CAPNOGRAPHY IN ICU WHO NEEDS IT?!

Nazir J. Habib, MD

ICU Vallejo

CASE ER: ARREST

55 yr male, obese, BMI 48 with sedentary occupation c/o sudden onset of SOB and dizziness. Progresses rapidly to arrest, EMS intubate in field PMH:lipids, OSA. MED: statin In ER: HR is 125 sinus, intubated , sats 92% , BP 95/53.RR 24/min. Sedation versed 2 mg IV CBC and Chem is normal, Bicarb 18 and AGap 18 ABG: pH 7.15, pCO2 56, pO2 80 on 100% O2, TV 700 ml, RR 24/min.PEEP 5 cm. No ETCO2 placed Waveform : No autoPEEPWhat is your management?

ETCO2 COMMON APPROACH

WHAT IS CAPNOGRAPHY?
CO2 from cell metabolism

CO2 exhaled Measure

OXYGEN Inhaled

GAS EXCHANGE :OXYGEN AND CO2!!

RESPIRATION = OXYGENATION AND VENTILATION

Oxygenation

Two separate physiologic processes

The process of getting O2 into the body

The process of eliminating CO2 from the body

Ventilation

FACTORS AFFECTING ETCO2

Production (metabolism)

Perfusion (blood flow)

Elimination (ventilation)

NORMAL ARTERIAL & ETCO2 VALUES

CAPNOGRAPHY VS. CAPNOMETRY

Capnography:

Capnometry:

Measurement and display of both ETCO2 value and capnogram (CO2 waveform) Time based display Volume based

Measurement and display of ETCO2 value (no waveform) Measured by a capnometer

CAPNOGRAPHY BASICS
Normal value is 3-7 mm Hg BELOW arterial pCO2
SO Check ABG

Always evaluate ETCO2 value

Check pCO2 ETCO2 gap
LOOK at the shape waveform

Follow Trends:
RR, BP, O2 sats, ABGs

VALUE OF THE CO2 WAVEFORM

The Capnogram: Provides ETCO 2 value

Assessment of adequate ventilation

Assessment of ETT placement/ circuit integrity Assessment of cardiac function and adequacy of pulmonary perfusion

ELEMENTS OF CAPNOGRAPH WAVEFORM

End of exhalation Alveolar Gas

Alveolar gas mixes with dead space

Inspiration

THE NORMAL CO2 WAVEFORM

AB BC CD DE

Baseline should be zero Expiratory Upstroke is rapid Expiratory Plateau Inspiration begins

D is the ETCO 2 value!

MEASURE DEADSPACE

ETCO2 VALUE REPRESENTS CO2 FROM ALL ALVEOALI. PERFECT V/Q LEAD TO HIGHER ETCO2 VALUE! EVALUATE BOTH V AND Q

GAP PCO2 ETCO2 ..EXPLAIN.

38-42
Normal 3-7 32-37

pCO2

ETCO2

Bigger the gap bigger the deadspace CAUTION..!!!!!!

80

20

CAUSES OF INCREASE GAP-LOW ETCO2

LOWER PULMONARY PERFUSION
IS PATIENT DRY (LOW WEDGE)? SHOCK/BLEEDING? Pulmonary Embolism? Low Cardiac output (MI or CM)

VENTILATOR PROBLEMS
AUTOPEEP PRESENT RAPID RESP HIGH TV EXCESS PEEP

WHAT CLINICAL SITUATIONS IS ETCO2 USEFUL??

INDICATIONS :END-TIDAL CO2 MONITORING

Validation of proper endotracheal tube placement and maintain position Evaluation of ventilation-perfusion mismatch :hemodynamic Adequacy of pulmonary perfusion/Cardiac function and volume status Evaluate ventilator settings (TV, RR and PEEP) Detection of obstruction airways : Bronchospasm Detection of airway leaks or loss airway (transport patient) CPR (adequacy of compression and detect ROSC/prognosis)

[Respir Care 2003;48(5):534 539]

SHOULD ETCO2 BE USED FOR ALL VENTILATOR PATIENTS..?

No RCT trials or data comparing outcomes
2003 Guidelines AARC: [Respir Care 2003;48(5):534 539] recommendations JCAHO sentinel events:2002 recommends ETCO2 2011 ACLS GUIDELINE recommendations Training on application and understanding of capnography is lacking Most ICU physicians do not use as standard of care on ventilator patients NO consensus /guidelines Impact on patient safety and monitoring in ICU ?

ACLS : CAPNOGRAPHY IN CPR

Non-survivors Average ETCO2: 4-10 mmHg after 20 minutes CPR Survivors (to discharge) Average ETCO2: >30 mmHg ETCO2 rises to >15 mm. with ROSC in most studies

Persistent low ETCO2 with 20 minutes CPR indicates poor survival and lack of cardiac response
R.Levine NEJM 1997:36:310 :150 patients with CPR out of hospital

CAPNOGRAPHY IN CPR
An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patients. Levine R, End-tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 311997 :301-306

ESOPHAGEAL TUBE

A normal capnogram is the best evidence that the ETT is correctly positioned
With an esophageal tube little or no CO2 is present
Occasionally false + or negative. Cuff leak look at ETCO2 FIRST!................Getting CXR may be risky

INADEQUATE SEAL AROUND ETT

Loss of TVPossible causes:

Leaky or deflated endotracheal or tracheostomy cuff

ETT position high

ETT position on CXR (moving patient may be risky!)

DECREASE OR LOSS OF WAVEFORM

Airway Obstruction Dislodged airway or too high Airway/circuit disconnection

Inadequate cardiac output/shock/arrhythmias

Cardiac Arrest !

