17 capnography part4 non-intubated
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17 capnography part4 non-intubated
- 1. CAPNOGRAPHY In Emergency Care EDUCATIONAL SERIES Part 4: Non-intubated
- 2. Part 4: The Non-intubated Patient CAPNOGRAPHY In Emergency Care
- 4. The Non-intubated Patient CC: “ trouble breathing”
- 5. The Non-intubated Patient CC: “trouble breathing” Asthma? Emphysema? Pneumonia? Bronchitis? CHF? PE? Cardiac ischemia?
- 17. Capnography in Bronchospastic Conditions Classification of Asthma Source: Edmond S. D. 1998. 1997 National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: 579-594 Adopted from the NIH Guidelines for the Diagnosis and Management of Asthma <91% 91-95% >95% SaCO 2 Sitting upright Prefers sitting Can lie down Position > 42mmHg <42mmHg <42mmHg PaCO 2 Brady >120 100-120 <100 Pulse Absent Loud: I/E Loud; Exp Mod; EE Wheeze Paradox Usually Commonly No Accessory >30/min Increased Increased Resp Rate Drowsy Agitated Agitated Agitated? Alertness Words Phrases Sentences Talks in Resting Talking Walking Breathless Arrest Imminent Severe Moderate Mild Symptoms
- 21. Capnography in Bronchospastic Conditions Capnogram of Asthma Source: Krauss B., et al . 2003. FEV1 in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA Changes in dCO 2 /dt seen with increasing bronchospasm Bronchospasm Normal
- 24. Capnography in Bronchospastic Conditions Asthma Case Scenario Initial After therapy
- 34. Capnography in Bronchospastic Conditions COPD Case Scenario Initial Capnogram A Initial Capnogram B 4 5 0
- 41. Capnography in Hypoventilation States Hypoventilation Time condensed; actual rate is slower
- 45. Capnography in Low Perfusion Case Scenario Low EtCO 2 seen in low cardiac output Ventilation controlled
- 48. Capnography in Pulmonary Embolus Case Scenario Strong radial pulse Low EtCO 2 seen in decreased alveolar perfusion
- 50. Part 4: The Non-intubated Patient Ready to take capnography for a run?
Notas del editor
- Part 4: Capnography on the non-intubated patient builds on the information presented in parts one, two and three. It may be presented as part of the series or in as a separate independent class. This PowerPoint program is designed for initial training on capnography in EMS. It is strictly an introduction and all information be adapted to your local protocols. The program is not product specific and qualifies for continuing education credits through individual CE providers and/or the Center for Healthcare Education. Information on the Center for Healthcare Education and the CE process is contained on this CD. You may also contact the Center at 1-800-888-8700 or their website http://www.healthcareeducation.org All contents are under the copyright of Medtronic Physio-Control Corp.
- Capnography has been available and used for the intubated patient for several years. Now, new technology with nasal/oral cannulas provide easy ventilation monitoring of your non-intubated patients.
- The learning objectives for part four are for you to be able to: List three non-intubated applications Identify four characteristic patterns seen in: - Bronchospasm such as Asthma COPD - Hypoventilation states - Hyperventilation - Low-perfusion states
- Neighbors called 911 when they found an elderly woman sitting in her front yard dressed in pajamas. They reported her to be “a bit confused” and complaining of “some chest or breathing problems”.
- Familiar? What comes to mind?
- Capnography can be useful in this fairly typical EMS situation in: - Identifying the problem and underlying pathology - Assessing the patient’s status and - Helping you to anticipate sudden changes
- Applications for capnography in your non-intubated patients include: Identification and monitoring of bronchospasm as in: - Asthma - COPD Assessing and monitoring: - Hypoventilation states - Hyperventilation - Low-perfusion states
- Capnography reflects changes in: Ventilation - the movement of gases in and out of the lungs Diffusion - the exchange of gases between the air-filled alveoli and the pulmonary circulation Perfusion - circulation of blood through the arterial and venous systems
- Patients can have several alterations in their ventilatory status. One that is of frequent concern in EMS is: Airway obstruction such as in: Smooth muscle contraction Bronchospasm Airway narrowing Uneven emptying of the alveoli Mucous plugs Capnography is useful in monitoring your patient’s airway.
