Riding the Waves | Respiratory Tract | Exhalation

RIDING THE WAVES

The Role of Capnography in EMS
By Bob Page, AAS, NREMT-P, CCEMT-P, I/C Powerpoint by Steven Carter NREMT-P, FTO

RIDING THE WAVES: THE ROLE OF CAPNOGRAPHY IN EMS

Objectives ²following this lesson, you should be able to:  Describe the structure and function of the upper and lower airways.  Describe the mechanics and science of ventilation and respiration.  Describe the basic physiology behind perfusion.  Describe the relationship between ventilation and perfusion.  Describe the principles behind CO2 measurement.  Discuss the various clinical applications of capnography in the field.

OBJECTIVES CONTINUED«   



Describe the various methods of EtCO2 measurement including quantitative and qualitative capnometry and capnography. Describe the technology of EtCO2 measurement including mainstream, sidestream, and microstream sampling. Identify the components of a normal capnogram waveform. Given various cases, discuss the role of capnography in identifying the problem and in the management of the patient.

and assess efficacy of code efforts and predict outcomes. .INTRODUCTION Capnography is a non-invasive method for monitoring the level of carbon dioxide in exhaled breath (EtCO2). or capnogram. warning of airway leaks and ventilator circuit disconnections. to assess a patient·s ventilatory status. Capnography is also useful for ensuring proper endotracheal tube placement. capnograms are useful for monitoring ventilatory status. On CCT. make treatment decisions. A true capnogram produces an EtCO2 value as well as a waveform. Capnography also helps clinicians diagnose specific medical conditions.

.Capnography offers many clinical uses. but technical limitations have prevented EMS personnel from embracing its use outside the operating room. Today. technological advances have made it possible for these devices to be used in the demanding setting of the prehospital environment.

REVIEW OF AIRWAY A & P .

UPPER AIRWAY .

. The primary roles of the upper airway are to _____________. the air entering the lungs. and _____________. The purpose of PEEP is to prevent alveolar collapse.UPPER AIRWAY CONTINUED Upper airway physiology: Positive End Expiratory Pressure (PEEP) can be defined as the pressure against which exhalation occurs. The structure and pathway of the upper airway provides for a natural or ´physiological PEEPµ. _______________.

LOWER AIRWAY .

bronchi. This is air that is not exchanged.LOWER AIRWAY CONTINUED The lower airway is comprised of the trachea. The area from the bronchioles to the nose comprise the total dead space air. . and the 25 divisions of the bronchial tree terminating at the bronchioles and the alveoli.

.ALVEOLI The alveoli are tiny sacs where gas exchange occur. O2 and CO2 are exchanged at the capillary-alveolar membrane.

Rule #1 of life: Air MUST go in and out.   Ventilation is the movement of air. . Designed to eliminate CO2 and take in O2.VENTILATION THE PHYSIOLOGY OF VENTILATION .

´ Hypoxic drive (low O2 levels) is secondary drive. triggering ventilation. ´ Intercostal muscles spread the chest wall out increasing the volume inside the chest. ´ Diaphragm contracts and moves downward. Known as the hypercarbic drive. ´ Differences in pressure inside the chest and outside causes air to move into the lungs.HOW AIR MOVES Chemoreceptors in the medulla sense elevated levels of CO2 or lowered pH. ´ .

Typically 500 mL in an adult at rest ´ Anatomical Dead Space (Vd). ´ . ´ Alveolar Volume (Va). Typically about 350 mL (Vt²Vd= Va) ´ Anything that affects tidal volume only affects alveolar volume.air not available for gas exchange.the amount of air moved in one breath.air that is available for gas exchange.VOLUME CAPACITIES Tidal Volume (Vt). Typically 150 mL.

FACTORS AFFECTING TIDAL VOLUME HYPERVENTILATION  Tachypnea doesn·t necessarily increase tidal volume.  Anxiety. diabetic emergencies. narcotic use. . head injuries.  CNS disorders. PE. and others HYPOVENTILATION  Bradypnea doesn·t necessarily decrease tidal volume. AMI. etc.

Alveolar respiration occurs between the __________ and the ___________ in the lungs.RESPIRATION Respiration is the exchange of gases. .

ALVEOLAR RESPIRATION .

CELLULAR RESPIRATION Cellular respiration occurs between the __________ in the body and the __________. (a. gas will move from the area of greater concentration to the area of lower concentration. diffusion) .k.a. When there is a difference in partial pressure between the two containers.

