CCU/ED Procedural sedation Capnography CCU/ED Procedural sedation

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

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.

Physiology of ETCO2 Metabolism + Circulation + Ventilation Cellular Metabolism of food into energy, O2 consumption and Co2 production The heart pumps the freshly oxygenated blood throughout the body to the cells where oxygen is consumed, and carbon dioxide, produced as a byproduct, diffuses out of the cells into the vascular system. Circulation/Transport of O2 and CO2 between cells and pumped through the pulmonary capillary bed where the carbon dioxide diffuses across the alveolar capillary membrane Ventilation between alveoli and atmosphere. Exhaled via the nose or mouth. Ventilation/perfusion ratio- effective pulmonary gas exchange depends on balanced V/Q ratio.

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 In patients without lung disease, substantial hypercarbia may present before pulse oximetry notifies the clinician of a change in ventilation Monitoring the adequacy of pulmonary, systemic, and coronary blood flow, as well as estimation of the effective (non-shunted) pulmonary capillary blood flow by a partial rebreathing method. (Walsh, Crotwell, & Restrepo, 2011)

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

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 * Hutton & Clutton-Brock, BMJ 1993:307:157-8.

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

ETCO2 monitoring fig. 1 fig. 2 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

ETCO2 not to be confused with CO2 detector! CO2 detector – color change Capnography/ETCO2 Value Waveform

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. Capnography is a useful technique for detecting respirator depression during and after procedural sedation and analgesia (PSA) ETCO2 is a more sensitive indicator of respiratory depression then saturation of peripheral oxygen SPO2 or clinician assessment during PSA as well as in the recovery phase.’ Negative outcomes associated with sedation are usually related to airway or respiratory issues. Unfortunately in the ED, vital signs and pulse oximetry are late to respond to hypoventilation. However, superoxygenated patients desaturate only after prolonged apnea so this practice inadvertently further negates the use of pulse oximetry as an early warning sign for respiratory depression or upper airway obstruction. End tidal CO2 monitoring has been shown to detect hypoventilation before changes in vital signs, SpO2, or clinicians’ observations. The American Society of Anesthesiologist (ASA) The ASA standards for anesthesia practice state that “the adequacy of ventilation shall be evaluated by the continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment. (ENA Emergency Nursing Resources Development Committee, 2009)

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. Significant ETCO2 findings warranting intervention: absolute change in ETCO2 of 10 mm Hg or greater, ETCO2 50 mm Hg or greater, or absent waveform. Other authors considered an ETCO2 of 30 mm Hg or less abnormal. One study found that a change in ETCO2 of greater than 10 % of the patient’s baseline. Instead of an absolute change of 10 mm Hg, identified twice the number of patients who developed hypoxia. Another study defined respiratory depression as ETCO2 greater than 50 mm Hg, a change of 10% from baseline, or loss of waveform for 15 seconds or more. Initial interventions include repositioning the patient’s head to restore airway patency and verbal or physical stimulation to encourage the patient to breathe. If these measures are inadequate to reverse the situation then decreasing medication doses, ceasing medication administration, or the administering reversal agents may be considered. If apnea occurs and all else fails, bag-mask ventilation is indicated.

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 ETCO2 monitoring required Deep Sedation: RASS level -4 A privileged physician must administer the medications

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 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 (To be used for patients older than 14 years of age)

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.

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

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 (<10 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)

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

The ETCO2 documentation is under the vitals section 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. Cerner Documentation

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