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1 CO 2 Physiology. 2 What is Carbon Dioxide? Capnos comes from the Greek word for “smoke” –smoke from the fire of metabolism –a natural waste product.

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Presentation on theme: "1 CO 2 Physiology. 2 What is Carbon Dioxide? Capnos comes from the Greek word for “smoke” –smoke from the fire of metabolism –a natural waste product."— Presentation transcript:

1 1 CO 2 Physiology

2 2 What is Carbon Dioxide? Capnos comes from the Greek word for “smoke” –smoke from the fire of metabolism –a natural waste product of cellular activity CO 2 is a compound molecule –1 element of carbon and 2 elements of oxygen –colorless and heavier than air –green plants clean up after our exhaled CO 2

3 3 Physiology of CO 2 CO 2 produced by cellular metabolism diffuses across the cell membrane into the circulating blood. The blood transports the CO 2 to the lungs. Then it diffuses from the blood into the lungs. CO 2 is eliminated with alveolar ventilation on exhalation.

4 4 Physiology of CO 2 Carbon Dioxide is transported in the blood in three (3) principle forms: –5 to 10% as gas & reflected by the PCO 2 –20 to 30% is bound to blood proteins, the major one being hemoglobin –60 to 70% is carried as bicarbonate (HCO 3 )

5 5 Physiology of CO 2 About 5-10% of CO 2 is eliminate through exhalation only. The rest is recycled in the body through the circulatory and renal systems. The heart and lungs would have to increase their work 10 times if they were required to eliminate all the CO 2 the body produces!

6 6 Ventilation & EtCO 2 Monitoring Endtidal CO 2 (EtCO 2 ) is the CO 2 measured at the end of expiration. EtCO 2 concentration provides a clinical estimate of the PaCO 2, if ventilation and perfusion are appropriately matched. EtCO 2 monitoring allows for a breath by breath assessment of ventilation.

7 7 Capnography— The continuous measurement and graphic display (waveform) of the CO 2 concentration in the patient ’ s airway during the respiratory cycle. Normal waveform:

8 Respiratory Cycle O2O2 CO 2 O2O2

9 9 Respiratory Cycle Oxygenation = oxygen → lungs→ alveoli→ blood Monitored by a Pulseoximeter Metabolism = oxygen is converted to energy + CO 2 Monitored by a Metabolic Computer Hymodynamic Parameter Monitored by ECG, IPB, NIBP, Temperature Ventilation = CO 2 → blood→ lungs→ exhalation Monitored by a Capnograph

10 10 Normal conditions: EtCO2 is between 35 – 45 mmHg PaCO 2 & EtCO 2 will be very close EtCO 2 is most mmHg less with normal physiology Widening of this difference can be caused by: Incomplete alveolar emptying Ventilation-perfusion abnormalities Poor sampling Capnography monitoring of Critically ill patient may alert clinicians to underlying conditions The relationship – EtCO 2 and PaCO 2

11 11 PaCO 2 vs. EtCO 2 PaCO 2 – Partial pressure of CO 2 present in arteries (similar to concentration) Invasive ABG analysis EtCO 2 – concentration of CO 2 exhaled in each breath Non-invasive measurement at airway

12 12 A-B: Baseline = no CO 2 in breath B-C: Rapid rise in CO 2 D-E: Inhalation C-D: Alveolar plateau D D: End expiration (EtCO 2 ) Normal waveform D

13 13 Normal waveform mmHg

14 14 Hypoventilation

15 15 Hypoventilation with shallow breathing

16 16 Relationship between EtCO 2 and RR Breath-to-breath measure of ventilatory status

17 17 Hyperventilation

18 18 Some Definitions Capnometer Capnography

19 19 Capnometer A Capnometer provides only a numerical measurement of carbon dioxide in mmHg or kPa or Vol.-%

20 Capnograpy Capnography provides the CO 2 value and the waveform of carbon dioxide over time

21 21 Capnography— The Ventilation Vital Sign™ Earliest sign that something is going wrong Breath by breath assessment of ventilation

22 22 Capnography An EtCO 2 value of e.g. 38 mm/Hg without a it´s like a heart rate of e.g. 80 without an

23 23 CO 2 Measurement Technology General: CO2 measurement technology Infrared absorption Technique of airway gas sampling Main stream vs. side stream vs. Microstream

24 24 Sampling Technology Mainstream sampling - CO 2 analysis chamber is in-line between the patient airway and the ventilator circuit Sidestream sampling - CO 2 analysis chamber is within the device. The patient’s expired gas is sucked from the airway and drawn to that chamber through a sampling line.

