CAPNOGRAPHY

CLINICAL
APPLICATIONS

PRESENTED BY
AHMED ATEF
CAPNOGRAPHY, EM
COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and
internationally registered trademarks of Covidien AG. Other brands are trademarks of a
Covidien company or their respective owner.
©2012 Covidien. All rights reserved.
CAPNOGRAPHY CLINICAL APPLICATIONS

ED/EMS

Critical
Sedation
Care

EtCO2
CAPNOGRAPHY IN CRITICAL CARE
CAPNOGRAPHY IN THE CRITICAL CARE

Indications of use:
 Confirmation of correct ETT placement

 Manage and monitor ventilated patients

 Monitor ventilator status Warning

 Airway leaks

 Ventilator circuit disconnections

 Monitor patient’s response during mechanical ventilation

 Monitor patient’s ventilation after removal from ventilatory support
(T-piece)
CAPNOGRAPHY IN THE CRITICAL CARE
Indications of use:
 Monitor Non-invasive ventilation (adult: bi-level/CPAP)

 Assist clinician

 Identification of cardio-respiratory or metabolic conditions

 Monitor ventilation/perfusion

 Assist Treatment decisions

 Limit routine use of ABG

 Assess code efforts

 Effective compressions

 ROSC
VENTILATION – PERFUSION MATCHING

Pulmonary
Blood
Circulation

Systemic Blood
Circulation
VENTILATION – PERFUSION MATCHING
VENTILATION – PERFUSION MATCHING
VENTILATION – PERFUSION MATCHING
 VENTILATION – PERFUSION MATCHING

Perfusion Problems:

 Pulmonary embolism

 Cardiac arrest

 Hypovolemia

All values in the examples below are for illustrative purposes only.
 VENTILATION – PERFUSION MATCHING

Ventilatory Problems:

 Bronchial intubation

 Increased bronchial & alveolar

secretions

 Mucus plugging

 Bronchospasm

 Atelectasis

All values in the examples below are for illustrative purposes only.
VENTILATION – PERFUSION MATCHING

 Ventilation-perfusion matching
 EtCO2 closely reflects PaCO2

 Ventilation-perfusion mismatch (a-ET)PCO2

 EtCO2 < PaCO2

 EtCO2 trend (draw ABG as necessary)

 EtCO2 + PaCO2 (use together to manage care)

VENTILATION – PERFUSION MATCHING

 Capnography

 Does not replace ABGs

 Capnography shows

 Airway integrity – alveolar ventilation

 Indicates pulmonary perfusion

 Capnography provides

 Breath-by-breath assessment of ventilation

 Objective, non-invasive data

ABNORMAL ETCO2 WAVEFORMS
ABNORMAL WAVEFORMS
Sudden loss of waveform:

Sudden loss of waveform and

EtCO2 to zero or near zero / no
respiration detected

Possible causes for intubated patient:

 Apnea
 Total airway obstruction
 Kinked or misplaced ETT
 Complete disconnect from ventilator
 Ventilator malfunction
 Defective CO2 / technical error – patient not in danger
ABNORMAL WAVEFORMS
Sudden loss of waveform:

Possible causes for Non Intubated

patient :
 Apnea
 Very shallow respirations
– not deep enough for gas
exchange to occur
(dead space ventilation)
 Total airway obstruction
 Kinked or displaced cannula
CLINICAL INTERVENTIONS

Assess patient (ABC’s)

 If intubated, assess airway
 For breath sounds

 For airway obstruction

 BVM if indicated

 Check equipment connections

CLINICAL INTERVENTIONS

 If non-intubated, assess
 Airway and position of cannula

 Head and neck position

 Adjust as necessary

 Follow your protocol

ABNORMAL WAVEFORMS –
loss of alveolar plateau

Absent alveolar plateau indicates

incomplete alveolar emptying or
loss of airway integrity

Possible causes For Intubated patients :

 Bronchospasm
 Partial airway obstruction caused by secretions
 Leak in the airway system
 Partial disconnect from ventilator
 Endotracheal tube in the hypopharynx
ABNORMAL WAVEFORMS –
loss of alveolar plateau

Possible causes for

Non Intubated patients :
 Partial airway obstruction caused
by secretions
 By tongue

 Position of head

 Hypoventilation due to decrease

tidal volume
CLINICAL INTERVENTIONS

Assess patient first!

