“Is this affecting the shape?” If so, correct the condition causing the irregular shape. Figure 1 reviews the meaning of each phase of the wavefor… If the top of the shape is irregular (e.g., like two different EtCO2 waves mashed together) it may indicate a problem with tube placement. 51.) St. Joseph’s Hospital and Candler Hospital, the main facilities of St. Joseph’s/Candler Health System (SJ/C) in Savannah, Georgia are 2 of the oldest continuously operating hospitals in the United States. What can be intimidating is the idea of reading the shape of the waveform, but in practice it’s not difficult at all. The PQRST part of the EKG is caused by the electrical conduction system of the heart.. Easy Way to Learn the PQRST Wave on the EKG. By the time the oxygen gets to the end of its journey, it has a partial pressure of approximately 40 mmHg, still high enough to allow it to move into muscles and organs that have a lower partial pressure of approximately 20 mmHg.4 (See Figure 2, p. Capnography should be used to monitor all patients receiving pain management or sedation for evidence of hypoventilation and/or apnea. Thompson JE, Jaffe MB. If not, consider changing your current treatment strategy. If EtCO2 is low (i.e., being blown off too fast), begin by assisting the patient to breathe more slowly or by ventilating at 10-12 bpm. This shape is produced when one lung-often the right lung-ventilates first, followed by CO2 escaping from the left lung. 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Acknowledgment: Special thanks to Patrick Holland, LP, and David Bunting, RRT, AEMT, MS, for their assistance with this article. Because this is a fairly stable amount, the graph levels off into a plateau. In this case, normal means what we find in a healthy person with no metabolism, ventilation or perfusion problems. Capnography uses infrared (IR) radiation to make measurements. Howev When used with patients who have been administered paralytics or who are on ventilators, other waveforms can help providers finetune their critical care by identifying medication problems such as inadequate sedation or malignant hyperthermia, mechanical problems such as air leaks and ventilator rebreathing, and physiological issues such as ventilation/perfusion mismatch conditions.3,12. Unsurprisingly, this also applies to individuals who are dealing with pain. 49. The normal partial pressure of oxygen in ambient air is approximately 104 mmHg. Children should be ventilated at a rate of 15-30 bpm; 25-50 bpm for infants. P: Ventilation. By implementing the mnemonic “PQRST”, rescuers have a ready-made checklist to help them achieve the full potential of capnography. Capnography. When a person is breathing in, it goes back down. After the end of phase 3, the patient inhales again, bringing clear air past the sensor, dropping the graph back down to zero to start over again at phase 1. This is CO2 being squeezed out of the alveoli by the poorly compliant lung tissue, obese chest wall, or pregnant belly, before the same weight closes off the small bronchi. He's a member of the JEMS editorial board, a career fire captain and paramedic EMS coordinator, founder and director of the New England Center for Rescue and Emergency Medicine and an emergency services advocate, author and speaker at conferences around the world. Capnography is commonly used in EMS to monitor a patients’ ventilation adequacy but can be used as a tool for a number of other reasons that are valuable to an EMS provider. Phase II (expiratory upstroke) represents expiration of both dead space gas and alveolar gas from the re… One of the great things about EtCO2 is that although ventilation rates vary based on age, normal readings for quantity, shape and trends are the same for men and women of all age groups, making them easy to remember. The shape of the capnography waveform helps determine the cause of the problem CO2 begins to travel from the alveoli through the anatomical dead space of the airway causing a rapid rise in the graph as the CO2. Guerra WF, Mayfield TR, Meyers MS, et al. EtCO2 can aid in differentiation between hypoglycemia and diabetic ketoacidosis. A patient who’s experiencing diabetic ketoacidosis will have increased respirations, lowering the quantity of CO2. National Association of EMS Physicians. In a 2006 published study of 60 patients undergoing sedation, in 14 of 17 patients, *** 10 Things Every Paramedic Should Know About Capnography. Although hemoglobin, myoglobin and other body chemicals play a part in transporting gasses, it can be helpful to begin by just picturing the partial pressures pushing the gasses from one part of the body to the next.3. Quantitative Waveform Capnography. Waveform capnography (Quantitative): When ETCO2 is graphically displayed and analysed quantitatively (real time quantitative waveform as depicted below). Association between prehospital cpr quality and end-tidal carbon dioxide levels in out-of-hospital cardiac arrest. 4. 37 The authors of this study state capnography may be used to rule out PE if used in patients stratified as low risk for PE. P: Ventilation and perfusion. Retrieved May 19, 2017, from www.naemsp-blog.com/emsmed/2017/3/22/be-all-end-tidal-the-expanding-role-of-capnography-in-prehospital-care. Watch for a sudden spike indicating ROSC or a sudden drop indicating displacement of the airway device and/or re-occurrence of cardiac arrest. American Academy of Orthopaedic Surgeons. Retrieved May 20, 2017, from www.derangedphysiology.com/main/core-topics- Capnography includes the noninvasive measurement of CO2 partial pressure during respiration (primarily exhalation). A meta-analysis finds sensitivity 80%, specificity 49%, and area under the summary receiver operating characteristic curve (AUROC) 84% for diagnosis of PE using capnography. R: Goal is 12-20 bpm for spontaneous respirations; 10-12 bpm for artificial ventilations. If you continue to use this site we will assume that you are happy with it. Sometimes the difference is obvious, but in other situations, every diagnostic tool can help. ASA Standards for 2011 - Capnography Volume Capnography in the Intensive Care Unit: Potential Clinical Applicaitons Capnography in Pediatric and Neonatal Intensive Care Units Capnography - Sub-Saharan Africa Royal College of Anaesthetists - Educational Campaign on Capnography During CPR Volume capnography: A narrative review Using EtCO2 along with other vital signs can help you identify a mismatch between ventilation and perfusion. In addition to using EtCO2 in the ways described above, patients with poor lung compliance, obese patients and pregnant patients may also exhibit a particular wave shape that may indicate that they’re highly sensitive on adequate ventilation.8. Circulation. 41 Although capnography has shown to be an efficient tool for assessing nocturnal hypoventilation and predicting good ... Of 184 reports meeting inclusion criteria, 133 related … 3. In this case you may have a “normal” pulse oximetry reading even though organs aren’t getting the oxygen because hemoglobin is saturated with oxygen, but this oxygen remains “locked” to the hemoglobin.4,5 In this way your EtCO2 reading can help you better interpret the validity and meaning of other vital signs like pulse oximetry, blood pressure and more. Retrived May 20, 2017, from www.opentextbc.ca/anatomyandphysiology. Photos and images courtesy Rommie Duckworth Capnography is a great way to confirm airway device placement and monitor ventilation, but it … Rieves A, Bleess B. 9. Watch for a sudden drop indicating displacement of the airway device and/or cardiac arrest. Patients with emphysema may have so much damage to their lung tissue that the shape of their waveform may “lean in the wrong direction.” In a similar way, patients with a pneumothorax won’t be able to maintain the plateau of phase 3 of the EtCO2 wave. 12. T: As with shock, the quantity will continuously trend down as the patient’s hypoperfusion worsens. T: Consistent Q, R and S with each breath as always is our goal. An end-tidal capnography waveform is a simple graphic measurement of how much CO2 a person is exhaling. If the waveform takes on a near-normal shape (see Figure 4c, p. 50) then the placement of the advanced airway was successful.8, T: Consistent Q, R and S with each breath.