This site uses cookies. By continuing, your consent is assumed. Learn more

130.4m shares

Standards mandating capnography monitoring

opinion

In the past few decades, assessment of exhaled CO 2 in both intubated and non-intubated patients has evolved into an essential component in many aspects of patient monitoring. Besides the basic assessment of ventilation, exhaled CO 2 monitoring Standards mandating capnography monitoring provide valuable patient safety information and critical physiologic data in regard to the ventilation and perfusion matching in the lungs, Standards mandating capnography monitoring output, and metabolic rate.

Despite these important clinical monitoring benefits and widespread availability, exhaled CO 2 monitoring is often underutilized.

The purpose of this paper is to review the importance and present the extensive body of knowledge to support the use of exhaled CO 2 monitoring in various areas of clinical practice. Advanced application concepts and the future development Standards mandating capnography monitoring exhaled CO 2 monitoring will also be discussed.

The measurement of CO 2 in air was first developed around and performed to analyze gas concentrations in mines.

of Evidence III studies]), stating,...

The Standards mandating capnography monitoring of absorbed CO Standards mandating capnography monitoring was then compared with the total gas volume, which yielded the fraction or percentage of CO 2 present. A decade Standards mandating capnography monitoring, a technique Standards mandating capnography monitoring mandating capnography monitoring developed to analyze exhaled CO 2 from a single breath during vigorous exercise.

The collected CO 2 in each bag was then Standards mandating capnography monitoring multiple times to yield the average CO 2which was plotted over time, thus resulting in the first exhaled capnogram. By the s, exhaled CO 2 was monitored in ICUs using Standards mandating capnography monitoring spectrometry systems that aspirated exhaled Standards mandating capnography monitoring through long lengths of capillary tubing to a central monitoring location.

The technological advancement of exhaled CO 2 monitoring has coincided with the progression of use and importance in clinical practice.

The significance of exhaled CO 2 monitoring extends well beyond the very basic utilization Standards mandating capnography monitoring monitoring the adequacy of ventilation. Detection of exhaled CO 2 has proven to be an invaluable mechanism for confirming tracheal intubation, recognizing accidental esophageal intubations, and Standards mandating capnography monitoring critical patient safety benefits.

The patient protection enhancements provided by CO 2 monitoring also include: Of critical significance is the use of P ETCO 2 to gauge the effectiveness of cardiopulmonary resuscitation CPRto predict outcome, and to guide the continuation of resuscitation efforts.

The recognition and importance of monitoring exhaled CO 2 in many areas of patient Standards mandating capnography monitoring has led to the expanding recommendation for its use by regulatory agencies and inclusion Standards mandating capnography monitoring the standards and Standards mandating capnography monitoring guidelines of many professional organizations, such as the American Society for Anesthesia ASAthe American Heart Association, the American Association for Respiratory Care, the Joint Commission, and the Centers for Medicare and Medicaid Services.

Despite this heightened level of awareness and the regulatory and organizational guidance, exhaled CO 2 monitoring is often underutilized. The reasons for this disparity between knowledge and practice may be due in part to the cost burden of acquiring the technology; the clinician time required for set-up, maintenance, and troubleshooting; and the lack of awareness of best practices for optimal utilization.

Universally accepted standards of care mandating the use of CO 2 monitoring in specific circumstances or patient categories yielding the highest potential to impact patient safety and influence outcomes are also lacking. The purpose of Standards mandating capnography monitoring review is to increase the awareness and understanding of health-care providers of the importance of exhaled CO 2 monitoring and Standards mandating capnography monitoring application in clinical practice.

An appraisal of the different technologies will be followed by a review of Standards mandating capnography monitoring recognized indications for monitoring and an assessment of the potential for further advancements in exhaled CO 2 monitoring.

Understanding available Standards mandating capnography monitoring and how they functions can Standards mandating capnography monitoring important insights into their appropriate application, potential limitations, and problems associated with use. The following is a brief review of the classification and types of exhaled CO 2 monitoring commonly utilized. Standards mandating capnography monitoring CO 2 detectors provide continuous qualitative and semi-quantitative exhaled CO 2 monitoring.

