ETCO2 capnography by dr deepak kumar nirwal

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capnography by dr deepak nirwal kalyani hospital kiratpur bijnor up

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PowerPoint Presentation:

The Standard of Care Capnography Presented by :- Dr Deepak Nirwal Guided By :- Dr R . Subhedar sir SBH GMC ,Dhule

Objectives:

Objectives Understand why we use capnography Understand the physiology of respiration/ ventilation Define normal & abnormal EtCO 2 values/ waveforms Understand the 4 major applications of EtCO 2 intubated applications (mainstream) non-intubated applications (sidestream) The Standard of Care Capnography

Why Capnography?:

Why Capnography? Advanced Airway Management :- Esophageal Detection Device (EDD) End tidal CO2 detector (ETCO2) colorimetric or capnography “Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO2 monitoring. Failure to use continuous EtCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate . The Standard of Care Capnography

Why Capnography?:

Why Capnography? Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!! no waveform = no tube!!! The Standard of Care Capnography

Why Capnography?:

Why Capnography? It’s a window into the patient’s ventilatory status 50 mmHg 50 mmHg The Standard of Care Capnography

Why Capnography?:

Why Capnography? Core Concepts What intubation verification method is most reliable? How do oxygenation and ventilation differ? The Standard of Care Capnography

Physiology:

O2 oxygenation alveoli perfusion metabolism + oxygen glucose energy back to lungs capillary vein CO2 Physiology Ventilation The Standard of Care Capnography Transport Cell Metabolism

PowerPoint Presentation:

The Standard of Care Capnography Factors influencing the reading ; Atmospheric pressure : Changes in atmospheric pressure are usually of the order of 20 mm Hg . This results in a change in PaCO2 of less than 0.5 - 0.8 mm Hg PEEP . Water vapour : Can condense on the sensor cell and produce falsely high readings. This may be prevented by Heating sensor above body temperature sampling tube can be made of a semipermeable polymer that allows water vapour to pass outside. Absorbent filters.

PowerPoint Presentation:

The Standard of Care Capnography TYPES - I Side stream capnography A pump aspirates gas samples from the patient’s airway through a 6 foot long capillary tube into the main unit at a rate of 50-200 ml/min Disadvantages Children Multiple sites for leaks and breakage Delay Scavenging needed Advantages Spontaneous breathing subjects Patients on O2 nasal cannula Easy to sterilise Use in unusual positions.

PowerPoint Presentation:

The Standard of Care Capnography TYPES –II Main stream capnography Disadvantages : Heavy Hot Window to be kept clean Advantages : Faster No gas is removed No uncertainity by rate of gas sampling

PowerPoint Presentation:

The Standard of Care Capnography Type of capnogram Time capnogram Volume capnogram Fast 7mm/sec Slow 0.7 mm/sec Phase I No CO2 Anatomical and apparatus dead space gas Phase II Rising CO2 Mixing of dead space gas and alveolar gas. Phase III Static or rising CO2 Alveolar gas Phase IV Falling CO2 Beginning of inspiration

Inspiratory Phase 0: Inspiration Beta Angle - Angle between phase III and descending limb of inspiratory  segment. Phase I   - Anatomical dead space Phase II  - Mixture of anatomical and alveolar dead space Phase III - Alveolar plateau Alfa angle - Angle between phase II and phase III (V/Q status of lung). :

Inspiratory Phase 0 :  Inspiration Beta Angle  - Angle between phase III and descending limb of inspiratory  segment. Phase I     - Anatomical dead space Phase II    - Mixture of anatomical and alveolar dead space Phase III   - Alveolar plateau Alfa angle  - Angle between phase II and phase III (V/Q status of lung). The Standard of Care Capnography α angle - 100-110 º ; Airway Obstruction causes larger angle. β angle - 90 º ; Rebreathing increases the angle.

PowerPoint Presentation:

The Standard of Care Capnography Volume capnogram Advantages Volume of CO2 per exhaled breath can be measured Significant changes in the morphology of the expired wave form can be detected Dead space can be partitioned Disadvantages Intubation mandatory Elaborate equipment Only monitors expiration

Questions?:

Questions? The Standard of Care Capnography

Questions?:

Questions? The Standard of Care Capnography

Questions?:

Questions? The Standard of Care Capnography

Methods of measurement Infrared spectrography Raman spectrography Mass spectrography Photoacoustic spectrography Chemical colorimetric analysis :

Methods of measurement Infrared spectrography Raman spectrography Mass spectrography Photoacoustic spectrography Chemical colorimetric analysis The Standard of Care Capnography

PowerPoint Presentation:

Factors that affect CO2 levels: INCREASE IN ETCO 2 DECREASE IN ETCO 2 Increased muscular activity Decreased muscular activity Increased cardiac output (during resuscitation) Decreased cardiac output (during resuscitation) Effective drug therapy for bronchospasm Bronchospasm Hypoventilation Hyperventilation The Standard of Care Capnography

