8/12/2009

Why Capnography?

ETCO2 Monitoring in the

Pediatric ED

Randolph Cordle FAAEM

Medical Director: Division of Pediatric Emergency Medicine
Program Director: Pediatric Emergency Medicine Fellowship
Levine Childrens Hospital
Carolinas Medical Center

Great deal of information from the shape of the curve

Can visualize respiratory pattern
Can follow trends
Exact number not as important as relative change
Sample size assurance test QA

Why?

Why?
ASA closed claim study
93% preventable if ETCO2 and oxygen sat
Only 10% of life-threatening intubation events detected
before adverse event

Detect ventilation
Trend
Too little, too much, just right
Is there any blood in the lungs?
Ideal when you cant watch the chest- transportation

35 events detected by ETOC2

20 were life threatening
Only 2 detected clinically

1.

Tinker Anesthesiology 1989; 71:541-546

2.

Cote Can. Anes. Soc. J 1986; 33:315-320

Nomenclature

Microstream Technology Makes

Ideal for The Pediatric ED

Primary system used in the ED

Laser-based-increased sensitivity/specificity for CO2
Sample size (15 L)
Decreased condensation problems d/t diminished flow
Able to use in much smaller children and even neonates

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Capnography

Capnography
We generally use time-based capnography not volume
This allows us to monitor non-intubated patients
This allows observation of inspiratory and expiratory
dynamic values

Time capnography= inaccurate dead-space calculation

Therefore, less accurately demonstrates V/Q status
Volume typically used in research
No inspiratory arm to volume curve

Apnea

Chemical Indicators

Useful in perfusing patient after intubation

Not sensitive when perfusion decreased (CPR)
Change from purple to yellow when CO 2 present
False-positive CO2 with mucous exposure, gastric
content exposure, and epinephrine
Not a good indicator in the cardiac arrest patient

Normal ETCO2 Curve

What Decreases ETCO2

Hypovolemia
Pulmonary embolism
Air embolism
Cardiac arrest
Apnea
Hyperventilation

Decreased temperature
Decreased cardiac output
Airway obstruction
Hypotension
Extubation

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What Raises the ETCO2

Decreased ventilation
Partial airway obstruction
Rebreathing
Increased carbon dioxide
Increased pulmonary
perfusion

Hyperpyrexia
Tourniquet release
CO2 gas embolism
Increased cardiac output
Sodium bicarb infusion
Decreased ventilation
Nitrous oxide

ETOC2 Inherent Error

Atmospheric pressure Directly correlates,
usually minor 1-2 mm of mercury
Oxygen Inverse correlate

ETOC2 Inherent Error

Procedural Sedation

H2O Direct correlate

May want to have humidity filter near patient and
monitor to alleviate this source of air

Nitrous Oxide Direct correlate

Up to approximately 9% overestimation at 70%
nitrous oxide

Not proven to improve patient outcomes

Allows use of oxygen during procedural sedation
ETCO2 increase or level >50 = respiratory depression
Should become standard of care

Many monitors will correct for this if data entered

Rebreathing

Expiratory Obstruction

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Alpha Angle

Alpha Angle in Asthma

Angle made between Phase II and III

Generally reflects the slope of Phase III
An indirect indicator of the time constants in the lungs
alveoli or the V/Q status of the lung
Diagonal lines are typically bad!

Cardiac Arrest- No Perfusion?

ETCO2 Reflects Cardiac Output

ETCO2 measurement and height of Phase III dependent
upon cardiac output
If blood CO2 is high but ETCO2 is low then
1. Poor ventilation
2. Poor perfusion of lungs
3. Equipment error

Cardiac Arrest
Essentially no perfusion during arrest
Minimal perfusion during CPRlow ETCO2
Typically being hyperventilated
Indicator of poor outcome

Cardiac Arrest
ROSCperfusionETOC2
ETCO2 10 mm mercury at 20 minutes of PEA
99% probability that survival <3.9%
Initial ETCO2 not discriminatory at all
GRMEC et al showed that no patient with an average,
initial, and final ETCO2 level of <10 were resuscitated

JAMA 1989 262:1347-51

N Eng J Med 1997 337(5):301-306
European Journal of Emergency Medicine 2001 8:263-269

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Phase IV
Cyanotic Heart Disease

Right to left shunt

Decreased pulmonary perfusion
ETCO2 underestimates arterial CO2
Correlates with O2 saturation

Those with diminished functional capacity due to greater

variability in alveolar CO2 release.
ETCO2 may be higher than actual arterial CO2
Primarily seen in pregnant patients and the obese
Also seen in children: especially young children

Roughly 3 mm mercury ETCO2 for a 10% O2 saturation

Nasal Intubation
Phase IV or Equipment Fail
ETCO2 detection Can be Used to improve the safety
and success rate of blind nasal intubation
Most easily performed if an audio capnometer is used
Position the tube until the ETCO2 is the greatest and
then advance the tube.
Confirmation is immediate

ETCO2 Through LMA

Clefts

Can be useful at times to follow changes.

Correlates well in adults breathing spontaneously
Does not correlate in spontaneously breathing children

Correlates well in mechanically ventilated infants

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Arterial-ETCO2 Gap
Patients with pulmonary edema and ARDS will typically
have a decrease in their Arterial-ETCO2 Gap as PEEP is
increased.
Once the optimum level of PEEP is reached the ArterialETCO2 Gap will begin to increase again.
Gap determines the optimal level of PEEP

Questions