Capnography During Cardiopulmonary Resuscitation(b) Effective CPR will result in PETCO 2 values...
Transcript of Capnography During Cardiopulmonary Resuscitation(b) Effective CPR will result in PETCO 2 values...
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Capnography During Cardiopulmonary Resuscitation
(CPR)
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Objectives
• American Heart Association (AHA) recommends the use of capnography not only for confirmation of tracheal tube placement but also to monitor the effectiveness of chest compressions during CPR.
• After reviewing this brief clinical concept, the code leader will be able to interpret capnography to direct CPR more effectively
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Definitions
• PETCO2: The maximum partial pressure of CO2 at the end a breath. It is about 36- 40 mm Hg in healthy adults.
• PACO2: Partial pressure of CO2 in the alveoli.
• Capnogram: A plot of PCO2 versus time (time capnogram), or expired volume (volume capnogram). Time capnogram is common in clinical practice
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Basic Physiology
• When you inhale CO2 free air, and exhale and measure CO2 at the mouth, you get the following tracing
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Basic Physiology
The expiratory segment divided into three phases phase I, II, and III
Phase I: Dead space gases Phase II: Dead space gases mix with alveolar gases resulting in the rise of PETCO2
Phase III: Represent CO2 evolving from alveoli
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Basic Physiology
The height and slope of the alveolar plateau (phase III ) is dependent on CO2 content of the alveoli. The CO2 content is in turn dependent on V/Q ratio of the alveoli. High V/Q alveoli contain relatively low PCO2, while low V/Q alveoli contain relatively high PCO2
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Basic Physiology
Hence, it can be concluded that the height and the slope of the alveolar plateau is dependent on Ventilation, cardiac output and more importantly on V/Q relationship.
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Basic Physiology
As for example in COPD, the V/Q perfusion abnormalities result in sloping phase II and phase III
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Basic Physiology
Hypoventilation
Hyperventilation
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In the acute settings, for a given ventilation, PETCO2 is function of cardiac output (pulmonary perfusion). This is the basic principle of directing the uses of capnography during CPR
Basic Physiology
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Utility of Capnography in CPR
• Most reliable method of confirming and monitoring correct placement of endotracheal tube.
• If there is no CO2 waveform during CPR, rule out esophageal intubation
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CO2 waveform during CPR
Optimize chest compression for effective CPR so that PETCO2 values are between 10 and 20
mm Hg. If PETCO2 values less than 10 mm Hg or less measured after initiation of ACLS is
associated with poor outcome
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A B
An abrupt increase in PETCO2 may indicate return of
spontaneous circulation (ROSC). Increase in pulmonary
circulation brings more CO2 into lungs for elimination
CO2 waveform during CPR
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Code Leader - Duties
• Delegate someone to check Check if CO2 monitor is working
• After intubation, look for CO2 waveforms during chest compressions. A flat tracing should alert for a misplaced ET tube.
• Monitor effectiveness of CPR by ensuring PETCO2 values between 10 to 20 mm Hg.
• An abrupt increase in PECO2 values indicate ROSC
Make sure that the CO2 monitor and ECG are visible to the Code Team Leader
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References
• Br J Anaesth 2011;106:632-42
• Anaesthesia 2011;66:544-9
• JAMA 1989;262;1347-51
• Resuscitation 2012;83:789-90
• Resuscitation 2012;83:813-8
• N Engl J Med 1997;337:301-6
• Acad Emerg Med 2011;18:468-75
• Crit Care 2011;15:R29
• Mayo Clinic Proceedings 2011;86:544-8
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Questions 1
• American Heart Association recommends capnography during CPR for:
(a) Confirming tracheal tube placement
(b) Monitoring Ventilation
(c) Monitoring effectiveness of chest compressions
(d) A and C
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Answer
(d)
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Questions 2
• During CPR the code leader sees that there is no CO2 waveform. What is most likely?
(a) Ineffective CPR
(b) Hypovenitlation
(c) Esophageal intubation
(d)Low cardiac output
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Answer
(c)
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Questions 3
• Which of the following is not true?
(a) During acute hemodynamic instability, PETCO2 is a direct function of cardiac output.
(b) Effective CPR will result in PETCO2 values between 5-10mmHg
(c) An abrupt increase in PETCO2 indicates ROSC
(d) Capnogarphy is the most reliable method of confirming endotracheal tube placement during CPR
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Answer
(b)
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Questions 4
• The height of the slope of the alveolar plateau on the capnogram is dependent on:
(a) Ventilation
(b) Cardiac output
(c) V/Q ratio
(d) All of the above
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Answer
(d)
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Questions 5
• An abrupt increase in PETCO2 may indicate:
(a) Effective CPR
(b) Return of spontaneous circulation
(c) Hypoventilation
(d) Hyperventilation
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Answer
(b)