4/30/12

Volumetric Capnography:
Clinical Utility of VCO2 during Mechanical
Ventilation of Pediatric and Neonatal Patients

Robert Campbell, RRT FAARC

National Ventilation Technical Specialist
Philips Healthcare

Objectives
•  Define VCO2
•  Describe how VCO2 measured
•  Describe the difference between EtCO2 & PaCO2
•  Explain the relationship between VCO2 & PaCO2
•  Understand the clinical application of VCO2 for ventilator
management in the Pediatric and Neonatal environment

What is VCO2???
•  VCO2 is the volume of carbon dioxide
eliminated or excreted through the lungs
•  VCO2 reflects changes in both ventilation
and perfusion
•  In steady state, reflects CO2 production

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Why Monitor VCO2???

•  Validates need for ABG
s
•  Identifies immediate changes in Ventilation and
Perfusion (V/Q matching)
•  Allows optimization of MV parameters
•  Trended data may expedite weaning
•  VD/VT measurements can determine the severity
of insult and prognosis

Ventilation- Perfusion Relationships

Relationship between ventilated alveoli and blood

flow in the pulmonary capillaries

CO2 O2

Shunt perfusion Normal Deadspace Ventilation

Alveoli perfused Ventilation and Alveoli ventilated but not
but not ventilated perfusion is matched perfused

What Have We
Traditionally Used
To Monitor Our
Patients?

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Respiratory Parameters
•  ABG – Arterial Blood Gas
–  Gold standard
–  Measures ventilation and oxygenation
•  Pulse oximetry measures oxygenation
•  Capnography measures ETCO2

Non-Invasive CO2
•  Detector/Indicator
•  Capnometry
•  Capnography

Advanced Monitoring
Capabilities

•  EtCO2 •  CO2 Elimination

•  Capnogram •  Deadspace
•  Respiratory •  Alveolar
Rate Ventilation
•  Physiologic VD/VT

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Volumetric CO2
Leap Frog Technology

Single Breath CO2

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Volumetric Capnography Measures

the Volume of Exhaled CO2

ETCO2 is a Measure of the partial

pressure exerted in a gas

Volumetric CO2

EtCO2 = 32 mmHg EtCO2 = 32 mmHg EtCO2 = 32 mmHg

.
Vt = 600 ml .
Vt = 800 ml .
Vt = 1000 ml
VCO2 = 50 ml/min VCO2 = 200 ml/min VCO2 = 300 ml/min

Important Parameters

–  Phys VD / VT PaCO2 - PeCO2 Y+Z

=
PaCO2 X+Y+Z

–  Alveolar
Ventilation

–  Min. Vol. CO2

(VCO2)

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ETCO2/PaCO2 Gradient

•  What Does This Gradient tell us?

Capnography
Arterial - End Tidal CO2 Gradient

In healthy lungs the normal PaCO2 to

ETCO2 gradient is 2-4 mmHg

In diseased lungs, the gradient will

increase due to ventilation/perfusion
mismatch

Gradient as a tool
•  Why?
–  Lets clinicians know when patient status
improves

  PaCO2/ETCO2 gradient narrows
–  Aids in determining what caused a drop in
ETCO2

  If ventilation hasn
t changed a sudden and
large drop in ETCO2 usually indicates a
change in perfusion
– Requires an ABG to differentiate

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Dead Space Ventilation

ETCO2 = 33 mmHg
PaCO2 = 53 mmHg

Alveoli that do not

53 take part in gas
53 exchange will still
0 have no CO2 –
Therefore they will
0 0 53 dilute the CO2 from the
0 alveoli that were
0 perfused
0 0

The result is a widened ETCO2 to PaCO2 Gradient

VD/VT
•  Ratio of Total Deadspace (VD and VDphys) to Tidal
Volume (VT)
•  Total Deadspace = Airway + Alveolar Deadspace
•  Normal = 0.25 to 0.30
•  Estimates the Overall (In)efficiency of the
Cardiorespiratory System

Why measure Vd/Vt?

