Capnography and Ventilation for the EMS Professional
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1 Capnography and Ventilation for the EMS Professional Advanced concepts in the ventilation of the acutely ill patient
2 Raymond L. Fowler, M.D., FACEP Associate Professor of Emergency Medicine The University of Texas Southwestern Chief of Medical Operations The Dallas Metropolitan BioTel System Co-Chief Chief in the Section on EMS, Disaster Medicine, and Homeland Security UT Southwestern Medical Center
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4 The Objective Question: What is the relationship between exhaled carbon dioxide and cardiac output?
5 The Objective Question: Directly proportional or Inversely proportional??
6 What is Carbon Dioxide? Capnos comes from the Greek word for smoke smoke from the fire of metabolism a natural waste product of cellular activity CO 2 is a compound molecule 2 elements of oxygen and 1 element of carbon colorless and heavier than air green plants clean up after our exhaled CO 2
7 Carbon dioxide physiology CO 2 + H 2 O H 2 CO 3 H + + HCO 3 -
8 More specifically Oxygen -> lungs -> alveoli -> blood breath CO 2 lungs Oxygen muscles + organs Oxygen CO 2 blood CO 2 energy cells Oxygen + Glucose
9 Carbon dioxide physiology 0.03% concentration in air Resting adult produces 2.5 mg/kg/min In a 70 kg adult, that is about 175 mg per minute, or about 4% of a teaspoonful
10 Carbon dioxide physiology Transported in blood 60-70% bicarbonate ion after conversion in RBCs using carbonic anhydrase 20-30% bound to proteins (e.g., Hb) 5-10% in physical solution (PCO 2 ) Cleared by alveolar ventilation
11 Alveoli: The Place Where Gas Exchange Happens
12 Oxygen Consumption Largely Dependent on Oxygen Delivery......in low flow states
13 Oxygenation Adequate Lung Inflation Supplemental O2
14 CO2 Production Largely Dependent on Oxygen Consumption
15 Need to Ventilate CO2 Production (O2 Consumption & Venous Return) Dead Space (wasted ventilation)
16 Thus!!! The Speed of Ventilation CO2 Production Increased Dead Space
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21 Blood pressure = (Cardiac output) x (Volume) x (Peripheral resistance)
22 Shock Cardiogenic Rapid pulse Distended neck veins Cyanosis Volume Loss Rapid pulse Flat neck veins Pale Vasodilatory Variable pulse Flat neck veins Pale or or pink
23 Signs of Shock Early Late Weak, thirsty, lightheaded Pale, then sweaty Tachycardia Tachypnea Diminished urinary output Hypotension Altered LOC Cardiac arrest Death
24 As circulation fails, the ability of the heart to blow on the coals that are the cells of the body is reduced
25 Examples: Shock of any cause Tension pneumo Massive hemorrhage Cardiac arrest Sepsis
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31 Consider Cardiac Arrest Little O2 Delivery & Consumption Little CO2 Production & Venous Return...Little Need to Ventilate!!
32 We went to California to watch them practice CPR training
33 Cardiac Arrest. 8 breaths / min Little CO2 Excretion
34 Where did this hyperventilation thing come from anyway? All of the head trauma discussion dating back to the 80 s and before Grief and relief after dealing with a difficult airway
35 Higher IICPICP I Hypoxemia or Hypotension Lower ICP PaCO PaCO2 (mmhg) PaCO PaCO2 (mmhg)
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39 The Response of Intracranial Pressure to changes in carbon dioxide is less when the patient is in circulatory compromise
40 Higher IICPICP I Hypoxemia or Hypotension Lower ICP PaCO PaCO2 (mmhg) PaCO PaCO2 (mmhg)
41 Let s think about a Cardiac Arrest case
42 A 55 year old man is found down in Cardiac Arrest by his wife. EMS is called. Citizen CPR is being done He was well until this happened. He has no medical problems and takes no medications.