 If intubated, assess airway
 For bronchospasm

 For secretions

 For ETT air leak

CLINICAL INTERVENTIONS

 If non-intubated, assess
 Airway

 Position of head and cannula

- Adjust as necessary

 Ask patient to take a deep breath

 Follow your protocol

ABNORMAL WAVEFORMS –
Decreased EtCO2

Gradual decrease in EtCO2 with

normal waveform indicates
a decreasing CO2 production, or
decreasing systemic or pulmonary
perfusion

Possible cause in Intubated patients:

 Hypothermia (decrease in metabolism)
 Hyperventilation
 Hypovolemia
 Decreasing cardiac output
ABNORMAL WAVEFORMS –
Decreased EtCO2

Possible cause in
Non Intubated patients:
 Hyperventilation
 Decreased cardiac output
 Hypothermia
CLINICAL INTERVENTIONS

Assess patient -
 With ventilated patient
 Watch trend – gradual decrease EtCO2

 Assess changes in ECG/BP

 Assess for bleeding/shock

 Cardiac malfunction
CLINICAL INTERVENTIONS

 With non-intubated, assess

 Evaluate for anxiety

 Evaluate for adequate sedation and

analgesia

 Follow your protocol

ABNORMAL WAVEFORMS –
Increased EtCO2

Possible cause in Intubated patients :

 Rising body temperature
 Hypoventilation
 Ventilator Tidal Volume adequate
with low RR
 Ventilator settings where the
minute volume too low
ABNORMAL WAVEFORMS –
Increased EtCO2

Possible cause in
Non Intubated patients :
 Hypoventilation (drop in RR) due
to analgesia or sedation
 Sudden increase in delivery of
CO2 to pulmonary circulation
 Bolus of Sodium Bicarbonate

 Release of limb tourniquet / very

tight BP cuff
CLINICAL INTERVENTIONS

Assess patient
 If on ventilator
 Work with RT to adjust settings
CLINICAL INTERVENTIONS

 If non-intubated, assess
 Assess airway

 Assess LOC

 Evaluate medications

 Follow protocol
ABNORMAL WAVEFORMS –
Rise in EtCO2 Baseline

Rise in baseline CO2 indicates rebreathing of CO2

 Intubated patient
 Addition of mechanical dead space
to ventilator circuit

 Technical errors in CO2 analyzer

 Non-intubated patient
 Poor head & neck alignment

 Draping at the airway

 Insufficient flow to O2 mask

 Shallow breathing that does not clear anatomical dead space

CLINICAL INTERVENTIONS

Assess patient first!

With ventilated patient
 Work with RT to evaluate
 Patient respiratory status

 Ventilator circuit & equipment

CLINICAL INTERVENTIONS

 If non-intubated
 Assess airway

 Check for shallow respirations,

ask patient to take a deep breath

 Check head and neck alignment

 Check bed covers around airway

 Verify adequate flow to O2 mask

 Follow your protocol

CAPNOGRAPHY IN THE MANAGEMENT OF
THE CRITICALLY ILL PATIENT – ED, PACU, ICU, PICU, NICU

Review

 End tidal CO2 measured at the end of expiration,

non-invasively
 EtCO2 provides a clinical estimate of the PaCO2,
with ventilation-perfusion matching
CAPNOGRAPHY IN THE MANAGEMENT OF
THE CRITICALLY ILL PATIENT – ED, PACU, ICU, PICU, NICU

