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CO2 Physiology 1 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 • CO2 is a compound molecule – 1 element of carbon and 2 elements of oxygen – colorless and heavier than air – green plants clean up after our exhaled CO2 2 Physiology of CO2 • CO2 produced by cellular metabolism diffuses across the cell membrane into the circulating blood. • The blood transports the CO2 to the lungs. • Then it diffuses from the blood into the lungs. • CO2 is eliminated with alveolar ventilation on exhalation. 3 Physiology of CO2 • Carbon Dioxide is transported in the blood in three (3) principle forms: – 5 to 10% as gas & reflected by the PCO2 – 20 to 30% is bound to blood proteins, the major one being hemoglobin – 60 to 70% is carried as bicarbonate (HCO3) 4 Physiology of CO2 • About 5-10% of CO2 is eliminate through exhalation only. • The rest is recycled in the body through the circulatory and renal systems. • The heart and lungs would have to increase their work 10 times if they were required to eliminate all the CO2 the body produces! 5 Ventilation & EtCO2 Monitoring • Endtidal CO2 (EtCO2) is the CO2 measured at the end of expiration. • EtCO2 concentration provides a clinical estimate of the PaCO2, if ventilation and perfusion are appropriately matched. • EtCO2 monitoring allows for a breath by breath assessment of ventilation. 6 Capnography— The continuous measurement and graphic display (waveform) of the CO2 concentration in the patient’s airway during the respiratory cycle. Normal waveform: 7 Respiratory Cycle O2 CO2 CO2 O2 Respiratory Cycle • Oxygenation = oxygen → lungs→ alveoli→ blood Monitored by a Pulseoximeter • Metabolism = oxygen is converted to energy + CO2 Monitored by a Metabolic Computer • Hymodynamic Parameter • Monitored by ECG, IPB, NIBP, Temperature • Ventilation = CO2 → blood→ lungs→ exhalation Monitored by a Capnograph 9 The relationship – EtCO2 and PaCO2 Normal conditions: • • EtCO2 is between 35 – 45 mmHg PaCO2 & EtCO2 will be very close • EtCO2 is most 2 - 5 mmHg less with normal physiology Widening of this difference can be caused by: • • • Incomplete alveolar emptying Ventilation-perfusion abnormalities Poor sampling Capnography monitoring of Critically ill patient may alert clinicians to underlying conditions 10 PaCO2 vs. EtCO2 PaCO2 – Partial pressure of CO2 present in arteries (similar to concentration) Invasive ABG analysis 11 EtCO2 – concentration of CO2 exhaled in each breath Non-invasive measurement at airway Normal waveform DD A-B: Baseline = no CO2 in breath B-C: Rapid rise in CO2 C-D: Alveolar plateau D: End expiration (EtCO2) D-E: Inhalation 12 Normal waveform - 35-45 mmHg 13 Hypoventilation 14 Hypoventilation with shallow breathing 15 Relationship between EtCO2 and RR Breath-to-breath measure of ventilatory status 16 Hyperventilation 17 Some Definitions • Capnometer • Capnography 18 Capnometer A Capnometer provides only a numerical measurement of carbon dioxide in mmHg or kPa or Vol.-% 19 Capnograpy Capnography provides the CO2 value and the waveform of carbon dioxide over time Capnography— The Ventilation Vital Sign™ • Earliest sign that something is going wrong • Breath by breath assessment of ventilation 21 Capnography An EtCO2 value of e.g. 38 mm/Hg without a 50 40 30 20 10 0 Time it´s like a heart rate of e.g. 80 without an 22 CO2 Measurement Technology General: • CO2 measurement technology Infrared absorption • Technique of airway gas sampling Main stream vs. side stream vs. Microstream 23 Sampling Technology • Mainstream sampling - CO2 analysis chamber is in-line between the patient airway and the ventilator circuit • Sidestream sampling - CO2 analysis chamber is within the device. The patient’s expired gas is sucked from the airway and drawn to that chamber through a sampling line. 24 Conventional main stream technology Monitor Expiration Inspiration Fresh gas 25 Conventional side stream technology Sample line (Monitor) 26 Unique solutions for Capnography = Microstream® 27 Microstream® CO2 • A combination of a unique CO2 sidestream measurement technology