43 After defibrillation the patient remains in this rhythm He does not improve after CPR and the administration of epinephrine or amiodarone
44 What do you do??
45 REMEMBER: The heart only pumps out what it gets back!
46 The negative pressure in the thorax PULLS blood back!
47 AGAIN!!!! The negative pressure in the thorax PULLS blood back!
48 Blood pressure = (Cardiac output) x (Volume) x (Peripheral resistance)
49 Cardiac Output = Pulse Rate x Stroke Volume
50 Understanding the body by regions Positive pressure Negative pressure Positive pressure
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53 The negative pressure inside the thorax pulls blood back from the positive pressure areas. Positive pressure Negative pressure Positive pressure
54 Maintaining the negativity of the pressure inside of the thorax is one of the most vital areas of understanding resuscitation Negative pressure
55 Positive Pressure in the Thorax decreases Venous Return!!
56 Much of what we do for patients during resuscitation is bad physiology!!
57 Positive pressure breaths Chest compressions
58 Breathing the patient too fast INCREASES pressure inside the chest!
59 It seems that we have been over-ventilating people in circulatory collapse for years
60 Coronary perfusion pressure drops with over-ventilation
61 Chest Compressions & Coronary Perfusion Pressure 20 mmhg 5:1 Ratio 15:2 Ratio 40 mmhg 20 mmhg
62 Venous return drops with over-ventilation
63 Intrathoracic pressure is raised with over-ventilation
64 Sanders, et al 15:2 (e.g., former standard CPR) 50:5 (e.g., Great Britain) CC (chest compressions only) 4 min CC only; then 100:2
65 Neurological Outcomes... 4 min CC only; then 100:2 Did Significantly Better than 15:2 (e.g., standard CPR) CC -- (chest compression only) Did Much Worse
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69 It appears that a one hand squeeze at a rate of one every eight seconds is ALL the ventilation that a patient in circulatory collapse needs!
70 This is the minute ventilation that you are breathing right now! About five liters per minute
71 Breathing the patient faster than that may reduce venous return, worsen shock, and kill the patient!
72 Let capnography guide you!
73 Oridion
74 First-generation sidestream instruments continuously draw sample gases via an endotracheal tube adapter, through a sampling tube, to an IR light source and detector within a remote bedside monitor. Sidestream sampling tubes and adapters frequently become clogged and contaminated by respiratory secretions unless the tubes are routinely and frequently replaced.
75 Second-generation mainstream capnographs mount the IR source and detector lateral to an adapter at the end of the patient's endotracheal tube.
76 Microstream technology addresses this problem in this way: The filter line airway adapters collect air from the middle, not the side, of the air stream through three hollow sampling ports oriented in different directions.
77 Microstream technology: Minimizes aspiration of secretions in the device and makes sampling less dependent on patient posture and device orientation.
78 Colorimetric method A (purple) = < 4 mm Hg B (tan) = 4-15 mm Hg C (yellow) = > 15 mm Hg
79 Physiology Reminder Oxygen -> lungs -> alveoli -> blood breath Oxygen CO 2 lungs muscles + organs Oxygen CO 2 blood CO 2 energy cells Oxygen + Glucose
80 Normal Capnogram Normal
81 Prolonged Exhalation Capnogram
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83 Capnography shows: 1.Is the airway in? 2.What s the shape? 3.What s the absolute height of the wave?
84 Capnography: 1.Verification 2.Bronchoconstriction 3.Circulatory collapse
85 Quick Review of Causes of a Decreased EtCO 2 Decreased Metabolism Analgesia / 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
86 Quick Review of Causes of an Elevated EtCO 2 Increased 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 Exhausted CO 2 absorber
87 Misplaced Endotracheal Tubes by Paramedics in an Urban EMS System Steven H. Katz, M.D. Jay L. Falk, M.D., FACEP, FCCM Marybeth Wash, R.N. Department of Emergency Medicine Orlando Regional Medical Center Orlando, FL
88 Misplaced Endotracheal Tubes by Paramedics in an Urban EMS System Of 108 patients presenting to their emergency department with an endotracheal tube in place, 27 of the tubes were misplaced Of the 27 misplaced, 18 were in the esophagus, or 17% of the intubation
89 Misplaced Endotracheal Tubes by Paramedics in an Urban EMS System Conclusions Alarming rate of unrecognized, misplaced ETTs in the field Unique to Orange County? Under-reported national problem?