Clinical conditions result in mismatch (a-ET)PCO2

 EtCO2 – valuable tool to “trend” CO2
 Can minimize need for arterial sticks

 And act as early indicator for need to draw ABG

 EtCO2 + PaCO2
 Aid in identification of disease states

 And monitor progress of treatment

CAPNOGRAPHY IN THE MANAGEMENT OF
THE CRITICALLY ILL PATIENT – The Total Picture

 Capnography (EtCO2) = Ventilation

 NIBP, HR, ECG = Perfusion
 Pulse oximetry (SpO2) = Oxygenation
CAPNOGRAPHY IN THE MANAGEMENT OF THE
CRITICALLY ILL PATIENT – The Total Picture

 Breath-by-breath assessment of ventilation

 Patient care management

 Objective non-invasive data

CAPNOGRAPHY IN CRITICAL CARE - NAP4

NAP4 BJA March 2011 – “Major complications of airway management

in the UK”: results of the Fourth National Audit Project of the Royal College
of Anaesthetists and the Difficult Airway Society.

“The most important finding was that the absence of a

breathing monitor (capnograph) contributed to 74% of
airway related deaths reported from ICUs.”
“We recommend that a capnograph is used for all patients
receiving help with breathing on ICU; current evidence
suggests it is used for only a quarter of such patients.
Greater use of this device will save lives.”
NAP4 - ICU RECOMMENDATIONS

 Capnography should be used for intubation of all critically ill patients

irrespective of location.
 Continuous capnography should be used in all ICU patients with tracheal
tubes (including tracheostomy) who are intubated and ventilator-
dependent. Cost and technical difficulties may be practical impediments
to the rapid introduction of routine capnography. However, these need
not prevent its implementation.
 Where capnography is not used, the clinical reason for not using it
should be documented and reviewed regularly.
 Training of all clinical staff who work in ICU should include interpretation
of capnography. Teaching should focus on identification of airway
obstruction or displacement. In addition, recognition of the abnormal
(but not flat) capnograph trace during CPR should be emphasized.
NAP4 - ED RECOMMENDATIONS

 Many of the above recommendations apply equally to

the ED. To these are added:
 Capnography should be used for all intubations in the ED.
 Capnography should be used for all anaesthetized patients in the
ED.
 Capnography should be used for intubated patients during transfers
from the ED to other departments.
CONTINUOUS CAPNOGRAPHY DECREASES
THE UTILIZATION OF BLOOD GASES
Society of critical care medicine (abstract 340).
 Rowan, Courtney et al Riley Hospital for Children

 Methods:

 Standard continuous capnography was implemented for all

mechanically ventilated patients in March 2011. Prior, it was available,
but was not routinely used. The utilization of blood gas measurement
in the paediatric intensive care unit was retrospectively analysed. The
time period of April 2010 to July 2010 was compared to April 2011 to
July 2011. Parameters collected included total number of blood gases
analysed, cost of blood gas analysis, ventilator days, and patient
days.
CONTINUOUS CAPNOGRAPHY DECREASES
THE UTILIZATION OF BLOOD GASES
Society of critical care medicine (abstract 340).
Results :
 The total number of blood gases in the time period after the institution of end-tidal
CO2 (ETCO2) monitoring compared to the year prior decreased from 8667 to 3738.
The average number of blood gases per encounter decreased from 21.3 to 11.0. When
comparing the blood gases per ventilator days there was a decrease from 5.37 to 2.33.
The total blood gas charge decreased from $1,487,886 to $717,006 for a total cost
savings of $770,880. During this time period, however, the cost of an individual blood
gas analysis increased from $171.68 to $192.05. When adjusting for the increased cost
the savings rise to $947,491. Our initial purchase of the ETCO2 monitors was
approximately $111,700. Therefore, adjusting for the increased cost of the blood gas
analysis and the cost of the ETCO2 monitoring, the total savings over a 4 month period
was $835,791. Future months will still be analysed.
 Conclusions:
 Continuous capnography resulted in a significant cost savings over a 4 month period by
decreasing the utilization of blood gas measurements. Decreasing the number of blood
gases analyses may also have other cost savings advantages such as decreased blood
transfusions and decreased catheter associated blood stream infections.
CAPNOGRAPHY FILTERLINES® IN THE ICU

FilterLine® H Set FilterLine® H Set I/N

Smart CapnoLine® H CapnoLine® H

CAPNOGRAPHY DURING
PROCEDURAL SEDATION
PROCEDURAL SEDATION

 Definition: "a technique of administering

sedatives or dissociative agents with or
without analgesics to induce a state that
allows the patient to tolerate unpleasant
procedures while maintaining
cardiorespiratory function.

