Capnography Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine Cardiac Surgical ICU RN & Chair Resuscitation Committee – Albany Medical Center

Mike McEvoy: www.mikemcevoy.com

Outline: Carbon dioxide Capnography – what, where, why? Oxygenation Ventilation EtCO2 equipment Waveforms Uses Cases

Carbon Dioxide = CO2 2 oxygen atoms + 1 carbon atom Trace gas on earth (0.036-0.039%) CO2 produced by: Coal combustion (hydrocarbons) Fermentation of beer Respiration of living organisms Plants: sunlight + CO2 + water  O2 Plants scavenge CO2 and, in the presence of sunlight, convert CO2 into oxygen.

Carbon Dioxide = CO2 Human body produces 2.3 # per day Solid form = dry ice Gas = fire extinguishers, carbonated drinks…

CO2 (Carbon Dioxide) Greenhouse gas (heavier than air) Global warming Ocean acidification (carbonic acid) CO2 is a well known Greenhouse gas that is considered responsible for global warming and acid rain which results in acifidication of large bodies of water.

Physiology of Metabolism Oxygen  Lungs  alveoli  blood Oxygen Breath CO2 Muscles + Organs Lungs Oxygen CO2 Cells The body uses oxygen, glucose and water to produce energy. The byproduct of this process (metabolism) is CO2. The more energy produced, the more CO2. The less metabolism (less energy produced), the less CO2. ENERGY Blood Oxygen + Glucose CO2 7

Carbon Dioxide Oxygen (O2) enters the body through the lungs and is used to produce energy This process is called metabolism Carbon Dioxide (CO2) is the waste product of metabolism

Typical Gas Percentages Atmospheric Exhaled Nitrogen (N2) 78% 74% Oxygen (O2) 21% 16% Carbon Dioxide (CO2) 0.04% 4% Water (H2O) 0.5% 6% Atmospheric air is mostly nitrogen with some oxygen, trace amounts of CO2 and water. Exhaled air contains 4% CO2. Normal Exhaled CO2 = 35 – 45 mmHg

CO2 In the Blood CO2 is your drive to breathe  CO2 causes air hunger Goal is to maintain PaCO2 at 40 Body adjusts respiratory rate & depth Oxygen does not affect respirations CO2 is the gas that produces the respiratory drive. When CO2 levels increase, people experience air hunger. The body responds to increased CO2 in the blood by increasing respiratory rate and depth. Oxygen levels in the blood do not affect respirations in the vast majority of people.

Question: What would happen if you injected CO2 into the blood? Respiratory rate and depth would 

Question: Why do swimmers who hyperventilate loose consciousness underwater?  CO2 eliminates the drive to breathe Swimmers who deliberately hyperventilate in order to hold their breath underwater for longer periods of time sometimes loose consciousness. The mechanism for this phenomena is marked reduction of CO2 induced by hyperventilation, resulting in loss of drive to breathe and elimination of air hunger. When the oxygen level in the blood drops below that needed to maintain consciousness, the swimmer passes out. The usual warning that s/he should surface to breathe is bypassed by hyperventilating before diving into the water.

Turns yellow when CO2 is detected Measuring Exhaled CO2 Colorimetric Capnometry Capnography In the 1970’s colorimetric devices were used to measure CO2. These devices use a piece of pH paper positioned in the airway to indicate the presence of CO2 by changing from purple to yellow. Turns yellow when CO2 is detected

Colorimetric Pros Cons Accurate Secretions Cheap (~$10-15) Changes color when CO2 present Work for 2+ hours Disposable Cons Secretions Not quantitative Adds dead space False positives Hard to read at night Colorimetric devices are inexpensive, disposable and usually last for at least 2 hours (sometimes as long as 24 hours). They can be damaged when the pH paper gets wet from secretions resulting in false positive CO2 readings. It is difficult to quantify the amount of CO2 using a colorimetric device, although the degree of color change can suggest various levels of CO2. In small patients, the dead space added to the airway by placing a CO2 detector can be excessive.

Measuring Exhaled CO2 Capnometry Colorimetric Capnography Second generation CO2 measuring devices were capnometers. These provide a respiratory rate and digital measurement of CO2 as well as a bar graph with each breath.

