Capnography in EMS - faculty at Chemeketa

Presentation by Steve Jones
Capnography: The New smoke in EMS
Paramedic Care: Introduction to Advanced Prehospital
Care Vol.1
CASE 1 “Link Goes Down”
Meet Link, an above
average kind of guy,
enjoying the life of
retirement after his
hit show the Mod
Squad. Until…
Link crashes to the floor
right in front of his EMT
friend, “hot dog” Paramedic
Henry Jackson. Henry right
away does his ABC’s, gets a
monitor on ol’ Link and
noticed his SpO2 was 99.
Thinking that Link was
ventilating okay, Henry
decided to double check by
putting the nasal cannula
with the capnography device
on Link to see what his
PetCO2 was. Well this is
what he saw….
Holy baby
He saw an indication of a
small amount of CO2
showing on the monitor.
Link’s ETCO2 level was low.
This meant that his PaCO2
was probably high. Quickly a
BVM, with O2, was applied
to assist Link with his
breathing. But in all the
excitement Henry started to
Hyperventilate good Ol’
Link. Henry happened to
look at to monitor again and
… a large amount of CO2 was
showing on the monitor. Link
was now exhaling too much
CO2. Henry said to himself,
“Slow down little doggie.”
Well, Henry did eventually
get it right, thanks to
Capnography, and Ol’ Link
ended up being back to his old
self ….
And once again
enjoying life
after his hit
show, the Mod
So what is capnography?
 “CO2 is the smoke from the flames of metabolism.”– Ray
Fowler, M.D. Dallas, Street Doc’s Society
 Metabolism generating CO2 is like an automobile
generating exhaust.
 Capnography is the tool that
detects and measures the
Capno (kapnos) – graphy (graphos) (Kapnos=smoke)
(graphos=to write or record data)
“To record the smoke”
Capnography – the measurement of carbon dioxide (CO2) in
exhaled breath.
Capnometer – the numeric measurement of CO2.
Capnogram – the wave form.
End Tidal CO2 (ETCO2 or PetCO2) - the level of (partial
pressure of) carbon dioxide released at end of expiration.
Capnography: Ventilation vs.
 Oxygenation is how we get oxygen to the tissue. Oxygen is
inhaled into the lungs where gas exchange occurs at the
capillary-alveolar membrane. Oxygen is transported to the
tissues through the blood stream. Pulse oximetry measures
At the cellular level, oxygen and glucose combine to produce
energy. Carbon dioxide, a waste product of this process (The
Krebs cycle), diffuses into the blood.
Ventilation (the movement of air) is how we get rid of carbon
dioxide. Carbon dioxide is carried back through the blood and
exhaled by the lungs through the alveoli. Capnography measures
Krebs Cycle
Capnography versus Pulse Oximetry
 Capnography provides an immediate picture of patient
condition. Pulse oximetry is delayed. Hold your
breath. Capnography will show immediate apnea,
while pulse oximetry will show a high saturation for
several minutes.
Circulation and Metabolism
 While capnography is a direct measurement of
ventilation in the lungs, it also indirectly measures
metabolism and circulation. For example, an increased
metabolism will increase the production of carbon
dioxide increasing the ETCO2. A decrease in cardiac
output will lower the delivery of carbon dioxide to the
lungs decreasing the ETCO2.
“CO2 is the smoke from the flames of metabolism.”–
Ray Fowler, M.D. Dallas, Street Doc’s Society
ETCO2 in Asthma, COPD, and CHF
End-tidal CO2 monitoring on non-intubated
patients is an excellent way to assess the
severity of Asthma/COPD, and the
effectiveness of treatment. Bronchospasm
will produce a characteristic “shark fin” wave
form, as the patient has to struggle to exhale,
creating a sloping “B-C” upstroke. The shape
is caused by uneven alveolar emptying.
Fig. 2
Multiple studies have confirmed the sloping shape
correlates to bronchospasm and obstructive lung disease.
Respiratory Assessment & Treatment
“One issue for many paramedics, both experienced and new to the street, is lung
sound auscultation and definition. Is that high-pitched sound wheezing, rales,
something else? In one previous set of protocols, our respiratory treatment algorithm
divided in part based on lung sounds. If the patients had wheezes, they received
albuterol and epinephrine. If it was rales, they received nitroglycerin, lasix, and
One comment heard often in the field is just to treat respiratory issues with albuterol.
Although albuterol has several positives in the treatment of some respiratory
diseases, it is certainly not a cure-all by any means. Its cardiac side effects should
always be taken into consideration, and a patient whose respiratory condition is
secondary to their cardiac problem could deteriorate from inappropriate albuterol
Lung sounds and dispatch information are not enough. Thorough assessment
is required in any patient, but capnography can take us another step into the
realm of definitive respiratory assessment and treatment by giving us another
tool to better care for our patients.” Capnography: The New Smoke in EMS
ETCO2 readings can also be used to assist in difficult
intubations of spontaneously breathing patients.
“Paramedics can attach the capnography filter to
the ET tube prior to intubation and, in cases
where it is difficult to visualize the chords, use the
monitor to assist placement. This includes cases
of nasal tracheal intubation.”
 You’re Out! (missed the
 You’re In!
Reason ETCO2 is zero: The tube is
in the esophagus.
A good wave form indicating the
presence of CO2 ensures the ET
tube is in the trachea.
When a person hypoventilates,
their CO2 goes up.
When a person hyperventilates,
their CO2 goes down.
The use of
capnography in the
emergency medical
field is a plan that
should be
implemented at all
agencies. After all,
wouldn’t it be nice to
see a smile back on
the face of the
patients we help?
Just like Link’s smile
Credits for “Link Goes Down”
Link - Himself
CO2 large – Cheryl Jones
CO2 small – Grand daughter Payten Jones
Henry Jackson Jones as “Hot Dog Paramedic Henry Jackson”

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