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Capnography: Taking the Guesswork Out of Ventilation & Perfusion! Shawn Brast, MSN, RN, CCRN, NREMT-P Johns H opkins LIFELINE

Capnography • PetCO2 35-45 mmHg – Hypocapnia vs. Hypercapnia • PaCO2 > PetCO2 2-5 mmHg – Large PaCO2 : EtCO2 gradient has diagnostic value • Relationship on trends remain consistent • Correlate to blood gas & follow the trend

Capnogram

Phase I Phase II

Phase III Phase IV

Alpha Beta

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Shawn’s Step Approach to Capnogram Interpretation 1. Is there CO2? – If no . . . . 2. Does the waveform return to baseline? – Rebreathing? – Height? – Width? – Frequency?

3. What is the shape of the waveform? – Steep rise (Phase 2) – Plateau (Phase 3) – Alpha & Beta Angles

– Sloping, notching or prolong – Steep return to baseline (Phase 4) 4. What is the value and RR?

Capnogram Pattern Recognition

Capnogram Pattern Recognition

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Capnogram Pattern Recognition

Capnogram Pattern Recognition

Capnogram Pattern Recognition

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Capnogram Pattern Recognition

FLAT PETCO2 TRACE ■ Ventilator disconnection ■ Airway misplaced – extubation, esophageal intubation ■ Capnograph not connected to circuit ■ Respiratory/Cardiac arrest ■ Apnea test in brain death dead patient ■ Capnongraphy obstruction

INCREASED PETCO2 ■ CO2 Production

■ Alveolar ventilation

– – – – –

– – – –

Fever Sodium Bicarbonate Tourniquet Release Venous CO2 Embolism Overfeeding

■ Pulmonary perfusion

Hypoventilation Bronchial Intubation Partial Airway Obstruction Rebreathing

■ Apparatus malfunctioning

– Exhausted CO2 Absorber – Increased Cardiac Output – Inadequate Fresh Gas Flows – Increased Blood Pressure – Leaks In Ventilator Tubing – Ventilator Malfunctioning

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DECREASED PETCO2 ■ CO2 production

■ Alveolar ventilation

– Hypothermia

– – – –

■ Pulmonary perfusion – – – – –

Reduced Cardiac Output Hypotension Hypovolemia Pulmonary Embolism Cardiac Arrest

Hyperventilation Apnea Total Airway Obstruction Extubation

■ Apparatus malfunctioning – Circuit Disconnection – Leaks In Sampling Tube – Ventilator Malfunctioning

Sudden Waveform Change SUDDEN DROP IN PETCO2 TO ZERO

SUDDEN CHANGE IN BASELINE (NOT TO ZERO)

■ Kinked ET Tube

■ Calibration Error

■ CO2 Analyzer Defective ■ Total Disconnection

■ CO2 Absorber Saturated (Check Capnograph With Room Air)

■ Ventilator Defective

■ Water Drops In Analyzer Or Condensation In Airway Adapter

Sudden Waveform Change SUDDEN INCREASE IN PETCO2 ■ ROSC During Cardiac Arrest ■ Correction Of ET Tube Obstruction

ELEVATED INSPIRATORY BASELINE ■ CO2 Rebreathing (E.G. Soda Lime Exhaustion) ■ Contamination Of CO2 Monitor (Sudden Elevation Of Base Line And Top Line) ■ Inspiratory Valve Malfunction (Elevation Of The Base Line, Prolongation Of Down Stroke, Prolongation Of Phase III)