Capnometry Pros Cons Numeric value + RR Portable Cheaper than waveform capnography Cons No waveform Does not trend Bulky adapter/unit Capnometers are portable, provide more information than colorimetric devices but lack a waveform which would be helpful for visualizing trends and tend to be somewhat bulky (which means they may add additional weight to an advanced airway, potentially dislodging an endotracheal tube). In 2012, the EMMA Capnometer (Masimo Corp., Irvine CA) was redesigned to include a waveform which transformed the capnometer into a waveform capnography device. PHASEIN EMMA™ (Masimo)

Measuring Exhaled CO2 Capnography Colorimetric Capnometry Waveform capnography is the third and current generation of devices used to measure exhaled CO2.

Capnography Pros Cons Numeric value + RR Waveform Trending Very accurate Cons Expensive Fragile Warm-up time (some units) Secretions Temperature sensitive (some) Waveform capnography is extremely accurate but expensive, fragile, prone to clogging from respiratory secretions and, in some cases, require time to warm up prior to use and/or are affected by environmental or patient temperature extremes.

Infrared Spectroscopy CO2 absorbs 4.26 µm wavelength Infrared light aimed at sample Infrared sensors detect absorption and calculate CO2 CO2 in gas form absorbs light at the 4.26 micrometer spectrum.

Capnography Technologies Sidestream (1st generation) Sensor in remote location Samples gas from circuit (150-250 mL/min) Mainstream (2nd generation) Sensor in the airway First generation CO2 technologies were sidestream devices. The sensor was in a remote location and sampled large amounts of gas from the respiratory circuit in order to make measurements. This large volume sampling mandated that sidestream analyzers have moisture traps. Second generation devices moved the sensor into the airway itself.

Capnography Technologies Microstream® (next generation) Sensor in remote location Samples only 50 mL/min from circuit Third generation devices (Microstream) work in a similar fashion to sidestream devices but sample significantly less air from the line, eliminating the need for a large moisture trap and allowing use in very small patients and in spontaneously breathing patients. Moisture is trapped by a filter placed in the Microstream connector.

SpO2 versus EtCO2 The is a significant difference between pulse oximetry and capnography.

Oxygenation and Ventilation Oxygenation (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 A quick summary of the two physiological processes. They require different monitoring modalities which are complimentary measures of your patient’s status.

Physiology of Metabolism Oxygen  Lungs  alveoli  blood Oxygen Breath CO2 Muscles + Organs Lungs Oxygen CO2 Cells In summary, pulse oximetry measures oxygen going IN to the body; capnography measures CO2 coming OUT of the body. ENERGY Blood Oxygen + Glucose CO2 24

Pulse Oximetry Problems: Accuracy Motion & artifact Dyshemoglobins Perfusion Pulse oximetry has some problems.

Pulse Oximetry First generation pulse oximetry has been known to produce a reading and a waveform even when not connected to patient.

Pulse Oximetry First generation pulse oximetry sometimes produces “weird” readings. Seemingly healthy patients may exhibit very low saturations. When a blood gas is drawn, the actual oxygen saturation is found to be normal.

Model of Light Absorption At Measurement Site Without Motion AC Variable light absorption due pulsatile volume of arterial blood DC Constant light absorption due to non-pulsatile arterial blood. DC Constant light absorption due to venous blood. DC Constant light absorption due to tissue, bone, ... Absorption Time IMPORTANT POINTS on the original design of pulse oximetry: AC (alternating current) represents the arterial blood that is moving inside the body. DC (direct current) represents the blood and other components that are not moving inside the body. This is the Aoyagi model that assumed the only component that moves inside the body is the pulsating arterial blood. One of the reasons for many false alarms for this model is that it does not accurately predict what is occurring inside the body. Aoyagi assumed that the only thing that moves in the body is pulsating arterial blood. So, when he uses the pulse for his in vivo calibration, if other components move, the reading will be in error.

Model of Light Absorption At Measurement Site With Motion AC Variable light absorption due pulsatile volume of arterial blood DC Constant light absorption due to non-pulsatile arterial blood. AC Variable light absorption due to moving venous blood DC Constant light absorption due to venous blood. DC Constant light absorption due to tissue, bone ... Time Absorption IMPORTANT POINTS Moving (AC) venous blood is the main contributor to motion artifact. This was not predicted by the Aoyagi design. This effect is significant in monitored patients and causes erroneous values. Aoyagi’s model was correct as long as the patient did not move. But as soon as the patient proceeded with even normal daily activity the above moving venous blood (AC) was introduced and affected the reading.