25 25 Conventional main stream technology Monitor Fresh gas Inspiration Expiration

26 26 Conventional side stream technology Sample line (Monitor)

27 27 Unique solutions for Capnography = Microstream ®

28 28 Microstream ® CO 2 A combination of a unique CO 2 sidestream measurement technology and; FilterLine  (proprietary sampling lines) - for single patient use Only system providing accurate EtCO 2 readings for non-intubated patients that receive supplemental O 2 and switch between oral and/or nasal breathing

29 29 Microstream ® CO 2 — Major benefits Ease of Use Reliable Technology Flexible for all patient types Versatile for all environments

30 30 Microstream ® advantages Superior moisture handling of liquids, secretions and humidity CO 2 specificity – no cross-sensitivity to anesthetic gases Rugged – no moving parts in sensor Long-term monitoring Reliable technology

31 50 ml/min flow rate supports entire patient population – including neonates (Competition at 3 – 5 times the flow rate) Does not compete for Neonate tidal volume The lower the flow, the less moisture to be handled Flexible for all patient populations – solution for monitoring Neonates Microstream ® advantages

32 32 Microstream ® advantages No expensive sensors to replace Yearly calibration – done in 5 minutes Warm up time – 45 seconds from ON until first waveform and number appears One-piece Plug & Play consumables Ease of use

33 33 Light source Micro sample cell 15 µL Light source housing 1 Eurocent Microstream ® advantages

34 34 Microstream ® Core Technology Sensor Housing I.R Source Optic Block (Micro Sample Cell) I.R Detectors

35 35 Microstream ® advantages Fast response time 1 mm micro bore tubing reduces delay time Crisp waveform – longitudinal filter maintains laminar flow Build-in water trap – don't clean and re-use any FilterLine – it destroys the inline filter Reliable Technology

36 36 Microstream ® advantages Flexible Both intubated and nonintubated applications Alternating mouth and nose breathing Oxygen delivery (low flow O 2 solution; solution for high flow O 2 delivery) Adult, pediatric, and neonates

37 37 Microstream ® advantages Versatile All clinical environments: Critical Care Sedation Procedures EMS/ED Operating Room

38 38 Unique solutions for Capnography FilterLine ® patient interfaces

39 39 FilterLine ® solutions for all applications FilterLine ® Sets Intubated Non-Intubated Smart Solutions NIV-Line CapnoLine H Smart CapnoLine / Smart CapnoLine O 2

40 40 Smart Solutions for nonintubated patients Continuous sampling from both mouth and nose Special oral-piece design optimally samples from mouth - Increased surface area provides greater sampling accuracy in the presence of low tidal volume (adult/intermediate size) “Microstream ® technology allows the accurate measurement of EtCO 2 in the absence of an endotracheal tube.”* *ASA 2001 Jay Brodsky, MD Professor of Anesthesia, Stanford University Medical Center, CA USA

41 41 Smart Solutions for nonintubated patients Smart CapnoLine ™ Plus / Smart CapnoLine ™ Plus O 2 nasal cannula for CO 2 measurement and O 2 delivery Uni-junction sampling method ensures optimal waveform and ultra-fast response time Unique O 2 delivery method reduces CO 2 sampling dilution (up to 5l/min) Solution for high flow O 2 delivery (works effectively under oxygen delivery mask)

42 42 Solutions for non-intubated patients CapnoLine H* ™ / CapnoLine H O 2 Enables continuous EtCO 2 monitoring in high humidity environments (i.e. ICU) Can be used up to 72 hours * = Humidity Piece of Nafion

43 43 Small pin holes deliver pillow of oxygen around both nose and mouth Nasal and Oral Sampling Microstream ® —A Unique Solution For Non-intubated Patients CO 2 sampling / O 2 delivery for non-intubated patients (up to 5 L/min.) Uni-junction™ of sampling ports prevents dilution from non-breathing source Increased surface area provides greater sampling accuracy in the presence of low tidal volume