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Reference List A d a ms, L., Bu ta s, S., & Sp u rl o ck , D. (2015). Cap n ogra p h y (E TCO₂), Re sp i ra tory De p re ssi o n , a n d Nu rsi n g In te rve n tio n s i n Mo d e ra te ly Se d a te d A d u l ts Un d ergo i n g Tra n se so p h a ge a l Ech o ca rd i o gra p hy (TE E ). Jo u rn al o f P e ri An e sth e si a Nu rsi n g , 30(1). 14-2 2. Ba e rl o ch e r, M.O., Ni k o l i c, B., Si l be rzwe i g, J.E ., Ki n ne y, T.B., Kuo , M.D. & Rose , S.C. (2013). So ci e ty o f In te rve nti o n al Ra di o lo gy P o si ti on Sta te me n t o n Re ce n t Ch a n ge to th e A SA s’ Mo d e ra te Se d a tio n Sta n da rd s: Ca pn o gra p h y. Jou rn a l o f Va scu l a r a n d In terve n ti o na l Ra d i o l o g y, 24, 939-940. Be i tz, A ., Ri p h a u s, A ., Me i n i ng, A ., Kron sh a ge , T., Ge i st, C., Wa ge n p fe li , S., . . . Del i u s, S. (2012). Ca pn o gra p h ci Mo n i to ri n g Re du ce s the In ci d e n ce o f A rte ri a l Oxyge n De sa tu ra tio n an d Hyp o xe mi a Du ri n g P ro po fo l Se da ti o n fo r Co l o no sco p y: A Ran d o mi ze d , Co n trol l ed Stu dy (Co l o Ca p Stu d y). Th e A me ri ca n Jo urn a l o f Ga stro e nte ro lo g y, 107(8). 1205-12. Ca ch o , G., P é re z-Ca l l e , J., Barb a d o, A ., Ll e d ó, J., Oje a , R., & Fe rn á nd e z-Ro drí gu e z, C. (2010). Ca p n ogra p h y i s su p e ri or to pu l se oxi me try fo r th e d e te cti o n o f resp i ra to ry d ep re ssi o n du ri n g co l o no sco p y. Re vi sta E sp a ñ ol a De E n ferme d a d e s Di ge sti va s. 102(2). 86-9. Co n wa y, A ., P a ge , K., Ro l e y, J., & Wo rra l l -Ca rte r, L. (2011). Nu rse -ad mi n i ste re d P ro ce d u ral Sed a tio n an d An a l ge si a in th e Ca rdi a c Ca th e te r La b o ra to ry: A n Inte gra ti ve Re vi e w. In te rna ti on a l Jo u rn a l o f Nursi n g Stud i e s, 48(8), 1012-1023. Co ttre l l , J. & Y o u n g, W. 2010. Co ttre l a nd Y ou n g' s Ne u roa n e sth e si a: E xp e rtCo n su l t: On l in e an d Pri n t, 5e. D”Urb a n o , J. 2010. Ca p n o gra p hy: Th e Oth e rV i ta l Si gn . 3r d E d ti i o n. h ttp://www.b re a th so u n d s.o rg. E n gl i sh , J., P o i n te r, J., & Ja co b s, M. (2008) Ca pn o gra p h y: Th e Sta n da rd of Ca re [P o werP o i nt sl i d e s]. Retri e ve d fro m A l a me d a Co un ty P u b l i c He a l th De p a rtme n t (ALCO E MS) we b si te : www.acp h d .o rg/me d i a /86883/ca p n o gra p h y_ ho tto pi cs_ 3_ 08_ qu i z.p pt. F ri e d ri ch -Ru st, M., We l te , M., We l te , C., A l be rt, J., Me ck b a ch , Y ., He rrma n n , E ., . . . Bo j un ga , J. (2014). Ca pn o gra p hi c Mo n i to ri ng o f P ro p o fo l -b a se d Se da ti on d u rin g Co l on o sco p y. E n do sco p y, 46(3). 236-244. Jo p l i n g, M., Ko fo l , T., & He a rd , L. (2015). Eva l u a tin g th e Cost-E ffe cti ve n e ss o f Cap n o gra p hy Mo n i to ri n g i n P ro ce d ura l Se d a tio n : A Ga stro e n te ro l o gy (GI) Su i te Co st-A vo i da n ce Mo d el . Ga stro i nte sti n a l E n do sco p y, 81(5S), AB193. Kra u ss, B., Si l ve stri , S., & F a l k , J. 2013. Ca rb on Di oxi d e Mo n ito ri ng (Ca p n o gra p hy). Up To Date .

