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TERMINOLOGY
CAPNOMETRY- Measurement and display of expired CO2 on a digital or analog monitor. CAPNOMETER- Device that performs the measurement and displays the readings in numerical forms CAPNOGRAPHY- A graphical display of instantaneous CO2 concentration versus time or expired volume during a respiratory cycle CAPNOGRAM- Actual waveform
ASA GUIDELINES
Standard for every patient receiving general anaesthesia. Continual monitoring for expired co2 For verification of positioning of endotracheal tube or laryngeal mask airway
3. The capnometer must have a high CO2 alarm for both inspired and exhaled co2. High CO2 alarm must be of medium priority 4. An alarm for low exhaled CO2 is required. Low CO2 alarm shall be medium priority 5. Must disclose the quantitative effects of barometric pressure on capnometer performance in instruction for use.
CHEMICAL METHODS
(a) ph sensitive also k/a the colorimetric method
It is the most common technology in use. Gases that have two or more dissimilar atoms in the molecule have a specific and unique absorption spectrum of IR light CO2 absorbs infra red light at 4.3 micrometer
INTERFERENCE
1. 2. 3. 4. 5.
Halogenated anaesthetic agents do not absorb infra red light at the wavelength used for CO2 Atmospheric pressure can also influence readings Water vapour can occlude tubing and or sampling chamber. Response time also affects the analyzing process N20 absorbs while oxygen does not absorb infra red light
Effect of N2O
COLORIMETRIC METHOD
Consists of ph sensitive chemical indicator, which when exposed to CO2, becomes more acidic & changes color Is portable & used mainly to confirm successful tracheal intubation Minimum of 6 breaths should be performed Paediatric version also available
RESPONSE TIME
2.
TYPES OF CAPNOMETER
MAINSTREAM CAPNOMETER
Placed between breathing system & pt. Gas passes through a chamber (cuvette) with 2 sapphire windows transparent to IR light The sensor which houses both the light source & the detector, fits over the cuvette
ADVANTAGES
Better fidelity No need of scavenging or to increase the fresh gas flow Sample contamination with fresh gas flow is less likely Standard gas is not required for calibration Fewer disposable items
DISADVANTAGES
Traction on airway device and may cause kinking of ETT Increases dead space Leaks , disconnections and circuit obstructions can occur Condensed water or secretions on the cuvette interfere with light transmission Sensor may get dislodge from cuvette Measures only C02 and O2 Must be cleaned and disinfected between uses
Thermal burns
Pressure injury
CLINICAL IMPLICATIONS
HEAVY hence must be supported HEATED hence direct contact avoided RESPONSE TIME IS FASTER since no gas is subtracted. CALIBRATION must be done at least once a day SECRETION or CONDENSED WATER may interfere with light transmission and interpretation
SIDESTREAM CAPNOMETER
Sampling flow rate varies from 50 to 500 ml/min. If sampling flow exceeds expired gas flows contamination from fresh gas flow will occur
ADVANTAGES
Calibration and zeroing are usually automatic Added dead space is minimal Potential for cross contamination between patients is low Sampling port can be used to administer bronchodilators Can be used when monitor must be remote from the patient (MRI) Several gases can be measured simultaneously
DISADVANTAGES
Leaks, sampling tube obstruction, failure of aspiratory pump . Aspirated gas must be either scavenged or returned to the breathing system. Increased delay time. Supply of calibration gas must be available. Deformation of wave form fresh gas dilution. More variable difference between arterial and end tidal CO2 levels.
CAPNO-TIPS
Positioning of monitor higher than the patient. Position sampling tube upwards Use filters Regular calibration if required should be done by using standard gases In monitors equipped with automated calibration anaesthesist can check by expiring into detecting device.
DUAL CAPNOGRAPHY
IN THIS, CO2 IS SAMPLED FROM BOTH LUMENS OF DLT
CIRCUIT OF CO2
APPLICATIONS OF CAPNOGRAPHY
APPLICATION OF CAPNOGRAPHY
Abs of CO2 from peritoneal cavity Soda bicarb Pain, anxiety, shivering Inc ms tone
Convulsions Hyperthermia
Normal
Normal Normal Normal Normal Normal
0
0 0 0 0 0
Normal
Normal Normal Normal Normal Normal
Hypothermia
Inc. anaesthesia depth Use of ms. relaxants Release of tourniquet
Normal
Normal May see curare cleft Normal
0
0 0 0
Normal
Normal Normal Normal
Dec CO2 Normal transport to lungs Dec CO2 Normal through lungs Rt Lt shunt Normal Increased pt dead space Normal
Normal
Elevated
0
0
Elevated
Elevated
Disconnection Apneic pt
Hyperventilation Hypoventilation
Upper airway obs Rebreathing
Normal Normal
Abnormal Baseline elevated
0 0
0
Normal Normal
Elevated Normal
Esophageal int.