and; • FilterLine (proprietary sampling lines) - for single patient use • Only system providing accurate EtCO2 readings for non-intubated patients that receive supplemental O2 and switch between oral and/or nasal breathing 28 Microstream® CO2— Major benefits • Ease of Use • Reliable Technology • Flexible for all patient types • Versatile for all environments 29 Microstream® advantages Reliable technology • Superior moisture handling of liquids, secretions and humidity • CO2 specificity – no cross-sensitivity to anesthetic gases • Rugged – no moving parts in sensor • Long-term monitoring 30 Microstream® advantages Flexible for all patient populations – solution for monitoring Neonates • 50 ml/min flow rate supports entire patient population – including neonates (Competition at 3 – 5 times the flow rate) • Does not compete for Neonate tidal volume • The lower the flow, the less moisture to be handled Microstream® advantages Ease of use • No expensive sensors to replace • Yearly calibration – done in 5 minutes • Warm up time – 45 seconds from ON until first waveform and number appears • One-piece Plug & Play consumables 32 Microstream® advantages Light source Micro sample cell 15 µL Light source housing 33 1 Eurocent Microstream® Core Technology Sensor Housing I.R Source Optic Block (Micro Sample Cell) I.R Detectors 34 Microstream® advantages Reliable Technology • Fast response time • 1 mm micro bore tubing reduces delay time • Crisp waveform – longitudinal filter maintains laminar flow • Build-in water trap – don't clean and re-use any FilterLine – it destroys the inline filter 35 Microstream® advantages Flexible • Both intubated and nonintubated applications • Alternating mouth and nose breathing • Oxygen delivery (low flow O2 solution; solution for high flow O2 delivery) • Adult, pediatric, and neonates 36 Microstream® advantages Versatile All clinical environments: • Critical Care • Sedation Procedures • EMS/ED • Operating Room 37 Unique solutions for Capnography FilterLine® patient interfaces 38 FilterLine® solutions for all applications Intubated Non-Intubated Smart Solutions NIV-Line Smart CapnoLine / Smart CapnoLine O2 CapnoLine H 39 FilterLine® Sets Smart Solutions for nonintubated patients “Microstream® technology allows the accurate measurement of EtCO2 in the absence of an endotracheal tube.”* • Continuous sampling from both mouth and nose • Special oral-piece design optimally samples from mouth - Increased surface area provides greater sampling accuracy in the presence of low tidal volume (adult/intermediate size) *ASA 2001 Jay Brodsky, MD Professor of Anesthesia, Stanford University Medical Center, CA USA 40 Smart Solutions for nonintubated patients Smart CapnoLine™ Plus / Smart CapnoLine™ Plus O2 nasal cannula for CO2 measurement and O2 delivery • Uni-junction sampling method ensures optimal waveform and ultra-fast response time • Unique O2 delivery method reduces CO2 sampling dilution (up to 5l/min) • Solution for high flow O2 delivery (works effectively under oxygen delivery mask) 41 Solutions for non-intubated patients CapnoLine H*™ / CapnoLine H O2 • Enables continuous EtCO2 monitoring in high humidity environments (i.e. ICU) • Can be used up to 72 hours Piece of Nafion * = Humidity 42 Microstream®—A Unique Solution For Non-intubated Patients CO2 sampling / O2 delivery for non-intubated patients (up to 5 L/min.) Small pin holes deliver pillow of oxygen around both nose and mouth Uni-junction™ of sampling ports prevents dilution from non-breathing source 43 Nasal and Oral Sampling Increased surface area provides greater sampling accuracy in the presence of low tidal volume FilterLine® Sets - Solutions for intubated patients • Easily handles moisture and secretions without water traps • Able to measure in any position • Nafion® tubing allows for longterm monitoring without moisture build up • Easily switches to nonintubated monitoring without recalibration of monitor • Low add. dead space (0,4 cc) to use on neonates 44 FilterLine® recommendations: Sedation Areas; GI Lab, Cath Lab, EP Lab Is the Patient on Oxygen? 