CAPNOGRAPHY In Emergency Care

CAPNOGRAPHY In Emergency Care
EDUCATIONAL SERIES This PowerPoint program is designed for initial training on capnography in EMS. It is strictly an introduction and all information will be adapted to comply with your local protocols. The program is not product specific and qualifies for continuing education credits through individual CE providers and/or the Center for Healthcare Education. Information on the Center for Healthcare Education and the CE process is contained on this CD. You may also contact the Center at or their website at All contents are under the copyright of Medtronic Physio-Control Corp. Part 1: Overview

Program Learning Objectives Relate a normal capnogram to the phases of breathing List five clinical applications for capnography Identify the four most common abnormal capnograms Describe how to incorporate capnogram to patient care according to local protocol The program was designed to meet the following learning objectives. At the completion of this program you will be to: Relate a normal capnogram to the phases of breathing List five clinical applications for capnography Identify the four most common abnormal capnograms Describe how to incorporate capnogram to patient care according to your local protocol

Program Parts Part 1: Overview Part 2: Introduction to Capnography Part 3: Capnography in the Intubated Patient Part 4: Capnography in the Non-intubated Patient The program is divided into four parts* Part 1 Overview - includes key definitions, a brief history of respiratory monitoring in EMS and the evolution of technologies Part 2 Introduction to Capnography - differentiates capnography and pulse oximetry, identifies parts of the normal capnogram and presents four common abnormal patterns. Part 3 Capnography in the Intubated Patient - presents common applications for monitoring and assessing patients who require ET tube placement. Part 4 Capnography in the Non-intubated Patient- presents common applications for monitoring and assessing non-intubated patients. * This may be presented in a 4-hour training course or divided into several class sessions.

Part 1: Overview Let’s start with an overview of capnography and address a few key terms and questions.

(Corollary: Why should I learn capnography?)
Why use capnography? (Corollary: Why should I learn capnography?) The first question you may ask before learning something new: “Why?” Why would I use capnography? Or the corollary: Why should I go through all the effort of learning capnography? Teaching Note: The next slide (#6) is a case scenario to help stimulate a discussion on why.You may prefer to skip the scenario and go on to the next slide for discussion.

Case Scenario 61 year old male C/O: “short-of-breath” and “exhausted”
H/O: > 45 years of smoking 2 packs a day, 3 heart attacks, high blood pressure Meds: “too expensive to take every day ” Exam: HR 92, RR 18, 160/100, 2+ pitting edema, wheezing, crackles Let’s look at a fictional case scenario: - 61 year old male. His wife called 911 because her husband was “having trouble breathing”. On scene, your patient is sitting upright and speaking in short sentences. He is clearly in respiratory distress, skin is pallor in color and moist to touch. - C/O: “short-of-breath” and “exhausted”. Although he has chronic respiratory problems and fatigue, his condition has worsened in the past 24 hours. - H/O: > 45 years of smoking 2 packs a day, 3 heart attacks, high blood pressure. - Meds: “too expensive to take every day ” Uses an inhaler, takes a “water pill, pressure pill and a couple of heart pills”. His wife is trying to locate his meds. - Exam: HR 92, RR 18, 160/100, 2+ pitting edema, wheezing, crackles Teaching Note: Discuss the additional information needed. Cardiac - ECG monitoring and/or 12-lead ECG Oxygenation - Pulse oximetry Ventilation - Technology that can help distinguish between obstructive and restrictive lung disease CHF? COPD? What other information would you want in making your assessment?

Capnography Overview A technology that:
Provides another measurement in assessing your patient Gives an objective measure of your patient’s ventilatory status Shows a graphic picture of your patient’s ventilatory status Presents an early warning of changes in your patient's cardiopulmonary status Supplies important documentation on your patient Capnography is a tool that: Provides you with another measurement in assessing your patient Gives you an objective measure of your patient’s ventilation Shows you a graphic picture of your patient’s ventilatory status Presents you with an early warning of changes in your patient's cardiopulmonary status Supplies you with important documentation on your patient Training note: Ask class members (as individuals or break into small groups) to share an experience where having a tool like this would have been useful. You may want to list some of these on an easel and go back at the end of the session to show the role capnography would play.

