Draegerwerk Ag & Co. Kgaa · XETR:DRW8
Draegerwerk Ag & Co. Kgaa — Dräger — Technical Presentation (2021)
35 slides from Draegerwerk Ag & Co. Kgaa's technical presentation, 2021
Slide 1: Dräger
Slide 2: Capnography: Clinical insights
Capnography Clinical insights © 2021 Draeger Medical Canada Inc.“
Slide 3: Introduction
Introduction EtCO2 monitoring can be invaluable when assessing cardiopulmonary status particularly when a patient is receiving oxygen therapy as this may mask the presence of respiratory compromise (SpO2 may remain normal while ventilation is compromised). © 2021 Draeger Medical Canada Inc.“
Slide 4: Objectives
Objectives •Understand the role of capnography in therapeutic interventions •Identify types of CO2 monitoring •Identify indications for capnography measurement •Identify factors affecting the results of EtCO2 measurements •Discuss the role of volumetric CO2 in guiding therapy © 2021 Draeger Medical
Slide 5: General Principles of CO2 Measurement
General Principles of CO2 Measurement •Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO2) in respiratory gases (typically expressed in mmHg). •EtCO2 is frequently used to assess a patients’ gas exchange and help guide therapy (often used for trending betwe
Slide 6: General Principles of CO2 Measurement
General Principles of CO2 Measurement Factors contributing to gas exchange: •Ventilation •Perfusion •Diffusion © 2021 Draeger Medical Canada Inc.“
Slide 7: General Principles of CO2 Measurement
General Principles of CO2 Measurement How can using capnography assist the Clinician in making therapeutic decisions? • The normal lung has varying degrees of ventilation/perfusion matching because of the uneven distribution of ventilation and blood flow (caused by anatomical dead space and gravity)
Slide 8: General Principles of CO2 Measurement
General Principles of CO2 Measurement Monitoring capnography allows the clinician to guide their therapeutic interventions: • Identify efficacy of bag-mask ventilation and ensure appropriate MV • Assess cardiopulmonary resuscitation efforts (evaluate efficacy of chest compressions and identify ROSC)
Slide 9: General Principles of CO2 Measurement
General Principles of CO2 Measurement Monitoring capnography allows the clinician to guide their therapeutic interventions: • Rapidly identify ventilatory compromise • Identify metabolic issues such as Malignant Hyperthermia during Anesthesia • Assess effectiveness of recruitment maneuvers • Guide t
Slide 10: Examples of factors affecting V/Q ratio
Examples of factors affecting V/Q ratio Dead space ↑: • Addition of equipment between patient’s mouth and Y-piece • Hyperinflation or over-distension of the lungs (causes collapse of pulmonary vessels and therefore decreases perfusion) • Any process that causes vasoconstriction or blockage of blood
Slide 11: General Principles of CO2 Measurement
General Principles of CO2 Measurement Mainstream • Analysed at the patient wye • Additional weight on circuit/ETT (although units now are much smaller/lighter) • Generally for intubated patients only • Real time analysis • More susceptible to condensation and secretions
Slide 12: General Principles of CO2 Measurement
General Principles of CO2 Measurement Sidestream • Gas samples are drawn from the ventilator circuit and analysed • Delay in values due to distance the sample has to “travel” before being analysed • Patient does not have to be intubated • ~100-200 ml/min sampling rate • Infrared Spectroscopy: Sample
Slide 13: A Normal Capnograph
A Normal Capnograph A rapid rise in A plateau CO2 after the towards the pause end of absence of exhalation obstructive processes exhalation is affecting gas flow complete (zero or minimal gas flow) prior to the next inspiration A brief pause at the ETCO2 value beginning of stable approx. 2-5 expirat
Slide 14: PaCO2 - ETCO2 Gradient: What does it tell us?
PaCO2 - ETCO2 Gradient: What does it tell us? PaCO2 - ETCO2 Gradient • In healthy lungs normal gradient Arterial PaCO2 is 2 – 5 mmHg • Gradient increases with V/Q mismatching • An acute decrease in ETCO2 may indicate a decrease in pulmonary perfusion • A large gradient could also be caused by incomp
Slide 15: So Why the Difference Between PaCO2 and ETCO2?
So Why the Difference Between PaCO2 and ETCO2? 1. Arteriovenous Admixture 2. Mixing of gases 3. V/Q
Slide 16: Why is my EtCO2 so much lower than PaCO2?
Why is my EtCO2 so much lower than PaCO2? PaCO2 = 50 Normal V/Q Scenario EtCO2 = 46 PACO2 = 48 PACO2 = 44 PaCO2-ETCO2 Gradient = 4 © 2021 Draeger Medical Canada Inc.“
Slide 17: Why is my EtCO2 so much lower than PaCO2?
Why is my EtCO2 so much lower than PaCO2? Poor V/Q Scenario: PaCO2 = 50 EtCO2 = 20 PACO2 = 40 PACO2 = 0 PaCO2-ETCO2 Gradient = 30
Slide 18: What will affect the CO2 Content in Exhaled Gas?
