1. UNION HOSPITAL EMERGENCY DEPARTMENT KELLY MILLS RN CEN
CAPNOGRAPHY
UNION HOSPITAL
EMERGENCY DEPARTMENT
KELLY MILLS RN CEN

2. History of capnography
Used by anesthesiologists since the 1970s
Standard of care in the OR since 1991
New recommendations and JCAHO standards now expanding utilization in other areas specifically for procedural sedation.

3. Indications for Use - End-Tidal CO2 Monitoring
Validation of proper endotracheal tube placement
Detection and Monitoring of Respiratory depression
Hypoventilation
Obstructive sleep apnea
Procedural sedation
Adjustment of parameter settings in mechanically ventilated patients

4. Definition of Capnography
A numerical value of the EtCO2
AND
A waveform of the concentration of CO2 present in the airway
Respiratory rate detected from the actual airflow

5. Capnometer
A Capnometer provides only a numerical measurement of carbon dioxide.

6. Capnogram
A Capnogram is a waveform display of carbon dioxide over time

7. Oxygenation and Ventilation
What is the difference?

8. Oxygenation Measured by pulse oximetry (SpO2) Noninvasive measurement
Percentage of oxygen in red blood cells
Changes in ventilation take minutes to be detected
Affected by motion artifact, poor perfusion, etc.

9. Ventilation Measured by the end-tidal CO2
Partial pressure (mm Hg) or volume(% vol) of CO2 in the airway at the end of exhalation
Breath-to-breath measurement provides information within seconds
Not affected by motion artifact , poor perfusion, etc.

10. Oxygenation and Ventilation
Respiratory Cycle = separate physiologic processes:
Oxygenation
Ventilation

11. Comparing Capnography with Pulse Oximetry
Carbon dioxide
Reflects ventilation
Hypoventilation / apnea detected immediately
Reflects change in ventilation within 10 seconds
Should be used with pulse oximetry
Pulse oximetry
Oxygen saturation
Reflects oxygenation
SpO2 changes lag when patient is hypoventilating or apneic
Reflects change in oxygenation within 5 minutes
Should be used with capnography

12. Respiration–The BIG Picture

13. Physiological Factors Affecting ETCO2 Levels

14. Normal Arterial & ETCO2 Values

15. Physiology
Relationship between CO2 and RR
RR  CO2 Hyperventilation
 RR   CO2 Hypoventilation
There is an inverse relationship between your respiratory rate and your CO2 level.
As you breath faster your RR goes up, your body is unable to hold onto CO2 and therefore blows it off faster so those levels go down.
As you breath more slowly, your RR goes down, your body is holding more CO2 due to the lack of breaths taken and the CO2 level goes up.

16. Elements of a Waveform End of exhalation Alveolar Gas
Alveolar gas mixes with dead space
Inspiration

17. The Normal CO2 Waveform A – B Baseline B – C Expiratory Upstroke
C – D Expiratory Plateau
D ETCO2 value
D – E Inspiration begins

18. ETT
A normal capnogram is the best evidence that the ETT is correctly positioned
With an esophageal tube little or no CO2 is present

19. Hypoventilation (increase in ETCO2)
Possible causes:
Decrease in respiratory rate
Decrease in tidal volume
Increase in metabolic rate
Rapid rise in body temperature (hypothermia)

20. Waveform: Regular Shape, Plateau Above Normal
Indicates increase in ETCO2
Hypoventilation
Respiratory depressant drugs
Increased metabolism
Fever, pain, shivering
Interventions
Adjust ventilation rate
Decrease respiratory depressant drug dosages
Assess pain management
Conserve body heat

21. Hyperventilation (decrease in ETCO2)
Possible causes:
Increase in respiratory rate
Increase in tidal volume
Decrease in metabolic rate
Fall in body temperature (hyperthermia)

22. Waveform: Regular Shape, Plateau Below Normal
Indicates CO2 deficiency
Hyperventilation
Decreased pulmonary perfusion
Hypothermia
Decreased metabolism
Interventions
Adjust ventilation rate
Evaluate for adequate sedation
Evaluate anxiety
Conserve body heat

23. Obstruction-Shark Fin
Possible causes:
Partially kinked or occluded artificial airway
Presence of foreign body in the airway
Obstruction in expiratory limb of the breathing circuit
Bronchospasm-Can indicate need for bronchodilators.

24. Sudden Loss of Waveform
Apnea
Airway Obstruction
Dislodged airway (esophageal)
Airway disconnection
Ventilator malfunction
Cardiac Arrest

25. Curare Cleft Curare cleft is when a neuromuscular blockade wears off
The patient takes small breaths that causes the cleft
Management: consider neuromuscular blockade
re-administration

26. Troubleshooting Sudden increase in EtCO2
Malignant Hyperthermia
Ventilation of previously unventilated lung
Increase of blood pressure
Release of tourniquet
Bicarb causes a temporary <2 minute rise in ETCO2

27. Troubleshooting EtCO2 values drop to 0
Extubation/Movement into hypopharynx
Ventilator disconnection or failure
EtCO2 defect
ETT kink

28. Troubleshooting Sudden decrease EtCO2 (not to 0)
Leak or obstruction in system
Partial disconnect
Partial airway obstruction (secretions)
High-dose epi can cause a decrease

29. Troubleshooting Continual, exponential decrease in EtCO2
Pulmonary Embolism
Cardiac Arrest
Sudden hypotension/hypovolemia
Severe hyperventilation

30. What does it really do for me?
Non-Intubated Applications
Bronchospasms: asthma, COPD, anaphlyaxis
Hypoventilation: drugs, stroke, CHF, post-Ictal
Shock and circulatory compromise
Hyperventilation Syndrome: biofeedback
Intubated Applications
Verification of ETT placement
ETT surveillance during transport
Control ventilations during CHI and increased ICP
CPR: compression efficacy, early signs of ROSC, survival predictor

31. MICROSTREAM CAPNOGRAPHY SOLUTIONS

32. MICROSTREAM CAPNOGRAPHY SOLUTIONS
Small pin holes deliver pillow of oxygen around both nose and mouth Nasal and Oral Sampling
CO2 sampling / O2 delivery for non-intubated patients
Uni-junction™ of sampling ports prevents dilution from nonbreathing source
Increased surface area provides greater sampling accuracy in the presence of low tidal volume

33. Smart CapnoLine™ Plus O2 nasal cannula for CO2 measurement and O2 delivery
O2 delivery method reduces CO2 sampling dilution
–Solution for high flow O2 delivery (works effectively under oxygen delivery mask)

34. FilterLine® patient interfaces
Prevents moisture from entering monitor
Replaces water trap

35. Capnography in procedural sedation
Accurately monitors RR
Monitors adequate ventilation with non-intubated patients
Monitors potential risk of over-sedation resulting in
Hypoventilation more effectively than pulse oximetry
Early indicator of airway obstruction
Early warning of apnea
Adds an additional level of patient safety providing the caregiver with vital information to make accurate assessments and timely interventions for the patient