Capnography Overview Capnography provides an objective measure of ventilation Capnography provides Numeric value of “End-Tidal CO2” Waveform of respiration Capnography provides an objective measure of ventilation, your patient’s respiratory status. As with all monitoring, the information provided by capnography is an adjunct to your patient assessment, to be added to your patient’s symptoms and your observations. Capnography provides: A numeric value of “end-tidal CO2” A waveform of respiration

Capnography Overview End Tidal CO2—what is it?
Breathing is done in waves EtCO2 is the amount of CO2 measured at the peak of the wave EtCO2 is measured at the nose, mouth, or hub of the ET tube What is End-Tidal CO2? Breaking the term apart, “carbon dioxide at the end of the tide” Breathing is done in waves (in and out) EtCO2 is the amount of CO2 measured at the peak of the wave going out at the end of exhalation EtCO2 is measured at the nose, mouth, or hub of the ET tube

Capnography Overview “Capnos” is Greek for smoke
From the “fire of life”—metabolism Metabolism produces carbon dioxide as a waste product “Capnos” is the Greek root meaning smoke. The Greeks believed that each living being is fueled by the “fire of life” - today we call this metabolism Metabolism produces carbon dioxide as a waste product

Capnography Overview Carbon Dioxide (CO2) Produced by all living cells
Diffused into the bloodstream Transported to the lungs Perfused into the alveoli Exhaled through the airway A quick review of cardiopulmonary physiology: Carbon Dioxide (CO2): - Is produced by all living cells and excreted by - diffusion into the the venous bloodstream where it is - transported to the lungs. There it is - perfused into the air sacs called alveoli. - On exhalation, the CO2 exits through the airway

History of Capnography in EMS
Initially used for monitoring anesthetized patients in the OR New technology now available for EMS in both intubated and non-intubated patients Capnography is not new. The technology was initially used for monitoring anesthetized patients in the OR. New technology is now available for EMS in both intubated and non-intubated patients.

Used by anesthesiologists since the 1970s Standard of care in the OR since 1991 New JCAHO standard now expanding utilization Ventilatory monitoring has been used in the OR for over 30 years. The American Society of of Anesthesiology made continuous ventilatory monitoring of anesthetized patients a standard of care in the 1990s. With the expansion of the use of procedures requiring sedation outside of the OR, the Joint Commission has looked at the safety of these patients undergoing procedural sedation and added a new standard. Source: PRACTICE GUIDELINES FOR SEDATION AND ANALGESIA BY NON-ANESTHESIOLOGISTS (Approved by the House of Delegates on October 25, 1995, and last amended on October 17, 2001) Anesthesiology 96: , 2002 Source: PRACTICE GUIDELINES FOR SEDATION AND ANALGESIA BY NON-ANESTHESIOLOGISTS (Approved by the House of Delegates on October 25, 1995, and last amended on October 17, 2001) Anesthesiology 96:

JCAHO January 2001 standard on procedural sedation In any hospital or clinic setting Monitoring vital signs, continuous monitoring of oxygenation and ventilation The first notice of this new standard was published in Joint Commission Perspectives, Special Report. July/August As of January 2001 the JCAHO standard on procedural sedation applies to patients undergoing procedural sedation in any hospital or clinic setting. The standard states required staffing, defines the various levels of sedation and states that patients undergoing procedural sedation (formally called conscious sedation) are required to have ongoing monitoring of vital signs and continuous monitoring of oxygenation and ventilation. All facilities who fall under JCAHO review will be required to abide by this standard. Until now, many facilities have used pulse oximetry to monitor patient ventilations, but as you will see, pulse oximetry monitors oxygenation, not ventilation. Capnography provides the only continuous visual monitoring of ventilation. So, although capnography is fairly new to the ED as well as EMS, in the future you may see it being used to monitor patients undergoing a procedure in your ED. Capnography provides the only continuous visual monitoring of ventilation Source: Joint Commission Perspectives, Special Report. July/August 2000

Pulse oximetry preceded capnography Pulse oximetry measures oxygenation Capnography measures ventilation New technologies now allow use in EMS Pulse oximetry preceded capnography and has been used for two decades. Some healthcare providers forget that pulse oximetry measures oxygenation only. Capnography measures ventilation.We will go in to the details of the differences between oxygenation and ventilation in the next section. For now, let’s look at the old and new technologies for ventilatory assessment in EMS and the new technologies that can now be used in EMS.

Colorimetric Capnometry Capnography Colorimetric technology is quite well known and we will start with it, then look at capnometry and the types of capnography. How many of you have used a colorimetric device when intubating a patient? Training Note: It is helpful to show samples of the different tools as you discuss them. Students may also appreciate sharing some of their experiences. Relating the new technology to a familiar one helps many students assimilate information.

Colorimetric: Specially treated litmus paper Color changes indicate qualitative amount of CO2 detected For intubated patients only Disposable detector fits on ET tube hub Colorimetric This is basically a device that contains specially treated litmus paper, that changes color indicating the amount of CO2 detected. Litmus paper changes color in reaction to the an acid-base balance and carbon dioxide is a gaseous state of carbonic acid. This disposable detector for intubated patients only; it fits on the hub of the ET tube.