Influence of Perfusion on Accuracy of Conventional Pulse Oximetry During Motion Good Perfusion (Conventional PO) SpaO2=98 SpO2=93 SpvO2=88 Poor Perfusion (Conventional PO) IMPORTANT POINTS Venous averaging is a significant clinical problem. When the perfusion is good the effect is only slightly observed. When perfusion is very poor, the effect can be dramatic and cause an inappropriate clinical response. Common Cause of a False Alarm: This effect can be demonstrated with a motion low perfusion ice water demonstration. By cooling the hand using a glass of ice water and then moving the cold hand with a conventional sensor attached, poor peripheral perfusion (the second example above) can be simulated. The moving venous blood causes a conventional oximeter to average the arterial and venous values together and report a value between arterial and venous. This erroneous value will set off alarms, bring the clinician to the bedside, and potentially waste caregiver time responding to the situation. If this situation persists, the caregiver may silence or turn off the alarms and put the patient at risk for a true desaturation event later. SpaO2=98 SpO2=74 SpvO2=50

Conventional Pulse Oximetry Algorithm Digitized, Filtered & Normalized R/IR Post Processor % Saturation R & IR MEASUREMENTT CONFIDENCE 3 options during motion or low perfusion: Freeze last good value Lengthen averaging cycle Zero out In conventional pulse oximetry, the incoming red and infrared signals are received from the photodetector. In many of the newer oximeters, the signals are digitized. The signals then pass through band filters to remove much of the unwanted artifact above and below the signal bandwidth. These filters address external noise sources like electrical devices or mechanical artifact. After the signals have been filtered, a red to infrared ratio is calculated. This calculated ratio is compared to a “look up” table that converts the red to infrared ratio to a corresponding SpO2%. Once the SpO2 is calculated, the oximeter’s decision matrix must decide if the data is reportable or not. If the decision is “Yes, it looks good” the SpO2 and pulse rate are reported. If the decision is ‘No, this looks questionable” , there are a few paths the oximeter can take depending on what the oximeter manufacturer has programmed into the system. Some oximeters might “lie” and freeze or continue to display the last valid SpO2 and pulse rate value it recorded for one minute or longer, regardless of the patient’s changing clinical status. Others might go into a longer averaging cycle “hoping” that whatever was interfering with the signal will just go away or self resolve. Some device will just “zero out” and give up. Regardless of whether the oximeter chooses to “lie, hope or give up” the clinician no longer has reliable pulse oximetry data, often in situations when it is needed the most..

Next Generation Pulse Oximetry Each manufacturer has designed confidence based algorithms to improve the accuracy of their pulse oximetry. Nellcor (now Covidien) uses an algorithm that focuses on the accuracy of the pulse rate being detected by the oximeter.

Next Generation Pulse Oximetry Philips also uses a confidence based algorithm.

Masimo SET: Signal Extraction Technology R/IR (Conventional Pulse Oximetry) Confidence Based Arbitrator 0 50% 66% 97% 100% SpO2% Post Processor Digitized, Filtered & Normalized % Saturation SSTTM Proprietary Algorithm 4 DST SET – 97% DSTTM FSTTM MEASUREMENT CONFIDENCE R & IR IMPORTANT POINTS 1) Signal Extraction Technology uses a variety of algorithms or engines. Each is designed for a different type of signal noise. 2) The confidence based arbitrator determines which engines are providing the most accurate saturation value and displays that value. 3) Discrete Saturation Transform is the most powerful engine and can remove the noise caused by moving venous blood which is the number one cause of motion artifact. While this slide may look complicated, focus on the R/IR, DST engines and the Confidence based Arbitrator. The R/IR engine is the same as other conventional pulse oximeters and reads accurately about 50% of the time. When patients are healthy, well perfused and without motion artifact, most pulse oximeters can determine the saturation. As was discussed earlier, DST can remove the number one cause of motion artifact which is moving venous blood. It is used about 25 % of the time and eliminates the false reading associated with venous blood artifact. Finally, the confidence based arbitrator gives SET the ability to change as patient conditions change. It can select from any one or a combination of the engines and accurately determine the saturation in spite of challenging conditions. SET “Parallel Engines”

