capnography and pulse oximetry the standard of respiratory care

capnography and pulse oximetry the standard of respiratory care

1. CAPNOGRAPHY- and PULSE OXIMETRY : The Standard of RESPIRATORY Care Dr.Gehan A Tarrabih , MD , Ass. Prof .Anesthesia and SICU , Mansoura Faculty Of Medicine.

2. CAPNOGRAPHY-OXIMETRY Why use them?

3. Capnography & Pulse Oximetry CO 2 : Relects ventilation Detects apnea and hypoventilation immediately Should be used with pulse oximetry O 2 Saturation: Reflects oxygenation 30 to 60 second lag in detecting apnea or hypoventilation Should be used with capnography

4. Indications for Use - End-Tidal CO 2 Monitoring Validation of proper endotracheal tube placement Detection and Monitoring of Respiratory depression Hypoventilation Obstructive sleep apnea Procedural sedation Adjustment of parameter settings in mechanically ventilated patients

5. ETCO 2 & Cardiac Resuscitation Non-survivors Average ETCO 2 : 4-10 mmHg Survivors (to discharge) Average ETCO 2 : >30 mmHg

6. ETCO 2 & Cardiac Resuscitation If patient is intubated and pulmonary ventilation is consistent with bagging, ETCO 2 will directly reflect cardiac output Flat waveform can establish PEA Increasing ETCO 2 can alert to return of spontaneous circulation Configuration of waveform will change with obstruction

7. Capnography What are we measuring?

8. Respiration–The BIG Picture

9. Capnography Depicts Respiration

10. Physiological Factors Affecting ETCO 2 Levels

11. Normal Arterial & ETCO 2 Values

12. Deadspace

13. CAPNOGRAPHY Theory of Operation

14. Infrared Absorption A beam of infrared light energy is passed through a gas sample containing CO 2 CO 2 molecules absorb specific wavelengths of infrared light energy. Light emerging from sample is analyzed. A ration of the CO 2 affected wavelengths to the non-affected wavelengths is re[ported as ETCO 2

15. Capnography vs. Capnometry Capnography: Measurement and display of both ETCO 2 value and capnogram (CO 2 waveform) Measured by a capnograph Capnometry: Measurment and display of ETCO 2 value (no waveform) Measured by a capnometer

16. Mainstream vs. Sidestream

17. Quantitative vs. Qualitative ETCO 2 Quantitative ETCO 2 : Provides an actual numeric value Found in capnographs and capnometers Qualitative ETCO 2 : Only provides a range of values Termed “CO 2 Detectors”

18. Colorimetric CO 2 Detectors A “detector” – not a monitor Uses chemically treated paper that changes color when exposed to CO 2 Must match color to a range of values Requires six breaths before determination can be made

19. CAPNOGRAPHY The Capnogram

20. Elements of a Waveform Dead Space Beginning of exhalation Alveolar gas mixes with dead space Alveolar Gas End of exhalation Inspiration

21. Value of the CO 2 Waveform The Capnogram: Provides validation of the ETCO 2 value Visual assessment of patient airway integrity Verification of proper ETT placement Assessment of ventilator/breathing circuit integrity

22. The Normal CO 2 Waveform A – B Baseline B – C Expiratory Upstroke C – D Expiratory Plateau D ETCO 2 value D – E Inspiration begins

23. Esophageal Tube A normal capnogram is the best evidence that the ETT is correctly positioned With an esophageal tube little or no CO 2 is present

24. Inadequate Seal Around ETT Possible causes: Leaky or deflated endotracheal or tracheostomy cuff Artificial airway too small for the patient

25. Hypoventilation (increase in ETCO 2 ) Possible causes: Decrease in respiratory rate Decrease in tidal volume Increase in metabolic rate Rapid rise in body temperature (hypothermia)

26. Hyperventilation (decrease in ETCO 2 ) Possible causes: Increase in respiratory rate Increase in tidal volume Decrease in metabolic rate Fall in body temperature (hyperthermia)

27. Rebreathing Possible causes: Faulty expiratory valve Inadequate inspiratory flow Insufficient expiratory flow Malfunction of CO 2 absorber system

28. Obstruction Possible causes: Partially kinked or occluded artificial airway Presence of foreign body in the airway Obstruction in expiratory limb of the breathing circuit Bronchospasm

29. Muscle Relaxants “Curare Cleft”: Appears when muscle relaxants begin to subside Depth of cleft is inversely proportional to degree of drug activity

30. Faulty Ventilator Circuit Valve Baseline elevated Abnormal descending limb of capnogram Allows patient to rebreath exhaled gas

31. Sudden Loss of Waveform Apnea Airway Obstruction Dislodged airway (esophageal) Airway disconnection Ventilator malfunction Cardiac Arrest

32. QUIZ TIME

33. #1 Normal capnogram controlled ventilations spontaneous respirations

34. #2 Muscle relaxants General anesthesia The cleft on the alveolar plateau is due to spontaneous respiratory effort

35. #3 Normal capnogram Spontaneous ventilation in children Sampling from nasal cannula or O 2 mask in adults

36. #4 Esophageal intubation following a mask ventilation

37. #5 Bronchospasm

38. #6 Hyperventilation

39. #7 Esophageal intubation

40. #8 Contamination of CO 2 sensor

41. #9 Rebreathing

42. #10 Flat line

43. Waveform: Regular Shape, Plateau Below Normal Indicates CO 2 deficiency Hyperventilation Decreased pulmonary perfusion Hypothermia Decreased metabolism Interventions Adjust ventilation rate Evaluate for adequate sedation Evaluate anxiety Conserve body heat

44. Waveform: Regular Shape, Plateau Above Normal Indicates increase in ETCO 2 Hypoventilation Respiratory depressant drugs Increased metabolism Fever, pain, shivering Interventions Adjust ventilation rate Decrease respiratory depressant drug dosages Assess pain management Conserve body heat

45. Questions

46. References Capnography, Bhavani Shankar Kodali, MD Capnography in ‘Out of Hospital’ Settings, Venkatesh Srinivasa, MD, Bhavani Shankar Kodali, MD Capnography, Novametrix Systems, Inc. Clinical Physiology of Capnography, Oridion Emergency Medical Services Evolutions/Revolutions: Respiratory Monitoring, RN/MCPHU Home Study Program CE Center End-Tidal Carbon Dioxide, M-Series, Zoll Medical Corporation