17 capnography part4 non-intubated

1. CAPNOGRAPHY
In Emergency Care
EDUCATIONAL SERIESEDUCATIONAL SERIES
Part 4:Part 4:
Non-intubatedNon-intubated

2. Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient
CAPNOGRAPHYCAPNOGRAPHY
In Emergency CareIn Emergency Care

3. Part 4: The Non-intubated Patient Part 4: The Non-intubated Patient
Learning ObjectivesLearning Objectives
•List three non-intubated applicationsList three non-intubated applications
•Identify four characteristic patterns Identify four characteristic patterns
seen in seen in
–BronchospasmBronchospasm
•AsthmaAsthma
•COPDCOPD
–Hypoventilation statesHypoventilation states
–HyperventilationHyperventilation
–Low-perfusion statesLow-perfusion states

4. The Non-intubated PatientThe Non-intubated Patient
CC: CC:
““trouble breathing”trouble breathing”

5. The Non-intubated Patient The Non-intubated Patient
CC: “trouble breathing”CC: “trouble breathing”
Asthma?Asthma?
Emphysema?Emphysema?
Pneumonia?Pneumonia?
Bronchitis?Bronchitis?
CHF?CHF?
PE?PE?
Cardiac ischemia?Cardiac ischemia?

6. The Non-intubated Patient The Non-intubated Patient
CC: “trouble breathing”CC: “trouble breathing”
•Identifying the problem and Identifying the problem and
underlying pathogenesis underlying pathogenesis
•Assessing the patient’s statusAssessing the patient’s status
•Anticipating sudden changesAnticipating sudden changes

7. The Non-intubated Patient The Non-intubated Patient
Capnography ApplicationsCapnography Applications
•Identify and monitor bronchospasmIdentify and monitor bronchospasm
–AsthmaAsthma
–COPDCOPD
•Assess and monitor Assess and monitor
–Hypoventilation statesHypoventilation states
–HyperventilationHyperventilation
–Low-perfusion statesLow-perfusion states

8. The Non-intubated Patient The Non-intubated Patient
Capnography ApplicationsCapnography Applications
•Capnography reflects changes in Capnography reflects changes in
–VentilationVentilation - movement of gases in and out of - movement of gases in and out of
the lungsthe lungs
–Diffusion Diffusion - exchange of gases between the air-- exchange of gases between the air-
filled alveoli and the pulmonary circulationfilled alveoli and the pulmonary circulation
–PerfusionPerfusion - circulation of blood through the - circulation of blood through the
arterial and venous systemsarterial and venous systems

9. The Non-intubated Patient The Non-intubated Patient
Capnography ApplicationsCapnography Applications
•VentilationVentilation
•Airway obstructionAirway obstruction
–Smooth muscle contractionSmooth muscle contraction
–BronchospasmBronchospasm
–Airway narrowingAirway narrowing
–Uneven emptying of alveoliUneven emptying of alveoli
–Mucous plugsMucous plugs

10. The Non-intubated Patient The Non-intubated Patient
Capnography ApplicationsCapnography Applications
•Diffusion Diffusion
•Airway inflammationAirway inflammation
•Retained secretionsRetained secretions
•Fibrosis Fibrosis
•Decreased compliance of alveoli wallsDecreased compliance of alveoli walls
•Chronic airway modeling (COPD)Chronic airway modeling (COPD)
•Reversible airway disease (Asthma)Reversible airway disease (Asthma)

11. Capnography in Capnography in
Bronchospastic ConditionsBronchospastic Conditions
•Air trapped due to Air trapped due to
irregularities in airwaysirregularities in airways
•Uneven emptying of Uneven emptying of
alveolar gas alveolar gas
–Dilutes exhaled CODilutes exhaled CO
22
–Slower rise inSlower rise in
COCO
2 2
concentration during concentration during
exhalationexhalation
Alveoli

12. Capnography in Capnography in
Bronchospastic DiseasesBronchospastic Diseases
•Uneven emptying of Uneven emptying of
alveolar gas alters alveolar gas alters
emptying on exhalationemptying on exhalation
•Produces changes in Produces changes in
ascending phase (II) ascending phase (II)
with loss of the sharp with loss of the sharp
upslopeupslope
•Alters alveolar plateau Alters alveolar plateau
(III) producing a “shark fin”(III) producing a “shark fin”
AB
C D
E
II
III

13. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Prevalence of AsthmaPrevalence of Asthma
•Asthma is increasing in the USAsthma is increasing in the US
–20.3 million citizens report having asthma20.3 million citizens report having asthma
–Prevalence increased 75% from 1980-1994Prevalence increased 75% from 1980-1994
–Two million ED visits each yearTwo million ED visits each year
–Most common chronic health problem in childrenMost common chronic health problem in children
•Increasing deaths due to asthmaIncreasing deaths due to asthma
–1987 to 1995, death rate doubled to 56001987 to 1995, death rate doubled to 5600
Sources: Delbridge T., et al. 2003 Prehospital Asthma Management.
Prehospital Emergency Care 7(1) 42-47
Asthmatic Statistics. American Academy of Allergies,
Asthma and Immunology. http.//www.aaaai.org

14. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of AsthmaPathology of Asthma
•Acute onset or progressive over weeksAcute onset or progressive over weeks
•Airway Airway
–Increased responsiveness (hyper-reactivity)Increased responsiveness (hyper-reactivity)
–Bronchospasm Bronchospasm
•Reversible obstructionReversible obstruction
–InflammationInflammation

15. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of AsthmaPathology of Asthma
•Release of inflammatory mediatorsRelease of inflammatory mediators
–Histamine, bradykinin, prostaglandinsHistamine, bradykinin, prostaglandins
•Bronchial wall reactionBronchial wall reaction
–Spasm of bronchial smooth muscleSpasm of bronchial smooth muscle
–Vasodilatation with swelling of bronchial Vasodilatation with swelling of bronchial
mucous membranesmucous membranes
–Increased mucous productionIncreased mucous production

16. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of AsthmaSymptoms of Asthma
•TachycardiaTachycardia
•TachypneaTachypnea
•WheezingWheezing
•Cough Cough
•Chest tightnessChest tightness
•Use of accessory muscles (retractions)Use of accessory muscles (retractions)
•AnxietyAnxiety
•DiaphoresisDiaphoresis

17. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Classification of AsthmaClassification of Asthma
<91%91-95%>95%SaCO
2
Sitting uprightPrefers sittingCan lie downPosition
>42mmHg<42mmHg<42mmHgPaCO
2
Brady>120100-120<100Pulse
AbsentLoud: I/ELoud; ExpMod; EEWheeze
ParadoxUsuallyCommonlyNoAccessory
>30/minIncreasedIncreasedResp Rate
DrowsyAgitatedAgitatedAgitated?Alertness
WordsPhrasesSentencesTalks in
RestingTalkingWalkingBreathless
Arrest
Imminent
SevereModerateMildSymptoms
Source: Edmond S. D. 1998. 1997 National Asthma Education and Prevention Program Guidelines:
A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: 579-594
Adopted from the NIH Guidelines for the Diagnosis and Management of AsthmaAdopted from the NIH Guidelines for the Diagnosis and Management of Asthma

18. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Assessment of AsthmaAssessment of Asthma
•Symptoms and observations are Symptoms and observations are
primarily subjectiveprimarily subjective
•Severity of symptoms and your patient’s Severity of symptoms and your patient’s
perception may not accurately reflect perception may not accurately reflect
severity of conditionseverity of condition
More More objectiveobjective data needed data needed
Source: Teeter J.G., et al. 1998. “Relationship Between Airway Obstruction and Respiratory
Symptoms in Adult Asthmatics. CHEST.113:5:272-277

19. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
•28 normal volunteers; 20 asthma 28 normal volunteers; 20 asthma
patients in EDpatients in ED
•Correlation between PEFR and Correlation between PEFR and
slope of capnogram waveformslope of capnogram waveform
•ConclusionConclusion
–Slope value correlated with PEFRSlope value correlated with PEFR
–““dCOdCO
22/dt is an effort independent, rapid noninvasive /dt is an effort independent, rapid noninvasive
measure that indicates significant bronchospasm”measure that indicates significant bronchospasm”
Source: Yaron M. 1996. Utility of the Expiratory Capnogram in the Assessment of
Bronchospasm. Annals of Emergency Medicine 28: 4

20. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
•““expiratory airflow obstruction affects the expiratory airflow obstruction affects the
shape of the COshape of the CO
22 time curve due to uneven time curve due to uneven
emptying of alveolar gas.”emptying of alveolar gas.” P 312 P 312
•Waveform examples show increasing Waveform examples show increasing
change in normal expiratory plateau with change in normal expiratory plateau with
increasing obstruction (bronchospasm)increasing obstruction (bronchospasm)
Source: Hall J.B., Acute Asthma, Assessment and Management,
McGraw-Hill, New York.

21. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of AsthmaCapnogram of Asthma
Source: Krauss B., et al. 2003. FEV1 in Restrictive Lung Disease Does Not Predict
the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic
Society, May, Seattle, WA
Changes in dCOChanges in dCO
22/dt seen with increasing bronchospasm/dt seen with increasing bronchospasm
Bronchospasm
Normal

22. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnography in AsthmaCapnography in Asthma
•Research is underway on the correlation Research is underway on the correlation
of capnographic changes to patient’s of capnographic changes to patient’s
respiratory statusrespiratory status
•Anticipating clinical trials on the impact Anticipating clinical trials on the impact
on patient care, outcomes and on patient care, outcomes and
healthcare costs healthcare costs

23. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Asthma Case ScenarioAsthma Case Scenario
•16 year old female16 year old female
•C/O “having difficulty breathing”C/O “having difficulty breathing”
•Visible distressVisible distress
•History of asthma, physical exertion, “a cold”History of asthma, physical exertion, “a cold”
•Patient has used her “puffer” 8 times over the Patient has used her “puffer” 8 times over the
last two hourslast two hours
•Pulse 126, BP 148/86, RR 34Pulse 126, BP 148/86, RR 34
•Wheezing noted on expirationWheezing noted on expiration

24. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
AsthmaAsthma Case ScenarioCase Scenario
Initial Initial
After therapyAfter therapy

25. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Prevalence of COPDPrevalence of COPD
•COPD is increasing in the U.S.COPD is increasing in the U.S.
–Fourth leading cause of death in adultsFourth leading cause of death in adults
–16 million cases in 199616 million cases in 1996
•Increasing deaths due to COPDIncreasing deaths due to COPD
–1999 estimated 110,0001999 estimated 110,000
–Number of deaths doubled in the past 25 yearsNumber of deaths doubled in the past 25 years
Source: Boyle, A.H. 2000. Recommendations of the National Lung Health Education Program,
Heart & Lung 29: 6: 446-449

26. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
•Chronic, progressive disease processChronic, progressive disease process
–Major risk factors: smoking, exposure to Major risk factors: smoking, exposure to
dusts and fumes, history of frequent dusts and fumes, history of frequent
respiratory infectionsrespiratory infections
•Spectrum of diseasesSpectrum of diseases
–Chronic bronchitisChronic bronchitis
–EmphysemaEmphysema
–AsthmaAsthma
–BronchiectisisBronchiectisis

27. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
•Progressive Progressive
•Partially reversiblePartially reversible
•Airways obstructedAirways obstructed
–Hyperplasia of mucous glands Hyperplasia of mucous glands
and smooth muscleand smooth muscle
–Excess mucous productionExcess mucous production
–Some hyper-responsivenessSome hyper-responsiveness

28. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Pathology of COPDPathology of COPD
•Small airways Small airways
–Main sites of airway obstructionMain sites of airway obstruction
–InflammationInflammation
–Fibrosis and narrowingFibrosis and narrowing
–Chronic damage to alveoliChronic damage to alveoli
–Hyper-expansion due to Hyper-expansion due to
air trappingair trapping
–Impaired gas exchangeImpaired gas exchange
Alveoli

29. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation
•Increase in chronic symptomsIncrease in chronic symptoms
–SOB SOB
–CoughCough
–WheezingWheezing
–Use of accessory musclesUse of accessory muscles
–Sputum - increased volume, tenacity Sputum - increased volume, tenacity
and purulenceand purulence
–AnxietyAnxiety
–DiaphoresisDiaphoresis
–Chest tightnessChest tightness

30. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Symptoms of COPD ExacerbationSymptoms of COPD Exacerbation
•May also have May also have
–Fever - underlying infectionFever - underlying infection
–Co-morbidity Co-morbidity
•Congestive heart failureCongestive heart failure
•Acute coronary syndromeAcute coronary syndrome
•Diabetes mellitusDiabetes mellitus
•HypertensionHypertension

31. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Assessment of COPDAssessment of COPD
•Symptoms and observations are Symptoms and observations are
primarily subjectiveprimarily subjective
•Severity of symptoms and your patient’s Severity of symptoms and your patient’s
perception may not accurately reflect perception may not accurately reflect
severity of conditionseverity of condition
More objective data neededMore objective data needed

32. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnography in COPDCapnography in COPD
•Arterial COArterial CO
22 in COPD in COPD
–PaCOPaCO
22 increases as disease progresses increases as disease progresses
–Requires frequent arterial punctures for ABGsRequires frequent arterial punctures for ABGs
•Correlating capnograph to patient statusCorrelating capnograph to patient status
–Ascending phase and plateau are altered by Ascending phase and plateau are altered by
uneven emptying of gasesuneven emptying of gases

33. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
COPD Case ScenarioCOPD Case Scenario
•72 year old male72 year old male
•C/O difficulty breathingC/O difficulty breathing
•History of CAD, CHF, smoking History of CAD, CHF, smoking
and COPD and COPD
•Productive cough, recent Productive cough, recent
respiratory infectionrespiratory infection
•Pulse 90, BP 158/82 RR 27 Pulse 90, BP 158/82 RR 27

34. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
COPD Case ScenarioCOPD Case Scenario
45
0
45
0
Initial Capnogram AInitial Capnogram A
Initial Capnogram BInitial Capnogram B

35. Capnography in Bronchospastic ConditionsCapnography in Bronchospastic Conditions
Capnogram of CHFCapnogram of CHF
•207 patients in pulmonary function lab207 patients in pulmonary function lab
–61 with obstructive disease (OD); 34 with restrictive 61 with obstructive disease (OD); 34 with restrictive
disease (RD) disease (RD)
–Correlation of slope of exhalation plateau Correlation of slope of exhalation plateau
•C/O severe difficulty breathing (FEV1<50%)C/O severe difficulty breathing (FEV1<50%)
–97% of OD had elevations >4°; 5% of RD had elevations >4°97% of OD had elevations >4°; 5% of RD had elevations >4°
–P<0.0001P<0.0001
•ConclusionConclusion
–Changes in shape of capnogram in OD confirmedChanges in shape of capnogram in OD confirmed
–Changes in capnogram in RD did not occurChanges in capnogram in RD did not occur
Source: Krauss B., et al. 2003. FEV1in Restrictive Lung Disease Does Not Predict the Shape of the
Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA.

36. Capnography in CHFCapnography in CHF
Case ScenarioCase Scenario
•88 year old male 88 year old male
•C/O: Short of breathC/O: Short of breath
•H/O: MI X 2, on oxygen at 2 L/mH/O: MI X 2, on oxygen at 2 L/m
•Pulse 66, BP 114/76/p, RR 36 labored and Pulse 66, BP 114/76/p, RR 36 labored and
shallow, skin cool and diaphoretic, shallow, skin cool and diaphoretic,
2+ pedal edema2+ pedal edema
•Initial SpOInitial SpO
22 69%; EtCO 69%; EtCO
22 17mmHG 17mmHG

37. Capnography in CHFCapnography in CHF
Case ScenarioCase Scenario
•Placed on non-rebreather mask with 100% Placed on non-rebreather mask with 100%
oxygen at 15 L/m; IV diuretic and SL nitroglycerin oxygen at 15 L/m; IV diuretic and SL nitroglycerin
as per local protocolas per local protocol
•Ten minutes after treatment:Ten minutes after treatment:
SpOSpO
22 69% 99% 69% 99%
EtCOEtCO
22 17mmHG 35 mmHG 17mmHG 35 mmHG
45
35
0
25
Time condensed Time condensed
to show changesto show changes

