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admin | Category: Ed Treatment Exercise | 13.04.2016
A A A  ETCO2 represents the partial pressure or maximal concentration of CO2 at the end of exhalation. A A A  The third stage is where the buffer action of hemoglobin and pulmonary blood flow maintain the normal level of CO2 tension by eliminating the excess CO2. A A A  The fourth stage involves CO2 elimination by alveolar ventilation under the control of the respiratory center. During acutely low cardiac output state as in cardiac arrest, decreased pulmonary blood flow becomes the primary determinant resulting in abrupt decrease of ETCO2. A A A  One way of measuring ETCO2 is with the infrared capnometer, which contains a source of infrared radiation, a chamber containing the gas sample, and a photodetector. During acutely low cardiac output state as in cardiac arrest, decreased pulmonary blood flow becomes the primary determinant resulting in abrupt decrease of ETCO2. The MicroCapStar End-Tidal Carbon Dioxide Analyzer provides accurate end-tidal or continuous measurement of expired CO2 in animals as small as mice.
The heart of the MicroCapStar is a new temperature-controlled infrared CO2 sensor with digital output.
The front-panel display (see above) shows CO2 concentration (either instantaneous or ETCO2) in either percent or mmHg, and a 5-minute trend plot of ETCO2.. The advanced features, reliability, and ease of operation of the MicroCapStar make it the perfect companion to our SAR-830 series Small Animal Ventilators for monitoring respiratory status. CO2 monitoring is widely recognized as an important measure of the respiratory status of experimental animals. Capnography refers to the comprehensive measurement and display of CO2 including end-tidal and inspired CO2, and the CO2 waveform which is referred to as the capnogram.
Sidestream CO2 sensorsare located away from the airway, requiring a gas sample to be continuously aspirated from the breathing circuit or patient and transported to the sensor by means of a pump. The principle of pulse oximetry is to transmit two specific wavelengths of light through a pulsating vascular bed. Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through.
Once an endotracheal tube is placed, it is important that it be secured to keep it from moving out of the trachea.
Although the process of confirming tube placement will be described later, it is important that the Paramedic prepare his equipment for tube placement confirmation prior to beginning intubation.
Auscultation of lung sounds, listening to the lung fields with a stethoscope, is a commonly accepted technique for assessing endotracheal tube placement. Esophageal intubation detection devices should also be used to confirm endotracheal tube placement.
A number of studies have been performed on both the syringe type and self-inflating bulb devices. End-tidal carbon dioxide (ETCO2) measurement and monitoring has become a standard method of both confirming endotracheal tube placement and monitoring patient status, ventilation, and continuing tube placement.14 Carbon dioxide is a colorless, odorless gas that is produced during cellular metabolism. End-tidal carbon dioxide monitoring, in all of its forms, has been demonstrated to be a reliable and highly sensitive method for assessing endotracheal tube placement and monitoring tube placement over time.15-19 End-tidal carbon dioxide monitoring has become the gold standard of confirming endotracheal tube placement. The least expensive, and probably most commonly used, device for measuring end-tidal carbon dioxide is the colorimetric device (Figure 23-14). The remaining two classes of monitoring—capnometry and capnography—are, outside of the operating room, based on infrared analysis of exhaled gasses. Although mainstream measurements have the advantage of being instantaneous, the probes are more vulnerable to breakage and are more expensive. For a patient requiring airway and ventilatory assistance, the ideal situation is placement of an endotracheal tube. The laryngeal mask airway (Figure 23-17), a blind rescue airway device, was originally designed for use in the operating room.
The laryngeal mask airway, in essence, moves the mask of face-mask ventilation from the face to the opening of the larynx. The design of the esophageal-tracheal Combitube (ETC) (Figure 23-18) reflects a response to the complications associated with the esophageal obturator airway (EOA) and the esophageal-gastric tube airway (EGTA). EOA and EGTA, the ETC is placed into the esophagus; however, tracheal placement of the ETC is possible.
The Combitube is a double-lumen device with two separate and distinct lumens, a proximal and distal lumen named by where they exit from the tube. Both devices are intended for esophageal placement, which occurs approximately 90% to 99% of the time. All the features and economy of the nGenuity packaged with the outstanding performance of Criticare's patented end tidal CO2 technology makes the "EP-1" an easy choice for your next anesthesia monitor.
The 8100EP-1 comes complete with the standard nGenuity accessories plus water traps, and sample lines. When it comes to patient connections, we have economical solutions that will keep the cost of disposables to $3 or less per patient.
Sodium nitroprusside enhanced cardiopulmonary resuscitation improves survival with good neurological function in a porcine model of prolonged cardiac arrest. Yannopoulos D, Matsuura T, Schultz J, Rudser K, Halperin HR, Lurie KG.SourceFrom the Departments of Medicine and Emergency Medicine (DY, TM, JS, KGL) and Biostatistics (KR), University of Minnesota, Minneapolis-St.
As the intracellular CO2 increases, CO2 diffuses out into the tissue capillaries and is carried by the venous circulation to the lungs, where it diffuses from pulmonary capillaries into the alveoli. This process allows the diffusion of CO2 from blood to the alveoli where the partial alveolar pressure of CO2 is lower than the tissue pressure. Changes in alveolar ventilation can also influence ETCO2 as PACO2 closely approximates PaCO2 and ETCO2. When the expired CO2 passes between the beam of infrared light and photodetector, the absorbence is proportional to the concentration of CO2 in the gas sample.