HYPOVENTILATION(INCREASE IN ETCO2)

Possible causes:
Decrease in respiratory rate or Decrease in tidal volume

Signifies fatigue during weaning.

?P. exam/WOB and RR Fever/metabolism/shivering/agitation/seizures

HYPERVENTILATION (DECREASE IN ETCO2)

Possible causes:
Excess ventilation or ?air trapping (?TV?RR ? PEEP) OR.Decreased pulmonary perfusion..why SHOCK? Hypovolumia? Low cardiac output? Pulmonary embolism?

OBSTRUCTION

Possible causes:
Partially kinked or occluded artificial airway

Obstruction in expiratory limb of the breathing circuit

Bronchospasm ( Sharkfin wave:look at alpha angle is bigger and upstroke slow)

AIRWAY OBSTRUCTION :ELEVATION

ANGLE

ETCO2 BELOW NORMAL

Indicates CO2 elimination decreased
Excess ventilation (low pCO2 and ETCO2)
Decreased pulmonary perfusion eg P.E. Shock/hypovolumia (increased GAP)

Cardiac arrest or low CO

Interventions To Consider: Decrease minute ventilation: check auto PEEP SEDATE patient Evaluate cardiac function: P.E, MI,shock? RX:Give fluids, evaluate for shock ?

VENTILATOR CASES

CASE ER: ARREST

55 yr male, obese, BMI 48 with sedentary occupation c/o sudden onset of SOB and dizziness. Progresses rapidly to arrest, EMS intubate in field PMH of OSA. MED: statin In ER: HR is 125 sinus, intubated , sats 92% ,bp` 80/52.RR 24/min. Sedation versed 2 mg IV CBC and Chem is normal, Bicarb 18 and Agap 18, no lactate ABG: pH 7.15, pCO2 56, pO2 80 on 100% O2, TV 700 ml, RR 24/min.PEEP 5 cm. ETCO2 18, GAP 38
Waveform : No autoPEEP EKG shown.Troponin

0.8, BNP 120

EKG: REF AM J MED 2009 APRIL

CASE : ETCO2 MONITOR

QUESTION

Best Management is:

A. Obtain STAT CT scan for PE B. Increase PEEP 14 cm, lasix 40 mg C. Consult cardiology for STAT angiogram and angioplasty vs. TNK

D. Start EGDT for sepsis

E. Increase resp. rate to 35/min

ECHOCARDIOGRAM

ETCO2 AND P.EMBOLISM.

Patient was treated with TPA 100 mg IV over 2 hours. Saline 1 liter/Levophed drip started for hypotension. ETCO2 improved with 2 hours of TPA Fluids administration: may worsen LV filling BP and O2 improved Over next 24 hrs patient off pressors and weaned and extubated.

Start warfarin

CASE : SEPSIS AND ARDS

66 yr male, BMI 35, with history of COPD/smoking: Perforated colon with peritonitis/sepsis Ventilator management with ARDSnet protocol TV 6 cc/kg, RR 20/min PEEP 10 cm, FiO2 .70

ABG : 7.35, Co2 42,pO2 120

Sedation: versed 1 mg/hr Morphine 4 mg ATC 3h

CXR IN ICU

CASE PRESENTATION CONT.

2 am O2 sats start to decrease.

Peak 48/Plat 28 cm
BP 80 systolic HR 98 ,RR 30/min. CVP 15 cm.
Placed on 100% O2 STAT CXR SAME

ABG :pH 7. 28, CO2 55, pO2 70 on 100% o2 ET Co2 is 24, dropped from 34 over 2 hours. BP still low

QUESTION

What is the optimum patient management at this point?

A. Decrease resp rate to 18/min with sedation and paralysis

B. Obtain STAT spiral CT scan for PE

C. Increase resp. rate to 30/min D. Increase PEEP to 14 cm

E. Lasix 40 mg

TIP - ETCO2 low with high pCO2. ?? Auto PEEP.

QUESTION
Most likely etiology of deterioration in condition is:
A. Pulmonary embolism B. Tension pneumothorax C. Tachypnea and bronchospasm causing airtrapping and deadspace

D.Loss of endotracheal tube

E. Septic shock and ARDS/edema

Answer: C.Explain

ETCO2 WAVEFORM ANALYSIS

ETCO wave shows delayed exhalation CO2

Sharkfin appearance capnograph ETCO2 value is VERY LOW (24) Calculate pCO2-ETCO2 GAP is 26! : pCO2 is 50 Consider air-trapping if high LOOK at the ventilator waveform ?Auto PEEP CXR shows no change

Decreased expiratory times can lead to Auto-PEEP

120

V
LPM

SEC

Complete exhalation
120

Incomplete exhalation causing air-trapping

AUTO=PEEP IN COPD

PHYSIOLOGICAL FACTORS AFFECTING ETCO 2 LEVELS

SUMMARY
Capnography should be standard of care for confirmation and continuous monitoring of airway status eg. OR , EMS, Transport, and in ICU. Useful in assessing adequacy and outcome in CPR ICU : Monitoring ALL ventilator patients:
V/Q mismatch or dead space Early detection of airway problems Bronchospasm Ventilator settings/weaning:reduce ABGs DIAGNOSE: V/Q abnormalities: eg. PE, shock, low

cardiac output, cardiomyopathy, arrest

REFERENCES
Capnography Clinical Aspects:Gravenstein MD Capnography In ICU: Cheifetz. Respiratory Care MAY 2007: 423439: controversies