38. Capnography in Capnography in
Hypoventilation StatesHypoventilation States
•Altered mental statusAltered mental status
–SedationSedation
–Alcohol intoxicationAlcohol intoxication
–Drug IngestionDrug Ingestion
–StrokeStroke
–CNS infectionsCNS infections
–Head injuryHead injury
•Abnormal breathing Abnormal breathing
•COCO
22 retention retention
–EtCOEtCO
22 >50mmHg >50mmHg

39. Capnography in Capnography in
Hypoventilation StatesHypoventilation States
•EtCOEtCO
22 is above 50mmHG is above 50mmHG
•Box-like waveform shape is unchangedBox-like waveform shape is unchanged
45
0
Time condensed; actual rate is slowerTime condensed; actual rate is slower

40. Capnography in Hypoventilation StatesCapnography in Hypoventilation States
Case ScenarioCase Scenario
•Observer called 911Observer called 911
•76 year old male sleeping and 76 year old male sleeping and
unresponsive on sidewalk, “gash unresponsive on sidewalk, “gash
on his head”on his head”
•Known history of hypertension, Known history of hypertension,
EtOH intoxication EtOH intoxication
•Pulse 100, BP 188/82, RR 10, SpOPulse 100, BP 188/82, RR 10, SpO
22 96% 96%
on room airon room air

41. Capnography in Hypoventilation StatesCapnography in Hypoventilation States
HypoventilationHypoventilation

45
35
0
25
55
65
Time condensed; actual rate is slowerTime condensed; actual rate is slower

42. Capnography in Hypoventilation StatesCapnography in Hypoventilation States
HypoventilationHypoventilation
45
0
Hypoventilation in shallow Hypoventilation in shallow
breathingbreathing

43. Capnography in Low PerfusionCapnography in Low Perfusion
•Capnography reflects changes in Capnography reflects changes in
•PerfusionPerfusion
–Pulmonary blood flow Pulmonary blood flow
–Systemic perfusionSystemic perfusion
–Cardiac outputCardiac output

44. Capnography in Low PerfusionCapnography in Low Perfusion
Case ScenarioCase Scenario
•57 year old male 57 year old male
•Motor vehicle crash with injury to chestMotor vehicle crash with injury to chest
•History of atrial fib, anticoagulantHistory of atrial fib, anticoagulant
•UnresponsiveUnresponsive
•Pulse 100 irregular, BP 88/pPulse 100 irregular, BP 88/p
•Intubated on sceneIntubated on scene

45. Capnography in Low PerfusionCapnography in Low Perfusion
Case ScenarioCase Scenario
45
35
0
25
Low EtCOLow EtCO
22 seen in seen in
low cardiac outputlow cardiac output
Ventilation controlledVentilation controlled

46. Capnography ApplicationsCapnography Applications
on Non-intubated Patientson Non-intubated Patients
•New applications now being reportedNew applications now being reported
–Pulmonary emboliPulmonary emboli
–CHFCHF
–DKADKA
–BioterrorismBioterrorism
–Others? Others?
rr Oxygen
O2
VeinAtey

47. Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus
Case ScenarioCase Scenario
•72 year old female 72 year old female
•CC: Sharp chest pain, short of breath CC: Sharp chest pain, short of breath
•History: Legs swollen and pain in right calf History: Legs swollen and pain in right calf
following flight from Alaska following flight from Alaska
•Pulse 108 and regular, RR 22, BP 158/88 Pulse 108 and regular, RR 22, BP 158/88
SpOSpO
22 95% 95%

48. Capnography in Pulmonary EmbolusCapnography in Pulmonary Embolus
Case ScenarioCase Scenario
45
35
0
25
Strong radial pulseStrong radial pulse
Low EtCOLow EtCO
22 seen in seen in
decreased alveolar perfusiondecreased alveolar perfusion

49. Part 4: Part 4:
The Non-intubated Patient SummaryThe Non-intubated Patient Summary
•Identify and monitor bronchospasmIdentify and monitor bronchospasm
–AsthmaAsthma
–COPDCOPD
•Assess and monitor Assess and monitor
–Hypoventilation statesHypoventilation states
–HyperventilationHyperventilation
–Low perfusionLow perfusion
–Many others now being reportedMany others now being reported

50. Part 4: The Non-intubated PatientPart 4: The Non-intubated Patient
Ready to take capnography for a run?Ready to take capnography for a run?