11 capnography

112
CAPNOGRAPHY presented by: Fred Halazon, NREMT-P Mike Burke, NREMT-P Cunningham Fire

Upload: dang-thanh-tuan

Post on 07-May-2015

7.612 views

Category:

Health & Medicine


1 download

TRANSCRIPT

Page 1: 11 capnography

CAPNOGRAPHYCAPNOGRAPHYpresented by:

Fred Halazon, NREMT-P

Mike Burke, NREMT-P

Cunningham Fire

presented by:

Fred Halazon, NREMT-P

Mike Burke, NREMT-P

Cunningham Fire

Page 2: 11 capnography

What is Capnography?What is Capnography?

Noninvasive, continuous measurement of exhaled carbon dioxide concentration over time

Digital display provides EtCO2 value

Provides a distinct waveform for each respiratory cycle

Noninvasive, continuous measurement of exhaled carbon dioxide concentration over time

Digital display provides EtCO2 value

Provides a distinct waveform for each respiratory cycle

Page 3: 11 capnography
Page 4: 11 capnography

OverviewOverview

History

Anatomy & Physiology

Capnographic waveform

Diagnosing different waveforms

Case studies

History

Anatomy & Physiology

Capnographic waveform

Diagnosing different waveforms

Case studies

Page 5: 11 capnography

RelevanceRelevance

ETT Verification

Cardiac Arrest

Ventilation

Bronchospastic Disease

Early detection of cellular hypoxia

ETT Verification

Cardiac Arrest

Ventilation

Bronchospastic Disease

Early detection of cellular hypoxia

Page 6: 11 capnography

History of capnographyHistory of capnography

Used by anesthesiologists since the 1970s

Standard of care in the OR since 1991

Used by anesthesiologists since the 1970s

Standard of care in the OR since 1991

Page 7: 11 capnography

History of Capnography in EMSHistory of Capnography in EMS

Colormetric- Useful device to confirm ET tube placement in patients not in cardiac arrest

Tube could be in esophagus or that circulation is not bringing CO2 to the lungs

Prone to contamination, leads to false negatives

Colormetric- Useful device to confirm ET tube placement in patients not in cardiac arrest

Tube could be in esophagus or that circulation is not bringing CO2 to the lungs

Prone to contamination, leads to false negatives

Page 8: 11 capnography

History of Capnography in EMSHistory of Capnography in EMS

Pulse oximetry preceded capnography

Pulse oximetry measures oxygenation

Capnography measures ventilation

New technologies now allow use in EMS

Pulse oximetry preceded capnography

Pulse oximetry measures oxygenation

Capnography measures ventilation

New technologies now allow use in EMS

Page 9: 11 capnography

CapnometryCapnometry

Provides only a numerical measurement of carbon dioxide (EtCO2)Provides only a numerical measurement of carbon dioxide (EtCO2)

Page 10: 11 capnography

CapnogramCapnogram

A waveform display of carbon dioxide over timeA waveform display of carbon dioxide over time

Page 11: 11 capnography

Definition of CapnographyDefinition of Capnography

Numerical value of the EtCO2 AND

Waveform of the concentration present in the airway

Respiratory rate detected from the actual airflow

Numerical value of the EtCO2 AND

Waveform of the concentration present in the airway

Respiratory rate detected from the actual airflow

Page 12: 11 capnography

DefinitionsDefinitions

PACO2—Partial pressure of CO2 in the alveoli

PaCO2—Partial pressure of CO2 in arterial blood

PEtCO2—Partial pressure at the end of expiration

PvCO2—Partial pressure of CO2 in mixed venous blood

PCO2—Partial pressure of CO2

PACO2—Partial pressure of CO2 in the alveoli

PaCO2—Partial pressure of CO2 in arterial blood

PEtCO2—Partial pressure at the end of expiration

PvCO2—Partial pressure of CO2 in mixed venous blood

PCO2—Partial pressure of CO2

Page 13: 11 capnography

DefinitionsDefinitions

PaO2—Partial pressure of O2 in arterial blood (hypoxemia)

SPO2—Saturation of arterial blood (POX) percent

SaO2—Percentage of arterial hemoglobin saturated with O2 (POX)

PO2—Partial pressure of O2

PaO2—Partial pressure of O2 in arterial blood (hypoxemia)

SPO2—Saturation of arterial blood (POX) percent

SaO2—Percentage of arterial hemoglobin saturated with O2 (POX)

PO2—Partial pressure of O2

Page 14: 11 capnography

What is Carbon Dioxide?What is Carbon Dioxide?