CELLULAR RESPIRATION CONTINUED .

the following must be present: .   Fick Principle: oxygen transport In order for cellular perfusion to occur.PERFUSION The physiology of perfusion: Rule #2 in life: Blood must go round and round.

 Adequate blood pressure to push the cells.  RBCs must be able to offload and take on O2. .PERFUSION CONTINUED Adequate number of Red Blood Cells (RBCs) .Hemoglobin on the RBCs to carry the O2 molecules  Adequate O2: See rule #1 of life.Some conditions such as CO poisoning and cyanide poisoning affect the RBC·s ability to bind and release O2 molecules.  .

PHYSIOLOGIC BALANCE .

CRITICAL THINKING CASES A. C. D. Normal ventilation/ Normal perfusion Normal ventilation/ Compromised perfusion Compromised ventilation/ Normal perfusion Compromised ventilation & perfusion B. .

V/S are 110/70. RR is 12 and very shallow. COMPROMISED VENTILATION/ NORMAL PERFUSION  . She is UNCONSCIOUS. skin is warm and dry.CRITICAL THINKING CASE #1 ´ 26y/o female patient took an overdose of valium. P 64.

V/S are 140/78.CRITICAL THINKING CASE #2 ´ 65y/o male complaining of a sudden onset of right sided chest pain with dyspnea. RR is 20 and normal depth. NORMAL VENTILATION & PERFUSION  . P 110. He has no medical history except for a hip replacement surgery 3 weeks ago. His lung sounds are clear.

CRITICAL THINKING CASE #3 ´ 80y/o male complains of sudden onset of severe headache. RR 16 and normal depth. He has flushed skin and has obvious facial droop to the left side. He has a history of HTN and V/S are 180/110. P 100. NORMAL VENTILATION/ COMPROMISED PERFUSION  .

CRITICAL THINKING CASE #4 ´ 37 y/o female involved in a head on collision. Windshield is starred and the steering wheel is broken. Patient is unconscious. difficult to bag with absent breath sounds on the left. skin is cool & clammy. P 130 and weak at the carotid. V/S 60/40. COMPROMISED VENTILATION & PERFUSION  . obvious JVD. Bruising and crepitus found over the left chest.

TECHNOLOGY OF CAPNOGRAPHY ´ The role of CO2 .CO2 is the ´Gas of Lifeµ -Produced as a normal by-product of metabolism ´ Measurement of EtCO2 (Capnometry) -Qualitative Color change assay CO2 turns the sensor from purple to yellow   .

QUALITATIVE CAPNOMETRY Standard Color Change Device .

MEASUREMENT OF ETCO2 CONTINUED - Quantitative Gives you an ETCO2 value Gives you a respiratory rate .

WAVEFORM CAPNOGRAPHY   Features quantitative value and waveform Capnography includes Capnometry ´ETCO2 reading without a waveform is like a heart rate without an EKG tracing.µ .

TYPES OF CO2 SAMPLING ´     Infrared Spectroscopy Most often used Infrared light is used to expose the sample IR sensors detect the absorbed light and calculate a value Broad spectrum IR beams can absorb N20 and high O2 levels .

CO2 SAMPLING CONTINUED ´    Side Stream Sampling 1st generation devices Draws large sample into the machine from the line Can be used on intubated and nonintubated patients with a nasal cannula attachment .

SIDE STREAM DEVICES .

CO2 SAMPLING CONTINUED ´   MicrostreamŒ Technology Position independent adapters Moisture. secretion. samples taken from center of line in 1/20th the volume 2. & contaminant handling in 3 ways 1. vapor permeable tubing 3. sub-micron multi-surface filters Expensive parts are protected Microbeam IR sensor is CO2 specific Suitable for adults and pediatrics    .

7. or prolonged? Read the EtCO2 If ABG is available. sloping. If they are within 5 mmHg of each other then the problem is ventilatory and not perfusion. prolonged. b. compare EtCO2 to PaCO2 a. or sloping? Inspiratory downstroke: steep. 5. Is CO2 present? (waveform present) Look at the respiratory baseline. 6. Is there rebreathing? Expiratory upstroke: steep. 3.SYSTEMATIC APPROACH TO WAVEFORM INTERPRETATION 1. EtCO2 can be used in many cases in lieu of ABGs . 4. sloping or prolonged? Expiratory plateau: flat. notched. 2.

THE ABCS OF WAVEFORM INTERPRETATION
A.

B.

C.

Airway- look for signs of obstructed airway (steep, upsloping expiratory plateau) Breathing- look at EtCO2 reading. Look for waveforms and elevated respiratory baseline. Circulation- look at your trends, long and short term for increases or decreases in EtCO2 readings.