45 YES NO Smart CapnoLine Plus O2 Smart CapnoLine Plus FilterLine® information to avoid problems Do not try to dry the FilterLine® - this will damage the filter Ensure there are no kinks in the sampling line Do not cut the oral flange on the Smart CapnoLine Do not cover the Nafion® Do not instill medications through the airway adapter Never pass a suction catheter or stylus through the airway adapter Change the FilterLine® or the Set if a “Blockage” message appears on the monitor screen or if the readings become extremely erratic 46 FilterLine® answers for the most FAQ´s: Latex free Single-patient use Not sterile 47 Sedation Procedures “Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation.”* *Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non Anesthesiologists: Anesthesiology 2002; 96:1004 48 Microstream® solutions during Sedation Procedures Benefits and Uses • Assesses patent airway (airway obstruction) protective reflexes response to verbal/physical stimuli • Respiratory changes can immediately be assessed • Microstream® allows for continuous respiratory monitoring with no nuisance alarms in procedural sedation environments where currently there is minimal usage of monitoring 49 Microstream® solutions during Sedation Procedures Applications • Cardiac Cath. Lab • GI lab • Pulmonary lab • Emergency Department • Hyperbaric medicine • Dental Clinics • Radiology 50 Moderate – procedural sedation 51 Capnography and sedation How can capnography make a difference in how you care for the sedated patient? • What you do will not change • When you do it will! Early detection of potential patient compromise 52 Protocol during procedural sedation Baseline Ventilatory Assessment • E.g. after 12 hours NPO (nothing by mouth) = EtCO2 • Know the respiratory rate, waveform, and EtCO2 numeric value before drug administration Continuous monitoring throughout case and recovery • • RR, ETCO2 value…changes from baseline (trends) Changes in the Waveform…Earliest indicator of potential problems. (size, shape) Early intervention 53 Changes from baseline • Change in EtCO2 value > 10 mmHg • Significant waveform change Becomes erratic Flatlines 54 Changes from baseline - action • Remember the ABC’s (airway, breathing, circulation) • Assess the patient • Follow your normal protocol, which may include: 55 Ensure open airway Stimulate patient if necessary Check the cannula positioning Stop drug delivery Inform M.D. / pause procedure if necessary Administer reversal agents as prescribed Deep sedation • Requires higher vigilance in ventilatory monitoring • • Maintain patent airway Potential dead space ventilation • • Chest moves up and down Inadequate respiratory effort to clear dead space 56 Assessing for changes from baseline Hypoventilation with shallow respirations 57 Nursing interventions • Continue to monitor • Ask patient to take a deep breath 58 Abnormal waveforms Absent alveolar plateau indicates incomplete alveolar emptying or loss of airway integrity Possible causes • Partial airway obstruction caused by: • Tongue • Position of head 59 Assessing for changes from baseline Rebreathing often results from: • Poor head and neck alignment • Draping near the airway • Shallow breathing – not clearing dead space 60 Assessing for changes from baseline Dead space ventilation • Chest movement • Little – to no air movement in and out of lungs 61 Abnormal waveforms Absent alveolar plateau indicates incomplete alveolar emptying or loss of airway integrity Possible causes • Partial airway obstruction caused by: – Tongue – Position of head 62 Nursing interventions • Assess patient • Ask patient to take a deep breath • Adjust patient’s head position, if necessary • Adjust cannula position, if necessary 63 Putting it all together • The transition from conscious sedation to unconscious/anesthesia is very subtle and can be undetected until oxygenation is impaired • You must be prepared to monitor a patient at a level deeper than intended • “Respiratory frequency and adequacy of pulmonary ventilation are continually monitored” • Only capnography provides an immediate notification of a ventilatory event 64