11/17/2009

Outline:
 Why Capnography
 Review Airway Anatomy and Physiology
 Applied Physics
 Types of End Tidal CO2
Mike Watkins
EMT-P, RN
 Using Capnography in the Field
Clinical Nurse, Cardiac Surgery ICU  Overview of Equipment
Virginia Commonwealth University Health System
Virginia EMS Symposium 2009

Capnography 2009
 BLS Skill with placement of blind rescue
airways
 King LTD
 Combitube
 Applies to any ventilated patient
 Bag-mask
 ETI and rescue airways
 Transport vent
 CPAP?
 Noninvasive applications

The Journey of A Molecule

Capnography Through the Respiratory Cycle
 Defined as the monitoring of exhaled
carbon dioxide through the respiratory
cycle
 Measuring of End tidal CO2 is
considered a standard of care for
confirming endotracheal tube placement
 An important adjunct for assessing a
critical patient

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Comparison
Fundamental Comparison Human and Gas Engines
 What do we need to do work (use
energy)
 Fuel (glucose or petroleum)
 OXYGEN
 Chemical process: (ignition)
 What do we give off? (Respiration)
 Human: Carbon Dioxide
 Engine: Carbon Monoxide
Human Being Gas Engine

Anatomy Review

Action at the Alveoli Alveolar Detail

 Oxygenation of vital organs is the primary  O2 and CO2
function of the respiratory system exchange across CO2
CO2
 Ventilation is the movement of air/oxygen into the semi-permeable
lungs
membrane
 Perfusion is the oxygenation of the cells through CO2
the alveoli  “Pressures” in blood CO2
stream and tissue O2 O
 Gas exchange: In with the good, out with the bad O2
2
O2
○ Is the bad leaving?
affect quality of
exchange O2
 Ventilation versus perfusion: (V/Q)
 Is what you are putting in getting to the cells? CO2
CO2

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Normal V/Q Ratio Alveolar Perfusion Problems

 Shunt Problem
 Blocking of bronchial airways
○ Pneumonia, atelectasis
○ Right main stem intubation
 Causes retention of CO2, increased levels
 Dead Space Ventilation
 Capillary flow to alveoli impaired
○ Low Cardiac output, hypotension
○ Excessive PEEP
 CO2 does not cross into the alveoli for
exhalation
 Decreased levels of expired CO2

Impaired Ventilation
Shunt Problem Dead Space Ventilation

Cardiac Output and CO2 Normal Respiration

 Oxygen diffuses into blood stream
through the alveoli, and is transported to
the cells.
 Cells produce Carbon Dioxide as waste
product
 CO2 transport in venous blood to the
capillaries of the alveoli, and diffuse
across membrane into alveolar space
and exhaled

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Measuring End Tidal CO2 Percentage vs. mmHg

 Dalton’s Law:  Relate to the air we breath:
 Total pressure of a gas is the sum of the  78% Nitrogen
partial pressures of the gas
 21% Oxygen
 Expired CO2 measured (PetCO2)  1% CO2 and other gases
 mmHg in waveform
 Percentage
 Exhaled gases:
 16% Oxygen
 Normal Levels
 PaO2 85-100mmHg  4 to 5% CO2
 PaCO2 35-45mmHg

PetCO2 vs. PaCO2 Comparing Arterial and

End-tidal CO2
 PetCO2
 End tidal measurement from expired or
exhaled air
 PaCO2
 Arterial blood gas sample
 End tidal normally 2-5 mmHg lower than
arterial

Review of Airway Confirmation Types of End-Tidal CO2

 Visualization  Qualitative
 Auscultation:  Yes or No
 Negative Epigastric sounds  Nellcor, Portex, or built in to BVM
 Equal lung sounds  Quantitative
 Esophageal detector  Numerical value (capnogram)

 End tidal CO2 detector  Waveform (capnograph)

 Mainstream or Sidestream
 Secondary signs: misting, increased
SaO2

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Capnometry vs. Capnography Quality is Key

