CCU/ED

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Capnography

• CCU/ED
• Procedural sedation

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Objectives

• Overview of ETCO2 monitoring
• Physiology
• CO2 waveform
• New requirements for ETCO2 Monitoring
• Patient Monitoring in procedural sedation
• Recommendations for ETCO2 Monitoring
• Cardiopulmonary Resuscitation

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Capnography

• A non-invasive, continuous measurement of exhaled
  carbon dioxide (CO2) concentration
• Exhaled CO2 is sampled
• Via specialized nasal cannula
• Via airway adapter for ET/trach
• End tidal CO2 is the concentration of carbon
  dioxide in exhaled air at the end of expiration.
  
• The normal range is 35-45 mm Hg.

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Physiology of ETCO2
Metabolism Circulation
Ventilation
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Why do we use capnography?

• Assessment of pulmonary circulation and
  respiratory status
• Accurately measures respiratory rate/ventilation
• Determining changes in pulmonary circulation and
  respiratory status sooner than pulse oximetry
• Early indicator of ventilation issues
• Indicator of perfusion and metabolism
• Early warning of apnea
• Can screen for pulmonary embolism
• Evaluating the partial pressure of exhaled CO2
  especially PETCO2
• 
  
• 
  

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ETCO2 display

• Numerical value for ETCO2 Normal value 35-45 mmHg
• Distinct waveform (tracing) for each respiratory
  cycle

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What about pulse oximetry

• Until recently, only practical method to assess
  respiratory function
• The pulse oximeter is a LATE detector of
  respiratory depression
• Supplemental oxygen further delays detection
• O2 no longer linearly correlates with SpO2
• Historically, associated with frequent nuisance
  alarms
• Vital signs frequently stimulate patients prior
  to pulse oximetry assessment

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Ventilation and Oxygenation

• ETCO2 Monitoring
• (Measures Ventilation)

• SpO2 Monitoring
• (Measures Oxygenation)

• Measures carbon dioxide
• Reflects breath-to-breath ventilation
• Detects hypoventilation/apnea immediately
• Not effected by supplemental oxygen
• Does not appear normal if patient is not breathing

• Measures oxygen saturation (O2 attached to
  hemoglobin)
• Reflects oxygenation/ detects hypoxia
• Influenced by supplemental oxygen
• May remain normal even if patient is not
  breathing
• Should be used with capnography

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ETCO2 monitoring

• Nasal cannulas will measure CO2 and deliver
  oxygen to the patient. (fig.1)
• In- line infrared sensor will connect to the
  ventilator for monitoring. (fig. 2)

fig. 1
fig. 2
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ETCO2 not to be confused with CO2 detector!

• CO2 detector color change
• Capnography/ETCO2
• Value
• Waveform

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During Procedural Sedation

• Useful for detecting respiratory depression.
• More sensitive than saturation of peripheral
  oxygen SPO2 or clinician assessment
• Vital sign(including pulse oximetry) are late to
  respond to hypoventilation.
• Super-oxygenated patients desaturate only after
  prolonged apnea.
• End tidal CO2 monitoring detects hypoventilation
  earlier.

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Assessment Findings

• Findings

• Interventions

• Change in ETCO2 of 10 mm Hg or greater
• ETCO2 50 mm Hg or greater
• Absent waveform.
• ETCO2 of 30 mm Hg or less abnormal.
• Change in ETCO2 of greater than 10 of baseline.
  

• Repositioning
• Verbal/physical stimulation
• Decrease medication dose
• Stop medication administration
• Administer reversal agents
• Apnea bag-mask ventilation.

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TYPES OF SEDATION

• Minimal Sedation RASS level -1 and -2
• The RN may administer the medications as directed
  by the privileged physician
• ETCO2 monitoring not required
• Moderate Sedation/Conscious Sedation RASS level
  -3
• The RN may administer the medications as directed
  by the privileged physician
• ETCO2 monitoring required
• Deep Sedation RASS level -4
• A privileged physician must administer the
  medications
• ETCO2 monitoring required

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Richmond Agitation Sedation Scale (RASS)
Score Term Description
4 Combative Overtly combative, violent, immediate danger to staff
3 Very agitated Pulls or removes tube(s) or catheter(s) aggressive
2 Agitated Frequent non-purposeful movement, fights ventilator
1 Restless Anxious but movements not aggressive, vigorous
0 Alert and calm ---------
-1 Drowsy Not fully alert, but has sustained awakening(eye- opening/eye contact to voice greater than or equal to 10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (less than 10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
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Policy Documentation - PCS1600150

• Documentation for end tidal CO2 will consist of
  assessing for a normal appearing waveform which
  will be documented as a . It the waveform is not
  normal appearing then it would be documented as a
  and an action item would also be documented
  (i.e. - waveform action stopped case and
  repositioned airway). Numeric values will not be
  documented because they can be diluted down with
  normal room air contamination in an open
  breathing system. Documentation will occur every
  5 minutes during the procedure and every 15
  minutes in the recovery phase and until end of
  recovery.

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ETCO2 monitoring in CPR

• Quantitative Waveform Capnography
• The 2010-2015 AHA Guidelines for ACLS
• Recommend using quantitative waveform capnography
  in intubated patients during CPR
• Waveform capnography allows providers to
• Confirm and on-going monitoring of endotracheal
  tube placement
• Monitor CPR quality and optimize chest
  compressions
• Detect ROSC (return of spontaneous circulation)
  during chest compressions

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ETCO2 monitoring in CPR cont.

• Cardiac arrest- CO2 produced but not delivered to
  the lungs
• CPR-Cardiac output delivers CO2 to the lungs
• Can be altered by giving IV sodium bicarbonate
• Persistently low ETCO2 values (lt10 mm Hg)
• ROSC unlikely
• ROSC
• Abrupt sustained increase in ETCO2 is an
  indicator of ROSC
• Greater than 30 mmHg
• Represents drastic improvement in blood flow
  (more CO2 being transported to the lungs)

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ETCO2 and Chest Compressions

• Evaluates the effectiveness of chest compressions
• Monitoring ETCO2 trends guide in compression
  depth and rate and can detect fatigue
• 10-20 mmHg High quality chest compressions
• Less than 10 mmHg during CPR Indicates quality
  of chest compressions needs improvement

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Cerner Documentation

• The ETCO2 documentation is under the vitals
  section. This screen will be slightly different
  for each department, this is ICU. The dropdown
  will allow you to document (-) or (). This does
  not document a number.

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TEST TIME