Capnos comes from the Greek word for “smoke”

Smoke from the Fire of metabolism

Natural waste product of cellular activity

CO2 is a compound molecule

2 elements of oxygen and 1 element of carbon

Colorless and heavier than air

Capnos comes from the Greek word for “smoke”

Smoke from the Fire of metabolism

Natural waste product of cellular activity

CO2 is a compound molecule

2 elements of oxygen and 1 element of carbon

Colorless and heavier than air

Page 15: 11 capnography

Carbon Dioxide TransportCarbon Dioxide Transport

CO2 + H2O H2CO3

Carbonic acid dissociates:

H2CO3 H+ + HCO3

_

CO2 + H2O H2CO3

Carbonic acid dissociates:

H2CO3 H+ + HCO3

_

Page 16: 11 capnography

Gas Transport in BloodGas Transport in Blood

O2 carried in bloodDissolved in blood plasmaBound to hemoglobin with iron

CO2 carried in bloodDissolved in plasma (5-10%)Chemically bound to hemoglobin in (RBC’s) (carbaminohemoglobin) (20-30%)Most carried as bicarbonate ions (HCO3-) (60-70%)

O2 carried in bloodDissolved in blood plasmaBound to hemoglobin with iron

CO2 carried in bloodDissolved in plasma (5-10%)Chemically bound to hemoglobin in (RBC’s) (carbaminohemoglobin) (20-30%)Most carried as bicarbonate ions (HCO3-) (60-70%)

Page 17: 11 capnography

Physiology of CO2Physiology of CO2

End of inspiratory cycle, airways filled with CO2 free gas

CO2 is a product of cellular metabolism

CO2 is continuously diffused across the cell membrane into the circulating blood

End of inspiratory cycle, airways filled with CO2 free gas

CO2 is a product of cellular metabolism

CO2 is continuously diffused across the cell membrane into the circulating blood

Page 18: 11 capnography

Physiology of CO2Physiology of CO2

Transported to the lungs in the blood stream

Diffused across cell membrane into alveoli

Eliminated during exhalation

Transported to the lungs in the blood stream

Diffused across cell membrane into alveoli

Eliminated during exhalation

Page 19: 11 capnography

Oxygen> lungs> alveoli> blood

Muscles + organs

Oxygen + Glucose

O2

CO2

CO2

CO2

O2

cellsenergy

blood

lungs

breath

Page 20: 11 capnography
Page 21: 11 capnography

Physiology of CO2Physiology of CO2

The evolution of CO2 from the alveoli to the mouth during exhalation, and inhalation of CO2 free gases during inspiration gives the characteristic shape to the CO2 curve which is identical in all humans with healthy lungs

The evolution of CO2 from the alveoli to the mouth during exhalation, and inhalation of CO2 free gases during inspiration gives the characteristic shape to the CO2 curve which is identical in all humans with healthy lungs

Page 22: 11 capnography

Capnographic WaveformCapnographic Waveform

A B

C D

EExpirationInspiration Inspiration

Page 23: 11 capnography

Physiology of CO2Physiology of CO2

Alveoli in lower lung is more perfused, but less ventilated

In the more proximal respiratory tract, the CO2 falls gradually to zero at some point

Alveoli in lower lung is more perfused, but less ventilated

In the more proximal respiratory tract, the CO2 falls gradually to zero at some point

Page 24: 11 capnography

0

36

40

44

Page 25: 11 capnography

Physiology of CO2Physiology of CO2

Concentration of CO2 in alveoli is determined by:Concentration of CO2 in alveoli is determined by:

PERFUSION (Q)