Averaging - inaccurate Measure Through Motion Pulse Oximetry Discrete Saturation Transform (DST) SET separates the venous and arterial saturation values (conventional oximetry averages the values to produce a reading) Variable Constant 0 50% 66% 86% 97% 100% SpO2% Averaging - inaccurate 0 50% 66% 86% 97% 100% SpO2% Measure Through Motion Pulse Oximetry Separating - accurate Masimo actually identifies both the arterial and venous signals and displays only the arterial oxygen saturation value. Conventional Pulse Oximetry

Carbon Monoxide (CO) Gas: Physical Properties: Colorless Odorless Tasteless Nonirritating Physical Properties: Vapor Density = 0.97 LEL/UEL = 12.5 – 74% IDLH = 1200 ppm Physical properties of carbon monoxide (a dyshemoglobin): Vapor Density is just about equal to that of the ambient air. This means that rather than rising to the highest point (lighter than air) or sinking to the low lying areas, CO acts like the ambient air and travels through the entire occupancy, following natural air flow. This translates to poisonous gasses presenting themselves across the occupancy, rather than lingering near the offending source, and exposure should never be ruled out because the occupants’ report that they were not near fuel fired appliances. The flammability range, expressed as the range between the Upper Explosive Limits (UEL) and the Lower Explosive Limits (LEL) is rather wide, therefore efforts to control ignition sources should be undertaken. The Immediately Dangerous to Life and Health is expressed as the IDLH in parts per million. While this number may seem a bit on the high side, EMS providers should take caution as they typically do not respond with self-contained breathing apparatus (SCBA) and atmospheric levels in an enclosed environment can climb rather quickly. The bond length is 112.8 pm.

Limitations of Pulse Oximetry Conventional pulse oximetry can not distinguish between COHb and O2Hb From Conventional Pulse Oximeter SpCO-SpO2 Gap: The fractional difference between actual SaO2 and display of SpO2 (2 wavelength oximetry) in presence of carboxyhemoglobin From invasive CO-Oximeter Blood Sample IMPORTANT POINTS The arterial oxygen saturation (SpO2) from conventional two-wavelength pulse oximetry is inaccurate (often significantly inaccurate) in the presence of CO poisoning. Two-wavelength pulse oximeters actually count carboxyhemoglobin as oxyhemoglobin The reported functional value often lends a false sense of security that the patients oxygenation status is good, as SpO2 may read normal even when significant COHb is poisoning the patient. A standard 2 wavelength oximeter adds to the problem. They only read 2 parameters, which result in a ratio of the oxyhemoglobin to the hemoglobin that is available for binding . This is called the Functional value and does not decrease to any significant degree, as shown by the graph above, even when exposed to high levels of CO. In this experiment a dog is exposed to CO and the pulse oximeter only decreases slightly to 90% when the actual oxyhemoglobin saturation is 30%. This actual saturation value is called the fractional saturation. Fractional saturation is not subjected to this false reading and would have read 30% in this situation. Barker SJ, Tremper KK. The Effect of Carbon Monoxide Inhalation on Pulse Oximetry and Transcutaneous PO2. Anesthesiology 1987; 66:677-679

Pulse CO-oximetry The RAD-57 is a pulse CO-oximeter. It is able to measure both oxygen (oxyhemoglobin) and carbon monoxide (carboxyhemoglobin) in the blood.

Pulse CO-oximetry Uses multiple wavelengths of light Differentiates CO from O2 This is accomplished by using multiple (8+) wavelengths of light, some visible and some invisible spectra.

Hgb Signatures: Physics of O2 Pathways Extinction coefficients comparable to Absorption wavelengths of each analyte (in mm-1). Invisible spectrum range 660 to 940 nm.

Protect from ambient light SpCO User Concerns Multiple wavelengths of light (8+) = Probe Placement: Probe fits the finger Centered over nail bed Visible spectrum light = Protect from ambient light Sunlight, strobes, etc. The fact that CO is measured in a visible spectrum of light means that it is particularly susceptible to interference from visible light. Because the technology is using multiple wavelengths of light, probe positioning and probe size is much more important than a conventional pulse oximeter (which uses only 2 beams of light). If the probe is misplaced (or too large for the finger), light will pass around the finger (instead of passing through the finger). This may result in false CO readings.