 Procedural sedation and analgesia (PSA)

is intended to result in a depressed level
of consciousness that allows the patient
to maintain oxygenation and airway
control.
GOALS OF CONSCIOUS SEDATION

 Maintain patent airway

 Maintain protective reflexes
 Maintain response to verbal stimuli
 Maintain response to physical stimuli
 Allow the patient to tolerate
an unpleasant procedure
 Amnesia is ideally present
TYPES OF PROCEDURES

 Sedation in the ED:

 Fractures
 Small incisions and sutures

 Sedation in the Gastroenterology Lab

 Upper Endoscopy
 EGD
 ERCP
 Bronchoscopy

 Lower Endoscopy
 Colonoscopy
 Flexible Sigmoidoscopy (no sedation)
CONSCIOUS SEDATION
Medications commonly used

 Versed (Midazolam):
 Amnestic quality, reduces anxiety

 Valium(Diazepam):
 Amnestic quality (less than versed), reduces anxiety

 Fentanyl
 Narcotic, pain relief, short acting

 Demerol (Meperidine)
 Narcotic, pain relief, long acting
CONSCIOUS SEDATION

 A combination of a narcotic and an amnestic medications

 Combined drugs have a synergistic effect

 Dosing is done in a step-wise (Gradually) fashion until the desired effect
is achieved
 REVERSAL AGENTS

 Agents used to reverse the effects of conscious sedation

 Narcan (naloxone) – reverses the effect of opioid narcotics
 Flumazenil – reverses the effect of midazolam and diazepam
PROPOFOL
Sophisticated sedating agent

 A short-acting anesthetic agent

 Used for induction of anesthesia

 Rapid onset (within 30 seconds)

 Make it suitable for use in a day-procedure setting

 The use of Propofol by non-specialist anesthetists is controversial

 Inadequate margin of safety
 Propofol - Respiratory Depression

 No reversal agent (!!)

 THE IMPORTANCE OF CAPNOGRAPHY
DURING PROCEDURAL SEDATION

 Procedural sedation:
 A patient who has received procedural sedation should have
a depressed level of consciousness, but retain the ability to
independently and continuously maintain a patent airway

No 12.8 American Nurses Association Board of Directors Policy/Position

Title: Endorsement of Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving
IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures
Source: ANA Board of Directors
Date: September 6, 1991
THE IMPORTANCE OF CAPNOGRAPHY
DURING PROCEDURAL SEDATION

 Capnography can detect when the patient slips into a deeper level
of sedation than intended
 The earliest indicator of hypoventilation, airway obstruction, no
breathing
 Validates breathing and airway integrity (waveform shape)
CAPNOGRAPHY IN PROCEDURAL SEDATION

Capnography :

 Monitors adequate ventilation with non intubated patients

 Accurately monitors RR
 Monitors potential risk of over-sedation resulting in hypoventilation
more effectively than pulse oximetry
 Early indicator of airway obstruction

 Early warning of apnea

PROCEDURES
AT THE GASTROENTEROLOGY LAB
EGD ESOPHAGOGASTRODUODENOSCOPY

 Examination of the inner lining of

the esophagus, stomach and upper
duodenum using a small camera at
the end of a scope.