•  Pulmonary dead space is ventilation that is
wasted as it does not participate in gas
exchange.
•  Increase in Vd represents impaired ability to
excrete CO2
•  Increased dead-space fraction is a feature of
the early phase of the ARDS
•  Elevated values of Vd/Vt are associated with an
increased risk of death*
*New England Journal of Medicine 2002;346: 1281-6

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Outcomes

•  Deadspace fraction
•  Elevated in early ARDS:
0.58 ± 0.09
•  Higher in patients who
died (0.63±0.10 vs.
0.54±0.10)
•  For every 0.5
, odds of
death
by 45%

MValv
 

 

•  Alveolar ventilation per minute
•  Amount of VT that reaches the
alveoli and is available for gas
exchange (effective ventilation)

Why Measure MValv ?

  To provide the most effective CO2 Removal

  To manage alveolar ventilation and not Vte as measured by
the ventilator

Evaluate ventilator settings

500 ml delivered VT – 150 ml airway deadspace = 345 ml

Why is this important?

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Evaluate ventilator settings

Knowing how much of the delivered VT is available for

gas exchange is important – if the patient is fighting the
vent and restless, the issue may be
alveolar VT

Ineffective Ventilation

Monitoring CO2 elimination

•  CO2 elimination provides continuous feedback
regarding ventilation and perfusion
–  Relationship between PaCO2 and CO2
elimination is either stable or inverse
–  Instant feedback when making ventilator
setting changes:

  Did perfusion change?

  Did ventilation change?

  With PaCO2 from an ABG, you can
answer the question, did Vd/Vt change?

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VCO2/MValv Relationship

VCO2/MValv Relationship

VCO2/MValv Relationship

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Duke university medical center

•  Extubation Study
–  Demonstrated that VD/
100
VT ratio measurements 90
4

successfully predicted 80
33

extubation outcomes 70

–  Elevated VD/VT, 60 80

warning of patient risk 50 96

40
for respiratory difficulty 30
67

20

10 20

0
<0.50 0.51-0.64 >0.64

% Success % Failure

Independent Effect of Etiology of Failure and Time to Reintubation on Outcome for Patients Failing Extubation
S. Epstein & R Ciubotaru, AJRCCM, Vol. 158, N°2, August 1998, 489-493

Successful Weaning Trial

  Shows
in spontaneous alveolar
ventilation & corresponding decrease
in ventilator support.

 
VCO2 suggests
metabolic
activity due to additional task of
breathing by the patient.

  Delivered mechanical tidal volume

has not changed & spontaneous tidal
volume is increasing (SIMV rate
).

  Shows PATIENT RESPONSE to
the trial allowing for better
management of the weaning process.

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Unsuccessful Weaning
Trial

  SIMV
and patient started to
take over ventilation.

  But patient shows signs of fatigue
at early stage (
VCO2 followed by

in spontaneous tidal volume).

  Leads to
in PaCO2 & EtCO2.

  Return to mechanical ventilation.

  Assists clinicians in determining
PATIENT RESPONSE.

  When used effectively, these
utilities may help reduce costly
ventilator days.

Spont Breathing Trials-SBT

Successful SBT

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Unsuccessful SBT

  Initially, patient had a small amount of
ventilatory support, but then was placed
on a T-piece. The entire task of breathing
was placed on the patient.

  Within minutes trends showed that the
patient was unable to support the required
level of ventilation (VCO2 decreasing
since total Alveolar Ventilation is
decreasing).

  Spontaneous Tidal Volume trend also
shows inadequate ventilation.

  Removal of mechanical support,
increased Vd/Vt, reducing ventilatory
efficiency and the patient
s ability to
remove CO2. This resulted in a pattern of
rapid shallow breaths requiring the patient
to be placed back on full mechanical
support.

Stable Ventilation with

Decreasing VCO2 Showing
a Change in Perfusion

  Monitoring trends allows for
detection of sudden and rapid
in
VCO2, without change in Alveolar
Minute Volume or Tidal Volumes.

  Drop in VCO2 suggests change in
blood flow to the lungs.

 
VCO2 may be due to
in
C.O. or blood loss.

 
VCO2 may be due to
in
C.O. or malignant hyperthermia.

  Coupled with Alveolar Ventilation
and Deadspace measurements, this
allows for quick patient assessment.