Know Your Equipment It is important to know your equipment.

Back to CO2… What does exhaled CO2 tell us? Ventilation Perfusion Metabolism Back to CO2 – exhaled CO2 provides information about ventilation, perfusion, and metabolism.

Endotracheal Intubation Endotracheal intubation is a high risk procedure.

What Should Happen Lungs (Good) $tomach (Bad, Very Bad) A missed esophageal intubation can be catastrophic. $tomach (Bad, Very Bad)

Anesthesia Litigation Anesthesiologists in the 1960’s and 1970’s had the highest malpractice rates of any medical profession, largely due to lawsuits for unrecognized esophageal intubations. 46

Respiratory Damaging Events Capnography Introduced Beginning in the 1980’s, anesthesiologists using end tidal CO2 were able to reduce their claims for respiratory damaging events. Today, malpractice insurance premiums for anesthesiology providers are among the lowest in the medical community. American Society for Anesthesiologists: Closed Claims Project Database, 2010 47

#1 Capnography Use for EMS: Paramedics have the same risks as anesthesiologists. This is the number one use of end tidal CO2 monitoring.

Guidelines 2005 EtCO2 recommended to confirm ET tube placement Capnography was first recommended in the AHA Guidelines 2005.

Intubated Patient Airway adapter plugs into LifePak® Be sure adapter is tightly attached If not seated, waveform may flatten An important consideration in using capnography is to assure that the connector is tightly screwed into the monitor. If the connector is not firmly seated, atmospheric air will be pulled into the monitor from around the connector, resulting in poor or no end-tidal CO readings.

Capnography Information Respiratory Rate End Tidal Carbon Dioxide Waveform capnography provides three pieces of information. Capnography Waveform

Capnography Waveforms The higher the waveform, the more CO2 Normal EtCO2 is 35 – 45 mmHg (usually the same as arterial CO2) 45 The height of the waveform equates to the amount of CO2.

Capnography Waveforms The length of the waveform corresponds to respiratory rate Hyperventilation 45 The length of the waveform corresponds to the respiratory rate. The shorted the waveform, the faster the rate. 45 Hypoventilation

Inspiration or manual ventilation with a bag-valve-mask or ventilator Capnography Waveform Inspiration or manual ventilation with a bag-valve-mask or ventilator 54

Capnography Waveform Exhalation 55

Capnography Waveform End-tidal End-tidal (EtCO2) is the end point of expiration. This is the point on the waveform that produces the numeric CO2 value. 56

Capnogram Parts Start of exhalation No CO2 (dead space) Phase I 57

Capnogram Parts Phase II Exhalation continues Rapid rise in CO2 Mixing dead space & alveolar gases 58

Capnogram Parts Phase III also called the Alveolar Plateau End exhalation All alveolar gas 59

Capnogram Parts Phase IV Rapid drop in CO2 Start of inhalation 60

Capnogram Angles  (beta angle)  (alpha angle)  normal = 90° Rebreathing will   normal = 100 – 110° Airway obstruction will  61

Capnography Waveforms Normal 45 Hyperventilation 45 Hypoventilation 45

Intubation You have intubated a 36 year old motorcyclist laying in the roadway HR 128, RR 14 by BVM, SpO2 99% Esophageal intubation 6 breaths to evacuate gastric CO2 The standard practice for “washing out” gastric CO2 is to provide 6 breaths and then measure CO2. If the tube is in the esophagus, 6 breaths will wash out any gastric CO2.

SpO2 will not drop for several minutes (5+ minutes) What about the Pulse Ox? Sp02 98 Pulse oximetry takes considerably longer to drop once breathing ceases. SpO2 will not drop for several minutes (5+ minutes)

Intubation You re-intubate the motorcyclist This is the capnography waveform: Is the tube in? Is the ventilation rate and depth appropriate? mmHg Yes, the tube is now appropriately located in the trachea. The respiratory rate of 16 and depth (size of breaths) is adequate as the exhaled CO2 is 39, midway between the target of 35-45 mmHg.

