PART II CAPNOGRAPHY BY DR.RAKESH CHINTALAPUDI

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ITS A PART TWO PRESENSATION ON CAPNOGRAPHY

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Slide 1: 

DR.RAKESH CHINTALAPUDI cAPNOGRAPHY M.D., D.A., CONSULTANT ANAESTHESIOLOGIST e mail : rakesh1959@gmail.com Part ii

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Clinical applications of CAPNOMETRY

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operation theatre post operative moni. critical care setting pre hospital care cardio pulmonary

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Pet co2 as an estimate of paco2

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Unsteady hemodynamics Pet co2- pa co2 = not reliable

Asa Standards for Monitoring : 

Asa Standards for Monitoring Asa Standard i Asa Standard I i During all anesthetics, the patient’s oxygenation, ventilation, circulation and temperature shall be continually evaluated. Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care. Adequacy of Spontaneous ventilation

Integrity of anesthetic apparatus : 

Integrity of anesthetic apparatus

Accidental eosophageal : 

Accidental eosophageal

Cardiac output : 

Cardiac output Increases in cardiac output and pulmonary blood flow result in better perfusion of the alveoli and a rise in PETCO2. Under conditions of constant lung ventilation, PETCO2 monitoring can be used as a monitor of pulmonary blood flow

Hyper metabolic states : 

Hyper metabolic states

C p rescucitation : 

C p rescucitation PETCO2 <10 mmHg could be successfully resuscitated.1

(a-ET)PC02 and PEEP

(a-ET)PC02 and PEEP When oxygenation is at its best (optimum PEEP) the (a-ET)PCO2 is least. As the level of PEEP is increased beyond this the (a-ET)PC02 increases again and oxygenation worsens. Therefore it has been suggested that (a-ET)PC02 can be used as a sensitive indicator in order to titrate PEEP in patients with early ARDS or with alveolar edema.

laparoscopy : 

laparoscopy

Pulmonary thrombo embolism : 

Pulmonary thrombo embolism

Pulmonary air embolism : 

Pulmonary air embolism

Proper positioning of double lumen-tubes : 

Proper positioning of double lumen-tubes

lma : 

lma lma C e t t

High frequency jet ventilation HFJV : 

High frequency jet ventilation HFJV Assessment of the adequacy of HFJV is usually done by a series of arterial blood gas measurements. Monitoring PETCO2 can be used successfully to determine PaC02 levels during HFJV.

High frequency jet ventilation HFJV : 

High frequency jet ventilation HFJV This is done by delivering a single breath of large tidal volume and measuring PETCO2 during brief interruption of HFJV. If PaC02 can be measured simultaneously by arterial puncture Then (a-ET)PCO2 can be determined and subsequent monitoring of HFJV can be done by measuring PETCO2 in periodically given single large breaths.

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TERMINOLOGY Volume capnograph Trend capnograph Time capnogram

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infrared spectrography mass spectrography Raman spectrography photoacoustic analysers or colorimetric devices to measure carbon dioxide in the respiratory gases and then give a numerical reading (Capnometry) and a waveform (capnography)

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Trend capnography The overall CO2 changes (trend) can be followed at a slow ---- about 0.7 mm /sec

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Trend capnography

Successful weaning : 

Successful weaning

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Time capnography Time capnography can be used to monitor the dynamics of expiration as well as inspiration, whereas the SBT-CO2 curve monitors expiration exclusively. A high speed capnogram about 7mm/sec gives detailed information about each breath.

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Time capnography Carbon dioxide concentration can be plotted against time (time capnogram) Whereas, a time capnogram has both inspiratory (0) as well as expiratory segment. Phase – I, ii, iii, and o. expired volume (SBT-CO2 curve / Volume capnogram / CO2 expirogram / CO2 spirogram) during a respiratory cycle. A volume capnogram has only an expiratory segment. There is no inspiratory segment The expiratory segment of a volume capnogram is divided into three phases, phase I, II, and III. volume capnography

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volume capnography monitors expiration exclusively

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volume capnography

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volumetric capnography

What is volumetric capnography : 

What is volumetric capnography Integration of flow and carbon dioxide. Measures, calculates, and displays breath-by-breath measurements throughout the entire respiratory cycle. Digital numeric display Multiple graphics Single breath waveform (SBCO2) Multitude of information including VCO2

Volume-based Capnography : 

Integration of flow and CO2 Volume-based Capnography

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volume capnography II I III Pa CO2 Et CO2

Volumetric capnography : 

Volumetric capnography This integration allows for the display of breath by breath measurements throughout the entire respiratory cycle Data is both digitally and graphically displayed.