VENTILATION (V)

Page 26: 11 capnography

Physiology of CO2Physiology of CO2

Concentration of CO2 in alveoli:

Varies INDIRECTLY with ventilation

Increase Ventilation: Decrease CO2 in Alveoli

Decrease Ventilation: Increase CO2 in Alveoli

Varies DIRECTLY with perfusion

Decrease Perfusion: Decrease CO2 in Alveoli

Increase Perfusion: Increase CO2 in Alveoli

Concentration of CO2 in alveoli:

Varies INDIRECTLY with ventilation

Increase Ventilation: Decrease CO2 in Alveoli

Decrease Ventilation: Increase CO2 in Alveoli

Varies DIRECTLY with perfusion

Decrease Perfusion: Decrease CO2 in Alveoli

Increase Perfusion: Increase CO2 in Alveoli

Page 27: 11 capnography

Oxygenation and VentilationWhat is the difference?

Oxygenation and VentilationWhat is the difference?

Oxygenation: is the transport of O2 via the bloodstream to the cells

Oxygen is required for metabolism

Ventilation: is the movement of air into and out of the lungs

exhaling of CO2 via the respiratory tractCarbon dioxide is a byproduct of metabolism

Oxygenation: is the transport of O2 via the bloodstream to the cells

Oxygen is required for metabolism

Ventilation: is the movement of air into and out of the lungs

exhaling of CO2 via the respiratory tractCarbon dioxide is a byproduct of metabolism

Page 28: 11 capnography

OxygenationOxygenation

Measured by pulse oximetry (SpO2)

Noninvasive measurement

Percentage of oxygen in red blood cells

Changes in ventilation take several minutes to be detected

Affected by motion artifact, poor perfusion, temperature

Measured by pulse oximetry (SpO2)

Noninvasive measurement

Percentage of oxygen in red blood cells

Changes in ventilation take several minutes to be detected

Affected by motion artifact, poor perfusion, temperature

Page 29: 11 capnography

VentilationVentilation

Measured by the end-tidal CO2

Partial pressure (mm Hg) or volume (%) of CO2 in the airway at end of exhalation

Breath-to-breath measurement provides information within seconds

Not affected by motion artifact, distal circulation, temperature

Measured by the end-tidal CO2

Partial pressure (mm Hg) or volume (%) of CO2 in the airway at end of exhalation

Breath-to-breath measurement provides information within seconds

Not affected by motion artifact, distal circulation, temperature

Page 30: 11 capnography

Distinguishing between oxygenation and ventilation

Distinguishing between oxygenation and ventilation

Page 31: 11 capnography

Normal Ventilation/Perfusion RatioNormal Ventilation/Perfusion Ratio

The volume of blood returning to the lungs matches the capacity of the lungs to exchange gases

Ventilation

Cardiac Output

The volume of blood returning to the lungs matches the capacity of the lungs to exchange gases

Ventilation

Cardiac Output

Page 32: 11 capnography

Ventilation-Perfusion (V/Q) Mismatch

Ventilation-Perfusion (V/Q) Mismatch

Phenomenon where either perfusion or ventilation to an area of lung decreases; results in diminished gas exchange, hypoxemia, and hypercapnia

Phenomenon where either perfusion or ventilation to an area of lung decreases; results in diminished gas exchange, hypoxemia, and hypercapnia

Page 33: 11 capnography

If ventilation is held constant, then changes in EtCO2 are

due to changes in cardiac output

Page 34: 11 capnography

Cardiac Output

(L)

EtCO2 (mm Hg)

2 20

3 28

4 32

5 36

Page 35: 11 capnography
Page 36: 11 capnography

BreakBreak

Page 37: 11 capnography

Value of the Capnographic WaveformValue of the Capnographic Waveform

Provides valid EtCO2 value

Visual assessment of patient airway integrity

Verify proper ET tube placement (with pulmonary perfusion)

Waveforms have characteristic shape like an ECG

Provides valid EtCO2 value

Visual assessment of patient airway integrity

Verify proper ET tube placement (with pulmonary perfusion)