Absent
Gradient
Normal
Rebreathing
Blockage in sampling line
"
Absent
Normal
0
0
Increased
Increased
INCREASED PETCO2
OUTPUT
Fever Malignant Hyperthermia Sodium Bicarbonate Tourniquet Release Venous CO2 Embolism
PERFUSION
Inc. cardiac Output
VENTILATION
Hypoventilation
TECH . ERROR
Exhausted Absorber Inadequate Fresh Gas Flow Leaks in Breathing System Faulty Valve
DECREASED PETCO2
OUTPUT
Hypothermia
PERFUSION
Dec. Cardiac Output Dec. Blood Pressure Hypovolemia Cardiac Arrest
VENTILATION
Hyperventilation Apnoea Total Airway Obstruction Accidental Tracheal Extubation
TECH. ERRORS
Circuit Disconnection Sampling Tube Leak
Pulm.Embolism
TIME CAPNOGRAPHY
Simple popular and adequate for clinical use Monitors dynamics of inspiration as well as expiration Can be used for non intubated patients , for example pt of high spinal anaesthesia
TIME CAPNOGRAM
PHASE I Inspiration and
phase of expiration during which dead space gas is exhaled PHASE II Rapid upstroke d/t transition between airway & alveolar gas PHASE III Alveolar plateau, constant, slowly upsloping part
1st
PHASE IV Beginning of inspiration angle- normally 100-110. Airway obstruction leads to a larger angle
angle- normally approx. 90. Increased in rebreathing, prolonged
response time
CHARACTERISTICS OF A CAPNOGRAM
Height depends on EtCO2 Frequency depends on respiratory rate Rhythm determines regularity Baseline should be zero in normal conditions. It is increased in case of rebreathing or if CO2 is deliberately added to inspired gases Shape it helps diagnostically and therapeutically
SPEED OF OSCILLOSCOPE
FAST MOVING waveform observation
ELEVATED EtCO2
HYPOVENTILATION
Seen during spont. Ventilation Seen in last third of plateau phase and is caused by lack of synchronous action between intercostal muscles and diaphragm It may be also seen in cervical transverse lesions, flail chest, hiccups, and pneumothorax and when a patient tries to breath during mechanical ventilation.
RIPPLE EFFECT
Also known as CARDIOGENIC OSCILLATIONS RESULT of to and fro movement of gases due to cardiac pulsations Observed during plateau phase Rate of oscillations matches that of a simultaneously recorded HR Minimized when sampling port moves distal or lung volume is increased by PEEP. Routine in pediatric patients May be absent in a case of emphysema.
ALSO CALLED SHARK FIN WAVEFORM DUE TO ITS SHAPE As expiration is progressively prolonged, inspiration may start before expiration is complete, so EtCO2 falls & is no longer a good estimate of PACO2. Squeezing of patients chest may cause EtCO2 to rise towards normal. This SQEEZE PEtCO2 be used as an estimate of alveolar CO2
Leak in sampling line during PPV will result in upswing at end of phase III Peak of short duration is caused by next inspiration when positive pressure transiently pushes undiluted end tidal gas through sampling line
By placing sampling site too near the fresh gas inlet Too high a sampling rate
Incompetent expiratory valve or exhausted absorbent Insufficient gas flow Rebreathing under drapes
vena cava obstruction by re retractor/ packs PULMONARY EMBOLISM ( consider the type of surgery)
PULMONARY EMBOLUS
Release of tourniquet Unclamping of a major vessel may result in sudden increase in end -tidal CO2 that gradually return to normal.
END-TIDAL CO2 is a better guide to the presence of circulation than ECG , pulse or BP during resuscitation It is not susceptible to mechanical artifacts so that chest compression do not have to be interrupted to assess circulation.
An increase in EtCO2 during CPR IS PREDICTIVE OF A SUCCESSFUL OUTCOME. When EtCO2 does not rise above 10 mm hg after 15 to 20 min of CPR, the resuscitative effort is unlikely to be successful. CAPNOGRAPHY can also point to the fatigue of the rescuer if EtCO2 fall slowly after increasing or fails to rise from a constant value.
EtCO2 IN LAPROSCOPY
EtCO2
INCREASED No
Endobronchial intubation Subcutaneous emphysema Capnothorax Yes
DECREASED
Volume Capnography
Co2 conc.'s Exhaled volume Area under the curve can be integrated to obtain volume of expired Co2 per breath Phase 3 better representation of v/q mismatch than phase 3 of time Capnography Dead space can be partitioned
VOLUME CAPNOGRAPHY
Vd = PaCO2-PeCO2 Vt PaCO2
MAINSTREAM SENSORS
are now available in small light weight and less heating types.
Transcutaneous Capnography
Probe is placed on earlobe. Non invasive. Measures co2 from underlying arterioles. The skin beneath the electrode is heated up to 40C by the probe to promote diffusion of CO2 by promoting dilatation of surface arterioles More reliable than EtCO2 for monitoring arterial PCo2 in patients with abnormal pulmonary exchange Found to be more accurate in evaluating co2 levels during (a) one lung ventilation (b)obese (c) neurosurgical procedures and in older children