CPP - Waveform Capnography
CPP - Waveform Capnography
CPP - Waveform Capnography
Assessment/Waveform capnography
Policy code CPP_AS_WC_0120
Date January, 2020
Purpose To ensure a consistent procedural approach to waveform capnography.
Scope Applies to Queensland Ambulance Service (QAS) clinical staff.
Health care setting Pre-hospital assessment and treatment.
Population Applies to all ages unless stated otherwise.
Source of funding Internal – 100%
Author Clinical Quality & Patient Safety Unit, QAS
Review date January, 2023
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Waveform capnography
January, 2020
T ED
throughout the respiratory cycle. CO2 provides valuable information on ventilation, haemodynamics
U NC O NTR O L L ED WH E N PR IN
and metabolism in both intubated and non-intubated patients [1]. The corpuls3 mainstream
capnometer measures the CO2 concentration in the patient’s expiratory breath (EtCO2) in real
time, with the peak value displayed numerically in mmHg. A ‘normal’ EtCO2 is considered between
35–40 mmHg, however results may be influenced by various physiological factors.
Waveform EtCO2 monitoring is mandatory to confirm correct ETT placement and throughout
U N C O NTR O L L ED WH E N PR IN
subsequent patient ventilations.
T ED
The CO2 capnogram comprises four key phases:
IN T ED
Sedation and procedural sedation
R
•
U N C O NT R O L L ED W
than 90 degrees.
H E N P
Phase III (Alveolar plateau) – reflect last of the alveolar gas being sampled.
•. beta angle – reflects transition between Phases III to 0 and can be used to identify
•
•
Endotracheal intubation (placement confirmation)
Ongoing monitoring of ventilation
rebreathing. If rebreathing occurs, the beta angle will be greater than 90 degrees. Contraindications
Phase 0 (Inspiratory downstroke) – reflects the beginning of inspiration.
• Nil in this setting
U N C O NT R O L L ED WH E N PR IN T ED •
Complications
U NC O NTR O L L E H E N PR IN T ED
2. Attach the in-line connector to the breathing circuit, ensuring that a
D W
bacterial/viral filter is connected to the airway adjunct (mask/LMA/ETT).
U N C O NTR O L L ED WH E N PR IN T ED
U N C O NT R O L L ED WH E N PR IN T ED
U N C O NT R O L L ED WH E N PR IN T ED 3. Connect the capONE sensors (x2) to the CO2 oral connector. Ensure all
cables are free to avoid patient entanglement or strangulation.
U NC O NTR O L L ED WH E N PR IN T ED
2. Connect the capONE sensors (x2) to the CO2 oral connector.
U N C O NTR O L L ED WH E N PR IN T ED
U N C O NT R O L L ED WH E N PR IN T ED
3. Position the sensor cable behind the ears and gently
slide the fastening ring. Ensure all cables are free to avoid
patient entanglement or strangulation.
D
nose with adhesive tape, without occluding the patient’s nose or mouth.
U N C O NT R O L L ED WH E N PR IN T E
5. Attach the in-line connector to the breathing circuit, ensuring that
a bacterial/viral filter is connected to the airway adjunct (mask/LMA/ETT).
Normal capnography
Additional information
U NC O NTR O L L E WH E N PR IN T ED
• In cardiac arrest, tracheal placement
D
of the ETT must be confirmed using
capnography. If there is a complete
absence of EtCO2 (or if the capnography
device becomes unserviceable)
the ETT must be removed, and the
failed intubation algorithm is to be A normal capnograph is present when the patient:
U N C O NTR O L L
commenced.[3,4]
ED WH E N PR IN T ED
• In non-cardiac arrest situations,
tracheal placement of the ETT must be
• is spontaneously breathing or adequately ventilated
• has normal cardiac output
• has normal metabolic function
confirmed and monitored continually
with capnography. If the capnograph
indicates that tracheal placement
cannot be confirmed, the ETT must
Endotracheal tube in the oesophagus
U N C O NT R O L L ED WH E N PR IN T ED
be removed and the failed intubation
drill is to be commenced.[4,6]
• In situations where IPPV is provided
without an ETT, (i.e.when using a
BVM or LMA), capnography is highly
desirable and should be connected
as soon as other urgent priorities allow.[7]
U N C O NT R O L L ED WH E N PR IN T ED
• QAS clinicians must be familiar with
the operating instructions, with
Oesophageal intubation may be confirmed by:
• an absence of waveform and EtCO2
particular attention to warnings,
• small transient diminishing waveforms
alarms and troubleshooting.
U NC O NTR O L L ED WH E N PR IN T ED
Possible causes:
U
• shock
N C O NTR O L L ED
• pulmonary embolus
WH E N PR IN T ED
• effective CPR being performed during cardiac arrest
U N C O NT R O L L ED WH E N PR IN T ED
U N C O NT R O L
Possible causes:L ED WH E N PR IN T ED
• return of spontaneous circulation
524
Absent EtCO2 levels and waveform
U NC O NTR O L L ED WH E N PR IN T ED
Possible causes:
U N C O NTR O L L ED WH
• no metabolic activity
E N
• no CPR in cardiac arrest
PR IN
• exsanguination / profound shock
T ED
Inadequate seal around endotracheal tube
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U N C O NT R O L
Possible causes:
L ED WH E N PR IN T ED
• a leaky or deflated endotracheal or tracheostomy cuff
• an artificial airway that is too small for the patient
525
Increased EtCO2 levels from normal
U NC O NTR O L L ED WH E N PR IN T ED
Possible causes:
U N C O NTR O L L ED WH E N PR IN
• respiratory depression/failure
T ED
• inadequate respiratory rate and/or tidal volume
• increased CO2 production through increased metabolic rate or temperature or reperfusion of ischaemic tissue
U N C O NT R O L L ED WH E N PR IN T ED
U N C O NT R O L
Possible causes:L ED WH E N PR IN T ED
• inadequate respiratory rate and/or tidal volume
• diminished CO2 production through decreased metabolic rate
• falling cardiac output
526
Obstruction in breathing circuit or airway
U NC O NTR O L L ED WH E N PR IN T ED
Possible causes:
U N C O NTR O L L E PR IN T ED
• obstruction in the expiratory breathing circuit
D WH E N
• presence of a foreign body in the upper airway
•
•
partially kinked or occluded artificial airway
bronchospasm
U N C O NT R O L L ED WH E N PR IN T ED
U N C O NT R O L
Possible causes:
L ED WH E N PR IN T ED
• restoration of normal respiratory rate and/or tidal volume
• cardiac output improved
• improved integrity of airway seal (BVM/LMA/ETT)
527
Curare cleft
U NC O NTR O L L ED WH E N PR IN T ED
Possible causes:
U N C O NTR O L L ED WH E N PR IN T ED
• inadequate or ‘lightening’ of paralysis
U N C O NT R O L L ED WH E N PR IN T ED
U N C O NT R O L
Possible causes:
L ED WH E N PR IN T ED
• restoration of normal metabolism/CO2 production
• normalised respiratory rate and/or tidal volume
528