 Capnometry is a numerical value only  Poor Perfusion or Poor Ventilation
 Capnography is a waveform, providing a  Dramatic alternations in Homeostasis
visual representation of a ventilation  Poor Cardiac Output
 Provides the numerical value  Equals Poor Perfusion
 Waveform indicates pattern of breathing  Decreased Carbon Dioxide
 Quality of ventilation  Pearl of Wisdom
 Rate  “In with good air, out with bad”
 “Blood goes round and round”

Qualitative Detectors Quantitative Detectors

 Detect presence or absence of CO2, but  Electronic, infra-red analyzers
do NOT give specific values or levels  Use IR absorption spectrophotometry
 Colorimetric  Certain gases will Absorb IR light

 pH sensitive paper  Mainstream

 Color changes with CO2 exposure  IR detector in line, at end of ETT, “real time”

 Limited value once contaminated with  Sidestream

 IR detector in machine, attached by tubing
moisture, drugs, or body fluids
 Intubated and non-intubated
 Most common: Nellcor EasyCap II,  3-5 second time delay
Portex CO2 clip

Capnography Monitors Sample Capnography Display

 Wide variety: evolving as devices
change
 Oridion supports Microstream
 Sidestream devices, pulling gases into
device
 Respironics/Novametrix supports Zoll,
Propaq
 Mainstream

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Sidestream Sidestream
 Sensor is located in device like LP12  Easier to use non-invasively
 Adapter tube attaches to ETI  Key is quality of the patient’s
 Pump in machine pulls air in for respirations
measurement  Shallow is poor
 100 to 150 ml air in early devices  Mouth breathing is challenging
 50 ml in Microstream  Newer devices assist in increasing accuracy
 Concerns:  Sidestream is LESS specific because of
 Delay of 3-5 seconds
its engineering
 Quality of sample

Side-stream Detector Sidestream Detector

Cannula with mouth Oxygen and sensor

scoop

Mainstream Detector Mainstream Detector

 Sensor at end of cable
 Disposable adapter to ET tube
 “Real time” values-best for critical care
 As the gas passes the IR sensor
 Concerns:
 Not easily adapted to non-intubated patient
 Can be heavy for pediatric of infant ET tubes
 Cable is expensive

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Lifepak 12 Propaq Critical Care Monitor

 Monitor/12 lead  Vital signs only
 Configures for critical  Capnography
care monitoring  Mainstream
 Defib/pacemaker  Critical care central
 Capnography line monitoring
 Sidestream  Collects and prints
 Microstream trends
 Downloadable, stores  DOES NOT STORE
100 activations DATA

Zoll M and E series Phillips

 EMS and Critical Care  Multi-parameter

 Capnography monitors
mainstream and  Capnography
sidestream  Microstream
 Depends on model
 Respironics/Novametrix
technology
 Data collection

Tidal Wave/Respironics Nellcor N85

 Hand held  Handheld
 Combined Pulse  Combined Pulse
Oximeter and Oximeter and
Capnography Capnography
 Downloadable

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Normal EtCO2 waveform Parts of the Waveform

CO2  Baseline: no CO2 is passing the sensor
50  Inhalation/ventilation by BVM

40
 Upslope: rapid rise in CO2 level
 Exhalation/relaxation of BVM
30
CO2
 Plateau: rest at end of exhalation
20
 May have a gradual rise at end
10
 Down slope: rapid decrease as
0
Time inhalation occurs

Pathology Associated
EMS Applications Capnography
 Confirmation of airway placement  Oxygen and Carbon Dioxide
 Endotracheal tube (CO2 present)  What do the numbers mean
 Gastric tube (no CO2 present)  Hypoventilation:
 Quality of Cardiopulmonary  O2 < 60mm/Hg
Resuscitation  CO2 > 45mm/Hg (Hypercapnea)
 Tube confirmed, but CO2 levels remain low  Hyperventilation:
 Poor cardiac output leads to lower PetCO2  O2 > 100mm/hg (SaO2 above 98%)
 Clinical Conditions require the use of  CO2 < 35mm/Hg
trend data and constant minute volumes