90 What Happened in Block 2? The endotracheal tube became dislodged!
91 Marked bronchospasm
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93 Warning, Warning!!! All good things can go wrong! The filter line can either not be hooked up correctly or can get clogged
94 The Height of the Curve Non-survivors of Cardiac Arrest Average ETCO2: 4-10 mmhg Survivors (to discharge) Average ETCO2: >30 mmhg
95 Flat waveform may indicate PEA if an EKG complex is present ROSC shows increasing ETCO2 Waveform configuration changes with bronchoconstriction
96 The Impedance Threshold Device 11/11/
97 The ITD together with waveform capnography should show an additive effect in improving survival from cardiac arrest
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99 American Heart Association in the 2005 Guidelines recommended slower ventilations during cardiac compressions.
100 My recommendations Start with the rate of eight, and then measure capnography every five minutes. If below 20 mmhg CO2, then slow to 1 every 10 seconds. If above 40 mmhg CO2, then increase rate to 1 every 6 seconds.
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111 So, what do we do with this guy??
112 Make SURE that his ventilation rate is a one hand squeeze every eight seconds
113 Evaluate capnography or capnometry five minutes later
114 Adjust the ventilation rate from there
115 and, if you do this AND YOU MUST you will likely be the only guy or gal on the team who understands that this is now the standard
116 The Objective Question: What is the relationship between exhaled carbon dioxide and cardiac output?
117 The ANSWER!! ETCO2 and Cardiac Output are DIRECTLY PROPORTIONAL when assisting the patient with positive pressure breathing such as Bag to ET tube in cardiac arrest
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120 EMS is leading the emergency medicine industry in critical care ventilation
121 Early AHA standards for the use of ventilators during resuscitation required that the ventilator be removed during cardiac compressions 11/11/ Ray Fowler MD, FACEP
122 EMS and Mechanical Ventilators These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Wayne, Delbridge, Ornato, Swor et et al al Turtle Creek Conference II II PEC Jan-Mar /11/ Ray Fowler MD, FACEP
123 Out-of-hospital ventilation: bag--valve device vs transport ventilator. Acad Emerg Med Aug; Acad Emerg Med Aug;2(8): Johannigman JA, Branson RD, Johnson DJ, Davis K Jr, Hurst JM. Department of Surgery, University of Cincinnati Medical Center, OH A prospective, nonrandomized, convenience sample of 160 patients requiring airway management in the out-of-hospital urban setting, an ABG study on arrival to the ED When ET intubation was accomplished, adequate ventilation could be achieved using either bag-valve ventilation or a transport ventilator. 11/11/ Ray Fowler MD, FACEP
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128 Specifications Control Module: Supply Pressure Range: 40 to 90 psig Storage Temperature: -40 F to 160 F Frequency: 8 to 28 BPM Tidal Volume: 200 to 1200 ml. Flow Rate: 16 to 48 LPM Inspiratory Time: seconds Expiratory Time: 1.5 to 6.0 seconds I:E Ratio: 1:1 to 1:4 Dead Space in Patient Valve Assembly: 8 ml Weight: 24 oz./680g. Expiratory Resistance: 5 cm. H20 Minute Volume: 0 to 24 LPM Case Material: ABS Input Connection: Plated brass Output Connectors: Plated brass Gas Consumption Driving Gas: 0.5 LPM Maximum 11/11/ Ray Fowler MD, FACEP