Ko d a l i , B. 2013. Cap n o gra p hy Ou tsi d e the Op era ti n g Ro oms. A n e sth e si o l ogy. 118(1):192-201, Ja n ua ry 2013. La n gh a n , M., Ch e n , L., Ma rsh a l l , C., & Sa n tu cci , K. (2011). Dete cti o n of Hyp o ve n til a ti on by Ca p n ogra p h y a n d Its A sso ci a ti o n with Hypoxi a i n Ch i l d re n Un d ergo i n g Se d ati o n wi th Keta mi n e . Pe d ia tri c E me rg e n cy Ca re , 27(5). 394-7. La n gh a n , M., Sh a b a n o va , V ., Li , F ., Be rn ste i n, S., & Sh a pi ro , E . (2015). A Ra n do mi ze d Con tro l le d Tri a l o f Ca p n ogra p h y d u ri ng Se d a tion in a P e d i a tri c E me rge n cy Se tti n g. Th e A me ri ca n Jo u rn a l o f E me rg en cy Me d i ci n e , 33(1). 25-3 0. Lo o n , K., Le yssi u s, A ., Z a a n e , B., De n te ne e r, M., & Ka l kma n , C. (2 014). Ca p n ogra p h y d u ri ng De e p Se d a tio n wi th P rop o fol b y No n a n e sth e si o l o gi sts. A n e sth e si a & A n a l ge si a ,119(1). 49-55. Ma n i fo l d , C & e t a l . 2013. Cap n ogra p h y fo r th e No n n i tu b ate d P a ti en t i n th e E me rge n cy Se tti n g . Th e Jo urn a l of E me rge n cy Me d i ci n e . McA rth u r CD. A A RC cl i n i ca l p ra cti ce gu i d e l i ne . Ca p n ogra p h y/ca p n o me try d u ri n g me ch a n i ca l ve nti l a tio n --2 003 revi si o n & u p da te . Re sp i r Ca re 2003 Ma y;48(5):534-9. Ni ck so n , C. (2016). Ca p n o gra p h y Wa ve fo rm In terp re ta tio n . Li fe In Th e F a st La n e . h ttp ://l i fe i n th efa stl a n e.co m/ccc/ca p n o gra p h ywa ve fo rm-i n te rp re ta ti o n . Sa l e n , Ca n Ca rd ia c So n ogra p h y a n d Ca p no gra p h y Be Use d In de p en d e ntl y a n d i n Co mb i n ati o n to P red i ct Re su sci ta ti o n Ou tco me s? , A ca d e mi c E me rge n cy Me d i ci n e , Ju n e 2001 Sl a ge l se , C., V i l ma n n , P ., Ho rn sl e t, P ., Ho rste d , T., Jørge n se n , H., &Ha mme ri n g, A . (2011). Ca n Ca p no gra p h y Re du ce Hyp o xi c E ve n ts i n E n d o sco p y P a ti e n ts Un d e rgo i n g Nu rse A d mi n i ste re d P ro po fo l Se da ti o n (NA P S): A Ra n d omi ze d Stu dy. Ga stro i n te sti n al E nd o sco p y, 73(4S), A B318. Sp i e ge l , J. (2013). E n d -Ti d a l Carb o n Di o xi d e: Th e Mo st V i tal of V i tal Sign s. A n e sth e si o l og y Ne ws, 21-27. Re tri eve d fro m h ttp ://www.a n e sth e si o l o gyn e ws.co m/ d o wn l o a d /Ca p n o gra p h y_ A NSE 13_WM.p d f V a rgo JJ, Z u cca ro G Jr, Du mo t JA , Co n we l l DL, Mo rro w JB, Sha y SS. A u toma te d gra p h i c a sse ssme n t o f re sp i ra to ry acti vi ty i s su p e ri o r to p u l se o xi me try a n d vi su a l a sse ssme n t fo r th e d e te cti o n o f e arl y re sp i ra tory d e p ressi o n d u ri ng th e ra p eu ti c u pp e r en d o sco p y. Ga stro i ntest E n d o sc 2002; 55: 826-31. Wa u gh , J., E p p s, C., & Kh o d n e va , Y . (2011). Cap n ogra p h y E n h an ce s Su rve i l l an ce o f Re sp i ra tory E ve n ts Du ri n g P ro ce d ura l Sed a tio n : A Me ta -A n a l ysi s. Jo u rn a l o f Cl i n ci a l A n esth e si a , 23(3 ). 189-1 96. We i l MH, Bi se ra J, Tre vi n o RP , Ra ck o w E C. Card i ac o u tp u ta n d e n d -ti d a l ca rb o n d i oxi d e . Cri t Care Me d 1985;13:907-9. We a ve r, J. (2011). Th e La te st A SA Ma n d a te : CO₂ Mo n i to ri ng fo r Mo d e ra te a nd De ep Sed a ti on . An e sth e si a P ro g ress, 58(3)111-2.

For Additional Questions: Shawn Brast [email protected] 443-287-7231

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