14 capnography part1 overview
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This document provides an overview of capnography, which is a technology that objectively measures ventilation by detecting exhaled carbon dioxide. It can be used for both intubated and non-intubated patients to continuously monitor ventilation and the patient's ABCs. The document reviews the history of capnography, from its initial use in operating rooms to new portable technologies suitable for emergency medical services. It also outlines the clinical applications of capnography such as verifying endotracheal tube placement and monitoring treatment effectiveness.
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14 capnography part1 overview
- 1. C A PNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 1: Overview
- 4. Part 1: Overview C A PNOGRAPHY In Emergency Care
- 5. Why use capnography? (Corollary: Why should I learn capnography?)
- 19. History of Capnography in EMS Colorimetric:
- 22. History of Capnography in EMS Capnometer:
- 27. History of Capnography in EMS Capnography:
- 43. Part 1: Capnography Overview Okay, let’s get started.
Notes de l'éditeur
- 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 1-800-888-8700 or their website at http://www.healthcareeducation.org. All contents are under the copyright of Medtronic Physio-Control Corp.
- 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
- 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.
- Let’s start with an overview of capnography and address a few key terms and questions.
- 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.
- 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
- 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 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 CO 2 ” A waveform of respiration
- What is End-Tidal CO 2 ? Breaking the term apart, “carbon dioxide at the end of the tide” Breathing is done in waves (in and out) EtCO 2 is the amount of CO 2 measured at the peak of the wave going out at the end of exhalation EtCO 2 is measured at the nose, mouth, or hub of the ET tube
- “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
- A quick review of cardiopulmonary physiology: Carbon Dioxide (CO 2 ): - 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 CO 2 exits through the airway
- 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.
- 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: 1004-1017, 2002
- The first notice of this new standard was published in Joint Commission Perspectives, Special Report. July/August 2000 . 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.
- 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 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 This is basically a device that contains specially treated litmus paper, that changes color indicating the amount of CO 2 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 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.
- 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 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.
- 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 CO 2 ? Is it changing?
- This is an illustration of a capnometer showing the two numbers, the respiratory rate and the EtCO 2 . This provides you more information a colorimetric check, however… (next slide)
- 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.
- However, the waveform may indicate a completely different situation in your patient’s condition.
- Capnography provides both a numerical value of the EtCO 2 AND a waveform of the concentration and flow of CO 2 present in the airway.
- 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 SpO 2 and pulse oximetry waveform. The lower is the EtCO 2 number (capnometry) and capnography waveform.
- 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 EtCO 2 number.
- 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.
- 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.
- However, conventional high-flow sidestream capnography requires 150-200 ml of air to measure the CO 2 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
- 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.
- 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.
- 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 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: - 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
- 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.
- 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.
- 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
- The exciting applications in the non-intubated patient include evaluating their breathing and differentiating. - Hyperventilation - Hypoventilation - Asthma - COPD
- 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 EtCO 2 values can be documented
- 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.