Waveforms have characteristic shape like an ECG

Page 38: 11 capnography

Capnographic WaveformCapnographic Waveform

Height shows amount of CO2

Length depicts time

Height shows amount of CO2

Length depicts time

45

0

Page 39: 11 capnography

Phases of CapnogramExpiratory segment

Phases of CapnogramExpiratory segment

Consists of the following three phasesConsists of the following three phases

Page 40: 11 capnography

Phase IPhase I

Phase I- Represents CO2 free gas from airways (Dead Space)Phase I- Represents CO2 free gas from airways (Dead Space)

Page 41: 11 capnography

Phase IPhase I

Beginning of exhalationBeginning of exhalation

A B

I

Page 42: 11 capnography

Phase IIPhase II

Phase II- Consists of rapid upswing (due to mixing of dead space gas with alveolar gas (Ascending Phase)

Phase II- Consists of rapid upswing (due to mixing of dead space gas with alveolar gas (Ascending Phase)

Page 43: 11 capnography

Phase IIPhase II

II

AB

CAscending Phase

Page 44: 11 capnography

Phase IIIPhase III

Phase III- Consists of an alveolar plateau, CO2 rich gas, positive slope, rise in PCO2 (Alveolar Plateau)

Phase III- Consists of an alveolar plateau, CO2 rich gas, positive slope, rise in PCO2 (Alveolar Plateau)

Page 45: 11 capnography

Phase IIIPhase III

A B

C D

I I I

Alveolar Plateau

Page 46: 11 capnography

Slope of Phase IIISlope of Phase III

CO2 is being continuously excreted into the alveoli

Late emptying of alveoli with lower (V/Q) ratios, produces higher PCO2

End-tidal End of the wave of exhalation

CO2 is being continuously excreted into the alveoli

Late emptying of alveoli with lower (V/Q) ratios, produces higher PCO2

End-tidal End of the wave of exhalation

Page 47: 11 capnography

Expiratory segment cont…Expiratory segment cont…

Alpha angle- Angle between phase II and phase III (V/Q status of lung)Alpha angle- Angle between phase II and phase III (V/Q status of lung)

A B

C D

E

Page 48: 11 capnography

Phases of CapnogramInspiratory segment

Phases of CapnogramInspiratory segment

Beta Angle- Angle between phase III and descending limb of inspiratory segmentBeta Angle- Angle between phase III and descending limb of inspiratory segment

A B

C D

E

Page 49: 11 capnography

Inspiratory segmentInspiratory segment

Phase 0- Inspiration, fresh gases inhaled and CO2 falls rapidly to zero (Descending Phase)

Phase 0- Inspiration, fresh gases inhaled and CO2 falls rapidly to zero (Descending Phase)

Page 50: 11 capnography

Phase 0Phase 0

A B

C D

E

0

Descending Phase

Inhalation

Page 51: 11 capnography

End-tidal CO2 (EtCO2)End-tidal CO2 (EtCO2)

Allows monitoring for changes inVentilation—Asthma, COPD, airway edema, FBAO, stroke

Diffusion—Pulmonary edema, alveolar damage, CO poisoning (COHb), smoke inhalation, hydrogen cyanide

Perfusion—shock, pulmonary embolus, cardiac arrest, severe dysrhythmias

Allows monitoring for changes inVentilation—Asthma, COPD, airway edema, FBAO, stroke

Diffusion—Pulmonary edema, alveolar damage, CO poisoning (COHb), smoke inhalation, hydrogen cyanide