44 44 Easily handles moisture and secretions without water traps Able to measure in any position Nafion ® tubing allows for long- term monitoring without moisture build up Easily switches to non- intubated monitoring without re- calibration of monitor Low add. dead space (0,4 cc) to use on neonates FilterLine ® Sets - Solutions for intubated patients

45 45 FilterLine ® recommendations: Sedation Areas; GI Lab, Cath Lab, EP Lab Is the Patient on Oxygen? YES Smart CapnoLine Plus O2 NO Smart CapnoLine Plus

46 46  Do not try to dry the FilterLine ® - this will damage the filter  Ensure there are no kinks in the sampling line  Do not cut the oral flange on the Smart CapnoLine  Do not cover the Nafion ®  Do not instill medications through the airway adapter  Never pass a suction catheter or stylus through the airway adapter  Change the FilterLine ® or the Set if a “Blockage” message appears on the monitor screen or if the readings become extremely erratic FilterLine ® information to avoid problems

47 47  Latex free  Single-patient use  Not sterile FilterLine ® answers for the most FAQ´s:

48 48 Sedation Procedures “Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation.”* *Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non Anesthesiologists: Anesthesiology 2002; 96:1004

49 49 Assesses -  patent airway (airway obstruction)  protective reflexes  response to verbal/physical stimuli Respiratory changes can immediately be assessed Microstream ® allows for continuous respiratory monitoring with no nuisance alarms in procedural sedation environments where currently there is minimal usage of monitoring Microstream ® solutions during Sedation Procedures Benefits and Uses

50 50 Microstream ® solutions during Sedation Procedures Cardiac Cath. Lab GI lab Pulmonary lab Emergency Department Hyperbaric medicine Dental Clinics Radiology Applications

51 51 Moderate – procedural sedation

52 52 How can capnography make a difference in how you care for the sedated patient? What you do will not change When you do it will! Capnography and sedation Early detection of potential patient compromise

53 53 Protocol during procedural sedation E.g. after 12 hours NPO (nothing by mouth) = EtCO 2  Know the respiratory rate, waveform, and EtCO 2 numeric value before drug administration Baseline Ventilatory Assessment RR, ETCO 2 value…changes from baseline (trends) Changes in the Waveform…Earliest indicator of potential problems. (size, shape) Continuous monitoring throughout case and recovery Early intervention

54 54 Changes from baseline Change in EtCO 2 value > 10 mmHg Significant waveform change Becomes erratic Flatlines

55 55 Remember the ABC’s (airway, breathing, circulation) Assess the patient Follow your normal protocol, which may include: Changes from baseline - action  Ensure open airway  Stimulate patient if necessary  Check the cannula positioning  Stop drug delivery  Inform M.D. / pause procedure if necessary  Administer reversal agents as prescribed

56 56 Requires higher vigilance in ventilatory monitoring Maintain patent airway Potential dead space ventilation Chest moves up and down Deep sedation Inadequate respiratory effort to clear dead space

57 57 Assessing for changes from baseline Hypoventilation with shallow respirations

58 58 Nursing interventions Continue to monitor Ask patient to take a deep breath

59 59 Abnormal waveforms Possible causes Partial airway obstruction caused by: Tongue Position of head Absent alveolar plateau indicates incomplete alveolar emptying or loss of airway integrity

60 60 Assessing for changes from baseline Poor head and neck alignment Draping near the airway Shallow breathing – not clearing dead space Rebreathing often results from:

61 61 Assessing for changes from baseline Chest movement Little – to no air movement in and out of lungs Dead space ventilation

62 62 Abnormal waveforms Possible causes Partial airway obstruction caused by: – Tongue – Position of head Absent alveolar plateau indicates incomplete alveolar emptying or loss of airway integrity

63 63 Nursing interventions Assess patient Ask patient to take a deep breath Adjust patient’s head position, if necessary Adjust cannula position, if necessary

64 64 Putting it all together The transition from conscious sedation to unconscious/anesthesia is very subtle and can be undetected until oxygenation is impaired You must be prepared to monitor a patient at a level deeper than intended “Respiratory frequency and adequacy of pulmonary ventilation are continually monitored” Only capnography provides an immediate notification of a ventilatory event

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