- Since capnography monitors the amount of carbon dioxide in the airway it is affected by changes in the diffusion of gases across into the alveoli. Decreased diffusion occurs with pulmonary changes found in bronchospastic diseases that produce: Airway inflammation Retained secretions Fibrosis Decreased compliance of alveoli walls Chronic airway modeling which is seen in COPD Reversible airway disease that occurs with asthma
- Bronchospasm interferes with the normally smooth flow of air as the degree and timing of spasm varies throughout the pulmonary tree. The alveoli are unevenly ventilated on inspiration and empty asynchronously during expiration. This uneven emptying dilutes the carbon dioxide which results in a slower rise in CO 2 concentration during exhalation.
- These spasmodic alterations in air flow affect phase II (ascending phase) and phase III (the plateau) of the capnography waveform and produce a characteristic pattern often referred to as the “shark fin”.
- Asthma is a bronchospastic disease often seen in EMS. Asthma is increasing in the US. • 20.3 million citizens report having the disease and • Prevalence increased 75% from 1980-1994 • There are over two million ED visits each year for asthma • It is the most common chronic health problem in children Unfortunately, there is an increase in deaths due to asthma. • From 1987 to 1995, the death rate doubled to 5600 per year Sources: Delbridge T., et al . 2003 Prehospital Asthma Management. Prehospital Emergency Care 7 (1) 42-47 Asthmatic Statistics. American Academy of Allergies, Asthma and Immunology. http.//www.aaaai.org
- An asthma attack may occur suddenly such as in reaction to an allergen or it may be progressive over days to weeks which may occur with an infection. The underlying pathology is in the airway with: • Increased responsiveness (or hyper-reactivity) of the airway • Bronchospasm resulting in reversible obstruction • and an inflammation process
- The asthmatic patient’s response to either intrinsic or extrinsic triggers is: The release of inflammatory mediators - histamine, bradykinin and prostaglandins produces reactions in the bronchial wall that include: • Spasm of bronchial smooth muscle • Vasodilatation with swelling of bronchial mucous membranes and • Increased mucous production
- In addition to the bronchi, this chemical release triggers responses in other systems. Symptoms produced by these reactions include: • Tachycardia • Tachypnea • Wheezing • Cough • Chest tightness • Use of accessory muscles (retractions) • Anxiety • Diaphoresis
- The National Institute of Health has issued “Guidelines for the Diagnosis and Management of Asthma”. This slide is a summary of the classification of asthma. As shown here, if your initial exam finds your asthmatic patient to be not agitated, not wheezing and not bradycardic, do not be lulled into thinking that everything is going okay. Respiratory arrest may be imminent. Source: Edmond S. D. 1998. 1997 National Asthma Education and Prevention Program Guidelines: A Practical Summary for Emergency Physicians. Annals of Emergency Medicine 31: 5: 579-594
- As we can see from the previous slide, your patient’s symptoms and your observations are primarily subjective. The severity of symptoms and your patient’s perception may not accurately reflect severity of condition. More objective data is needed to assess the situation. Source: Teeter J.G., et al. 1998. “Relationship Between Airway Obstruction and Respiratory Symptoms in Adult Asthmatics. CHEST .113:5:272-277
- Capnography may be able to provide that objective data. This study by Yaron compared the capnograms of 28 normal volunteers and those of 20 asthma patients. The study objectives were to determine whether the slope of the expiratory capnogram (dCO 2 /dt) can detect bronchospasm in adult asthma patients in the ED and to assess the correlation between the plateau and the peak expiratory flow rate (PEFR). Their conclusion: • The slope value correlated with PEFR • The “dCo 2 /dt is an effort independent, rapid noninvasive measure that indicates significant bronchospasm” Source: Yaron M. 1996. Utility of the Expiratory Capnogram in the Assessment of Bronchospasm. Annals of Emergency Medicine 28: 4
- The change in phase two is thought to be due to the uneven empting of the alveolar gas. Bronchospasm of varying degrees traps the carbon dioxide in alveoli throughout the lungs. This results in an uneven flow of the gas. Waveform examples show increasing change in the plateau with increasing obstruction. Source: Hall J.B., Acute Asthma, Assessment and Management, McGraw-Hill, New York.