Clinical Conditions
with Increased CO2 Hypoventilation
 Increased CO2 production CO2
100
 Bicarbonate administration, fever, seizures,
sepsis, thyroid storm 75
 Decreased alveolar ventilation
50
 COPD (retaining CO2), hypoventilation, CO2

muscular paralysis, respiratory depression 25

 Equipment Problem
0
 Rebreathing, ventilator leak Time

Gradual increase in CO2 levels, often from retention or V/Q

mis-match

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Hypercapnea Comparing Waveforms

CO2 CO2
50 50

40 40

30 30
CO2 CO2
20 20

10 10

0 0
Time Time

Increased CO2 levels with normal waveform Normal Hypercapnea

Clinical Conditions
with Decreased CO2
Comparing Waveforms
 Decreased CO2 production CO2 CO2
50 50
 Cardiac arrest, hypotension, hypothermia,
pulmonary emboli, pulmonary hypoperfusion 40 40

 Increased alveolar ventilation 30 30

 Hyperventilation Mm/Hg CO2 CO2
20 20
 Equipment Problems
10
 Airway obstruction, esophageal intubation, 10
ETT leak, incomplete exhalation, poor 0 0
Time
sampling, ventilator disconnect Time

Normal Hypocapnea

Hyperventilation Hyperventilation
CO2
50

40

30
CO2
20

10

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Bronchospasm/Asthma
CO2
50

40

30
Mm/Hg
CO2
20

10

0
Time

Air is “forced” out during exhalation,

resulting in up slope

Ripple-CO2 waveform Curare Cleft

CO2
50
CO2
50
40
40
30
30
CO2
20 CO2
20

10 10

0
0 Time
Time

Occurs during CPR or other types of chest Intubated Patient with Spontaneous Respiration
movement

Breathing Against Ventilation Rebreathing

CO2 CO2
50 50

40 40

30 30
Mm/Hg

Mm/Hg

CO2 CO2
20 20

10 10

0 0
Time

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Esophageal Intubation Esophageal Intubation

CO2
CO2
50
100

40
75

30
50
CO2 CO2
20
25
10
0
Time
0
After extended Bag-Valve-Mask
ventilation

Procedure Device Placement

 Perform standard interventions per  Place per protocol
protocol for managing Airway, Breathing,  Endotracheal Tube
and Circulation  Combitube
 Prepare intubation equipment including  King LT airway
end tidal CO2 detector  Inflate distal cuff, attach BVM
 Depending on device, the electronic  Auscultate for Lung sounds
capnograms may need to cycle or warm  3 quick, shallow ventilations – more distinct
up  Abdomen first, then opposing sides of chest

Colormetric/Qualitative Colormetric Detectors

 Place between Bag-valve and airway
 Perform 6 quality ventilations
 1 ventilation per 5-6 seconds
 Full, consistent depth
 Observe for color change from purple (No
CO2 present) to yellow (CO2 present)
 YEAH for YELLOW
 Purple <4mmHg, Tan 4 to <15mmHg,
Yellow 15 to 38 mmHg
 Replace after 2 hours or exposure to fluids Nellcor Easy Cap II Porttex CO2 clip

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Basic Operations Sidestream Attachment

 Connect sensor to activate mode in
monitor
 Place sensor between ETT and Bag-
valve
 Perform quality ventilations
 May take 15-30 second for detector to
initialize
 Observe for waveform
 Discard if tubing becomes obstructed LP12 port

LP12 CO2 Display LP12 Capnography Display

 Offers waveform with slight delay
 Very succeptible to ventilation style
 Bad pattern or rhythm gives choppy display
 Scale measured one right side of screen
 Autoscale: adjusts to waveform
 Range: 0 to 50mmHg, or 0 to 100mmHg
Display also gives respiratory/ventilatory
rate

Common Problems Ventilation and Capnography

 Machine needs to warm up  Provides a guideline
 Screen glare difficult to interpret  Educate your crews on techniqe

 Sensor adapters can clog with debris,  Rate:

moisture  Too fast = End Tidal Drops

 Sidestream requires air movement: pulls  Too slow = End Tidal Rises
air into device  Volume:
 Too much = End Tidal Drops
 Not enough = End Tidal Rises