Perfusion—shock, pulmonary embolus, cardiac arrest, severe dysrhythmias

Page 52: 11 capnography

Decreased EtCO2Decreased EtCO2

Decreased Metabolism

Analgesia/ sedation

Hypothermia

Circulatory System

Cardiac arrest

Embolism

Sudden hypovolemia or hypotension

Decreased Metabolism

Analgesia/ sedation

Hypothermia

Circulatory System

Cardiac arrest

Embolism

Sudden hypovolemia or hypotension

Respiratory System

Alveolar hyperventilation

Bronchospasm

Mucus plugging

Equipment

Leak in system

Partial obstruction

ETT in hypopharynx

Respiratory System

Alveolar hyperventilation

Bronchospasm

Mucus plugging

Equipment

Leak in system

Partial obstruction

ETT in hypopharynx

Page 53: 11 capnography

Increased EtCO2Increased EtCO2

Increased Metabolism

Pain

Hyperthermia

Malignant hyperthermia

Shivering

Circulatory System

Increased cardiac output with constant ventilation

Increased Metabolism

Pain

Hyperthermia

Malignant hyperthermia

Shivering

Circulatory System

Increased cardiac output with constant ventilation

Respiratory System

Respiratory insufficiency

Respiratory depression

Obstructive lung disease

Equipment

Defective exhalation valve

Exhausted CO2 absorber

Respiratory System

Respiratory insufficiency

Respiratory depression

Obstructive lung disease

Equipment

Defective exhalation valve

Exhausted CO2 absorber

Page 54: 11 capnography

Major Benefits in Pre-HospitalMajor Benefits in Pre-Hospital

Verifying ETT placement and continuous monitoring of position during transport

Cardiac ArrestEffectiveness of cardiac compression

Predictor of survival

Ventilation

Bronchospastic Disease

Verifying ETT placement and continuous monitoring of position during transport

Cardiac ArrestEffectiveness of cardiac compression

Predictor of survival

Ventilation

Bronchospastic Disease

Page 55: 11 capnography

Benefits in HospitalBenefits in Hospital

Verification of ETT placement and continuous monitoring

Cardiac Arrest

Ventilation

Procedural sedation

Verification of ETT placement and continuous monitoring

Cardiac Arrest

Ventilation

Procedural sedation

Page 56: 11 capnography

ETT DisplacementETT Displacement

Most likely occurs when patient is

moved

Page 57: 11 capnography

DislodgedDislodged

Page 58: 11 capnography

DislodgedDislodged

Page 59: 11 capnography

Right Main BronchiRight Main Bronchi

Page 60: 11 capnography

CPRCPR

Force, depth, and rate of chest compressionsForce, depth, and rate of chest compressions

4 5

0

100% mortality if unable to achieve an EtCO2 of 10 mm Hg after 20 minutes

Page 61: 11 capnography

CPRCPR

Page 62: 11 capnography

ROSCROSC

Page 63: 11 capnography

ROSCROSC

4 5

0

Page 64: 11 capnography

ROSC with NaHCO3ROSC with NaHCO3

Page 65: 11 capnography

CPRCPR

Positive pressure ventilation

Increased intrathoracic pressure

Pressure on Vena Cava, decreased preload

Increased RR does not allow for exhalation

Positive pressure ventilation

Increased intrathoracic pressure

Pressure on Vena Cava, decreased preload

Increased RR does not allow for exhalation

Page 66: 11 capnography

CPRCPR

Increased intrathoracic pressure leads to

Decrease in cardiac output, coronary artery perfusion, and CPP

Increased intrathoracic pressure leads to

Decrease in cardiac output, coronary artery perfusion, and CPP

Page 67: 11 capnography
Page 68: 11 capnography

Optimize VentilationOptimize Ventilation

Titrate carbon dioxide levels in patients sensitive to fluctuations

Head Injuries

Stroke

Brain tumors

Brain infections

Titrate carbon dioxide levels in patients sensitive to fluctuations

Head Injuries

Stroke

Brain tumors

Brain infections

Page 69: 11 capnography

Optimize VentilationOptimize Ventilation

Carbon dioxide affects cerebral blood flow (CBF)

Influencing intracranial pressureHypercapnia causes vasodilation

Hyperoxygenate, NOT hyperventilateHyperventilation does not improve oxygenation

Maintain CO2 of 35-40 mm Hg

Carbon dioxide affects cerebral blood flow (CBF)

Influencing intracranial pressureHypercapnia causes vasodilation

Hyperoxygenate, NOT hyperventilateHyperventilation does not improve oxygenation

Maintain CO2 of 35-40 mm Hg

Page 70: 11 capnography
Page 71: 11 capnography

HyperventilationHyperventilation

Hypocapnia < 35 mmHg

Normal range is 35-45 mm Hg (5% vol)