- These capnograms show the changes in the dCO 2 /dt seen with increasing bronchospasm. Source: Krauss B., et al . 2003. FEV1 in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA
- More research is needed on assessing and treating nonintubated patients. Research is now underway on the correlation of capnographic changes to patient’s respiratory status. Future studies will also look at the impact this technology will have patient care, outcomes and healthcare costs.
- Here’s another case scenario using the findings in the some of the research: 16 year old female - a cheerleader who has become dyspneic while cheering in the year’s first football game. C/O “having difficulty breathing” • Visible distress • History of asthma, physical exertion, and “a cold this week” • Patient has used her “puffer” 8 times over the last two hours • Pulse 136, BP 148/80, RR 34 • Wheezing noted on expiration
- Her initial capnogram is shown here with the “shark fin” on phase two. Note the change in the slope following therapy. Training Note: Ask about local protocol and what actions may be taken if the waveform changes as shown and what actions may be considered if the waveform does not change. Discuss what changes in patient symptoms and physical signs would be expected to be seen with these changes .
- Another respiratory condition that you may frequently encounter is chronic obstructive lung disease. COPD is increasing in the United States. In fact it is now the: • Fourth leading cause of death in adults • In 1996, there were 16 million cases of COPD in this country. We are seeing an increase in deaths due to COPD • There were an estimated 110,000 deaths in 1999 and the • number of deaths has doubled in the past 25 years Source: Boyle, A.H. 2000. Recommendations of the National Lung Health Education Program, Heart & Lung 29: 6: 446-449
- Although COPD is actually a group of diseases, the pathology includes several commonalities. The term COPD is used to describe a chronic, progressive disease process that usually has a history of one or more: • Major risk factors: smoking, exposure to dusts and fumes, history of frequent respiratory infections This spectrum of diseases includes: • Chronic bronchitis • Emphysema • Bronchiectisis
- The COPD disease process is progressive and may be partially reversible. Airways are obstructed by: • Hyperplasia of mucous glands and smooth muscle • Excess mucous production, especially during an exacerbation • There is often some hyper-responsiveness here
- The small airways are the: • Main sites of airway obstruction in COPD • There is usually chronic inflammation with • Fibrosis and narrowing and • Damage to alveoli • There is hyper-expansion of the alveoli due to air trapping which causes • Impaired gas exchange
- Patients with COPD live with daily respiratory limitations and symptoms and call EMS when there is an increase in their chronic symptoms which include: • Increased SOB - often they wait until this is severe • Frequent cough • More wheezing - which may be audible without your stethoscope • Greater use of accessory muscles • Sputum of increased volume, tenacity and purulence • Higher anxiety and restlessness - they may be sleep deprived at this point • Diaphoresis • and chest tightness.
- Patients with an acute escalation of their COPD may also have: • Fever from an underlying infection They frequently have other chronic conditions including: • Congestive heart failure • Acute coronary syndrome • Diabetes mellitus • Hypertension Many of these co-morbities have similar risk factors and presenting symptoms.
- The symptoms and observations of COPD are primarily subjective. Your patient’s “baseline” may not be “normal”. Patients living with this chronic condition may have difficulty differentiating the specific change in their symptoms and the degree of change. Severity of symptoms and your patient’s perception may not accurately reflect severity of condition. Objective data is often needed in order to differentiate the most problematic diagnosis and assess each patient.
- Correlating capnograms to patient status would provide objective data. Arterial CO 2 in COPD patients is known to: • Increase as the disease progresses • Blood gases require frequent arterial punctures for ABGs and the procedure is not available in EMS Correlating capnograph to the COPD patient status can be helpful. As with PaCO 2 : • Ascending phase and plateau is altered by uneven emptying of gases
- Here’s a scenario of a dyspneic patient on capnography. • 72 year old male • C/O difficulty breathing • History of CAD, CHF, smoking and COPD • Productive cough, recent respiratory infection • Pulse 90, BP 158/82 RR 27
- If his initial capnogram is similar to A. What would direction would your assessment take? If his initial capnogram is similar to B. How would your assessment change?