Colorimetric CO 2 detectors are the simplest form of Standards mandating capnography monitoring 2 monitors. They are portable, disposable, inexpensive, single-use devices that can rapidly detect and confirm tracheal intubation and estimate the amount of CO 2 in exhaled gas. Colorimetric detectors contain Standards mandating capnography monitoring treated material that is pH-sensitive and colorimetrically reflects CO 2 concentrations in expired gas.

Mainstream CO 2 monitoring devices utilize a small infrared sensor consisting of a sample cell or cuvette and an infrared optical bench placed Standards mandating capnography monitoring the gas flow pathway at the airway. This measurement location results in real-time CO 2 values within the airway and a real-time graphical representation of the CO 2 waveform plotted over time or by the exhaled volume.

Disadvantages of mainstream CO 2 monitoring include: Also, many mainstream devices are limited to use with intubated patients only. Sidestream CO 2 monitoring devices aspirate a gas sample from a ventilator breathing circuit or other patient Standards mandating capnography monitoring device through a length of Standards mandating capnography monitoring tubing.

Different interface designs for use on non-intubated patients incorporate nasal and oral sampling points to Standards mandating capnography monitoring measurement accuracy. Several interface designs include the ability to simultaneously administer oxygen through a split channel device.

Sidestream sampling devices utilize an infrared CO 2 sensor in a monitor located away from the patient and can only be displayed in a time-based waveform.

Time-based sidestream CO 2 monitoring is the type more commonly used in the operating room setting, during non-intubated patient monitoring, and during CPR. The sidestream sample method often requires use of a water trap and or specialized tubing Standards mandating capnography monitoring removes water Standards mandating capnography monitoring before analysis to prevent blockage and contamination of the sample tubing.

Sample Standards mandating capnography monitoring located away from the patient results in a time delay often several seconds in duration before measured results are displayed.

Since sidestream sampling requires a continuous aspirated sample flow rate from the ventilator circuit, interference Standards mandating capnography monitoring the measurement of ventilation parameters and the triggering mechanism can occur. Also, when sidestream systems are used intra-operatively with inhaled anesthetic agents, a scavenging system is required to prevent ambient contamination and health-care provider exposures.

Capnometry is performed by a capnometer. A capnometer is a monitor that measures CO 2 concentrations in respired gases over time Standards mandating capnography monitoring displays numeric values for P ETCO 2respiratory frequency, and Standards mandating capnography monitoring the inspired CO 2 concentration or partial pressure.

Capnometers can be either mainstream or sidestream in design. The terms capnometry and capnography are often used synonymously, but in contrast to capnometry, capnography Standards mandating capnography monitoring performed by a capnograph, Standards mandating capnography monitoring monitor that is functionally the same as a capnometer but incorporates the additional feature Standards mandating capnography monitoring displaying the CO 2 waveform known as a capnogram Fig.

Capnographs can also be mainstream or sidestream in design. The additional clinical monitoring value of capnography is the ability to Standards mandating capnography monitoring interpret the waveform and morphology of the capnogram. The value of viewing the capnogram is synonymous with the revelation of knowing the heart rate and seeing the electrocardiogram.

Interpretation of the different phases; the shape, area, and slope of the capnogram segments; and integration of the exhaled capnogram to exhaled tidal volume Standards mandating capnography monitoring clinically valuable information regarding ventilation and perfusion and cardiopulmonary physiology.

Exhaled CO 2 monitoring is essential and useful in clinical practice for an array of monitoring indications, including ventilation, circulation, metabolism, improving patient safety, and influencing and predicting outcomes Standards mandating capnography monitoring care. Following is a review of Standards mandating capnography monitoring indications for exhaled CO 2 monitoring for in- and out-of-hospital monitoring of intubated and non-intubated adult and pediatric patients.

Continuous monitoring of exhaled CO 2 from the onset of intubation to extubation, whether by capnometry or capnography, is an accepted method to ensure adequate ventilation during mechanical ventilation in both adult and pediatric patients.

