Upload File

capnography: the window into your patient capnography: the window into your patient mike mcevoy,...

  • Home
  • Documents
  • Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic
43
Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic Surgical ICUs – Albany Medical Ctr EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering Magazine EMS Director – New York State Association of Fire Chiefs Talk Code 682

Upload: louisa-hopkins

Post on 29-Dec-2015

218 views

Category:

Documents


0 download

Report

Tags:

TRANSCRIPT

Page 1: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnography:The Window Into Your

Patient

Capnography:The Window Into Your

Patient

Mike McEvoy, PhD, RN, CCRN, REMT-PSenior Staff RN – Cardiothoracic Surgical ICUs – Albany Medical Ctr

EMS Coordinator – Saratoga County, New YorkEMS Editor – Fire Engineering Magazine

EMS Director – New York State Association of Fire Chiefs

Mike McEvoy, PhD, RN, CCRN, REMT-PSenior Staff RN – Cardiothoracic Surgical ICUs – Albany Medical Ctr

EMS Coordinator – Saratoga County, New YorkEMS Editor – Fire Engineering Magazine

EMS Director – New York State Association of Fire Chiefs

Talk Code 682

Page 2: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

mikemcevoy.com

Page 3: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

SpO2 versus EtCO2

Page 4: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Oxygen lungs alveoli blood

muscles + organs

Oxygen

cells

Oxygen

Oxygen +Glucose

energy

CO2

blood

lungs

CO2

breath

CO2

Physiology Physiology

Page 5: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Contrasting Pulse Oxwith Capnography

Pulse oximetry measureoxygen going OUT

from the heart

Capnographymeasures

what is coming BACKfrom the periphery

Two Different Concepts

Contrasting Pulse Oxwith Capnography

Pulse oximetry measureoxygen going OUT

from the heart

Capnographymeasures

what is coming BACKfrom the periphery

Two Different Concepts

Page 6: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Oxygenation and VentilationOxygenation (Pulse Ox)

– O2 for metabolism

– SpO2 measures % of O2 in RBCs

– Reflects changes in oxygenation within 5 minutes

Ventilation (Capnography)

– CO2 from metabolism

– EtCO2 measures exhaled CO2 at point of exit

– Reflects changes in ventilation within 10 seconds

Page 7: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

What is Capnography?• “Capnos” = Greek for smoke

– From the “fire of life” metabolism

– CO2 is the waste product of metabolism

• Carbon Dioxide is a compound molecule– 2 oxygen + 1 carbon– Odorless; heavier than atmospheric air

– Green plants scavenge excess CO2

– 0.03% concentration in room air– Resting adults produce

2.5 mg/kg/min

Page 8: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnography BasicsCarbon Dioxide (CO2)

– Produced by all living cells

– Diffused into the bloodstream

– Transported to the lungs

– Perfused into the alveoli

– Exhaled through the airway

Page 9: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Page 10: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Page 11: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Measuring Exhaled CO2

Colorimetric

Capnometry

Capnography

Page 12: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Waveform Capnography• Available for spontaneously breathing and

for intubated patients

Page 13: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnographyis the window

INTO the patient

Capnographyis the window

INTO the patient

Page 14: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Normal Capnography Waveform

• Normal range is 35-45 mmHg

• Height = total CO2

• Length = time/rate

45

0

Page 15: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnogram Phases

Inhale

A B

C D End-tidal

E

Page 16: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnogram Phases

Exhale (dead space)

A B

C D End-tidal

E

Page 17: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnogram Phases

Exhale (rapid rise)

A B

C D End-tidal

E

Page 18: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnogram Phases

Exhale (plateau)

A B

C D End-tidal

E

Page 19: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnogram Phases

End of the wave of exhalation

A B

C D End-tidal

E

Page 20: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

How Capnography Can Help

• Airway• Breathing • Circulation

Page 21: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

What Happened?What Happened?

The endotracheal tube became dislodged!

Page 22: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Apnea

Airway Obstruction

Displaced airway (esophageal)

Airway or vent disconnection

Vent malfunction

Cardiac Arrest

Page 23: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

98

Sp02

What about the Pulse Ox?

Page 24: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Normal:

Esophageal tube:

Page 25: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Breathing

Page 26: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Capnography Waveforms

45

0

45

45

0

0Hypoventilation

Normal

Hyperventilation

Page 27: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Rebreathing

Possible causes:Faulty expiratory valve Inadequate inspiratory flowBreath stacking (wrong mode, undersedated)Malfunction of CO2 absorber system

Page 28: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

What’s the SHAPE?What’s the SHAPE?