 Lining is examined and biopsies can

be obtained

 Length of procedure 30-60 minutes

(actual can be much shorter)
INDICATIONS FOR EGD

 Upper Gastro Intestinal bleeding

 Swallowing difficulties
 Determining cause of abdominal pain
 Tumors
 Inflammation or narrowing of the esophagus
FILTERLINE® FOR EGD –
SMART CAPNOLINE GUARDIAN™

 Oral/Nasal Cannula (adjustable) fits into bite block for monitoring

before/during/and after procedure
 Wings for easy and secure placement on patient
CO2 SAMPLING SUBSYSTEM
(BACK (PATIENTS) VIEW)

Dual Nare
Nasal CO2 Oral CO2
Sampling Sample
CO2 Sample Periscope
Line to monitor sample well

Oral CO2
Sample
Periscope

Flexible
Wings
Oral CO2 sample
port
O2 DELIVERY SUBSYSTEM (BACK VIEW)

Nasal O2 O2 Delivery
Nasal O2
Delivery Line Line from
Delivery
Hole O22 source
Array

O2 Check
Valve

Oral O2 delivery port Oral O2 Delivery Line

CO2 SAMPLING DETAIL BACK VIEW

Wide Periscope sample well allows lateral movement

of Oral O2 sample periscope
USING THE ORAL NASAL CANNULA
WITHOUT THE BITE BLOCK

O2 Tube
100%
nasal
delivery
Normally closed
O2 Check Valve
GUM COMFORT PAD

Silicon Rubber Gum Comfort Pad

Optional accessory for patients without teeth

60 FRENCH BITE BLOCK

Polished inner surface and rounded edges

minimize endoscopic instrument drag
ERCP
Endoscopic retrograde cholangiopancreatography

 Study of the ducts that drain the liver and pancreas.

 This procedure enables the MD to diagnose liver, gallbladder, bile duct

and pancreas diseases.

 Ducts are drainage routes into the

bowel
 The ones that drain the liver and
gallbladder are called bile or biliary
ducts
ERCP

 The one that drains the pancreas is called the pancreatic duct
 The bile and pancreatic ducts join together just before they drain into the upper
bowel, about 3 inches from the stomach
 This duct drain the Gall bladder fluids and directs it to the lower bowel and out
of the body.
ERCP

 During an ERCP, contrast dye is injected into the bile duct, the pancreatic
duct, or both. Fluoroscopy is used to visualize and X-rays may be taken.
 Treatment can then include stone removal, stent placement, balloon
dilation, and tissue sampling
 Length of procedure can be as short as 30 minutes to several hours
ERCP

 “Hypoxemia is the most common unplanned cardiovascular event

during elective ERCP and EUS reportedly. occurring in 40-70% of
patients. While most episodes are transient, current treatment
patterns may perpetuate the underlying mechanisms and may lead to
more serious adverse events in the ensuing period.

 Conclusions: Microstream capnographic monitoring of respiratory

activity significantly reduces hypoxemia, major hypoxemia, apnea and
oxygen requirements in patients undergoing ERCP and EUS”.

Capnography Prevents Hypoxemia During ERCP and EUS: A Randomized Controlled Trial
Mohammed A. Qadeer, John J. Vargo, John A. Dumot, Gregory Zuccaro, Tyler Stevens, Mansour A. Parsi,
Madhusudhan R. Sanaka, Sunguk Jang, Rocio Lopez
FILTERLINE® FOR ERCP

 Smart CapnoBloc™:
 Allows Monitoring of a patients ETCO2 values, respiration quality and
effectiveness during the procedure.
 Allows Patients monitoring even after the procedure by removing the
mouth piece and using just the filter line.
BRONCHOSCOPY

 Often done in the GI department in some

facilities

 Allows the practitioner to examine inside

a patient's airway for abnormalities such
as foreign bodies, bleeding, tumors, or
inflammation.

 The practitioner often takes samples

from inside the lungs such as biopsies
and fluid
FILTERLINE® BRONCHOSCOPY

 Can use oral or nasal approach nasal

seems to be more common
 Use Smart CapnoBloc™ if oral
approach
 Use Smart CapnoLine™

 Plus™ if nasal approach

COLONOSCOPY

 Colonoscopy allows the physician to

look inside the entire large intestine.