How would hyperventilation change the waveform? (26-30)

Frequency

Duration

Height

Shape

Hypocapnia < 35 mmHg

Normal range is 35-45 mm Hg (5% vol)

How would hyperventilation change the waveform? (26-30)

Frequency

Duration

Height

Shape

Page 72: 11 capnography

HyperventilationHyperventilation

45

0

Page 73: 11 capnography

HypoventilationHypoventilation

Hypercapnia > 45 mmHg

How would hypoventilation change the waveform? (4-12)

Frequency

Duration

Height

Shape

Hypercapnia > 45 mmHg

How would hypoventilation change the waveform? (4-12)

Frequency

Duration

Height

Shape

Page 74: 11 capnography

HypoventilationHypoventilation

45

0

Page 75: 11 capnography

Bronchospasm Bronchospasm

Alveoli unevenly ventilated on inspiration

Asynchronous emptying during expiration

Alters Phase II—“Shark Fin” shaped waveform

Alveoli unevenly ventilated on inspiration

Asynchronous emptying during expiration

Alters Phase II—“Shark Fin” shaped waveform

Page 76: 11 capnography

BronchospasmBronchospasm

45

0

Bronchospasm

Page 77: 11 capnography

BronchospasmBronchospasm

Page 78: 11 capnography

COPDCOPD

Page 79: 11 capnography

AsthmaAsthma

Initial

After therapy

Page 80: 11 capnography

PneumothoraxPneumothorax

Page 81: 11 capnography

Pulmonary EmbolismPulmonary Embolism

Page 82: 11 capnography

Hypercapnia/ RR~?Hypercapnia/ RR~?

Page 83: 11 capnography

15 Sec Triage Tool15 Sec Triage Tool

Rapidly assess pt

Toxins, chemical agents

Spontaneous respirations

Patent airway with adequate ventilation and perfusion

Most acute pts

Seizures

Rapidly assess pt

Toxins, chemical agents

Spontaneous respirations

Patent airway with adequate ventilation and perfusion

Most acute pts

Seizures

Page 84: 11 capnography

15 Sec Triage Tool15 Sec Triage Tool

Terrorism (BNICE)

Absorption skin and respiratory tract

Respiratory depression

Trends

Terrorism (BNICE)

Absorption skin and respiratory tract

Respiratory depression

Trends

Page 85: 11 capnography
Page 86: 11 capnography
Page 87: 11 capnography

Unresponsive patientsUnresponsive patients

Page 88: 11 capnography

6 year old female6 year old female

Status seizure

Found supine in bed with L disconjugate gaze

Unresponsive to stimuli

Vomiting

B/P- 136/66

HR- 136

RR- 40

Skin- warm, dry, acyanotic

Status seizure

Found supine in bed with L disconjugate gaze

Unresponsive to stimuli

Vomiting

B/P- 136/66

HR- 136

RR- 40

Skin- warm, dry, acyanotic

Page 89: 11 capnography

6 year old 6 year old

Tx pt to pram controlling airway

Supplemental O2

Unable to establish IV

Administer 5mg Valium PR

B/P- 108/70

HR- 116

RR- 36

Tx pt to pram controlling airway

Supplemental O2

Unable to establish IV

Administer 5mg Valium PR

B/P- 108/70

HR- 116

RR- 36

Page 90: 11 capnography

6 year old6 year old

Heent- ClrPerrlaChest = rise/fall w/clr BS B/LABD= sntPelvis= stableSmoeX4 w/o angulationBack ClrNo visual signs of Trauma

Heent- ClrPerrlaChest = rise/fall w/clr BS B/LABD= sntPelvis= stableSmoeX4 w/o angulationBack ClrNo visual signs of Trauma