129 Patient Valve Assembly: Flow: As required in demand valve mode: 0-48 LPM at 50 psig. Depends on volume setting. Peak Inspiratory Flow: 48 LPM at airway pressure Operating Temperature: -30 F to 125 F Storage Temperature: -40 F to 160 F Inlet Fitting: Standard Filter: 25 Micron Stainless Steel Mesh Delivery Pressure: 60 ±5 cm H20 (44 mm Hg) Crack Pressure: 0- to -2 cm H20 (0 to -.8 in H20) Exhalation Resistance: 0-10 LPM to 1.5 cm H20, LPM to 3.8 H20 Gas Consumption Driving Gas: 0.5 LPM Max Outlet: 22 mm outside diameter x 15 mm inside diameter (fits standard medical masks, endotracheal tubes and tracheostomy tubes) D Cylinder holds 425 liters of oxygen, so a full tank could run an Autovent for 800 minutes, Weight: 16 oz/450g or 13 hours Body: Anodized aluminum Cover: Polycarbonate Dead Space: 8 ml (excluding mask) Outlet: Polysulfone Supply Pressure: 40 to 90 psig Inlet Fitting: Plated brass 11/11/ Ray Fowler MD, FACEP
130 Ventilation requires attention during initial training, ETVs clearly have a role in the prehospital setting. Wayne, Delbridge, Ornato, Swor et et al al Turtle Creek Conference II II PEC Jan-Mar /11/ Ray Fowler MD, FACEP
131 All patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. Wayne, Delbridge, Ornato, Swor et et al al Turtle Creek Conference II II PEC Jan-Mar /11/ Ray Fowler MD, FACEP
132 Ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review. Wayne, Delbridge, Ornato, Swor et et al al Turtle Creek Conference II II PEC Jan-Mar /11/ Ray Fowler MD, FACEP
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143 Emergency mechanical ventilation at moderate altitude. Roeggla M, Roeggla G, Wagner A, Eder B, Laggner AN. Wilderness Environ Med Aug;6(3): Department of Emergency Medicine, University of Vienna, Austria. To evaluate the influence on minute ventilation and blood gas analysis of moderate altitude (3000 m) compared to 171 m in healthy volunteers during mechanical ventilation At 3000 m, the delivered minute volume increased by 9.8% in the air mix mode and by 14.6% in the no air mix mode. 11/11/ Ray Fowler MD, FACEP
144 Emergency mechanical ventilation at moderate altitude. Roeggla M, Roeggla G, Wagner A, Eder B, Laggner AN. Wilderness Environ Med Aug;6(3): Department of Emergency Medicine, University of Vienna, Austria. These changes are of sufficient magnitude and importance to require monitoring of minute volume to prevent barotrauma or volume-related trauma and to monitor oxygenation by pulse oximetry during emergency mechanical ventilation at moderate altitude. 11/11/ Ray Fowler MD, FACEP
145 Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. J Trauma Feb;54(2): R Adams Cowley Shock Trauma Center and University of Maryland Medical School 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. 11/11/ Ray Fowler MD, FACEP
146 Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. J Trauma Feb;54(2): R Adams Cowley Shock Trauma Center and University of Maryland Medical School Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results. 11/11/ Ray Fowler MD, FACEP
147 Mechanical ventilation works It decreases rescuer fatigue It gives consistent breaths It ain t a free lunch 11/11/ Ray Fowler MD, FACEP
148 Mechanical ventilation does not in ANY way decrease the need for monitoring of the airway 11/11/ Ray Fowler MD, FACEP
149 Mechanical ventilation can be a method to prevent over-ventilation during circulatory collapse 11/11/ Ray Fowler MD, FACEP
150 And we need more data on their use during low flow states such as shock and cardiac arrest 11/11/ Ray Fowler MD, FACEP
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152 As EMS professionalism continues to grow You, the heroes of the streets, must work harder each day to stay on top of skills
153 Because, someone out there is waiting to be cared for by you
154 Thank you for your kind attention! Links to follow!!!
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