Street wisdom: A patient complains of having difficulty breathing. The pulse oximeter shows 98% on 15 lpm. As you attempt to listen to lung sounds, they are hard to make out in the back of the ambulance. What benefit, if any could capnography make in the diagnosis and management of this patient? What is the difference between capnography and pulse oximetry?

SPO2 VS. ETCO2 

Pulse Oximetry = SpO2 - measures oxygenation Capnography = EtCO2 ² measures ventilation 

NORMAL CAPNOGRAPHY This is a normal capnogram that has all of the phases that are easily appreciated. Note the gradual upslope and alveolar plateau. .

ABNORMAL CAPNOGRAPHY Hyperventilation ‡ This capnogram starts slow and has an EtCO2 reading that is normal. . the waveform gets narrower and there is a steady decrease in the EtCO2 to below 30 mmHg. Notice as the rate gets faster.

HYPERVENTILATION CONTINUED Causes of this type of waveform include: Hyperventilation Syndrome  Overzealous bagging  Pulmonary Embolism  .

there is a gradual increase in EtCO2 with no apparent obstruction.HYPOVENTILATION In this capnogram. .

HYPOVENTILATION CONTINUED Causes may include: Narcotic Overdose  CNS Dysfunction  Heavy sedation  .

. Capnography allows for instantaneous recognition of this potentially fatal condition.APNEA This capnogram shows a complete loss of waveform indicating no CO2 present.

Check all connections and sampling chambers.APNEA CONTINUED Potential causes for this waveform include:  Dislodged ET tube  Total obstruction of the ET tube  Respiratory arrest in the non-intubated patient  Equipment malfunction (if the patient is still breathing). .

meaning incomplete or obstructed exhalation. .LOSS OF ALVEOLAR PLATEAU This capnogram shows abnormal loss of the alveolar plateau. Note the ´shark finµ pattern.

The ´shark finµ is typically found in the following conditions:  Bronchoconstriction  Asthma  COPD  Incomplete airway obstruction  Upper airway diseases  Sampling tube is kinked or obstructed by mucous .

The fatigue of the first rescuer was demonstrated when the second rescuer took over compressions. . Note the trough in the center of the capnogram. During this time.POOR PERFUSION (CARDIAC ARREST) This capnogram indicates perfusion during CPR and effectiveness of resuscitation efforts. there was a change in personnel doing CPR.

Studies have shown that consistently low readings (less than 10 mmHg) during resuscitation reflect a poor outcome and futile resuscitation. Notice the dramatic change in the EtCO2 when pulses are restored. .CARDIAC ARREST CONTINUED This patient was defibrillated successfully with a return of spontaneous pulse.

. This indicates incomplete inhalation and/or exhalation. CO2 does not get completely washed out on inhalation.ELEVATED BASELINE This capnogram demonstrates an elevation to the baseline.

ELEVATED BASELINE CONTINUED Possible causes for this include: Air trapping (asthma/COPD)  CO2 rebreathing (ventilator circuit problem)  .

increasing pressure Hyperventilation no longer recommended Ventilation should be geared towards controlling CO2 levels but not overdoing it     .FIELD CLINICAL APPLICATIONS FOR CAPNOGRAPHY   Closed head injury Increased intercranial pressure (ICP) tied to increased blood flow following injury Hypoxic cells produce CO2 in the brain CO2 causes vasodilation and more blood fills the cranium.

FIELD CLINICAL APPLICATIONS CONTINUED    COPD Waveform can indicate bronchoconstriction where wheezes may not have been heard Monitors the effectiveness of bronchodilator therapies .

FIELD CLINICAL APPLICATIONS CONTINUED       Tube Confirmation Capnography will detect the presence of CO2 in expired air confirming ETT placement No longer acceptable to use only the lung sounds to confirm A dislodged tube will detect immediately with capnography Kinking or clotting tubes can also be detected In cases of ventilator use. capnography can detect problems in rebreathing .

can detect ventilation or perfusion problems .FIELD CLINICAL APPLICATIONS CONTINUED     Perfusion Capnography can be set up to trend EtCO2 to detect the presence or absence of perfusion Is a proven predictor of those who do not survive resuscitation When an ABG is unavailable.

He has a history of cardiac disease and asthma. pulse rate of 100.CASE #1  Presentation The patient is a 65 year-old male complaining of crushing substernal chest pain. He denies shortness of breath or any other complaints. RR 20 SpO2 96% EtCO2 40 Cardiac monitor shows Sinus Tachycardia. He rates the pain a 10 on a scale of 1 to 10. .  Clinical Situation V/S 130/80.

