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ETCO2 The Vital Sign of Breathing. Jeff Schultz NREMT-P, CCEMT-P Mayo Clinic Medical Transport. EtCO2. Objectives Explain why we measure EtCO2 Distinguish ventilation from respiration Define what is a normal EtCO2 value Define what are abnormal values Identify the different wave forms

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etco2 the vital sign of breathing
ETCO2The Vital Sign of Breathing

Jeff Schultz NREMT-P, CCEMT-P

Mayo Clinic Medical Transport

etco2
EtCO2
  • Objectives
    • Explain why we measure EtCO2
    • Distinguish ventilation from respiration
    • Define what is a normal EtCO2 value
    • Define what are abnormal values
    • Identify the different wave forms
    • Discuss how to use the sidestream EtCO2 on the Zoll monitor
etco24
EtCO2
  • Why do we measure EtCO2
    • Standard of care
    • Gives us a measurement of respiratory status
    • Use as a tool to provide good pt. care
who do we monitor
Who Do We Monitor?
  • Patients with Altered Consciousness
  • Respiratory distress patients
  • Overdoses – Drugs and/or ETOH
  • All intubated patients
  • Anyone given conscious sedation
    • Any pt. given pain medications
    • Any pt. given sedation
ventilation vs respiration
Ventilation vs Respiration
  • Ventilation is air going in and out
  • Respiration is the exchange of gases that occur as a result of ventilation, circulation, and metabolism
capnography
Capnography Depicts Respiration

Metabolism

Transport

CO2

CO2

O2

CO2

Capnography

Ventilation

etco28
EtCO2
  • What values are normal?
    • Normal EtCO2 is 30-43mmHg
    • CO2 can affect pH
etco29
EtCO2
  • Abnormal Values
    • EtCO2 of 43 or greater may indicate Respiratory Acidosis
    • EtCO2 of 30 or less may indicate Respiratory Alkalosis
etco210
EtCO2
  • Normal values
    • Normal Range 7.35 to 7.45
    • Normal EtCO2 is 30-43mmHg
    • Normal PaCO2 is 35-45mmHg
etco211
EtCO2
  • Abnormal Values
    • Acidosis
      • pH < 7.35
      • PaCO2 > 45
      • EtCO2 > 43
    • Alkalosis
      • pH > 7.45
      • PaCO2 < 35
      • EtCO2 < 30
where should we be
Where Should We Be?
  • Our goal is to keep EtCO2 in normal range
    • Keep EtCO2 30-43 mmHg
      • Recognize abnormalities in breathing patients
      • Correct abnormalities in ventilated patients
etco213
EtCO2
  • How do we stabilize abnormal EtCO2 values?
    • By adjusting rates
      • Giving more ventilations
      • Giving less ventilations
etco214
EtCO2
  • Stabilizing abnormal EtCO2 values
    • By Adjusting tidal volumes
      • Giving less tidal volume
      • Giving more tidal volume
etco215
EtCO2
  • Stabilizing Abnormal values
    • EtCO2 greater than 43mmHg
      • Increase tidal volume
      • Increase respiratory rate and/or
      • This will bring down EtCO2
etco216
EtCO2
  • Stabilizing abnormal values
    • EtCO2 less than 30mmHg
      • Decrease respiratory rate and/or
      • Decrease tidal volume
      • This will increase EtCO2
etco217
EtCO2
  • Identifying the wave forms
    • Normal wave forms vs. Abnormal wave forms
etco218
EtCO2
  • Identifying wave forms
    • Normal wave forms
normal capnogram phase i

50

25

0

Beginning of expiration =

anatomical deadspace with no measurable CO2

Normal Capnogram - Phase I

CO2 mmHg

B

A

anatomical dead space
Anatomical Dead Space

Anatomical Deadspace

Conducting Airway - No Gas Exchange

  • Anatomical Dead Space
    • Internal volume of the upper airways
      • Nose
      • Pharynx
      • Trachea
      • Bronchi

Jan Stepanek, M.D., M.P.H.

normal capnogram phase ii

50

25

0

Normal Capnogram - Phase II

CO2 mmHg

C

exhalation

B

Mixed CO2, rapid rise in CO2 concentration

normal capnogram phase iii

50

Alveolar Plateau, all exhaled gas took part in gas exchange

25

inspiration

End Tidal

CO2 value

0

Normal Capnogram - Phase III

CO2 mmHg

D

C

Time

capnogram valuable tool

Alveolar Plateau

established

No Alveolar Plateau

Capnogram – Valuable Tool

CO2 (mmHg)

50

25

0

etco224
EtCO2
  • Identifying wave forms
    • Abnormal wave forms
capnography25
Capnography

Endotracheal Tube in Esophagus

  • Possible Causes:
  • Missed intubation
    • When the ET tube is in the esophagus, little or no CO2 is present
    • A normal capnogram is the best indication of proper ET tube placement
capnography26
Capnography

Obstruction in Airway or Breathing Circuit

  • Possible Causes:
  • Partially kinked or narrowed artificial airway
  • Presence of foreign body in the airway
  • Obstruction in expiratory limb of breathing circuit
  • Bronchospasm
capnography27
Capnography

Muscle Relaxants (curare cleft)

  • Possible Causes:
  • Patient attempts to take a breath
  • Appears when muscle relaxants begin to subside
  • Depth of cleft is inversely proportional to degree of drug activity
capnography28
Capnography