During Transport Enroute to the trauma center, you observe this on the capnography: What happened? When is this most likely to occur? Tubes most commonly displace during patient movement The tube came out. This most commonly occurs with patient movement, often at the moment the patient is transferred to the ED stretcher. This is a major reason for documenting the presence of a good capnography waveform following endotracheal intubation and during transport.

Ventilator Transport You are moving a 23 yo GSW to the head from a community ED to a neurosurgical ICU He is intubated and sedated: EtCO2 = 35, RR = 24 “Curare Cleft” = diaphragmatic movement (breathing over drugs)

Ventilator Transport You don’t make any changes The patient appears to awaken: EtCO2 = 30, RR = 38 “Curare Cleft” = diaphragmatic movement (breathing over drugs) “Bucking” ventilation needs drug tx

Ventilator Transport You are moving a ventilated patient The patient appears short of breath Waveform does not return to zero Baseline gradually increasing This is called “rebreathing” Rebreathing is more often seen in patients on mechanical ventilation and is often association either with excessive respiratory rates or faulty ventilator equipment. It is sometimes referred to as “breath stacking”

Ventilator Transport You’re cardiac arrest reversal is unresponsive, on BVM ventilation BP 110/58, HR 90, RR 22, SpO2 97 Is the patient ventilating? Causes: cuff leak, ETT displaced… NOT WELL

Cardiac Arrest

Carbon Dioxide (CO2) Production Oxygen Circulation Respiration Carbon Dioxide

Carbon Dioxide (CO2) Production Cardiac Arrest In cardiac arrest, CO2 production stops. Oxygen Circulation Respiration Carbon Dioxide

AHA Guidelines 2010 Continuous quantitative waveform capnography recommended for intubated patients throughout peri-arrest period. In adults: Confirm ETT placement Monitor CPR quality Detect ROSC with EtCO2 values

1. Confirm ET placement When is an advanced airway most likely to become dislodged? During patient movement

2. Monitor the quality of CPR Try to maintain a minimum EtCO2 of 10 mmHg Push HARD (> 2” or 5 cm) FAST (at least 100) Change rescuer Every 2 minutes In actuality, high quality CPR should produce near normal end-tidal values.

CPR in progress: Compression depth Compression rate Compressor Extreme acidosis Futility Other? Reasons for low EtCO2 during CPR can be related to any of these.

High-Quality CPR =  CO2 High quality CPR will produce near normal EtCO2 values. 78

3. EtCO2 to detect ROSC (Return Of Spontaneous Circulation) 90 pre-hospital intubated arrest patients 16 survivors 13 survivors: rapid rise in exhaled CO2 was the earliest indicator of ROSC Before pulse or blood pressure were palpable Using an EtCO2 of 10 mmHg or less as a theoretical threshold to predict death in the field successfully discriminated between the 16 survivors to hospital admission (those that achieved return of spontaneous circulation) and 75 prehospital deaths. Of the 16 survivors to hospital admission, 9 died in the hospital, and 7 were discharged from the hospital alive. In 13 of the 16 survivors, the first evidence of return of spontaneous circulation, before a palpable pulse or blood pressure, was a rising ETCO2. Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest” . Annals of Emergency Medicine. 1995; 25(6):762-767. Levine RL., Wayne MA., Miller CC. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” New England Journal of Medicine. 1997;337(5):301-306.

3. EtCO2 to detect ROSC Question: Would bicarbonate  EtCO2? ROSC is associated with significantly increases EtCO2. Administering bicarb will transiently elevate CO2 as acids buffered by the bicarbonate in the blood are eliminated as CO2. Question: Would bicarbonate  EtCO2? Answer: Yes

CPR – What Causes This? Notice the small “ripples” ? Compressions generate air movement – this expels CO2

Spontaneously Breathing Capnography helps assess: Accurate respiratory rate Airway patency (bronchospasm, air trapping, obstruction) Shock states Response to treatment

Bronchospasm Asthma, COPD… Elevation of  angle, loss of alveolar plateau (“shark-fin” appearance) Degree of angle = severity

Effects of Treatments This is a patient with significant SOB. With nebulizer treatment, the waveform demonstrates resolution of the bronchospasm.

Air Trapping Emphysema is results in prolonged expiration Increases  angle: Emphysema results in air trapping (difficulty inhaling). Hence, the beta angle increases and the alveolar plateau dips downward.

