The Standard of Care

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Capnography
The Standard of Care
Created by Joshua English, EMT-P James Pointer,
MD Mike Jacobs, EMT-P
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Objectives

• Understand why we use capnography
• Understand the physiology of respiration/
  ventilation
• Define normal abnormal EtCO2 values/ waveforms
• Understand the 4 major applications of EtCO2
• intubated applications (mainstream)
• non-intubated applications (sidestream)

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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 EtCO2 monitoring.
  Failure to use continuous EtCO2 monitoring was
  associated with a 23 unrecognized misplaced
  intubation rate.Annals of Emergency Medicine
  2005 45497-503

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Why Capnography?

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

no waveform no tube!!!
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Why Capnography?

• Because respiration, ventilation and oxygenation
  are
• VERY different concepts.

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Why Capnography?

• Its a window into the patients ventilatory
  status

50 mmHg
50 mmHg
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Why Capnography?

• Core Concepts
• What intubation verification method is most
  reliable?
• How do oxygenation and ventilation differ?

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Physiology
vein
back to lungs
oxygenation
metabolism
Cell Metabolism
Transport
Ventilation
capillary
alveoli
perfusion
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• Factors that affect CO2 levels

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Normal EtCO2
Normal
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Terminology
Capnogram a real-time waveform record of
the concentration of carbon dioxide in
the respiratory gases Capnograph Capnogram
waveform plus numerical value
38
mmHg
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Terminology
EtCO2 End Tidal CO2 The measurement of exhaled
CO2 in the breath Normal Range 35-45 mmHg
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Normal Waveform
End of exhalation
Alveolar plateau
Beginning of exhalation
D
C
Beginning of new breath
End of inspiration
A
B
E
A
TIME
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Common Waveforms
Normal
mmHg
RR
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Common Waveforms
Hypoventilation
mmHg
RR
Hyperventilation
mmHg
RR
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4 Main Uses of Capnography

• Severity of asthma patients
• Monitoring head injured patients
• Cardiac arrest
• Tube confirmation

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Terminology
Sidestream An indirect method of measuring
exhaled CO2 in non-intubated patients Mainstrea
m Direct method of measuring exhaled CO2 with
intubated patients
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Asthmatic Waveforms
Shark Fin
mmHg
RR
COPD patients have a difficult time exhaling gases
This is represented on the capnogram by a shark
fin appearance
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EtCO2 Asthma
Mild Attack
mmHg
RR
Moderate Attack
mmHg
RR
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EtCO2 Asthma
Severe Attack
mmHg
RR
Time To Get MOVING!!! The asthmatic who looks
tired and has a shark fin appearance on the
capnogram IS HEADED FOR RESPIRATORY ARREST
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The Head Injured Patient
Carbon dioxide dilates the cerebral blood
vessels, increasing the volume of blood in the
intracranial vault and therefore increasing ICP
Recognizing the head injured patient and
titrating their CO2 levels to the 30-35 mmHg
range can help relieve the untoward effects of ICP
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The Head Injured Patient
Titration IS NOT hyperventilation. Intubating a
head injured patient and using capnography gives
a means to closely monitor CO2 levels.
Titrate EtCO2
mmHg
RR
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EtCO2 and Cardiac Arrest
The capnograph of an intubated cardiac arrest
patient is a direct correlation to cardiac output
Increase in CO2 during CPR can be an early
indicator of ROSC
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Termination of Resuscitation
EtCO2 measurements during a resuscitation give
you an accurate indicator of survivability for
patients under CPR
Non-survivors lt10 mmHg
Survivors gt30 mmHg (to discharge)
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ET Tube Verification

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

no waveform no tube!!!
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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 patients CO2 at?
• What are two ways that capnography can assist
  during CPR?

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Troubleshooting
Inadequate Seal
mmHg
RR
As air escapes around the cuff during BVM
respirations the waveform will distort, alerting
you to a possibly deflated or damaged ET cuff
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Troubleshooting
Obstruction
mmHg
RR
An obstructed ET tube may have an erratic EtCO2
value with a very irregular waveform
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Troubleshooting
Rebreathing
mmHg
RR
A capnogram that does not touch the baseline is
indicative of a patient who is rebreathing CO2
through insufficient inspiratory or expiratory
flow
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QUIZ
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Hypoventilation
mmHg
RR
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Rebreathing
mmHg
RR
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Esophageal Tube
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Asthma
mmHg
RR
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Normal
mmHg
RR
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Questions?