As a reflection of this potential benefit, the ASA has identified CO 2 monitoring as Standards mandating capnography monitoring standard of care in anesthesia monitoring since It has been suggested that the lack of agreement with P aCO 2 in diseased lungs has Standards mandating capnography monitoring impacted the perception of value and Standards mandating capnography monitoring use of CO 2 monitoring.

Perhaps one of the most significant impacts of exhaled CO 2 monitoring is in its use as a definitive Standards mandating capnography monitoring for confirming endotracheal intubation and the reduction in harm associated with identifying the serious consequences of accidental esophageal intubation, death and anoxic brain injury. Use of a CO 2 monitor in addition to direct visualization of the endotracheal Standards mandating capnography monitoring passing through the vocal cords represent the accepted standards in clinical practice for confirming intubation in adult, pediatric, and neonatal patients.

Capnography and capnometry compared with auscultation have been shown to be the most reliable methods to confirm endotracheal Standards mandating capnography monitoring placement in the prehospital emergency setting.

Recognition of Standards mandating capnography monitoring important facts by the ASA, 2854 the American Association for Respiratory Care, 55 the American Heart Association, 5657 Emergency Medical Services systems, 4258 the Intensive Care Society in the United Kingdom, 42 the Royal College of Anesthetists, and the Association of Anesthetists of Great Britain and Ireland, 16 has resulted in the inclusion of the use of CO 2 monitoring during intubations in their respective standards of practice, clinical practice guidelines, and practice recommendations.

This compelling body of evidence mandates the use of CO 2 monitoring during intubation as a universal standard of care Standards mandating capnography monitoring confirming Standards mandating capnography monitoring intubation.

The standards for capnography were...

The use of exhaled CO 2 to monitor respiratory status is another area of growing significance and interest. Exhaled CO 2 offers an accurate and reliable means of measuring respiratory frequency.

New standards of monitoring which...

An elevated respiratory frequency is a sensitive Standards mandating capnography monitoring reasonably specific marker of respiratory dysfunction. Standards mandating capnography monitoring respiratory depression in the post-anesthesia care period is a major concern emphasized by ASA-mandated standards, 28 the Joint Commission Sentinel Event Alerts, 61 and the Centers for Medicare and Medicaid Services Regulations and Interpretive Guidelines for Hospitals.

A significant limitation to consider while using P ETCO 2 monitoring to detect respiratory depression is that there are 2 different types of drug-induced hypoventilation Table 1.

Type 1 or Standards mandating capnography monitoring hypoventilation is characterized by a decreased respiratory frequency, a slightly decreased tidal volume, and an increased P ETCO 2 and P aCO 2. Type 2 or hypopneic hypoventilation, on the other hand, is characterized by a significant Standards mandating capnography monitoring in tidal volume, slightly decreased respiratory frequency, and Standards mandating capnography monitoring decreased or normal P ETCO 2whereas the Standards mandating capnography monitoring aCO 2 can be elevated.

This significant distinction between bradypneic and hypopneic hypoventilation is critical for clinicians to acknowledge and comprehend. Another area of concern is the growing evidence that the use of patient-controlled analgesia PCA imposes significant risks to patients and potential liability exposure to health-care providers and hospitals.

This has led to serious and fatal outcomes considered possibly preventable if P ETCO 2 monitoring were being used. Furthermore, the value of CO 2 monitoring during procedural sedation 826287179 Standards mandating capnography monitoring, 80 and in the emergency department as an early indication Standards mandating capnography monitoring respiratory depression, especially when Standards mandating capnography monitoring are receiving oxygen, 658182 to aid in the identification of the Standards mandating capnography monitoring of illness and to improve patient safety 137083 — 85 is also increasingly being mandated for adult and pediatric patients.

It has been well substantiated that exhaled CO 2 monitoring during CPR provides invaluable information regarding the correct placement of an advanced airway, 285052565786 the effectiveness of cardiac compressions, 5686 — 88 the return of spontaneous circulation, 5686878990 and the prediction of outcome and survival during cardiac arrest. The value of exhaled CO 2 monitoring as a guide to the effectiveness of cardiac compressions was first demonstrated in from a series of 3 patients during CPR.

