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CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 4: Non-intubated.

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Presentation on theme: "CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 4: Non-intubated."— Presentation transcript:

1 CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 4: Non-intubated

2 Part 4: The Non-intubated Patient CAPNOGRAPHY In Emergency Care

3 Part 4: The Non-intubated Patient Learning Objectives List three non-intubated applicationsList three non-intubated applications Identify four characteristic patterns seen inIdentify four characteristic patterns seen in –Bronchospasm AsthmaAsthma COPDCOPD –Hypoventilation states –Hyperventilation –Low-perfusion states

4 The Non-intubated Patient CC: “trouble breathing”

5 The Non-intubated Patient CC: “trouble breathing” Asthma? Emphysema? Pneumonia? Bronchitis? CHF? PE? Cardiac ischemia?

6 The Non-intubated Patient CC: “trouble breathing” Identifying the problem and underlying pathogenesisIdentifying the problem and underlying pathogenesis Assessing the patient’s statusAssessing the patient’s status Anticipating sudden changesAnticipating sudden changes

7 The Non-intubated Patient Capnography Applications Identify and monitor bronchospasmIdentify and monitor bronchospasm –Asthma –COPD Assess and monitorAssess and monitor –Hypoventilation states –Hyperventilation –Low-perfusion states

8 The Non-intubated Patient Capnography Applications Capnography reflects changes inCapnography reflects changes in –Ventilation - movement of gases in and out of the lungs –Diffusion - exchange of gases between the air- filled alveoli and the pulmonary circulation –Perfusion - circulation of blood through the arterial and venous systems

9 The Non-intubated Patient Capnography Applications VentilationVentilation Airway obstructionAirway obstruction –Smooth muscle contraction –Bronchospasm –Airway narrowing –Uneven emptying of alveoli –Mucous plugs

10 The Non-intubated Patient Capnography Applications DiffusionDiffusion Airway inflammationAirway inflammation Retained secretionsRetained secretions FibrosisFibrosis Decreased compliance of alveoli wallsDecreased compliance of alveoli walls Chronic airway modeling (COPD)Chronic airway modeling (COPD) Reversible airway disease (Asthma)Reversible airway disease (Asthma)

11 Capnography in Bronchospastic Conditions Air trapped due to irregularities in airwaysAir trapped due to irregularities in airways Uneven emptying of alveolar gasUneven emptying of alveolar gas –Dilutes exhaled CO 2 –Slower rise in CO 2 concentration during exhalation Alveoli

12 Capnography in Bronchospastic Diseases Uneven emptying of alveolar gas alters emptying on exhalationUneven emptying of alveolar gas alters emptying on exhalation Produces changes in ascending phase (II) with loss of the sharp upslopeProduces changes in ascending phase (II) with loss of the sharp upslope Alters alveolar plateau (III) producing a “shark fin”Alters alveolar plateau (III) producing a “shark fin” AB CD E II III

13 Capnography in Bronchospastic Conditions Prevalence of Asthma Asthma is increasing in the USAsthma is increasing in the US –20.3 million citizens report having asthma –Prevalence increased 75% from –Two million ED visits each year –Most common chronic health problem in children Increasing deaths due to asthmaIncreasing deaths due to asthma –1987 to 1995, death rate doubled to 5600 Sources: Delbridge T., et al Prehospital Asthma Management. Prehospital Emergency Care 7(1) Asthmatic Statistics. American Academy of Allergies, Asthma and Immunology. http.//www.aaaai.org

14 Capnography in Bronchospastic Conditions Pathology of Asthma Acute onset or progressive over weeksAcute onset or progressive over weeks AirwayAirway –Increased responsiveness (hyper-reactivity) –Bronchospasm Reversible obstructionReversible obstruction –Inflammation

15 Capnography in Bronchospastic Conditions Pathology of Asthma Release of inflammatory mediatorsRelease of inflammatory mediators –Histamine, bradykinin, prostaglandins Bronchial wall reactionBronchial wall reaction –Spasm of bronchial smooth muscle –Vasodilatation with swelling of bronchial mucous membranes –Increased mucous production