 Used to view inflamed tissue, abnormal

growths, and ulcers

 Early detector of cancer recommended

after age 50

 Evaluate symptoms such as abdominal

pain, rectal bleeding, and weight loss
COLONOSCOPY

 When polyps are found, they are removed and biopsies are done

 The procedure usually takes about 30-60 minutes

FILTERLINE® FOR COLONOSCOPY

 Smart CapnoLine™ Plus O2

WHAT ABOUT UPPER AND LOWER PROCEDURES TOGETHER?

 Use Smart CapnoBloc™ product. If upper is done first:

 Apply cannula and then insert Smart CapnoBloc™

 Do the upper procedure

 Remove Smart CapnoBloc™ and pull oral prong down if necessary

 Proceed with lower procedure using cannula. Sometimes the Colonoscopy
is done first - just reverse this procedure
MISC. PROCEDURES

 Liver Biopsy – if sedation is used they may monitor EtCO2 these

patients

 PEG – Percutaneous Endoscopic Gastrostomy - A feeding tube is

placed through the abdominal wall and into the stomach. Sedation is
usually used on these patients
KEYS TO SUCCESS IN THE GI LAB

 Ensure use of proper FilterLine®

 For ERCP’s, apply cannula part of Smart CapnoBloc™ prior to
positioning patient on their stomach, if possible
 Make sure Smart CapnoBloc™ strap is attached properly around
patient’s neck (Under the ears)
 Make sure blue oral prong is inserted into opening when Smart
Capnobloc™ is inserted in patient’s mouth
PATIENT INTERFACE FOR NON-INTUBATED PATIENTS:
SMART CAPNOLINE® PLUS O2
Patented Uni-junction™
 Allows etCO2 sampling
from both nares and the
mouth –
 Uni-junction™ for
accurate sampling
 Oral prong for shallow
O.2 micron breathing
hydrophobic filter
– no water trap

Tubing for O2
delivery – up to
5 L/m
Connector compatibility
PATIENT INTERFACE FOR UPPER ENDOSCOPY

Smart CapnoLine
Guardian™

• Monitors ventilation before, during

& after procedure
• Protects endoscope while allowing
maneuverability
• Accepts endoscopes & devices up
to 60 F
• Delivers O2 up to 10-L/m
CAPNOGRAPHY IN EMERGENCY MEDICINE
CLINICAL INDICATIONS IN EMERGENCY MEDICINE

Intubated Patient

• Assisting in Appling endotracheal tube

• Assess quality of manual/asisted ventilations
• Assess resuscitation efforts in critical patients

Non-Intubated Patient

• Respiratory monitoring in all patients opioid sedation

& analgesia
• Assess ventilation support to prevent respiratory
failure
• COPD, asthma, CHF, etc.
ERC GUIDELINES - 2010

New guidelines published in Resuscitation 81 (2010), pages 1219-1276:

European Resuscitation Council Guidelines for Resuscitation 2010
ERC GUIDELINES- 2010
ADULT ADVANCED LIFE SUPPORT

“Increased emphasis on the use of capnography to confirm and

continually monitor tracheal tube placement, quality of CPR and to
provide an early indication of return of spontaneous
circulation(ROSC).”

Pediatric Life Support

“Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is
helpful to confirm correct tracheal tube position and recommended
during CPR to help assess and optimize its quality.”
ERC GUIDELINES –2010
AIRWAY MANAGEMENT (PG. 1235)

“… The accuracy of colorimetric CO2 detectors, esophageal detector

devices and non-waveform capnometers does not exceed the
accuracy of auscultation and direct visualization for confirming
the tracheal position of a tube in victims of cardiac arrest.
Waveform Capnography is the most sensitive and specific way to
confirm and continuously monitor the position of a tracheal tube in
victims of cardiac arrest and should supplement clinical assessment
(auscultation and visualization of tube through cords).
USING CAPNOGRAPHY IN EMS/ED

Airway management

Breathing Respiratory Rate and

Ventilation Monitoring

Circulation monitoring

Documentation
CAPNOGRAPHY IN EMS

 Clinical applications for EtC02 monitoring in EMS:

