created by joshua english, emt-p james pointer, md mike jacobs, emt-p
TRANSCRIPT
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Created byCreated by Joshua English, EMT-PJames Pointer, MDMike Jacobs, EMT-P
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Objectives
• Understand why we use capnography• Understand the physiology of respiration/
ventilation
• Define normal & abnormal EtCO2 values/ waveforms
• Understand the 4 major applications of EtCO2– intubated applications (mainstream)– non-intubated applications (sidestream)
• Understand why we use capnography• Understand the physiology of respiration/
ventilation
• Define normal & abnormal EtCO2 values/ waveforms
• Understand the 4 major applications of EtCO2– intubated applications (mainstream)– non-intubated applications (sidestream)
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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 EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.[Annals of Emergency Medicine 2005; 45:497-503]”
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 EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.[Annals of Emergency Medicine 2005; 45:497-503]”
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Why Capnography?
• Verification of proper tube placement
There is simply NO BETTER WAY to confirm proper tube placement
than with waveform capnography…. PERIOD!!!
• Verification of proper tube placement
There is simply NO BETTER WAY to confirm proper tube placement
than with waveform capnography…. PERIOD!!!
![Page 5: Created by Joshua English, EMT-P James Pointer, MD Mike Jacobs, EMT-P](https://reader036.vdocuments.site/reader036/viewer/2022070401/56649f1d5503460f94c344a0/html5/thumbnails/5.jpg)
Why Capnography?
Because respiration, ventilation and oxygenation are
VERYVERY different concepts.
Because respiration, ventilation and oxygenation are
VERYVERY different concepts.
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Why Capnography?
It’s a window into the patient’s ventilatory status
It’s a window into the patient’s ventilatory status
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Why Capnography?
Core Concepts• What intubation verification method is most
reliable?• How do oxygenation and ventilation differ?
Core Concepts• What intubation verification method is most
reliable?• How do oxygenation and ventilation differ?
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Factors that affect CO2 levels:Factors that affect CO2 levels:INCREASE IN ETCO2 DECREASE IN ETCO2
Increased muscular activity Decreased muscular activity
Increased cardiac output(during resuscitation)
Decreased cardiac output(during resuscitation)
Effective drug therapy for bronchospasm
Bronchospasm
Hypoventilation Hyperventilation
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Normal EtCO2
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Terminology
Capnograma real-time waveform record of theconcentration of carbon dioxide in therespiratory gases
CapnographCapnogram waveform plusnumerical value
Capnograma real-time waveform record of theconcentration of carbon dioxide in therespiratory gases
CapnographCapnogram waveform plusnumerical value
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Terminology
EtCO2 – End Tidal CO2
The measurement of exhaled CO2 in the breathNormal Range | 35-45 mmHg
EtCO2 – End Tidal CO2
The measurement of exhaled CO2 in the breathNormal Range | 35-45 mmHg
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Normal Waveform
End of inspiration
Beginning of exhalation
End of exhalation
Beginning of new breath
Alveolar plateau
Clearing of anatomic dead space
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Normal
Common Waveforms
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Hyperventilation
Hypoventilation
Common Waveforms
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4 Main Uses of Capnography
• Severity of asthma patients
• Monitoring head injured patients
• Cardiac arrest
• Tube confirmation
• Severity of asthma patients
• Monitoring head injured patients
• Cardiac arrest
• Tube confirmation
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Terminology
SidestreamAn indirect method of measuring exhaled CO2 in non-
intubated patients
MainstreamDirect method of measuring exhaled CO2 with intubated
patients
SidestreamAn indirect method of measuring exhaled CO2 in non-
intubated patients
MainstreamDirect method of measuring exhaled CO2 with intubated
patients
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Shark Fin
Asthmatic Waveforms
COPD patients have a difficult time exhaling gases
This is represented on the capnogram by a shark fin appearance
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Moderate Attack
Mild Attack
EtCO2 & Asthma
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Severe Attack
EtCO2 & Asthma
Time To Get MOVING!!!The asthmatic who looks tired and has a shark fin appearance
on the capnogram…IS HEADED FOR RESPIRATORY ARREST
Time To Get MOVING!!!The asthmatic who looks tired and has a shark fin appearance
on the capnogram…IS HEADED FOR RESPIRATORY ARREST
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The Head Injured PatientCarbon 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 CO2 levels to the 30-35 30-35 mmHgmmHg range can help relieve the untoward effects of ICP
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Titrate EtCO2
The Head Injured PatientTitration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO2 levels.
Keep them between 30 and 35 mmHg
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EtCO2 and Cardiac Arrest
The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output
Increase in CO2 during CPR can be an early indicator of ROSC
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Termination of Resuscitation
EtCO2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR
Non-survivors <10 mmHg10 mmHg
Survivors >30 mmHg30 mmHg ((to discharge)
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ET Tube Verification
• Verification of proper tube placement
There is simply NO BETTER WAY to confirm proper tube placement
than with waveform capnography…. PERIOD!!!
• Verification of proper tube placement
There is simply NO BETTER WAY to confirm proper tube placement
than with waveform capnography…. PERIOD!!!
![Page 26: Created by Joshua English, EMT-P James Pointer, MD Mike Jacobs, EMT-P](https://reader036.vdocuments.site/reader036/viewer/2022070401/56649f1d5503460f94c344a0/html5/thumbnails/26.jpg)
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 CO2 at?• What are two ways that capnography can assist during
CPR?
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 CO2 at?• What are two ways that capnography can assist during
CPR?
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Inadequate Seal
Troubleshooting
As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff
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Obstruction
Troubleshooting
An obstructed ET tube may have an erratic EtCO2 value with a very irregular waveform
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Rebreathing
Troubleshooting
A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO2 through insufficient inspiratory or expiratory flow
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QUIZ
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Hypoventilation
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Rebreathing
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Esophageal Tube
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Asthma
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Normal
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Questions?