Normal EtCO2:

Normal EtCO 2 O2 CO2 Normal The Standard of Care Capnography

Terminology:

Terminology Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value CO2 38 mmHg The Standard of Care Capnography

Terminology:

Terminology EtCO 2 – End Tidal CO 2 The measurement of exhaled CO 2 in the breath Normal Range | 35-45 mmHg CO2 The Standard of Care Capnography

Normal Waveform:

Normal Waveform A B C D E A 38 mmHg CO 2 TIME End of inspiration Beginning of exhalation End of exhalation Beginning of new breath Alveolar plateau The Standard of Care Capnography Clearing of anatomic dead space

Questions?:

Questions? The Standard of Care Capnography

Common Waveforms:

Normal Common Waveforms mmHg 39 16 RR The Standard of Care Capnography

Common Waveforms:

Hyperventilation Hypoventilation Common Waveforms mmHg 48 8 RR mmHg 24 35 RR The Standard of Care Capnography

4 Main Uses of Capnography:

4 Main Uses of Capnography The Standard of Care Capnography Severity of asthma patients Monitoring head injured patients Cardiac arrest Tube confirmation

Terminology:

Terminology The Standard of Care Capnography Sidestream An indirect method of measuring exhaled CO 2 in non-intubated patients Mainstream Direct method of measuring exhaled CO 2 with intubated patients

Asthmatic Waveforms:

Shark Fin Asthmatic Waveforms mmHg 45 18 RR COPD patients have a difficult time exhaling gases This is represented on the capnogram by a shark fin appearance The Standard of Care Capnography

EtCO2 & Asthma:

Moderate Attack Mild Attack EtCO 2 & Asthma mmHg 28 38 RR mmHg 36 20 RR The Standard of Care Capnography

EtCO2 & Asthma:

Severe Attack EtCO 2 & Asthma mmHg 49 9 RR Time To Get MOVING!!! The asthmatic who looks tired and has a shark fin appearance on the capnogram… IS HEADED FOR RESPIRATORY ARREST The Standard of Care Capnography

The Head Injured Patient:

The Head Injured Patient The Standard of Care Capnography Carbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault and therefore increasing ICP Recognizing the head injured patient and titrating their CO 2 levels to the 30-35 mmHg range can help relieve the untoward effects of ICP

The Head Injured Patient:

Titrate EtCO 2 The Head Injured Patient mmHg 30 16 RR The Standard of Care Capnography Titration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO 2 levels. Keep them between 30 and 35 mmHg

EtCO2 and Cardiac Arrest:

EtCO 2 and Cardiac Arrest The Standard of Care Capnography The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output Increase in CO 2 during CPR can be an early indicator of ROSC

ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses. End-tidal CO2 will often overshoot baseline values when circulation is restored due to carbon dioxide washout from the tissues. In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a person with ROSC, immediately check pulses. You may have to restart CPR. :

The Standard of Care Capnography ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses. End-tidal CO2 will often overshoot baseline values when circulation is restored due to carbon dioxide washout from the tissues. In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a person with ROSC, immediately check pulses. You may have to restart CPR. EXTRA TIPS FOR CPCR

Termination of Resuscitation:

Termination of Resuscitation The Standard of Care Capnography EtCO 2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR Non-survivors < 10 mmHg Survivors > 30 mmHg ( to discharge)

ET Tube Verification:

ET Tube Verification Verification of proper tube placement There is simply NO BETTER WAY to confirm proper tube placement than with waveform capnography…. PERIOD!!! no waveform = no tube!!! The Standard of Care Capnography

4 Main Uses of Capnography:

4 Main Uses of Capnography Core Concepts What is the characteristic shape of a capnogram for a COPD patient? Describe how to determine the severity of an asthma attack using capnography? What level should you maintain a severe head injured patient’s CO 2 at? What are two ways that capnography can assist during CPR? The Standard of Care Capnography

Troubleshooting:

Inadequate Seal Troubleshooting mmHg 39 16 RR The Standard of Care Capnography As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff

Troubleshooting:

Obstruction Troubleshooting mmHg 39 16 RR The Standard of Care Capnography An obstructed ET tube may have an erratic EtCO 2 value with a very irregular waveform

Troubleshooting:

Rebreathing Troubleshooting mmHg 42 16 RR The Standard of Care Capnography A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO 2 through insufficient inspiratory or expiratory flow

QUIZ:

QUIZ The Standard of Care Capnography

Hypoventilation:

Hypoventilation The Standard of Care Capnography mmHg 48 8 RR

Rebreathing:

Rebreathing The Standard of Care Capnography mmHg 42 16 RR

Esophageal Tube:

Esophageal Tube The Standard of Care Capnography

Asthma:

Asthma The Standard of Care Capnography mmHg 36 20 RR

Normal:

Normal The Standard of Care Capnography mmHg 39 16 RR

Questions?:

Questions? The Standard of Care Capnography

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