What will affect the CO2 Content in Exhaled Gas? • CO2 production in the cells • CO2 transport • CO2 elimination in the lungs
Slide 19: Physiological states affecting CO2 values
Physiological states affecting CO2 values Increases CO2 Decreases CO2 •Fever •Pulmonary embolism •Sepsis •Cardiac arrest •Malignant hyperthermia •Hypothermia •Bicarbonate bolus •Hyperventilation •Increased cardiac output •Hypometabolic state •ROSC •Hypotension •COPD •Decreased cardiac output •Esopha
Slide 20: Interpreting the Waveform
Interpreting the Waveform Normal Abnormal PaCO2 }ETCO 2 Plateau } ETCO2 Rise Return to “0” Normal range: 35-45 mmHg
Slide 21: Waveform Interpretation
Waveform Interpretation Falling ETCO2 Readings Rising ETCO2 Readings 1. Hyperventilation 1. Hypoventilation 2. Pulmonary embolism 2. Fever 3. Shock 3. Increased metabolic rate 4. Blood loss 4. Improving V/Q 5. Ventilator Changes 5. Sedation ( LOC)
Slide 22: Waveform Interpretation
Waveform Interpretation Upsloping (No expiratory plateau) Rising Baseline 1. Obstructive disease 1. Rebreathing (exhalation valve a. Asthma or soda lime) b. COPD 2. (mechanical) deadspace 2. Partial Airway Obstruction 3. Incomplete exhalation (air- 1. Kinked ETT trapping) 2. Mucous Plug
Slide 23: Waveform Interpretation
Waveform Interpretation Low End Tidal Measurements High End Tidal Measurements 1. Hyperventilation 1. Hypoventilation 2. Hypometabolic State ( CO2 2. Hypermetabolic State production) 3. Hypothermia 3. Hyperthermia 4. Hypothyroidism 4. Hyperthyroidism 5. Perfusion issue 6. CO2 transport issue
Slide 24: Waveform Interpretation
Waveform Interpretation Loss of Plateau Oscillations 1. Increased expiratory 1. Cardiac oscillations (more common in Ped/Neonatal patients) resistance 2. TEXP too short 3. Obstructive airway disease with rapid RR
Slide 25: End Tidal CO2 vs. Volumetric CO2 Measurement
End Tidal CO2 vs. Volumetric CO2 Measurement End Tidal CO2 Volumetric CO2 (V’CO2) • Time Based • ETCO2 + • Value obtained at end-expiration • CO2 Elimination • Capnogram • Volume of CO2 exhaled • Respiratory Rate • Deadspace • Vd/Vt • Alveolar Ventilation
Slide 26: Volumetric CO2 on the V500
Volumetric CO2 on the V500 Volume – CO2 Loop CO2 (elimination) = CO2 concentration X flow X time © 2021 Draeger Medical Canada Inc.“
Slide 27: CO2 Elimination (V'CO2)
CO2 Elimination (V’CO2) - Volume of CO2 expelled from the lungs over a minute - Normal ~ 200ml/min - Provides continuous information regarding ventilation and perfusion - Provides immediate indication of changes in gas exchange with changes in ventilator settings © 2021 Draeger Medical Canada Inc.“
Slide 28: Clinical Example: CO2 Removal Challenge
Clinical Example: CO2 Removal Challenge ΔP 36 cmH2O PaCO2 = 68 PaCO2 - ETCO2 gradient = 24 © 2021 Draeger Medical Canada Inc.“
Slide 29: Decrease RR and ΔP set, Increased PEEP
Decrease RR and ΔP set, Increased PEEP Decreased ΔP from 36 to 26 (Pinsp & PEEP) © 2021 Draeger Medical Canada Inc.“
Slide 30: Decreased ΔP
Decreased ΔP © 2021 Draeger Medical Canada Inc.“
Slide 31: Result of decreasing RR but increasing PEEP
Result of decreasing RR but increasing PEEP PaCO2-ETCO2 Gradient = 24 PaCO2 = 68 PaCO2-ETCO2 Gradient = 10 PaCO2 = 60 © 2021 Draeger Medical Canada Inc.“
Slide 32: CO2 Monitoring Summary
CO2 Monitoring Summary • EtCO2 is extrapolated from the highest point on the Capnogram • If ETCO2 not correlating, consider volumetric monitoring to track effects of ventilator changes • May not correlate with PaCO2 in the following clinical situations: 1. Increase V/Q mismatch 2. Air-trapping --→ i
Slide 33: CO2 monitoring summary
CO2 monitoring summary Capnography is a useful monitoring tool that can provide the clinician with vital information regarding patient cardiopulmonary status. • PEEP Titration: If V’CO2 increases = PEEP increase or decrease has improved V/Q. • Tidal Volume/MV: Should see an increase in V’CO2 with in
Slide 34: Many thanks
Many thanks Seana Martin, Marketing Manager Clinical Education © 2021 Draeger Medical Canada Inc.“
Slide 35: Drager. Technology for Life
Drager. Technology for Life®