1. CCU/ED Procedural sedation
Capnography
CCU/ED
Procedural sedation

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

3. 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 mm Hg.

4. 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.

5. 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)

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

8. 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.

9. 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

10. 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

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

12. 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)

15. 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.

16. 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

17. 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)

18. 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.

19. ETCO2 monitoring in CPR Quantitative Waveform Capnography
The 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

20. 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)

21. 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

22. 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

23. TEST TIME