CASE #1 CONTINUED Is the EtCO2 within normal limits?  Is the waveform normal or abnormal? Why or why not?  What can you deduce about the ventilation status?  .

He has been compliant with his medications until he ran out of albuterol. Today. He does not have his albuterol inhaler with him.  Clinical Situation V/S 140/76.CASE #2  Presentation The patient is a 25 year-old male with a history of asthma. RR 14 SpO2 94% EtCO2 50 . he suddenly becomes short of breath. in minor respiratory distress. It is noisy and hard to hear lung sounds. He presents sitting in the bleachers. while at a basketball game. pulse 100.

CASE #2 CONTINUED    Is the EtCO2 within normal limits? Is the waveform normal or abnormal? Why or why not? What can you deduce about the ventilation status? .

The patient is still unstable and the decision is made to load and go because of the very short transport time to the ED.CASE #3  Presentation You and your partner are working a cardiac arrest and are successful in resuscitation. pulse 88. The patient is not breathing on his own. He is intubated and EtCO2 is confirmed with a good waveform and an EtCO2 of about 42 mmHg. EtCO2 40-42 . RR 12 via BVM. SpO2 100%.  Clinical Situation V/S 100/70.

CASE #3 CONTINUED    Is the capnography within normal limits? Is the waveform normal or abnormal? Why or why not? What can you deduce about the ventilation status? .

CASE #3 CONTINUED  After loading the patient into the ambulance. The capnography alarm sounds and the following waveform is seen: . the first responders resume ventilation.

CASE #4  Presentation You have a 30 year-old female who was in status epilepticus. glucose 100 . SpO2 is 96% on 6 lpm nasal cannula. The patient appears to be postictal but is slow to respond fully. Your partner has administered Valium to halt the seizures. RR 12.  Clinical Situation V/S 114/68. pulse 96.

CASE #4 CONTINUED    Is the EtCO2 within normal limits? Is the waveform normal or abnormal? Why or why not? What can you deduce about the ventilatory status? .

He presents in obvious distress and cannot speak due to the distress. SpO2 88% . He is pale and diaphoretic and appears to be getting weaker. Family tells you that he has a bad heart and takes a ´heart pillµ and a ´water pillµ. RR is labored.  Clinical Situation V/S 158/90.CASE #5  Presentation Its 3 AM and you·re called to the residence of a 60 year-old male who is in respiratory distress. pulse 130. You find the gentleman sitting up on his bed with his feet dangling off the end. Patient becomes obtunded with labored breathing. His lung fields are very diminished with crackles heard. He still has a gag reflex.

CASE #5 CONTINUED    Is the EtCO2 within normal limits? Is the waveform normal or abnormal? Why or why not? What can you deduce about the ventilation status? .

however. The tube is passed although the lung sounds are so diminished they are hard to hear. The pulse oximeter offers no change. the capnogram shows the following: .CASE #5 CONTINUED The decision is made to nasally intubate this patient.

. For years. Now. Not since the cardiac monitor and paramedics manually reading EKG strips has one device had the ability to benefit such a wide variety of patients. Anesthesiologists have used waveform capnography as their standard for monitoring the vital functions of patients.CLOSING REMARKS Capnography represents another great stride in the advances in technology and medicine that have made way into the field. the technology allows a smaller version to be used by EMS.

SUMMARY Why do you need capnography?  Ventilation vital sign  Confirmation of tube placement  Constant monitoring of airway. and perfusion  Detect bronchoconstriction in obstructive airway diseases  Any respiratory patient  Closed head injuries to guide the careful elimination of CO2  Progressive monitoring of perfusion and ventilation . ventilation.

Why a color change device isn·t enough?  Only confirms the presence of CO2. it cannot detect bronchoconstriction  It cannot trend the level of CO2 . not the amount  Can·t monitor the patient Why a quantitative device isn·t enough?  While a number is better than color change.

lets go SURFING!! .NOW FOR SOMETHING A LITTLE DIFFERENT Grab your board.

ETCO2 AS A RESULT OF REDUCED CARDIAC OUTPUT .

WHAT¶S YOUR SUSPICION? 72 year-old female with severe exertional dyspnea. SpO2 of 97% EtCO2 12 with a normal waveform. RR 44. . Her medical history is HTN and recent surgery to remove the bladder and uterus due to cancer. pulse 118. Vital signs: 102/64.

CURARE CLEFT .

com .ACKNOWLEDGEMENTS   Riding the Waves: The Role of Capnography in EMS by Bob Page Capnography.

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