- In a study presented at the 2003 International Conference of the American Thoracic Society, the difference in the capnogram of patients with obstructive diseases such as COPD was compared with those of patients with restrictive diseases such as CHF. They studied 207 patients in a pulmonary function lab. • 61 with obstructive disease (OD); 34 with restrictive disease (RD) Change in the exhalation plateau: • C/O severe difficulty breathing • 80% of OD had elevations >4°; 5% of RD had elevations >4° P<0.0001 Source: Krauss B., et al. 2003. FEV1in Restrictive Lung Disease Does Not Predict the Shape of the Capnogram. Oral presentation. Annual Meeting, American Thoracic Society, May, Seattle, WA. Teaching Note : Obstructive diseases are conditions that increase resistance to airflow (a) inside the airway (obstruction by a foreign body, excessive secretions), (b) by altering the airway wall (bronchitis, bronchospasm) or (c) through narrowing the airway (emphysema). Restrictive diseases impair lung expansion secondary to alterations in the lung, pleura, chest wall or neuromuscular impairment. RD conditions include pulmonary pneumothorax, pleural effusion, and pulmonary edema.
- Here is a scenario based on a CHF report: • 78 year old male • C/O: Short of breath • H/O: COPD, MI X 2, on oxygen at 2 L/m • Pulse 66, BP 114/76/p, RR 36 labored and shallow, skin cool and diaphoretic, 2+ pedal edema • Initial SpO 2 69%; EtCO 2 17mmHG
- In the initial assessment, the medics noted that his capnogram had a normal pattern and no evidence of acute bronchospasm. Based on this, they followed their medical protocol for CHF rather than COPD. He was placed on a non-rebreather mask with 100% oxygen at 15 L/m and given an IV diuretic and SL nitroglycerin. Ten minutes after treatment his SpO 2 went from 69% to 99%. The patient’s his EtCO 2 increased from 17mmHG to 35mmHG as his circulatory and respiratory status improved.
- In hypoventilation, patients retain carbon dioxide with EtCO 2 >50mmHg. This can occur in an altered mental status and abnormal breathing such as in: • Sedation • Alcohol intoxication • Drug Ingestion • Postictal states • CNS infections • Head injury
- Observer called 911. 76 year old male sleeping and unresponsive on sidewalk, “gash on his head”. Known history of hypertension, EtOH intoxication, Pulse 100, BP 188/82, RR 10, Pulse oximetry is 96% on room air.
- This is his capnogram. Note the shape and height of the waveform.
- Hypoventilation may also be exhibited differently if the patient’s breathing becomes more shallow. Shallow breathing often involves such low exhaled volumes that the gas deep inside the lung, “alveolar gas”, may not flow all the way to the mouth to be sampled. Instead, some of the gas in the trachea, called dead space gas, that does not contain CO2 may mix with the alveolar gas and dilute it. In this scenario, even though blood and alveolar CO2 are elevated, end tidal CO2 will appear to decrease. When the patient takes a deep breath, the carbon dioxide in the airway system is exhaled and the EtCO 2 level is elevated.
- Capnography can also show alteration in perfusion both in the pulmonary tree and total body system. As we discussed in Part 3, it provides a noninvasive measure of cardiac output.
- Let’s look at a case scenario of a patient with low perfusion. • 57 year old male • Auto crash with injury to chest • History of atrial fib, anticoagulant • Unresponsive • Pulse 100 irregular, BP 88/p • Intubated on scene
- With his airway and ventilation controlled, capnography his perfusion status. The shape of the waveform is the normal rectangular box and the low EtCO 2 is an indication of his low cardiac output. Capnography provides another parameter to monitor the state of this critical patient.
- New applications for capnography are being reported as research and the use of the technology expands. These new applications include: • Pulmonary emboli • CHF • DKA • Bioterrorism • Others?
- Here is a scenario for a patient with a possible pulmonary embolus. • 72 year old female • CC: Sharp chest pain, short of breath • History: Legs swollen and pain in right calf following flight from Alaska • Pulse 98 and regular, RR 22, BP 158/88, SpO 2 95%
- In this case, the patient has a strong pulse and adequate blood pressure. Capnography indicates a low perfusion state. If the systemic circulation is adequate, the more likely reason for this reading is the diminished pulmonary perfusion. As always, this is to be added to the other information on the patient.
- In summary, capnography is now available in an easy-to-use cannula that provides for many applications in your non-intubated patients including: • Identification and monitoring bronchospasm as seen in asthma and COPD • Assessing and monitoring: - hypoventilation states - hyperventilation - low perfusion states - others that we have discussed.