Cardiac Oscillations

  • Characteristics:
  • Rhythmic and synchronized to heart rate
capnography29
Capnography

Inadequate Seal Around ET Tube

  • Possible Causes:
  • Leaky or uncuffed endotracheal or trach tube
  • Artificial airway that is too small for patient
capnography30
Capnography

Hypoventilation - Increase in ETCO2

  • Possible Causes:
  • Decrease in respiratory rate
  • Decrease in tidal volume
  • Increase in metabolic rate
  • Rapid rise in body temperature
capnography31
Capnography

Hyperventilation - Decrease in ETCO2

  • Possible Causes:
  • Increase in respiratory rate
  • Increase in tidal volume
  • Decrease in metabolic rate
  • Fall in body temperature
capnography32
Capnography

Rebreathing

  • Possible Causes:
  • Expiratory filter that is saturated or clogged, expiratory valve that is sticking
  • Inadequate inspiratory flow, or insufficient expiratory time
  • Anything that causes resistance to expired flow
etco233
EtCO2
  • Identifying wave forms
    • Normal vs. abnormal
      • Case studies
case study
Case Study

Normal capnogram, stable trend

ETCO2/PaCO2 gradient 4 mmHg

case study35
Case Study
  • Sudden decrease in ETCO2 from 38 mmHg to 20 mmHg and remains there RR increases to 24 bpm
case study36
Case Study
  • Pt. receives 5mg MS for pain and 12.5mg Promethazine for subsequent nausea.
  • EtCO2 climbs from 37 mmHg to 45 mmHg
etco237
EtCO2
  • Special Considerations
    • EtCO2 with RSI and Head Injuries
      • Standard of care is to keep EtCO2 levels at 32-36mmHg for RSI and head injured patients.
what can etco2 monitoring do for you
What can ETCO2 monitoring do for you?
  • Provide “Tube Vigilance” during intubation and transport
  • Identifies ROSC during CPR
  • Monitors the breathing status of the obtunded or sedated patient
  • Tracks progression of acute respiratory failure
  • For use in a wide range of environments
causes of an elevated etco2
Metabolism

Pain

Hyperthermia

Malignant hyperthermia

Shivering

Circulatory System

Increased cardiac output - with constant ventilation

Respiratory System

Respiratory insufficiency

Respiratory depression

Obstructive lung disease

Equipment

Defective exhalation valve

Causes of an Elevated ETCO2
causes of a decreased etco 2
Metabolism

Overdose / sedation

Hypothermia

Circulatory System

Cardiac arrest

Embolism

Sudden hypovolemia or hypotension

Respiratory System

Alveolar hyperventilation

Bronchospasm

Mucus plugging

Equipment

Leak in airway system

Partial airway obstruction

ETT in hypopharynx

Causes of a Decreased EtCO2
sidestream etco2 for zoll
Sidestream EtCO2 for Zoll
  • Equipment includes :
    • LoFlo® module
    • LoFlo® sampling cannula
    • Loflo® airway adapter kit
loflo module
LoFlo® module

Clear tube must remain unobstructed

sidestream etco2 setup
Sidestream EtCO2 Setup
  • Attach sampling cell to module
  • Ensure that exhaust tube vents gasses away from module
  • Turn Zoll monitor on
  • “Warm Up” will be displayed
    • Unit will give readings while

warming up but will not be accurate

until warm up is complete

zeroing the loflo module
Zeroing the LoFlo® Module
  • Zeroing should only need to be done once if same module is used with the same Zoll monitor.
  • Zeroing cannot be done when sampling kit is attached to the patient.
  • Do not attempt zeroing for 20 seconds after removing the adapter or cannula from the patient’s airway
select the appropriate sampling kit
Select the Appropriate Sampling Kit
  • There are two types of sampling kits
    • Nasal cannula sampling kit
    • Airway adapter sampling kit
applying the nasal cannula sampling kit
Applying the Nasal Cannula Sampling Kit
  • Apply sampling kit just like any other nasal cannula
  • Trim oral portion of the cannula to proper length
    • Tip should be just below the teeth at the mouth
    • Trim with trauma shears while not on the patient
applying airway adapter sampling kit
Applying Airway Adapter Sampling Kit
  • Attach airway adapter kit at, or as near as possible to the ET tube
  • Position sampling tube so that it exits the top of the airway adapter
    • This helps to prevent moisture from draining into the sampling tube
loflo airway adapter kit54
LoFlo® Airway adapter kit

Sampling tube should be upright

monitoring etco2
Monitoring EtCO2
  • Capnometer will read on main screen
  • To view capnography select Wave 2 on main screen
  • ECG and EtCO2 waveforms will be displayed
etco2 with cpap
EtCO2 with CPAP
  • Use the nasal cannula sampling kit
  • Zoll is defaulted to monitor in O2 enriched environment
  • If needed you can change the default by entering ETC02
summary
Summary
  • Measuring EtCO2 is a standard of care that gives us another tool to treat our patients
  • Understand the difference between ventilation and respiration
  • Recognize normal and abnormal levels and how they can affect the patient
summary58
Summary
  • Our goal is to achieve EtCO2 levels between 30-43mmHg
  • Recognize what a normal wave form is and what causes abnormal capnography waveforms
  • Properly set up and utilize the Sidestream EtCO2 system for the appropriate patient