1. Created by Joshua English, EMT-P James Pointer, MD Mike Jacobs, EMT-P

2. Objectives Understand why we use capnography Understand the physiology of respiration/ ventilation Define normal & abnormal EtCO 2 values/ waveforms Understand the 4 major applications of EtCO 2 –intubated applications (mainstream) –non-intubated applications (sidestream) Understand why we use capnography Understand the physiology of respiration/ ventilation Define normal & abnormal EtCO 2 values/ waveforms Understand the 4 major applications of EtCO 2 –intubated applications (mainstream) –non-intubated applications (sidestream)

3. Why Capnography? Advanced Airway Management (Policy #10102) All devices used to confirm tube placement must be documented on the PCR. Esophageal Detection Device (EDD) End tidal CO2 detector (ETCO2) colorimetric or capnography “Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO 2 monitoring. Failure to use continuous EtCO 2 monitoring was associated with a 23% unrecognized misplaced intubation rate. [Annals of Emergency Medicine 2005; 45:497-503]” Advanced Airway Management (Policy #10102) All devices used to confirm tube placement must be documented on the PCR. Esophageal Detection Device (EDD) End tidal CO2 detector (ETCO2) colorimetric or capnography “Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO 2 monitoring. Failure to use continuous EtCO 2 monitoring was associated with a 23% unrecognized misplaced intubation rate. [Annals of Emergency Medicine 2005; 45:497-503]”

4. Why Capnography? Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!! Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!!

5. Why Capnography? Because respiration, ventilation and oxygenation are VERY VERY different concepts. Because respiration, ventilation and oxygenation are VERY VERY different concepts.

6. Why Capnography? It’s a window into the patient’s ventilatory status

7. Why Capnography? Core Concepts What intubation verification method is most reliable? How do oxygenation and ventilation differ? Core Concepts What intubation verification method is most reliable? How do oxygenation and ventilation differ?

8. Physiology

9. Factors that affect CO2 levels: INCREASE IN ETCO 2 DECREASE IN ETCO 2 Increased muscular activityDecreased muscular activity Increased cardiac output (during resuscitation) Decreased cardiac output (during resuscitation) Effective drug therapy for bronchospasm Bronchospasm HypoventilationHyperventilation

10. Normal EtCO 2

11. Terminology Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value

12. Terminology EtCO 2 – End Tidal CO 2 The measurement of exhaled CO 2 in the breath Normal Range | 35-45 mmHg EtCO 2 – End Tidal CO 2 The measurement of exhaled CO 2 in the breath Normal Range | 35-45 mmHg

13. Normal Waveform End of inspiration Beginning of exhalation End of exhalation Beginning of new breath Alveolar plateau Clearing of anatomic dead space

14. Normal Common Waveforms

15. Hyperventilation Hypoventilation Common Waveforms

16. 4 Main Uses of Capnography Severity of asthma patients Monitoring head injured patients Cardiac arrest Tube confirmation Severity of asthma patients Monitoring head injured patients Cardiac arrest Tube confirmation

17. Terminology Sidestream An indirect method of measuring exhaled CO 2 in non-intubated patients Mainstream Direct method of measuring exhaled CO 2 with intubated patients Sidestream An indirect method of measuring exhaled CO 2 in non-intubated patients Mainstream Direct method of measuring exhaled CO 2 with intubated patients

18. Shark Fin Asthmatic Waveforms COPD patients have a difficult time exhaling gases This is represented on the capnogram by a shark fin appearance

19. Moderate Attack Mild Attack EtCO 2 & Asthma

20. Severe Attack EtCO 2 & Asthma Time To Get MOVING!!! The asthmatic who looks tired and has a shark fin appearance on the capnogram… IS HEADED FOR RESPIRATORY ARREST Time To Get MOVING!!! The asthmatic who looks tired and has a shark fin appearance on the capnogram… IS HEADED FOR RESPIRATORY ARREST

21. The Head Injured Patient Carbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault and therefore increasing ICP 30-35 mmHg Recognizing the head injured patient and titrating their CO 2 levels to the 30-35 mmHg range can help relieve the untoward effects of ICP

22. Titrate EtCO 2 The Head Injured Patient Titration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO 2 levels. Keep them between 30 and 35 mmHg

23. EtCO 2 and Cardiac Arrest The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output Increase in CO 2 during CPR can be an early indicator of ROSC

24. Termination of Resuscitation EtCO 2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR 10 mmHg Non-survivors < 10 mmHg 30 mmHg ( Survivors > 30 mmHg (to discharge)

25. ET Tube Verification Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!! Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!!

26. 4 Main Uses of Capnography Core Concepts What is the characteristic shape of a capnogram for a COPD patient? Describe how to determine the severity of an asthma attack using capnography? What level should you maintain a severe head injured patient’s CO 2 at? What are two ways that capnography can assist during CPR? Core Concepts What is the characteristic shape of a capnogram for a COPD patient? Describe how to determine the severity of an asthma attack using capnography? What level should you maintain a severe head injured patient’s CO 2 at? What are two ways that capnography can assist during CPR?

27. Inadequate Seal Troubleshooting As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff

28. Obstruction Troubleshooting An obstructed ET tube may have an erratic EtCO 2 value with a very irregular waveform

29. Rebreathing Troubleshooting A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO 2 through insufficient inspiratory or expiratory flow

30. QUIZ

31. Hypoventilation

32. Rebreathing

33. Esophageal Tube

34. Asthma

35. Normal

36. Questions?