Page 29: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

The Shark FinThe Shark FinPossible causes:

Partially kinked or occluded artificial airwayPresence of foreign body in the airwayObstruction in expiratory limb of vent circuitBronchospasm

Page 30: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Bronchospasm (asthma)

Mild Moderate

Page 31: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Marked bronchospasm

Page 32: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Airway:Leaking tube cuff

Airway:Leaking tube cuff

Page 33: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

“Curare Cleft”Appears when NMBAs begin to wear offDepth of cleft inversely proportional to

degree of blockade

Page 34: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

CirculationThe lungs and the heart

are inextricablytied together

CirculationThe lungs and the heart

are inextricablytied together

Page 35: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

CO2 clearance reflects perfusionCO2 clearance reflects perfusion

In other words: CO2 production is largely

dependent on oxygen

consumption!

Page 36: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Cardiac ArrestCardiac Arrest• Little O2 delivery or consumption

• Little CO2 production or venous return

• Little O2 delivery or consumption

• Little CO2 production or venous return

…Little Need to Ventilate!

Page 37: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

1. Use EtCO2 as guide to avoidoverventilation during

resuscitation:< 20: slooooow down> 40: increase breaths

2. Increased CO2 may = ROSC

1. Use EtCO2 as guide to avoidoverventilation during

resuscitation:< 20: slooooow down> 40: increase breaths

2. Increased CO2 may = ROSC

Page 38: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Decision to Call the Code• 120 prehospital patients in nontraumatic

cardiac arrest

• EtCO2 had 90% sensitivity in predicting ROSC

• Maximal level of <10mmHg during the first 20 minutes after intubation was never associated with ROSC

Source: Canitneau J. P. 1996. End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole, Critical Care Medicine 24: 791-796

Page 39: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

R. Fowler, P. PepeSeptember, 2007R. Fowler, P. PepeSeptember, 2007

What about other shock states?

“These data suggest that respiratory rate alone cannot

be used to predict measured capnography levels.”

Page 40: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Wide a-A gradient:

EtCO2 = 11PaCO2 = 28??

Page 41: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

• Pulmonary embolism• PNA, ALI or ARDS• Shunting• Low CO state• Very low HCO3

• Pulmonary embolism• PNA, ALI or ARDS• Shunting• Low CO state• Very low HCO3

Something is blocking gas exchange:

Page 42: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Test: your patient is seizing

Page 43: Capnography: The Window Into Your Patient Capnography: The Window Into Your Patient Mike McEvoy, PhD, RN, CCRN, REMT-P Senior Staff RN – Cardiothoracic

Thank You !

Talk Code: 682


03 capnography

16 capnography part3 intubated

Capnography During Cardiopulmonary Resuscitation

02 capnography

Capnography 2

Capnography During CPR

Perianesthesia Nurses Association of British Columbia Cathy Hanley, RN, BSN November 6, 2010 Capnography in the PACU: Theory and Clinical Applications

15 capnography part2 introduction

06 capnography and pulseoximetry

Capnography 102 - SCFR

Capnography Guidelines

Capnography tutorial

Important Capnography Traces - Think Anesthesia...Important Capnography Traces Title US - TA - Capnography Cheat Sheet.indd Created Date 9/19/2019 1:58:30 PM

Mainstream or Sidestream Capnography?

CAPNOGRAPHY In Emergency Care

Capnography for the intensivist

Capnography overview for ems.cole

WARNING Capnography handbook - CareFusionpages.carefusion.com/rs/565-YXD-236/images/RC_Capnography-Han… · Capnography handbook ... Technical aspects of capnography CO 2 measurement

Capnography During Sedation - Capnography - Capnography · Capnography During Sedation Bhavani Shankar Kodali MD Associate Professor, Harvard Medical School, Vice Chair, Clinical

Capnography d. Gihan Tarabih

Prehospital Capnography

Capnography Handbook.final

Capnography Reference Handbook

Capnography and interpretations

Interesting Capnography Cases - Stryker

capnography - im-medico.se

CAPNOGRAPHY IN EMS

Capnography - Philips

14 capnography part1 overview

Capnography Connections Guide€¦ · Capnography & EMS. Capnography Connections Guide p. 16 DECREASING ETCO2 LEVEL Decrease in the level of ETCO2 from previous levels. Possible causes:

WARNING Capnography handbook - Squarespacestatic1.squarespace.com/.../Capnography-Handbook.pdf · Capnography handbook ... This may be accomplished through pulse oximetry, ... Technical

Capnography in ems.ppt

NomoLine-O Capnography Sampling Lines · NomoLine-O ™ Capnography Sampling Lines Airway Adapter Sets and Cannulas for Effective Capnography Monitoring Ergonomically designed cannulas

McHenry Western Lake County EMS - Hospital in McHenry ... · What is Capnography? Capnography is an objective measurement of exhaled CO2 levels. Capnography measures ventilation

Capnography - the future