Page 91: 11 capnography

6 year old6 year old

No recent medical hx or illnesses

NKDA

Clonidine for sleep aid at night

Capnographic waveform

No recent medical hx or illnesses

NKDA

Clonidine for sleep aid at night

Capnographic waveform

Page 92: 11 capnography

EtCO2: 50 RR: 36

Page 93: 11 capnography

Decreased Cardiac OutputDecreased Cardiac Output

94 y.o. Female

DNR

Respiratory distress

Skin- ashen, cool, dry

94 y.o. Female

DNR

Respiratory distress

Skin- ashen, cool, dry

Page 94: 11 capnography

HR: 31

EtCO2: 8

RR: 7

Page 95: 11 capnography

CaseCase

35 y.o. male

DK, combative

Possible OD

35 y.o. male

DK, combative

Possible OD

Page 96: 11 capnography

EtCO2: 34RR: 33

Page 97: 11 capnography
Page 98: 11 capnography

DocumentationDocumentation

Continuous waveform allows for legal documentation

Proof of correct tube placement, RR, EtCO2

Effectiveness of treatment in patient care, early detection of deterioration

Continuous waveform allows for legal documentation

Proof of correct tube placement, RR, EtCO2

Effectiveness of treatment in patient care, early detection of deterioration

Page 99: 11 capnography

The era is over when we can justify not knowing whether an ETT is in place or

not.

We may not be able to intubate everybody, but we must always know

when the tube is in place or not.

The era is over when we can justify not knowing whether an ETT is in place or

not.

We may not be able to intubate everybody, but we must always know

when the tube is in place or not.

Page 100: 11 capnography

Break TimeBreak Time

Page 101: 11 capnography

What is up coming and how Capnography will assist

What is up coming and how Capnography will assist

The newest phase in CPR Protocols.

How it will effect our decisions to work a patient or not.

The CPR first protocols.

Therapeutic Hypothermia.

The newest phase in CPR Protocols.

How it will effect our decisions to work a patient or not.

The CPR first protocols.

Therapeutic Hypothermia.

Page 102: 11 capnography

What is Therapeutic Hypothermia

What is Therapeutic Hypothermia

Is an evidence based change in Cardiac Arrest patients

This change effects treatment of the patient with a return to spontaneous pulses.

The studies show good stats that back up this method of treating patients

Is an evidence based change in Cardiac Arrest patients

This change effects treatment of the patient with a return to spontaneous pulses.

The studies show good stats that back up this method of treating patients

Page 103: 11 capnography

The European StudyThe European Study

This study was conducted in Nine hospitals and 5 countries.

The Study was performed completely random.

The patients were accepted into the study based on speed of response to V-fib arrest.

This study was conducted in Nine hospitals and 5 countries.

The Study was performed completely random.

The patients were accepted into the study based on speed of response to V-fib arrest.

Page 104: 11 capnography

The Australian studyThe Australian study

Less involved study.

This study took place in Melbourne and involved four hospitals

This study was done Pseudo random format with patients selected based on an odd or even day.

Less involved study.

This study took place in Melbourne and involved four hospitals

This study was done Pseudo random format with patients selected based on an odd or even day.

Page 105: 11 capnography

CriteriaCriteria

The patient to be accepted into the study had to be a persistent V-fib arrest and still in coma state u/a to hospital.The patient must have Resuscitation efforts performed by trained personnel within 5-15 minutes of collapse.The patient must also have ROSC in under sixty minutes. The patient must also be intubated and ventilated.

The patient to be accepted into the study had to be a persistent V-fib arrest and still in coma state u/a to hospital.The patient must have Resuscitation efforts performed by trained personnel within 5-15 minutes of collapse.The patient must also have ROSC in under sixty minutes. The patient must also be intubated and ventilated.

Page 106: 11 capnography

European Study ProceduresEuropean Study Procedures

The patient was cooled to 32 to 34 degrees Celsius.

This temp was reached in the first four hours of the resuscitation.

Pt was held at this temp for twenty four hours and then passively re-warmed.

The patient was cooled to 32 to 34 degrees Celsius.

This temp was reached in the first four hours of the resuscitation.

Pt was held at this temp for twenty four hours and then passively re-warmed.

Page 107: 11 capnography

Australian Study Australian Study

Pt. Accepted on the same criteria however it was based on if it was an odd or even day.

