Created by Joshua English, EMT-P James Pointer, MD Mike Jacobs, EMT-P

Objectives • Understand why we use capnography • Understand the physiology of respiration/ ventilation • Define normal & abnormal EtCO 2 values/ waveforms • Understand the 4 major applications of EtCO 2 – 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 EtCO 2 monitoring. Failure to use continuous EtCO 2 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!!!

Why Capnography?

Because respiration, ventilation and oxygenation are VERY different concepts.

Why Capnography?

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?

Physiology

Factors that affect CO2 levels: INCREASE IN ETCO 2 Increased muscular activity Increased cardiac output (during resuscitation) Effective drug therapy for bronchospasm Hypoventilation DECREASE IN ETCO 2 Decreased muscular activity Decreased cardiac output (during resuscitation) Bronchospasm Hyperventilation

Normal EtCO 2

Terminology Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value

Terminology EtCO 2 – End Tidal CO 2 The measurement of exhaled CO 2 in the breath Normal Range | 35-45 mmHg

Normal Waveform

Beginning of exhalation Alveolar plateau End of inspiration End of exhalation Beginning of new breath Clearing of anatomic dead space

Common Waveforms

Normal

Common Waveforms

Hypoventilation Hyperventilation

4 Main Uses of Capnography • Severity of asthma patients • Monitoring head injured patients • Cardiac arrest • Tube confirmation

Terminology Sidestream An indirect method of measuring exhaled CO 2 in non-intubated patients Mainstream Direct method of measuring exhaled CO 2 with intubated patients

Asthmatic Waveforms

Shark Fin COPD patients have a difficult time exhaling gases This is represented on the capnogram by a shark fin appearance

EtCO 2 & Asthma

Mild Attack Moderate Attack

EtCO 2 & Asthma

Severe Attack

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 Patient Carbon 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 CO 2 levels to the

30-35 mmHg

range can help relieve the untoward effects of ICP

The Head Injured Patient Titration

IS NOT

hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO 2 levels.

Keep them between 30 and 35 mmHg

Titrate EtCO 2

EtCO 2 and Cardiac Arrest The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output Increase in CO 2 during CPR can be an early indicator of ROSC

Termination of Resuscitation EtCO 2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR Non-survivors Survivors (to discharge)

< > 10 mmHg 30 mmHg

ET Tube Verification • 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 CO 2 at?

• What are two ways that capnography can assist during CPR?

Troubleshooting

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

Troubleshooting

Obstruction An obstructed ET tube may have an erratic EtCO 2 value with a very irregular waveform

Troubleshooting

Rebreathing A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO 2 through insufficient inspiratory or expiratory flow

QUIZ

Hypoventilation

Rebreathing

Esophageal Tube

Asthma

Normal

Questions?