Unconscious 16 yo found unresponsive in high school locker room – unknown hx Hypoventilation (? pharmaceutical) Use capnography on EVERY patient you treat with narcotics! The best way to observe respiratory effort and rate is with capnography. Every patient given narcotics should have continuous waveform capnography monitored.

Difficulty Breathing 14 yo asthmatic – severely SOB Hyperventilation No evidence of airway obstruction or air trapping Fast respiratory rates are difficult for the capnography equipment to accurately track. Waveforms then, loose their crisp appearance in pediatric and neonatal patients as well as in adults with high respiratory rates.

Difficulty Breathing 81 yo with COPD and heart failure Acutely short of breath Capnogram favors pulmonary edema (no evidence acute COPD exacerbation)

Same Patient – Diff Breather 81 yo with COPD and heart failure Acutely short of breath Capnogram favors COPD exacerbation

Chest Pain 51 yo with substernal chest pain No distress, STEMI work up “Cardiac oscillations” – cardiac pressures being transmitted to airway (ripple effect)

Perfusion and pH Cardiac arrest = no CO2 Capnography reflects perfusion  cardiac output =  EtCO2 CO2 is transported in the blood as bicarbonate (HCO3) In severe acidosis,  HCO3 =  EtCO2 In cardiac arrest, no CO2 is produced. In profound metabolic acidosis, CO2 is used in the blood to combine with the acids and is not exhaled. The lower the bicarb level in the blood (i.e., the more acidotic the patient) the lower the exhaled CO2 will be.

Post Cardiac Arrest Patient You have resuscitated a 47 yo pt. found in v-fib on a city bus The patient is unresponsive, ventilated by BVM; pulses are weak Suspect falling cardiac output!

17 yo pt. in DKA You are called to a physician office to transport a patient in DKA The patient is alert and oriented; blood sugar is reportedly 880 This is another waveform tracing from a 17-year-old in diabetic ketoacidosis. Note here again the extremely low cardiac arrest level EtCO2 of 6 millimeters of mercury, and a corresponsive pH of 6.93. This waveform tracing illustrates how sensitive and accurate capnography is in detecting conditions of metabolic acidosis.

General Weakness Patient You are called to see a 75 yo heart failure pt. with general weakness She is cool, BP 80/50, HR 128 afib What does the capnography say? Low perfusion associated with lactic acidosis will produce a low EtCO2! Cardiogenic Shock!

Rounded Waveforms Be suspicious of rounded waveforms: These often imply low perfusion, acidosis, sepsis, poisoning or other metabolic derangements

Review

Label Inhalation & Exhalation Expiration Inhalation 97

Where is EtCO2 Measured? End-tidal CO2 Normal EtCO2 is 35 – 45 mmHg 98

AHA Guidelines 2010 What are the three reasons for use of continuous quantitative waveform capnography during cardiac arrest? Confirm ETT placement Monitor CPR quality Detect ROSC with EtCO2 values

Goals During Cardiac Arrest Try to maintain a minimum EtCO2 of ? 10 mmHg Push HARD (> 2” or 5 cm) FAST (at least 100) Change rescuer Every 2 minutes

Review 14 yo patient, SOB, asthma hx Clutching her albuterol inhaler Slow upstroke = bronchospasm

Review 67 yo COPD patient, acute SOB SpO2 97%, HR 88, BP 138/86 Normal waveform, hyperventilation

Review 74 yo ROSC post v-fib arrest, unconscious, on ventilator, VSS Cleft (“curare cleft”) suggests non-compliance with vent

Review 45 yo auto-pedestrian, bilateral tib-fib fractures, BP 120/60, HR 90, RR 16, SpO2 97%, EtCO2 45 Normal waveform

Review Elderly cancer pt., unresponsive at home in bed Normal waveform – hypoventilation RR 4, EtCO2 75 (> than 70 in without COPD = respiratory failure)

Review 60 yo COPD patient fever, chest pain, denies SOB, using accessory muscles to breathe Prolonged expiration (  angle); air trapping – normal capnogram in emphysema

Review 90 year old cardiac arrest, immediately after endotracheal intubation: Esophageal intubation 6 breaths to evacuate gastric CO2

Review 55 yo COPD patient with flu like s/s Cardiac oscillations – normal EtCO2

Review 18 yo GSW to chest Profound hypoperfusion – arrest imminent

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