The pt were cooled to 33 degrees Celsius and kept there for 12 hours and the actively re-warmed after 18 hours.

Pt. Accepted on the same criteria however it was based on if it was an odd or even day.

The pt were cooled to 33 degrees Celsius and kept there for 12 hours and the actively re-warmed after 18 hours.

Page 108: 11 capnography

The Results and they were impressive!

The Results and they were impressive!

In the European Study 75 of 136 patients(55%) had a favorable neurological outcome.

In the normothermic patients the results were still good but not great at 39%

The Australian Study showed a 49% save rate in the hypothermic pt and a 26% in the normothermic pt.

In the European Study 75 of 136 patients(55%) had a favorable neurological outcome.

In the normothermic patients the results were still good but not great at 39%

The Australian Study showed a 49% save rate in the hypothermic pt and a 26% in the normothermic pt.

Page 109: 11 capnography

Why do this work?Why do this work?

The proof is in the pudding for its benefits.

However the actions is slightly more theoretical.

Fist is hypothermia lowers the cerebral metabolic rate for oxygen by 6% for every 1 degree C

Second hypothermia suppresses chemical reactions.

The proof is in the pudding for its benefits.

However the actions is slightly more theoretical.

Fist is hypothermia lowers the cerebral metabolic rate for oxygen by 6% for every 1 degree C

Second hypothermia suppresses chemical reactions.

Page 110: 11 capnography

If this so great why don’t we use it!

If this so great why don’t we use it!

Simple LogisticsThe patient once taken to the hypothermic state must remain there to have benefit. A Rolla coaster approach is not going to work. The equipment to do this efficiently and controlled is expensive but is expected to fall in price as it becomes more widely spread.

Simple LogisticsThe patient once taken to the hypothermic state must remain there to have benefit. A Rolla coaster approach is not going to work. The equipment to do this efficiently and controlled is expensive but is expected to fall in price as it becomes more widely spread.

Page 111: 11 capnography

1. Barton, C. & Wang, E. (1994). Correlation of End-Tidal CO2 Measurements to Arterial PaCO2 in Nonintubated Patients. Annals of Emergency Medicine, 23 (3): 561-562.

2. Bergenholtz, K.F., RN, MSN, CRNP-CS. (2004). Using and understanding Capnography. Microstream capnography solutions. [email protected].

3. Bhavani-Shankar, K., MD, Philip, JH. Defining segments and phases of a time capnogram. Anesthesiology Analg (2000). 91(4): 973-977.

4. Bhavani-Shankar, K., MD. http://capnography.com/

5. Falk, J.L., Rackow, E.C., Weil, M.H. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. New England Journal of Medicine (1998) 318(10): 607-611.

6. Fowler, Ray, MD, FACEP. www.rayfowler.com

7. Fowler, W.S. Lung Function studies, II. The respiratory deadspace. American Journal of Physiology. (1998) 154: 405-416.

8. Kanowitz, A., MD, FACEP, EMS Director, Arvada, CO. (2004). [Capnography in EMS]. Unpublished raw data.

References

Page 112: 11 capnography

8. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine (2001) 37(1): 32-37.

9. Medtronic Physio-Control Corporation (2005). http://www.healthcareeducation.org

9. Raff, Hershel, PhD, (2003). Physiology Secrets (2nd ed.) Philadelphia, PA: Hanley & Belfus.

10.Scanlon, V.C. & Sanders, T., (1999). Essentials of Anatomy and Physiology (3rd ed.) Philadelphia, PA: F.A. Davis Co.

11.Thompson, J.E., RRT, FAARC, Jaffe, M.B., PhD. (2005 Jan). Capnography waveforms in the mechanically ventilated patient. Respiratory Care. 50(1): 100-109.

12.Wik L, et al: “Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest.” JAMA. 293(3): 299-304, 2005.

13.Woodruff, D.W., RN, CNS, CCRN, MSN. (2006 Jan/Feb) Deciphering Diagnostics. Nursing made incredibly easy!, 4(1): 4-10.