16 Capnography in Bronchospastic Conditions Symptoms of Asthma TachycardiaTachycardia TachypneaTachypnea WheezingWheezing CoughCough Chest tightnessChest tightness Use of accessory muscles (retractions)Use of accessory muscles (retractions) AnxietyAnxiety DiaphoresisDiaphoresis

17 Capnography in Bronchospastic Conditions Classification of Asthma SymptomsMildModerateSevere Arrest Imminent BreathlessWalkingTalkingResting Talks in SentencesPhrasesWords AlertnessAgitated?AgitatedAgitatedDrowsy Resp Rate IncreasedIncreased>30/min AccessoryNoCommonlyUsuallyParadox Wheeze Mod; EE Loud; Exp Loud: I/E Absent Pulse< >120Brady PaCO 2 <42mmHg<42mmHg >42mmHg SaCO 2 >95%91-95%<91% Position Can lie down Prefers sitting Sitting upright Source: Edmond S. D National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: Adopted from the NIH Guidelines for the Diagnosis and Management of Asthma

18 Capnography in Bronchospastic Conditions Assessment of Asthma Symptoms and observations are primarily subjectiveSymptoms and observations are primarily subjective Severity of symptoms and your patient’s perception may not accurately reflect severity of conditionSeverity of symptoms and your patient’s perception may not accurately reflect severity of condition More objective data needed Source: Teeter J.G., et al “Relationship Between Airway Obstruction and Respiratory Symptoms in Adult Asthmatics. CHEST.113:5:

19 Capnography in Bronchospastic Conditions Capnogram of Asthma 28 normal volunteers; 20 asthma patients in ED28 normal volunteers; 20 asthma patients in ED Correlation between PEFR and slope of capnogram waveformCorrelation between PEFR and slope of capnogram waveform ConclusionConclusion –Slope value correlated with PEFR –“dCO 2 /dt is an effort independent, rapid noninvasive measure that indicates significant bronchospasm” Source: Yaron M Utility of the Expiratory Capnogram in the Assessment of Bronchospasm. Annals of Emergency Medicine 28: 4

20 Capnography in Bronchospastic Conditions Capnogram of Asthma “expiratory airflow obstruction affects the shape of the CO 2 time curve due to uneven emptying of alveolar gas.” P 312“expiratory airflow obstruction affects the shape of the CO 2 time curve due to uneven emptying of alveolar gas.” P 312 Waveform examples show increasing change in normal expiratory plateau with increasing obstruction (bronchospasm)Waveform examples show increasing change in normal expiratory plateau with increasing obstruction (bronchospasm) Source: Hall J.B., Acute Asthma, Assessment and Management, McGraw-Hill, New York.

21 Capnography in Bronchospastic Conditions Capnogram of Asthma Source: Krauss B., et al FEV1 in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA Changes in dCO 2 /dt seen with increasing bronchospasm Bronchospasm Normal

22 Capnography in Bronchospastic Conditions Capnography in Asthma Research is underway on the correlation of capnographic changes to patient’s respiratory statusResearch is underway on the correlation of capnographic changes to patient’s respiratory status Anticipating clinical trials on the impact on patient care, outcomes and healthcare costsAnticipating clinical trials on the impact on patient care, outcomes and healthcare costs

23 Capnography in Bronchospastic Conditions Asthma Case Scenario 16 year old female16 year old female C/O “having difficulty breathing”C/O “having difficulty breathing” Visible distressVisible distress History of asthma, physical exertion, “a cold”History of asthma, physical exertion, “a cold” Patient has used her “puffer” 8 times over the last two hoursPatient has used her “puffer” 8 times over the last two hours Pulse 126, BP 148/86, RR 34Pulse 126, BP 148/86, RR 34 Wheezing noted on expirationWheezing noted on expiration