Graphical display : 

Graphical display Graphics provide rapid assessment of various parameters Help generate and test hypotheses of patient management Monitor for the presence of adverse effects of mechanical ventilation

Graphical displays : 

Graphical displays Trending bars Especially useful during the weaning phase of ventilation Useful for assessing effects of PEEP titration SBCO2 waveform Consists of 3 distinct phases Useful in determining pathophyiology Instrumental in designing optimal treatment strategies

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Overview with emphasis on SBCO2 waveform Clinical significance Tidal volume delivery Efficacy of delivered breaths Extubation success indication Length of ventilation

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Graphics provide rapid assessment of various parameters Monitor for the presence of adverse effects of mechanical ventilation.

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VCO2 is the volume of carbon dioxide eliminated via the lungs reflecting changes in ventilation and perfusion What is VCO2? VCO2 (ml/min) = volume CO2 per breath x RR

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Affected by ventilation, perfusion, & diffusion Reflects acute clinical changes −Respiratory −ventilator-lung interactions −Cardiovascular −pulmonary capillary blood flow −cardiac output VCO2

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VCO2 - A Few Basics

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CO2 Elimination (VCO2) Why Measure VCO2? Very Sensitive Indicator of PATIENT STATUS CHANGE Early Indicator Future Changes in PaCO2 Another Tool to Assist in Determining When to Draw a Blood GAS Reduces the # of ABGs VCO2 - A Few Basics

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Carbon dioxide-rich blood is then pumped through the pulmonary Capillary bed where the carbon dioxide diffuses across the alveolar capillary membrane and is exhaled via the nose or mouth

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The heart pumps freshly oxygenated blood throughout the body to cells where oxygen is consumed (metabolism). Carbon dioxide, produced as a byproduct, diffuses out of cells into the vascular system.

Single Breath CO2 Waveform : 

Single Breath CO2 Waveform EtCO2 P a CO2 S B CO2

MVALV Calculation from aSBCO2 Waveform : 

MVALV Calculation from aSBCO2 Waveform

Slide 47: 

Exhaled Volume Volume CO2 Expired CO2 PaCO2 EtCO2 A line is drawn parallel to the alveolar phase of the EtCO2 waveform. A 2nd line corresponding to PaCO2 is drawn.

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Exhaled Volume Expired CO2 PaCO2 EtCO2 q p A 3rd line is drawn perpendicular to the x axis so that area q = area p.

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A 3rd line is drawn perpendicular to the x axis so that area q = area p.

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Exhaled Volume Expired CO2 PaCO2 EtCO2 q p X = alveolar ventilation Y = alveolar dead space Z = airway dead space MValv = ‘X’ x RR X Z Y

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X = alveolar ventilation Y = alveolar dead space Z = airway dead space MValv = ‘X’ x RR

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X = alveolar ventilation Y = alveolar dead space Z = airway dead space Anatomical dead space alveolar dead space y z

Concept of dead space : 

Concept of dead space

Minute Ventilation : 

(VT - VD) X RR = VA VT X RR = V . . Minute Ventilation

Bohr’s equation : 

Bohr’s equation

Slide 56: 

Nonrespiratory airways ( anatomic dead space ) Alveoli that are not perfused ( alveolar dead space ) The sum of the two------ Physiological dead space. Normal Lung C o p d Pulmonary embolism

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% CO2 VD VALV %CO2 in Arterial Blood Z X Y Exhaled Tidal Volume

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X Y Z PaCO2 - PeCO2 PaCO2 Y + Z X + Y + Z = Phys VD / VT Alveolar Ventilation Min. Vol. CO2 ( VCO2 )

Slide 59: 

Volumetric capnography

Clinical significance : 

Clinical significance Phase 1 ↑ depicts an ↑ in airways dead space Phase 2 ↓ slope depicts reducing perfusion Phase 3 ↑ slope depicts mal-distribution of gas.

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Phase 1 – prolonged Phase 1 – relatively short Phase 1

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Phase 2 assessment If  in phase 2 Assure stable minute ventilation Assess PEEP level ↑ intrathoracic pressure may cause  venous return Assess hemodynamic status Is minute ventilation stable? Volume resuscitation or vasopressors may be indicated

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Baseline Perfusion Decreased Perfusion

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When minute ventilation is stable indicative of a  in perfusion.  Phase 2

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Phase 3 assessment

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Phase 3 assessment If ↑ or absent phase 3 mal-distribution of gas at alveolar level exists Assess for appropriate PEEP level Inadequate PEEP may be present Bronchospasm Bronchodilator tx my be indicated Structure damage at alveolar level may be present Pnuemothorax?

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RAPID SHALLOW BREATHINGINDEX RESPIRATORY RATE TIDAL VOLUME >100 BREATHS /MIN /L <100 BREATHS /MIN /L 50 / 0.5 = 100 30 / 0.5 = 60

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WEANING FAILURE RAPID RESPIRATORY RATE 45 TO 55 SHALLOW LOW TIDAL VOLUME RAPID SHALLOW BREATHINGINDEX

Slide 69: 

Thank you

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