Colorimetric: Single use Easily impaired by moisture or secretions False negatives during cardiac arrest Equates to checking a pulse on cardiac patient Presence Strength/amount Colorimetric devices can be used only once. It is for single use - not single patient use. The litmus paper is very sensitive and is easily impaired by moisture or patient secretions. In addition to the false positive readings when exposed to acid secretions, false negatives during cardiac arrest can occur. To equate this detection to the cardiac patient, colorimetric is similar to checking for a pulse: 1. Is it present? 2. If present, how strong? One pulse check provides you a one-time value.

Colorimetric: Here is a typical colorimetric device. Training note: Most experienced medics are familiar with this type of device. If this is a class of new students, you may want to take the time to identify the connectors, indicator, etc. and or pass samples around the room.

Capnometry: A numerical value of the EtCO2 For both non-intubated and intubated patients Continuous monitoring Capnometry is as the name implies, a “capno - meter”. A capnometer displays a number instead of a color. Capnometry provides continuous monitoring on both intubated and non-intubated patients.

Capnometry: No waveform of the EtCO2 in the airway Equates to monitoring heart rate in cardiac patient Present Amount or range Changes over time Although capnometry allows for continuous ventilatory monitoring, there is no waveform of the carbon dioxide flow in the airway. Again equating ventilatory monitoring to cardiac monitoring, capnometry is similar to monitoring the heart rate.Is it present? How fast is the pulse/or how much CO2? Is it changing?

Capnometer: This is an illustration of a capnometer showing the two numbers, the respiratory rate and the EtCO2. This provides you more information a colorimetric check, however… (next slide)

Capnometry: Numeric reading: HR 100 Waveform: Knowing the end tidal value and being able to continuously monitor that value is important in ongoing patient assessment. However, it is similar to monitoring your patient's heart rate.The heart rate number doesn’t tell you everything you may need to know. A numeric reading of 100 in your cardiac patient may be okay.

Capnometry: Numeric reading: HR 100 Waveform: However, the waveform may indicate a completely different situation in your patient’s condition.

A numerical value of the EtCO2 AND A waveform of the concentration of CO2 present in the airway Capnography provides both a numerical value of the EtCO2 AND a waveform of the concentration and flow of CO2 present in the airway.

For both non-intubated and intubated patients Continuous breath-to-breath monitoring Equates to ECG monitoring in cardiac patient Capnography (“graph of the capno”) provides a continuous measurement on a breath-to-breath basis and can be used on both intubated and non-intubated patients. Capnography equates to the ECG (electrocardiography) monitoring that you do on your cardiac patients.

This is a screen with a capnography capability. Note the waveform and corresponding numeric value. The top shows the heart rate and ECG cardiac monitor. The middle is SpO2 and pulse oximetry waveform. The lower is the EtCO2 number (capnometry) and capnography waveform.

Capnography systems Collector of the air sample Analyzer detects and measures CO2 Display shows waveform and number There are several types of capnography systems; all have three key components. 1. A collector to obtain the sample of air. This may be connected to the ET tube hub or it may be a cannula with nasal prongs. New cannulas have both nasal and an oral prong for mouth breathers. 2. An analyzer that detects and analyzes the air sample. 3. A display monitor showing the waveform and EtCO2 number.

Capnography Technologies: Conventional high-flow sidestream Mainstream New low-flow sidestream technology 1980’s Capnography systems used for out-of-hospital care have evolved over the past 20 years: Conventional high-flow sidestream, which has the analyzer inside of the monitor, was introduced in the 1980s. This high aspiration of air from the patient had many technical problems. The tubing frequently became clogged and blocked, needing clearing or replacing. It could not be used on patients with low tidal volumes. Frustrations with the high flow technology led to using mainstream capnography that has the analyzer on the hub of the ET tube Although mainstream capnography solved some of the problems with the high-flow in sidestream, its use is limited to the intubated patient. In the late 1990s, a new technology was introduced. This new low-flow sidestream technology solved the problems of the earlier high-flow sidestream and provided EMS with a tool for monitoring both intubated and non-intubated patients. Early 1990’s

Conventional high-flow sidestream capnography For both intubated and non-intubated patient Analyzer located inside the device for protection No added weight on patient’s airway Conventional high-flow sidestream capnography provides continuous monitoring: - for both intubated and nonintubated patients - with the analyzer is located inside the device for protection which very important in the EMS environment. With the analyzer in the monitoring device, there is no added weight on the patient’s airway.