24 Capnography in Bronchospastic Conditions Asthma Case Scenario Initial After therapy

25 Capnography in Bronchospastic Conditions Prevalence of COPD COPD is increasing in the U.S.COPD is increasing in the U.S. –Fourth leading cause of death in adults –16 million cases in 1996 Increasing deaths due to COPDIncreasing deaths due to COPD –1999 estimated 110,000 –Number of deaths doubled in the past 25 years Source: Boyle, A.H Recommendations of the National Lung Health Education Program, Heart & Lung 29: 6:

26 Capnography in Bronchospastic Conditions Pathology of COPD Chronic, progressive disease processChronic, progressive disease process –Major risk factors: smoking, exposure to dusts and fumes, history of frequent respiratory infections Spectrum of diseasesSpectrum of diseases –Chronic bronchitis –Emphysema –Asthma –Bronchiectisis

27 Capnography in Bronchospastic Conditions Pathology of COPD ProgressiveProgressive Partially reversiblePartially reversible Airways obstructedAirways obstructed –Hyperplasia of mucous glands and smooth muscle –Excess mucous production –Some hyper-responsiveness

28 Capnography in Bronchospastic Conditions Pathology of COPD Small airwaysSmall airways –Main sites of airway obstruction –Inflammation –Fibrosis and narrowing –Chronic damage to alveoli –Hyper-expansion due to air trapping –Impaired gas exchange

29 Capnography in Bronchospastic Conditions Symptoms of COPD Exacerbation Increase in chronic symptomsIncrease in chronic symptoms –SOB –Cough –Wheezing –Use of accessory muscles –Sputum - increased volume, tenacity and purulence –Anxiety –Diaphoresis –Chest tightness

30 Capnography in Bronchospastic Conditions Symptoms of COPD Exacerbation May also haveMay also have –Fever - underlying infection –Co-morbidity Congestive heart failureCongestive heart failure Acute coronary syndromeAcute coronary syndrome Diabetes mellitusDiabetes mellitus HypertensionHypertension

31 Capnography in Bronchospastic Conditions Assessment of COPD Symptoms and observations are primarily subjectiveSymptoms and observations are primarily subjective Severity of symptoms and your patient’s perception may not accurately reflect severity of conditionSeverity of symptoms and your patient’s perception may not accurately reflect severity of condition More objective data needed

32 Capnography in Bronchospastic Conditions Capnography in COPD Arterial CO 2 in COPDArterial CO 2 in COPD –PaCO 2 increases as disease progresses –Requires frequent arterial punctures for ABGs Correlating capnograph to patient statusCorrelating capnograph to patient status –Ascending phase and plateau are altered by uneven emptying of gases

33 Capnography in Bronchospastic Conditions COPD Case Scenario 72 year old male72 year old male C/O difficulty breathingC/O difficulty breathing History of CAD, CHF, smoking and COPDHistory of CAD, CHF, smoking and COPD Productive cough, recent respiratory infectionProductive cough, recent respiratory infection Pulse 90, BP 158/82 RR 27Pulse 90, BP 158/82 RR 27

34 Capnography in Bronchospastic Conditions COPD Case Scenario Initial Capnogram A Initial Capnogram B

35 Capnography in Bronchospastic Conditions Capnogram of CHF 207 patients in pulmonary function lab207 patients in pulmonary function lab –61 with obstructive disease (OD); 34 with restrictive disease (RD) –Correlation of slope of exhalation plateau C/O severe difficulty breathing (FEV1<50%)C/O severe difficulty breathing (FEV1<50%) –97% of OD had elevations >4°; 5% of RD had elevations >4° –P< ConclusionConclusion –Changes in shape of capnogram in OD confirmed –Changes in capnogram in RD did not occur Source: Krauss B., et al FEV1in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA.