Mean end tidal carbon dioxide P ETCO 2 Standards mandating capnography monitoring between survivors and non-survivors after 20 min of advanced cardiac life support during out-of-hospital cardiac arrest.

tive monitoring of the volume...

Data from Reference Additional investigations also demonstrated that changes in P ETCO 2 during resuscitation attempts predicted outcomes and return of spontaneous circulation, 89suggesting that P ETCO 2 could be useful Standards mandating capnography monitoring deciding when to terminate resuscitation efforts Standards mandating capnography monitoring adult and pediatric patients.

P ETCO Standards mandating capnography monitoring monitoring during CPR can be an effective tool to detect the effectiveness of external cardiac compression and the development of rescuer fatigue. Time-compressed capnograms of end-tidal carbon dioxide P ETCO 2 during Standards mandating capnography monitoring resuscitation CPRshowing ineffective cardiac compressions or rescuer fatigue A and return of spontaneous Standards Standards mandating capnography monitoring capnography monitoring B.

The use of quantitative waveform capnography interpretation has been incorporated into advanced cardiac life support training to confirm advance airway placement and to monitor resuscitation effectiveness since Volumetric capnography differs from standard capnography in that exhaled CO 2 is plotted against the exhaled tidal volume. Analysis of the phases of the volumetric capnogram, the shape and curve morphology, and measurements based on calculations from the volumetric capnogram can reveal important information in regard to the efficiency of ventilation and perfusion, the physiologic dead space fraction, and the metabolic rate of the patient.

The 3 phases of the volumetric capnogram are synonymous with the phases of the time-based capnogram. Phase 1 Standards mandating capnography monitoring emptying of the anatomic dead space the conducting airwayswhere exhaled CO 2 is near zero. Phase 2 represents a mixture of gas from the anatomic dead space and alveolar gas containing CO 2. Phase 3 signifies emptying Standards mandating capnography monitoring alveolar air spaces also known as the alveolar plateauthe end Standards mandating capnography monitoring mandating capnography monitoring of which is equal to the end-tidal CO 2 Fig.

The 3 phases of the exhaled CO 2 volumetric capnogram indicate the different stages of airway and alveolar gas emptying and terminate at the end-tidal carbon dioxide P ETCO 2. Using the principles described by Fowler, the anatomical dead space volume can be identified and measured by computer analysis of the volumetric capnogram.

When phase 2 is dissected by a vertical line originating from a line superimposed on the incline of phase 3, the intersection at the x axis such that Standards mandating capnography monitoring 2 areas on either side of the vertical line that are equal in Standards mandating capnography monitoring can be created.

This point of intersection and equivalent Standards mandating capnography monitoring is equal to the anatomic dead space volume on the volumetric capnogram Fig.

From References and Anatomical dead space in male and female volunteers at rest was originally approximated to be and mL, respectively. The ability to measure anatomical dead space by volumetric capnography enables the components of physiologic dead space to be partitioned by single-breath analysis. The single-breath CO 2 waveform analysis builds upon identification of the Fowler Standards mandating capnography monitoring dead space and enables extraction of additional information regarding ventilation efficiency and further analysis and study of physiologic dead space.

When the perpendicular line that identifies the anatomic dead space is drawn through the volumetric capnogram to the x axis, the point of intersection to this line from an additional line superimposed on phase 3 of the capnogram allows the component volumes in a exhaled tidal breath to be Standards mandating capnography monitoring Standards mandating capnography monitoring anatomical V Dalveolar V Dand alveolar V TFig.

From Referencewith permission. This dissection of the volumetric capnogram area allows further study of the various components and their relationships. A shark's fin volumetric capnogram of a patient diagnosed with ARDS with elevated dead-space fraction. Also, the gas collection bag method is no longer feasible due to the common presence of bias flow on current ventilators. P ACO 2 is affected by the dilution of CO 2 from the alveolar side of the alveolar-capillary membrane from gas exchange units with low or no perfusion.

Bohr dead space is recognized as true dead space, or the balance between effective and ineffective ventilation occurring in the lungs Fig.

The pure shunt compartment represents areas of perfusion without ventilation.

MORE: Parental online monitoring

News feed