Can visualize respiratory pattern
Can follow trends
Exact number not as important as relative change
Sample size assurance test QA

Why?





Why?
• ASA closed claim study
• 93% preventable if ETCO2 and oxygen sat
• Only 10% of life-threatening intubation events detected
before adverse event

Detect ventilation
Trend
Too little, too much, “just right”
Is there any blood in the lungs?
Ideal when you can’t watch the chest- transportation

– 35 events detected by ETOC2
– 20 were life threatening
– Only 2 detected clinically

1.

Tinker Anesthesiology 1989; 71:541-546

2.

Cote Can. Anes. Soc. J 1986; 33:315-320

Nomenclature

Microstream Technology Makes
Ideal for The Pediatric ED




Primary system used in the ED
Laser-based-increased sensitivity/specificity for CO2
Sample size (15 µL)
Decreased condensation problems d/t diminished flow
Able to use in much smaller children and even neonates

1

less accurately demonstrates V/Q status Volume typically used in research No inspiratory arm to volume curve Apnea Chemical Indicators • • • • Useful in perfusing patient after intubation Not sensitive when perfusion decreased (CPR) Change from purple to yellow when CO 2 present False-positive CO2 with mucous exposure. gastric content exposure.8/12/2009 Capnography Capnography • We generally use time-based capnography not volume • This allows us to monitor non-intubated patients • This allows observation of inspiratory and expiratory dynamic values • • • • Time capnography= inaccurate dead-space calculation Therefore. and epinephrine • Not a good indicator in the cardiac arrest patient Normal ETCO2 Curve What Decreases ETCO2 • • • • • • Hypovolemia Pulmonary embolism Air embolism Cardiac arrest Apnea Hyperventilation • • • • • Decreased temperature Decreased cardiac output Airway obstruction Hypotension Extubation 2 .

8/12/2009 What Raises the ETCO2 • • • • • Decreased ventilation Partial airway obstruction Rebreathing Increased carbon dioxide Increased pulmonary perfusion • • • • • • • Hyperpyrexia Tourniquet release CO2 gas embolism Increased cardiac output Sodium bicarb infusion Decreased ventilation Nitrous oxide ETOC2 Inherent Error • Atmospheric pressure – Directly correlates. usually minor 1-2 mm of mercury • Oxygen – Inverse correlate ETOC2 Inherent Error Procedural Sedation • H2O – Direct correlate – May want to have humidity filter near patient and monitor to alleviate this source of air • Nitrous Oxide – Direct correlate – Up to approximately 9% overestimation at 70% nitrous oxide • • • • Not proven to improve patient outcomes Allows use of oxygen during procedural sedation ETCO2 increase or level >50 = respiratory depression Should become standard of care – Many monitors will correct for this if data entered Rebreathing Expiratory Obstruction 3 .

Poor ventilation – 2. initial. Equipment error Cardiac Arrest • Essentially no perfusion during arrest • Minimal perfusion during CPR→low ETCO2 – Typically being hyperventilated • Indicator of poor outcome Cardiac Arrest • ROSC→↑perfusion→↑ETOC2 – ETCO2 ≤10 mm mercury at 20 minutes of PEA – 99% probability that survival <3. Poor perfusion of lungs – 3. and final ETCO2 level of <10 were resuscitated JAMA 1989 262:1347-51 N Eng J Med 1997 337(5):301-306 European Journal of Emergency Medicine 2001 8:263-269 4 .9% • Initial ETCO2 not discriminatory at all • GRMEC et al showed that no patient with an average.8/12/2009 Alpha Angle Alpha Angle in Asthma • Angle made between Phase II and III • Generally reflects the slope of Phase III • An indirect indicator of the time constants in the lungs’ alveoli or the V/Q status of the lung • Diagonal lines are typically bad! Cardiac Arrest.No Perfusion? ETCO2 Reflects Cardiac Output • ETCO2 measurement and height of Phase III dependent upon cardiac output • If blood CO2 is high but ETCO2 is low then – 1.

• Confirmation is immediate ETCO2 Through LMA Clefts • Can be useful at times to follow changes. • ETCO2 may be higher than actual arterial CO2 • Primarily seen in pregnant patients and the obese • Also seen in children: especially young children – Roughly ↓ 3 mm mercury ETCO2 for a ↓ 10% O2 saturation Nasal Intubation Phase IV or Equipment Fail • ETCO2 detection Can be Used to improve the safety and success rate of blind nasal intubation • Most easily performed if an audio capnometer is used • Position the tube until the ETCO2 is the greatest and then advance the tube.8/12/2009 Phase IV Cyanotic Heart Disease • • • • Right to left shunt Decreased pulmonary perfusion ETCO2 underestimates arterial CO2 Correlates with O2 saturation • Those with diminished functional capacity due to greater variability in alveolar CO2 release. • Correlates well in adults breathing spontaneously – Does not correlate in spontaneously breathing children • Correlates well in mechanically ventilated infants 5 .

• Once the optimum level of PEEP is reached the ArterialETCO2 Gap will begin to increase again. • Gap determines the optimal level of PEEP Questions 6 .8/12/2009 Arterial-ETCO2 Gap • Patients with pulmonary edema and ARDS will typically have a decrease in their Arterial-ETCO2 Gap as PEEP is increased.