Conventional high-flow sidestream capnography Requires ml of air to measure a CO2 level Air aspirating system Requires frequent calibration Frequent occlusion of tubing by moisture and secretions Inaccurate in neonates, infants, and young children However, conventional high-flow sidestream capnography requires ml of air to measure the CO2 level. - The air sample is aspirated back into the monitoring device - This high flow rate and strong aspiration requires frequent calibration and the tubing can be occluded by moisture and secretions - This system is inaccurate in neonates, infants, and young children due to their smaller air flow capacity or tidal volume

Conventional high-flow sidestream capnography system A i r S a m p l e W t T E n d - C O 2 o w h analyzer inside P B g Efforts to correct the problems of the conventional high-flow sidestream systems include adding a water trap to collect the secretions and decrease the number of occlusions in the tubing. This illustrates a high-flow sidestream system. The air sample is aspirated at this port and delivered to the analyzer in the monitor. The water trap is added to collect patient secretions, preventing them from blocking the tubing and entering the monitor.

History of Capnography
Mainstream Capnography Developed for intubated patient Analyzer on the hub of ET tube Not disposable Weight on the ET tube Adaptors attach to analyzer for non-intubated patients Mainstream capnography had been developed in the OR for the anesthetized intubated patient. The analyzer is outside of the device, located at the hub of ET tube. In the EMS patient, this added weight can be a hazard, especially in children. The analyzer is not disposable and requires frequent calibrations. For non-intubated patients, there are now adaptors the can be attached to the external analyzer.

Mainstream Capnography E l e c t r o n i C a b Analyzer d - O 2 m B g In mainstream systems, the air sample is analyzed in the analyzer at the ET tube connection and the information is sent electronically to the monitor.

New low-flow sidestream capnography Newer technology requires 50ml of air for sampling Occlusions uncommon Accurate in all age groups neonates to large adults New low-flow sidestream capnography developed in the 1990s has overcome the problems of the high-flow systems that frustrated EMS providers. This new technology requires only 50ml of air for accurate sampling. This lower flow makes occlusions uncommon. The new analyzing process is accurate in patients of all ages and the decreased air draw and increased accuracy make it applicable for neonates to large adults.

New low-flow sidestream capnography For intubated and non-intubated patients No calibration required between patients Disposable tubing and cannulas New in-line filters exclude contaminants Central collector system in tubing Durable for EMS environment New low-flow sidestream capnography: - Can be used on intubated and non-intubated patients - Requires only an annual calibration check with no calibration between patients - Has disposable tubing and cannulas (that are latex-free) - Includes in-line filters that exclude bacteria to prevent monitor contamination - Collects the air from the center of the adapter, decreasing the risk clogging - Was developed to meet the durability requirements for the EMS environment

New low-flow sidestream technology Here are examples of the newer low-flow sidestream cannulas and tubing. The nasal/oral cannula also delivers oxygen. The ET tube connector with the orange colored filter is easily seen here. Teaching Note: Samples of the cannulas are useful to show.

Using Capnography Immediate information via breath-to-breath monitoring Information on the ABCs Airway Breathing Circulation Documentation Capnography provides immediate information through breath-to-breath monitoring. It is noninvasive, yet can give you objective information on the important ABCs of your patients: Airway, Breathing, Circulation, and provide you documentation.

Using Capnography Airway Circulation Airway
Verification of ET tube placement Continuous monitoring of ET tube position Circulation Check effectiveness of cardiac compressions First indicator of ROSC Monitor low perfusion states Airway In the intubated patient, capnography can be used for: - Verification of ET tube placement - Continuous monitoring of ET tube position In the patient in cardiac arrest, capnography can be used: - To check effectiveness of cardiac compressions - As the first indicator of the return of spontaneous circulation, before the pulse or blood pressure - As a noninvasive measurement to monitor cardiac output in patient with low perfusion states Circulation

Using Capnography Breathing – Hyperventilation – Hypoventilation
– Asthma – COPD The exciting applications in the non-intubated patient include evaluating their breathing and differentiating. - Hyperventilation - Hypoventilation - Asthma - COPD

Using Capnography Documentation Waveforms Waveforms Initial assessment
Changes with treatment EtCO2 values Trends over time Waveforms Trends Documentation of this objective data on your patient includes: - Printouts of the waveforms of the initial assessment, as well as changes with treatment - Trends in the EtCO2 values can be documented

Part 1: Capnography Overview Summary
The only visual objective measure of ventilation Provides breath-to-breath readings For intubated and non-intubated patients Information and documentation of patient’s ABCs New technology for use in EMS In summary, capnography is the only visual objective measure of ventilation. It provides continuous breath-to-breath readings. The new low-flow sidestream technology can be applied to both intubated and non-intubated patients. Capnography gives you objective information that relates to your patient’s ABCs and provides documentation. This new technology is ideal for use in EMS.

Part 1: Capnography Overview
Okay, let’s get started.

CAPNOGRAPHY In Emergency Care

Similar presentations

Presentation on theme: "CAPNOGRAPHY In Emergency Care"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

CAPNOGRAPHY In Emergency Care

Similar presentations

Presentation on theme: "CAPNOGRAPHY In Emergency Care"— Presentation transcript:

Similar presentations

About project

Feedback