36 Capnography in CHF Case Scenario 88 year old male88 year old male C/O: Short of breathC/O: Short of breath H/O: MI X 2, on oxygen at 2 L/mH/O: MI X 2, on oxygen at 2 L/m Pulse 66, BP 114/76/p, RR 36 labored and shallow, skin cool and diaphoretic, 2+ pedal edemaPulse 66, BP 114/76/p, RR 36 labored and shallow, skin cool and diaphoretic, 2+ pedal edema Initial SpO 2 69%; EtCO 2 17mmHGInitial SpO 2 69%; EtCO 2 17mmHG

37 Capnography in CHF Case Scenario Placed on non-rebreather mask with 100% oxygen at 15 L/m; IV diuretic and SL nitroglycerin as per local protocolPlaced on non-rebreather mask with 100% oxygen at 15 L/m; IV diuretic and SL nitroglycerin as per local protocol Ten minutes after treatment:Ten minutes after treatment: SpO 2 69% 99% SpO 2 69% 99% EtCO 2 17mmHG 35 mmHG EtCO 2 17mmHG 35 mmHG Time condensed to show changes

38 Capnography in Hypoventilation States Altered mental statusAltered mental status –Sedation –Alcohol intoxication –Drug Ingestion –Stroke –CNS infections –Head injury Abnormal breathingAbnormal breathing CO 2 retentionCO 2 retention –EtCO 2 >50mmHg

39 Capnography in Hypoventilation States EtCO 2 is above 50mmHGEtCO 2 is above 50mmHG Box-like waveform shape is unchangedBox-like waveform shape is unchanged Time condensed; actual rate is slower

40 Capnography in Hypoventilation States Case Scenario Observer called 911Observer called year old male sleeping and unresponsive on sidewalk, “gash on his head”76 year old male sleeping and unresponsive on sidewalk, “gash on his head” Known history of hypertension, EtOH intoxicationKnown history of hypertension, EtOH intoxication Pulse 100, BP 188/82, RR 10, SpO 2 96% on room airPulse 100, BP 188/82, RR 10, SpO 2 96% on room air

41 Capnography in Hypoventilation States Hypoventilation Time condensed; actual rate is slower

42 Capnography in Hypoventilation States Hypoventilation Hypoventilation in shallow breathing

43 Capnography in Low Perfusion Capnography reflects changes inCapnography reflects changes in PerfusionPerfusion –Pulmonary blood flow –Systemic perfusion –Cardiac output

44 Capnography in Low Perfusion Case Scenario 57 year old male57 year old male Motor vehicle crash with injury to chestMotor vehicle crash with injury to chest History of atrial fib, anticoagulantHistory of atrial fib, anticoagulant UnresponsiveUnresponsive Pulse 100 irregular, BP 88/pPulse 100 irregular, BP 88/p Intubated on sceneIntubated on scene

45 Capnography in Low Perfusion Case Scenario Low EtCO 2 seen in low cardiac output Ventilation controlled

46 Capnography Applications on Non-intubated Patients New applications now being reportedNew applications now being reported –Pulmonary emboli –CHF –DKA –Bioterrorism –Others?

47 Capnography in Pulmonary Embolus Case Scenario 72 year old female72 year old female CC: Sharp chest pain, short of breathCC: Sharp chest pain, short of breath History: Legs swollen and pain in right calf following flight from AlaskaHistory: Legs swollen and pain in right calf following flight from Alaska Pulse 108 and regular, RR 22, BP 158/88 SpO 2 95%Pulse 108 and regular, RR 22, BP 158/88 SpO 2 95%

48 Capnography in Pulmonary Embolus Case Scenario Strong radial pulse Low EtCO 2 seen in decreased alveolar perfusion

49 Part 4: The Non-intubated Patient Summary Identify and monitor bronchospasmIdentify and monitor bronchospasm –Asthma –COPD Assess and monitorAssess and monitor –Hypoventilation states –Hyperventilation –Low perfusion –Many others now being reported

50 Part 4: The Non-intubated Patient Ready to take capnography for a run?


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