Capnography in the intubated patient Shannon M. Reynolds Widener University

The change I would like to see implemented into practice is the use of waveform End Tidal CO2 monitoring in all intubated patients.

A little about CO2  Carbon dioxide, CO2, is a normal byproduct of metabolism.  As we breathe, the deoxygenated blood gets circulated through the lungs where CO2 diffuses into the alveolar tissue and gets exchanged for oxygen (O2) and the CO2 is exhaled.  In a normal, healthy person with no circulatory compromise, End tidal CO2 (ETCO2) varies with ventilation and approximately 5% of the Partial Pressure of CO2 in a blood gas.  In a person with circulatory compromise, the ETCO2 reflects pulmonary perfusion, not necessarily ventilation.  High levels of CO2 found with hypoventilation (respiratory depression) and fever  Low levels of CO2 found with shock, cardiac arrest PE, airway obstruction (Bledsoe and Benner, 2006)

What is capnography?  Capnography is a non-invasive method of measuring the levels of Carbon dioxide (CO2) exhaled from the body and can provide information about the systemic metabolism and circulation.  Capnography is a graphic recording or display of the measurement overtime.  This measurement is done at the of expiratory phase and is called End-tidal CO2 (ETCO2)  Types of measurement  Color change  Numbers (measured in mmHg)  Waveform, also called a Capnogram (Bledsoe & Benner, 2006 )

What is capnography, cont’d  2 ways of achieving readings  Qualitative (is it present)  Color-metric  Consists of chemically impregnated paper encased in plastic that attached to the end of an endotracheal tube (ETT) that changes color when CO2 is detected  Cheap and disposable, single patient use  Cannot use if paper gets wet  Cannot be used for continuous monitoring  Only good for initial ETT placement (Bledsoe & Benner, 2006)

What is capnography, cont’d  2 ways of achieving readings  Quantitative  Electronic  Consists of use of infrared in a machine that detects the CO2 and gives a waveform or graph and a number amount of CO2 present  Brings the CO2 to the machine either directly or indirectly with the use of a small tube by attaching to the end of the ETT  Expensive  Use of equipment and equipment maintenance is required  Must be trained in the use and trouble shooting of the equipment (Bledsoe & Benner, 2006)

Electronic ETCO2  As stated in the previous slide, the CO2 is brought to the machine and then a waveform and number are given  Waveform is based on expiration and inspiration  4 phases  Phases I, II, III are seen first and are expiratory phases, Phase IV, sometimes called phase 0, is the inspiratory phase (Kodali, 2013)  I- baseline  II- rapid upstroke as CO2 levels rise  III- plateau, slight upward slope as CO2 reaches the highest point, typically between 35 and 45  IV or 0- inspiration (Canning, 2007)

Advantages of using Capnography  Other than direct visualization of ETT passing through the vocal cords, ETCO2 monitoring is best way to confirm ETT placement (Bhende & Thomas, 1995)  Monitor sedation, as respiratory depression is common and can be detected earlier than with pulse ox alone (Bledsoe & Benner, 2006)  Maintain specific CO2 levels for certain medical conditions and illnesses  Provides information about adequacy and efficiency of chest compressions and possibly detect compressor fatigue as CO2 level decreases during compressions (Gravenstein, Jaffe & Paulus, 2004)  Can alert the provider of Return of Spontaneous Circulation BEFORE a pulse is palpated due to the abrupt rise in ETCO2, which cannot be present unless there is perfusion to the lungs (Gravenstein, et al., 2004)  Gives diagnostic clues based on the waveform and the amount of CO2

Advantages of using Capnography, cont’d  Provides immediate detection of dislodged tube (Kodali, 2013)  Head and neck movement can cause ETT to move as much as 5 cm (Gravenstein, et al., 2004)  Can be used for enteric tube placement, though I don’t see this used in the ICUs that I work in. Basically, if the ETCO2 is increasing, the tube is in the trachea. If the ETCO2 is decreasing to 0, the tube is in the esophagus and passing into the stomach (Gravenstein, et al., 2004)  Can aid in detection of blocked tubes by kinking, bronchospasm or some other type of obstruction by the shape of the waveform (Kodali, 2013). Blocked tubes can be life threatening and can be detected by ETCO2, but is detected less frequently than dislodged ETT (Thomas & McGrath, 2009)  Changes is metabolic rate change CO2 elimination (Kodali, 2013)