 Intubated patients:
- Unconscious or not breathing

 Non Intubated patients:

- Conscious and breathing spontaneously
- Altered mental status
CAPNOGRAPHY FOR THE INTUBATED PATIENTS
CLINICAL APPLICATIONS IN THE INTUBATED PATIENT

 Verification of initial endotracheal tube (ETT) placement

 Continuous monitoring of ETT position

 Monitoring cardiac output during cardiac arrest and CPR

 CO2 titration in patients with suspected increased cranial pressure

VERIFYING ETT PLACEMENT

 Traditional methods of confirmation

 Fogging of the tube
 Detection of breath sounds over the stomach and
chest
 Observation of chest wall movement
 Auscultation to stomach
CARBONATED BEVERAGES OR ANTACIDS AFFECT
ETCO2 READINGS

 Intubation
 Carbonated beverages or antacids can show a false positive
reading for presence of CO2
 After 4-6 positive pressure breaths, abdominal CO2 is eliminated

 Therefore – after intubation true EtCO2 reading comes after

the several breaths
REDUCE PATIENT RISK WITH CONTINUOUS MONITORING

 Capnography

Immediately detects ETT dislodgement

immediate change in waveform

Identifies the location of the dislodged tube

in some instances

“Continuous waveform Capnography is recommended in addition to clinical assessment as the most reliable
method of confirming and monitoring correct placement of an endotracheal tube.”
American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC). Highlights of the 2010 American Heart Association Guidelines for CPR and ECC.
CHECK WAVEFORM CHANGES FOR LOCATION
OF ETT DISLODGEMENT

ETT dislodgement ETT Tube dislodgement

in esophagus in hypopharynx
CONFIRMATION OF ET TUBE PLACEMENT

 Capnography provides

 Documentation of correct placement

 Ongoing documentation over time

through the trending printout

 Documentation of correct position

at ED arrival

“Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor
endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient
transfer to reduce the risk of unrecognized tube misplacement or displacement.”
American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC). Highlights of the 2010 American Heart Association Guidelines for CPR and ECC.
CAPNOGRAPHY DURING CPR

 Use feedback from ETCO2 to evaluate

quality of CPR

45

0
ETCO2 CAN ASSESS CHEST COMPRESSION EFFECTIVENESS

 Use EtCO2 to assess the depth, rate, and force of chest compressions

“Because blood must circulate through the lungs for CO2 to be exhaled and measured, Capnography can also serve
as a physiologic monitor of the effectiveness of chest compressions and to detect return of spontaneous
circulation (ROSC).”
American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency
Cardiovascular Care (ECC). Highlights of the 2010 American Heart Association Guidelines for CPR and ECC
 CAPNOGRAPHY DETECTS RETURN OF SPONTANEOUS
CIRCULATION
 Indications of ROSC
 Sudden, sustained rise in EtCO2 from baseline
 This can occur before a pulse or blood pressure are palpable

 Pulse detection may be delayed

 Arterial vasoconstriction may make pulse difficult to initially detect

Increased emphasis on the use of Capnography to confirm and continually monitor tracheal tube placement, quality
of CPR and to provide an early indication of return of spontaneous circulation (ROSC).

European Resuscitation Council Summary of the Main Changes in the Resuscitation Guidelines, ERC Guidelines 2010.
CAPNOGRAPHY TO OPTIMIZE VENTILATION MONITORING
DURING TREATMENT/TRANSPORT

 Manual ventilation using BVM during long transport

 In hospital transportation of Ventilated patients
 Use capnography to titrate EtCO2 levels in patients sensitive to fluctuations
 Patients with suspected intracranial pressure (ICP)
 Head trauma
 Stroke
 Brain tumors
 Brain infections
VALUE OF CAPNOGRAPHY FOR PATIENTS
WITH INCREASED INTRACRANIAL PRESSURE

 When CO2 levels are low, less blood flows to brain

 When CO2 levels are high, more blood flows to brain

 Types of patients with suspected increased intracranial pressure (ICP)

 Head trauma

 Brain tumors

 Brain abscesses (HIV patients)

 Brain infections (meningitis, encephalitis)

 Spontaneous bleeds (arteriovenous malformations, aneurysms)

TITRATION OF CO2 LEVELS IN THE ICP PATIENT

 Important not to hypoventilate (EtCO2> 45mmHg) these patients

as this will further increase intracranial pressure.

