1. Capnography for EMS A powerful tool to objectively monitor your patients ventilatory status.

2. Session Objectives Define capnography and related terms Compare capnography to other monitoring parameters Describe the physiology behind capnography Identify a normal capnogram and normal end- tidal CO 2 values Identify abnormal waveforms List the basic clinical applications in EMS

3. Terminology: What is End Tidal CO 2 ? The non-invasive measurement of CO2 exhaled at the airway at the end of a breath Normal values are 33-42 mmHg (35-45 mmHg) “capnos” = smoke

4. Terminology Colorimetric –Disposable detector –Litmus paper –Color changes in the presence of CO 2

5. Terminology Capnogram –Graphical tracing or representation of exhaled CO 2 at the airway –Waveform

6. Terminology Capnograph –Instrument –Monitor that provides a number and a waveform Capnography

7. Physiology of Carbon Dioxide Oxygenation: The process of getting oxygen into the body and to the tissues for metabolism, is monitored with pulse oximetry. Ventilation: the process of eliminating CO2 from the body, is monitored with capnography.

8. Oxygen Oxygen -> lungs -> alveoli -> blood muscles + organs Oxygen cells Oxygen Oxygen +Glucose energy CO 2 blood lungs CO 2 breath CO 2 Physiology of CO 2OxygenationVentilation

9. Physiology of Carbon Dioxide Capnography can provide information about the profusion status. Example: Low cardiac output caused by cardiogenic shock or hypovolemia wont carry as much CO2 per minute back to the lungs. ETCO2 will be reduced. Reduced perfusion to lungs causes this phenomenon.

10. The Normal Capnogram A picture is worth a thousand words!

11. Capnographic Waveform Zero baseline (A-B) Rapid, sharp rise (B-C) Alveolar plateau (C-D) End tidal value (D) Rapid, sharp downstroke (D-E)

12. Phases of Exhalation Beginning exhalation = no CO 2 in breath Middle exhalation = Rapid rise in CO 2 End exhalation –CO 2 levels continue to gradually rise (alveolar plateau) –Peak just before inspiration (EtCO 2 )

14. Clinical Applications: Airway Verification of endotracheal tube placement –AHA Guidelines 2000 confirm ETT placement with non-physical examination techniques including capnography Controlled ventilation for sensitive to fluctuation- Neonates and Mild Hyperventilation for Head injuries 30 mm. Continuous monitoring of endotracheal tube position during transport (tube vigilance) CPR –Effectiveness of cardiac compression/pacing –Earliest sign of ROSC –Predictor of survival- ETCO2 of 10 mm or less at 20 minutes had little chance of survival.

15. Clinical Applications: Airway I KNOW THE TUBE WAS IN BUT…. –Moved to gurney –Moved to/from ambulance –Moved to ER –CPR –Seizures –Agitation REQUIRED FOR ALL INTUBATED/COMBI TUBE PATIENTS!!

16. Displaced Intubation The ETCO2 will respond much faster to the displacement. ETCO2 is a monitor of ventilation, SPO2 is oxygenation. 35 mmHg

17. Non-Intubated Applications Bronchospastic Disease Hypoventilation States Shock States The list goes on…

18. Phases of Acute Asthma Exacerbation PhaseClinical Assessment ETCO2 Levels MildHyperventilating<35 ModerateTiring40-50 SevereTired>50

19. Acute Respiratory Diseases Bronchospastic disease (Asthma, COPD) –Diagnose presence of bronchospasm –Assess response to treatment

21. Clinical Applications: Breathing Drug overdose ETOH overdose DKA Post ictal CVA Head trauma Neuromuscular Hypoventilation Syndromes

22. Shock States Precipitous drop or downward trending in the EtCO 2 Cardiogenic shock Septic shock Hemorrhagic shock (trauma) Hypovolemic shock –Heat stroke

23. Pulmonary Embolism Pulmonary Hypo-perfusion 40 mmHg Low EtCO2 with small waveform Low SpO2

24. What should you do with bagging?

26. What’s wrong with this waveform?

27. What does this indicate on intubated patient?

28. What’s happening with this non-intubated patient?

29. Is your bagging OK?

30. The Gear

35. Summary: Capnography: The Ventilation Vital Sign What can capnography monitoring do for you? –Confirm tube placement during intubation –Provide tube vigilance during intubation and transport with alarms –Identify ROSC during CPR,effective compressions, outcomes –NON-INTUBATED Monitor breathing status of obtunded/sedated patients Track progression of acute respiratory failure

36. Summary