Capnography – ETCO2 monitoring and the way forward

Capnography now readily available to most paramedics and should be the prehospital standard of care for confirmation and continuous monitoring of intubation, as well as for monitoring ventilation and perfusion in any respiratory pt encountered. Additionally, it should see increasing use in the monitoring of any unstable patient of any aetiology, as well as optimizing trending within your perfusion assessment.images

Traditionally (here in the Lower Mainland of BC) in line ETCO2 was used only for the confirmation of tube placement in the intubated patient. Many resourceful practitioners saw the value of this tool and creatively would snip away the in line T piece, inserting the now open hosing into a simple face mask and then having access to microstream™ capnography technology and real time ventilatory telemetry in the conscious patient.

Many practitioners are now utilizing the dual purpose nasal ETCO2/O2 cannula to monitor any patient that is presenting with an increased WOB or complaining of SOB. This simple tool provides a clinical upgrade that allows one to immediately assess and real time trend the ventilatory status of any patient. In combination with physical assessment, historical findings, pharmacological interventions, ETCO2 now becomes another high yield vital sign available to the prehospital practitioner in quest of differential diagnosis in the respiratory patient.

Notable uses of capnography that are emerging (in addition to traditional indications) throughout current practice include;

  1. Upon arrival to a patient that is being ventilated by BVM by FR or PCP crews, the early application of ETCO2 monitoring allows the attendant to assess the efficacy and appropriateness of the ventilation strategy currently provided. i.e. overdose, asthma, CHF, COPD, cardiac arrest etc
  2. Application of ETCO2 monitoring in the altered/post ictal/head injured/sedated patient to assist in monitoring ventilatory status via telemetry throughout extrication and transport.
  3. Assessment of ETCO2 waveform characteristics in CHF/COPD exacerbation to differentiate between bronchspasm and bronchoedema for appropriate pharmacological interventions.
  4. ETCO2 in combination with SPO2 waveform telemetry to ensure not only appropriate oxygenation but adequate ventilation.
  5. Monitoring of ETCO2 in the hyperventilating patient to assist in the coaching of the individual to slow their respiratory rate along with the telemetry to gauge the efficacy of your coaching.
  6. ETCO2 monitoring throughout resuscitation as an early indicator of ROSC. i.e. spike in ETCO2 = ROSC.
  7. ETCO2 monitoring in the intubated patient throughout extrication and transport to flag displaced or dislodged ETT.
  8. ETCO2 monitoring in the chemically sedated patient to ensure the adequacy of ventilatory effort post sedation.

UnknownAs more research is done, the role of capnography in prehospital medicine will continue to grow and evolve. We look forward to hearing about your creative practical application of prehospital capnography.

This excellent link from MedicScribe further outlines the science and need to know content for all prehospital practitioners considering diversifying and maximizing their use of capnography in the prehospital environment.
http://medicscribe.com/capnography/

Finally, micro stream technology does not require a closed circuit to monitor accurate ETCO2 trending in your pt. Manufacturers and supporting documentation found here outlines the technological advances in micro stream technology in the nasal ETCO2 (non intubated) use of waveform capnography monitoring and requires breath sample sizes of only 50ml/min.

Keeping it light to close….lessons for us all.
If not the education…skip to the entertainment at 9.50 min