 Capnography can be used to precisely titrate CO2 levels

CAPNOGRAPHY FOR THE NON-INTUBATED PATIENT
IN EMERGENCY MEDICINE
RESPIRATORY RATE (RR) MONITORING

 Observation or auscultation by the clinician

 Accuracy may be limited by patient movement or positioning
 No automated documentation or alarm

 Impedance monitoring - recording chest wall or abdominal

movement with ECG leads
 Accuracy may be affected by repositioning, postural changes,
or diaphoresis
 Unreliable during obstructive apnea
RAPID VENTILATORY ASSESSMENT AND TRIAGE

 Reliable and Objective Respiratory monitoring during transport and

difficult conditions (Noise, seizures, motion etc’)
 Reliable and objective diagnostic tool (Asthma, COPD, Low-perfusion
states)
 Common conditions detected by Capnography:
 Not breathing
 Upper airway obstruction
 Laryngospasm
 Bronchospasm
 Respiratory failure
RAPID ASSESSMENT FOR CRITICALLY ILL PATIENTS

 Common conditions detected by capnography:

 Not breathing

 Upper airway obstruction

 Laryngospasm

 Bronchospasm

 Respiratory failure
UPPER AIRWAY OBSTRUCTION/ LARYNGOSPASM

Upper airway obstruction Laryngospasm

 No waveform  No waveform
 Chest wall movement  Chest wall movement
 No breath sounds  No breath sounds
 Responsive to airway  Unresponsive to airway
alignment maneuvers alignment maneuvers

Waveform returns Waveform remains flat line

CAPNOGRAPHY IN ASTHMA

 Patients with a mild asthma attack

 Low EtCO2 due to hyperventilation

 Patients with a moderate asthma attack

 Begin to tire
 Decreased respiratory rate
 Increased EtCO2 rising to normal

 Patients with a severe asthma attack

 Hypoventilation
CAPNOGRAPHY DURING CPAP/BIPAP

 Noninvasive ventilation in widely used in the field of Emergency Medicine:

 Asthma

 COPD

 Heart failure and Pulmonary Edema

 Weaning a patient from a ventilator

“The sampling site for CO2 in NIV can greatly influence the reliability of the EtCO2 value. The nasal/oral (Smart
CapnoLine H Plus) sample line proved to be the most reliable in trending EtCO2 with different ventilator settings
and leak rates in the normal patient.”
Paul F. Nuccio, RRT, FAARC, Michael R. Jackson, RRT-NPS, CPFT
Department of Respiratory Care, Brigham and Women’s Hospital, Boston, Massachusetts
VALUE OF CAPNOGRAPHY IN LOW PERFUSION STATES

 Perfusion monitoring with Capnography:

 Stable Vs Unstable arrhythmia

 Acute MI with respiratory distress

 External Cardiac Pacing

 Drug/ Medication intoxication

CAPNOGRAPHY IN HYPOVENTILATION STATES

 Sedation and analgesia

 Alcohol intoxication or drug ingestion

 Post-ictal states
SUMMARY

 Capnography provides
 Real-time measurement of ventilatory status
 Dynamic monitoring
 Advanced warning of adverse events
 Opportunity to avoid the progression of an adverse event
 Objective confirmation of clinical assessment
ORIDION MICROSTREAM® HARDWARE IN THE EMS/ED MARKET

Integrates as “standard” modules into

 Leading EMS/ED monitors and Defibs
 Oridion’s own portable 1-2 parameter monitors
QUESTIONS?
THANK YOU