Advantages of using Capnography, cont’d  Changes in ETCO2 may indicate change in Cardiovascular/respiratory status (Kodali, 2013)  Hypovolemic stats can cause decrease in CO2  Increasing CO2 may indicate fatigue due to respiratory distress and need for ventilation assistance  ETCO2 can detect changes in respiratory status or obstruction in lungs BEFORE Pulse ox (Canning, 2007)  Shark fin waveform indicates some type of obstruction, usually caused by bronchospasm (Canning, 2013)  Notch in the plateau of waveform can detect that a ventilated patient is breathing above the vent and more medication may be needed to prevent “bucking” of the ventilator (Canning, 2007).

Disadvantages of using Capnography  In my opinion, none. There are no disadvantages.  However, corporations may disagree due to cost of equipment and maintenance of equipment  Must give education to all staff using and caring for patients with capnography  It would be a change in care practices, and as we know, change is not always well received

How will this be accomplished?  Change is a challenge to humans (Porter-O’Grady & Malloch, 2011)  Several factors must be addressed in order for an organization to adapt to the change  First, senior management needs to be invested and committed to the change and everything that comes with it  Second, organizational commitment is essential. Change does not occur when expected  Third, everyone involved must have an understanding of the elements of the change process (Porter-O’Grady & Malloch, 2011)

How will this be accomplished?  Rogers Theory (Krouse, 2013)  Awareness  There is much evidence that Capnography is beneficial. Bring the evidence to the department manager, along with other disciplines such as anesthesia, respiratory and pulmonary care.  Interest  Allow anyone of interest, RNs, Respiratory therapists, etc. to be involved in how this can be accomplishes.  Evaluation  Evaluate the plan. Enough staff is needed to educate others not involved in the process before the trial period.

How will this be accomplished?  Rogers Theory, cont’d  Trial  There should be a trial period to ensure that all the bugs are worked out of the process.  Ensure everyone has been properly educated and there is a protocol that can be followed for use and detection of problems not only with the patient, but also the equipment.  Adoption  When the change takes place permanently.  Ensure proper continuing education for all staff involved.

Conclusion Capnography is a useful tool to use on intubated patients. It should be a standard of care in the ICU. Unfortunately, about 22-64% of ICU use this valuable tool (Kodali, 2013). In the ICU, 46% of cardiac arrests occur here but with the worst outcomes (Kodali, 2013). It did not specify the exact cause of cardiac arrest. Though it is another tool to learn and continuously update education, it is a valuable tool that could easily be implemented and assist with the detection of changes occurring with the patient that could be potentially detrimental to the patient. It can also aid as a tool to guide treatment of certain illness and injuries to which the patient is suffering.

References  American Psychological Association. (2010). Publication manual of the American Psychological Association (6 th Ed.) Washington, DC. American Psychological Association.  Bhende, M. S. & Thompson, A. E. (1995). Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics. 95(3),  Bledsoe, B. E. & Benner, R. W. (2006). Critical Care Paramedic. Upper Saddle River, NJ: Pearson Prentece Hall.  Canning, P. (2007). Ten things every paramedic should know about capnography. Retrieved from:  Gravenstein, M. B., Jaffe, D. A & Paulus, D. A. (Ed). (2004). Capnography: Clinical aspects. Cambridge, UK: Cambridge University Press.

References, cont’d  Kodali, B. S. (2013). Capnography outside the operating rooms. Anesthesiology. 118(1),  Krouse, A. (2013). Change and Conflict Management. [Lecture notes] Widener University, Chester, PA  Porter-O’Grady, T., & Malloch, K., (2011). Quantum Leadership: Advancing Innovation, transforming healthcare (3rd ed.). Sudbury, MA.: Jones & Bartlett Learning, LLC.  Thomas, A. N. & McGrath, B. A. (2009). Patient safety incidents associated with airway devices in critical care: a review of reports the UK National Patient Safety Agency. Journal of the Association of Anaesthetists of Great Britain and Ireland. 64, doi: 10,1111/j x