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Scenario 1 Scenario 1
 52 year old cardiac arrest-witnessed CO2
50
 AED, CPR, BLS prior to ALS arrival
 Advanced Airway placement as 40

appropriate for protocol 30

 Continued ventricular fibrillation, CO2
20
medications per ACLS guidelines
10

Scenario 1 Scenario 1
 Is the airway adequate? Correctly CO2
50
placed?
 What guidance can the AIC offer to 40

 The ventilator?
30
 The chest compressors?
CO2
 After 4 defibrillations, a PEA rhythm 20

results: 10

Scenario 1
CO2 Trend During Cardiac Arrest
 What has happened?
 What considerations for the
resuscitation team/ 76
Evolution of Cardiac Arrest

Prearrest ROSC
38
CPR
Arrest

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Scenario 2 Scenario 2
 65 year old obese trauma patient  Initial Et CO2 6-7mm/Hg
 Predicted Difficult Intubation  Intermittent sensor detection of
 Multiple Injuries numerical value
 Chest Contusions  Waveform present
 Abdominal Distention  Low “shark fin” appearance
 Fractures of right upper leg, left lower leg,  What is going on?
and right arm
 Is the ET good?
 Complains of Respiratory Distress

Scenario 2 Scenario 3
CO2  45 year old respiratory arrest
50
 Progressive dyspnea, fever for two days
40 prior, found down in bed by family
30
 EMS arrives; unable to ventilate through
CO2
clenched teeth
20  RSI medications administered
 Oral ETI attempts times two unsuccessful
10
 King LT airway placed
0

Scenario 3 Data Collection Capability

CO2  Limited Number of Devices
50
 Software support
40  Type of data:
30
 Snap shot: LP12
CO2  Continuous: Tidal wave
20
 How do you evaluate?
10

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Data Evaluation Future

 Benchmarks of Procedure  Integrated data systems
 Correlate PCR times and machine  Ability to collect over long transports
 Trend data: single point is often not  Military evacuations have identified need
useful for an improved, comprehensive
 Alarms: physiological monitor
 Decrease SaO2 waveform after intubation
 Pulse Oximeter correlation with EtCO2
 Pre intubation SaO2

A busy, but stabilized patient Capnography Summary

 Required for documentation of
Endotracheal Intubation
 Adjunct for Monitoring the quality of
ventilations
 Fundamental Understanding of
Principles offers:
 Increased awareness of potential problems
 Enhances scope and quality of pre-hospital
practice
Courtesy of the simulator mode on the machine

Sign of a Problem??
CO2
100

75

50
CO2

25

0
Time

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Sources Sources:
 “Capnography: Beyond the Numbers” by Carol Rhodes, RN, and
Frank Thomas, MD, MBA; Air Medical Journal, March-April 2002,  American Society of Anesthesiologists. (2005, October 25).
Standards for Basic Anesthetic Monitoring. Retrieved September
Volume 21:2 p. 43-48, Mosby Publishing 16, 2007, from American Society of Anesthesiologists:
 Web site: www.capnography.com http://www.asahq.org/publicationsAndServices/sgstoc.htm
 Operative End-tidal PCO2 Measurements with Mainstream and  Cooper, J. B. Medical Technology: Patient Safety is Paramount.
Sidestream Capnography in Non-obese Patients and In Obese  Foundation, B. T. (2000). Guidelines for Prehospital Treatment of
Traumatic Brain Injury. New York: Brain Trauma Foundation.
Patients with and without ObstructiveSleep Apnea. Anesthesiology
 Garey, B. (2007, August 18). Flight Paramedic, Medflight I. (M.
2009 , 111 (3), 609- Kasuya, M. Y., Akca, M. O., Sessler MD, D., Watkins, Interviewer)
Ozaki MD, M., & Komatsu MD, R. (2009). Accuarcy of Post 15.  Gravenstein, J. S., Jaffe, M. B., & Paulus, D. A. (2004).
Capnography. Cambridge, United Kingdom: Cambridge University
Press.
 Hassett, P., & Laffey, J. G. (2007). Permissive Hypercarbia:
Balancing Risks and Benefits in the peripheral microcirculation.
Critical Care Medicine , 2229-2230.
 Web site: www.capnography.com

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