Optimization of PEEP

•  To Minimize Lung Injury:

–  Provide enough PEEP to recruit the
recruitable alveoli, but not apply too much
PEEP to over distend the healthier regions
–  Avoid a PEEP/Vt/P combination that doesn
t
unnecessarily over distend lung regions at
end inspiration (overall PIP)

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How Much Peep is Enough?

ALuRT

Observe for stable

baseline
•  PEEP is at 10 cm
H2O in this
example

ALuRT

Step 1
•  PEEP is
from 10 cm
H2O to 12 cm H2O for
5-15 minutes. No change
in Vtalv and VCO2 (CO2
elimination) indicates no
alveolar recruitment

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ALuRT

Step 2
•  PEEP is
to 14 cm H2O
for
5-15 minutes and Vtalv
and CO2 elimination begin
to increase indicating
alveolar recruitment.

ALuRT

Step 3
•  PEEP is increased to
16 cm H2O and VTalv
and CO2 elimination
continue to rise.

ALuRT

Step 4
•  At a PEEP of 18 cm
H2O we see no
increase in Vtalv and
VCO2 drops indicating
worsening V/Q from
decreased pulmonary
perfusion.

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ALuRT

Step 5
•  When PEEP is
to 16
cm H2O, CO2 elimination

back to baseline
meaning optimal
recruitment pressures
and pulmonary
perfusion (V/Q).

Store plot prior to first PEEP increase

Single breath CO2 waveform

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Drop in Perfusion

Recruitment Maneuver

Before recruitment After recruitment

ALuRT provides continuous monitoring

to detect derecruitment of alveoli
•
Alveolar ventilation and VCO2 will decrease if the
lung de-recruits

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Using VTalv and VCO2 to recruit alveoli

•  Clinical Course
–  PEEP increased by 2 cm
H2O every 10 minutes
–  Observed Vtalv/VCO2/SpO2
•  Red arrows show PEEP 
•  No deterioration in VCO2

  V/Q stable

•  VTalv starts to  at 16 cm H2O,

alveoli are being recruited
•  SpO2 responds at 20 cm H2O

Pt in Bronchospasm

Patient with Asthma –

Improvement Following Aerosol
Therapy
CO2 Day 1

Day 5

Exhaled Volume

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Bedside Applications

Monitoring the
Patient
s Response to
Ventilator
Management

Ventilation Management

Optimize Vt Setting

•  Use Vdaw and Vdalv to assure adequate VT

VCO2 •  Use Single Breath Curve to assess phase III
Vd/Vt
MValv

Ventilation Management

Optimize PEEP

•  Use Vtalv, VCO2, and trend to determine lung

VCO2
recruitment and optimal PEEP
Vd/Vt •  Use Single Breath Curve for immediate
MValv feedback

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Ventilation Management

Optimize Weaning

•  Use MValv and VCO2 to trend weaning

VCO2
tolerance
Vd/Vt •  Early detection of fatigue and failure
MValv •  Enhanced titration of adequate support and
confirmation of
resting state

Ventilation Management

Surfactant Replacement

•  Use MValv, VCO2, and single breath curve to

VCO2
manage ventilation during surfactant
replacement therapy
Vd/Vt
MValv •  Detect open and available lung units
•  Enhanced titration of adequate settings as
lung compliance and volume change

Ventilation Management

Inhaled Nitric Oxide

•  Use MValv, VCO2, and single breath curve to

VCO2
manage ventilation during Inhaled Nitric
Oxide therapy
Vd/Vt
MValv •  Especially useful during weaning of INO
•  Confirm maintenance of lung recruitment and
adequate PEEP

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Weaning Criteria

Guide Weaning Process

Vd/Vt is a single variable that defines total
cardiorespiratory system efficiency and can predict
successful extubation

“A Vd/Vt ratio less than 0.50 reliably predicts successful

extubation whereas a Vd/Vt ratio greater than 0.65
correlates with extubation failure.

Dead Space to Tidal Volume Ratio (Vd/Vt) Predicts Successful Extubation in Infants and Children –
Christopher Hubble MD, Mike Gentile RRT, Donna Tripp RRT, Damian Craig MS, Jon Meliones
MD, FCCM, Ira Cheifetz MD – Critical Care Medicine, Vol. 28, N°6 – June 2000

VCO2:
Useful adjunct for monitoring
during Mechanical Ventilation

Questions ?

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