As the intracellular CO2 increases, CO2 diffuses out into the tissue capillaries and is carried by the venous circulation to the lungs, where it diffuses from pulmonary capillaries into the alveoli. This process allows the diffusion of CO2 from blood to the alveoli where the partial alveolar pressure of CO2 is lower than the tissue pressure.
Changes in alveolar ventilation can also influence ETCO2 as PACO2 closely approximates PaCO2 and ETCO2.
When the expired CO2 passes between the beam of infrared light and photodetector, the absorbence is proportional to the concentration of CO2 in the gas sample.
It features very low sample flow requirements, rapid response time, and long-term stability.
Low sample flow and rapid response is achieved with a carrier gas system employing digitally-controlled active flow management. It is useful in setting ventilator parameters, and serves to gauge depth of anesthesia in unassisted, spontaneously breathing animals as well. Capnography depicts respiration which includes all three components of respiration; metabolism, transport, and ventilation and therefore gives an excellent picture of the respiratory process.
Mainstream CO2 sensorsare placed at the airway of an intubated patient, allowing the inspired and expired gas to pass directly across the IR light path. These wavelengths are based on the red and infrared light absorption characteristics of oxygenated and deoxygenated hemoglobin.


Deoxygenated (or reduced) hemoglobin absorbs more red light and allows more infrared light to pass through. However, with digital technology and new processing specific for low perfusion cases the SpO2 readings have become more reliable and can indicate when return of circulation is achieved. Numerous devices, such as the Thomas tube holder (Figure 23-12), are available commercially. The three most commonly accepted methods of confirming endotracheal tube placement in the prehospital environment are auscultation, esophageal detection devices (EDD), and end-tidal carbon dioxide measurement.
Two major styles of these devices exist: self-inflating bulbs and syringe style aspirators (Figure 23-13).
It is the primary exhaled waste product and its concentration in the exhaled respiratory gasses depends on adequacy of ventilation and circulation. These devices are simply encapsulated pieces of litmus paper over which the exhaled breath flows. By shooting an infrared beam through a sample of exhaled gas, it is possible to measure the amount of CO2 in the sample based on the absorption of light in the correct wavelength. Sidestream devices protect the infrared sensors, but they have a delay in measuring due to the distance the gas sample must travel from the exhalation to the sample chamber. Microstream devices may also be better suited for use in pediatric patients with very small tidal volumes than standard sidestream devices or bulky mainstream devices that can kink an endotracheal tube.25 Regardless of the sampling system, however, the data interpretation and display methods differentiate between capnometry and capnography. These monitors are usually considerably less expensive than capnography devices although they are also much more expensive than disposable colorimetric caps. While numeric values for peak and trough ETCO2 levels are displayed, the monitor also displays a graph of the exhalation curve (Figure 23-15).
However, there will always be scenarios in which endotracheal intubation will not be possible. It is designed to be placed in the esophagus and seal off the pharynx and esophagus with two balloons filled through a single port. The LMA is composed of a single lumen tube with a standard 15 mm adapter at the proximal end and an inflatable mask at the distal end. Each lumen has a standard 15 mm connector at the proximal end to allow attachment to a ventilation device. Since they can be passed blindly, no special equipment is needed other than the device itself.
In the esophageal position, the distal cuff seals the esophagus while the proximal cuff seals the hypopharynx. Anecdotally, increased rates of tracheal placement occur with well-performed cricoid pressure.
They must be removed from their packages and the cuffs inflated to test their integrity and the functioning of the valves. Whether you intubate or not, we have accessories that will let you reliably obtain capnography on both adult and pediatric patients. CO2 reflects cardiac output (CO) and pulmonary blood flow as the gas is transported by the venous system to the right side of the heart and then pumped to the lungs by the right ventricles.
The hydrogen ions are buffered by hemoglobin, and the bicarbonate ions are transported into the blood.
If ventilation and chest compressions are constant with the assumption that CO2 production is uniform, then the change in ETCO2 reflects the changes in systemic and pulmonary blood flow.
The gas samples can be analyzed by the mainstream (in-line) or sidestream (diverting) techniques. CO2 reflects cardiac output (CO) and pulmonary blood flow as the gas is transported by the venous system to the right side of the heart and then pumped to the lungs by the right ventricles. The hydrogen ions are buffered by hemoglobin, and the bicarbonate ions are transported into the blood. If ventilation and chest compressions are constant with the assumption that CO2 production is uniform, then the change in ETCO2 reflects the changes in systemic and pulmonary blood flow. The gas samples can be analyzed by the mainstream (in-line) or sidestream (diverting) techniques. This technique precisely and automatically maintains the ratio of carrier flow to sample flow, which is essential for accurate measurements.
An adjustable ETCO2 alarm provides a warning when end-tidal values fall out of a user-adjustable preset range. An accessory pack containing spare low-volume sample tubing and a variety of connectors and fittings is included with the instrument. The microCapStar extends this important technique to the realm of small experimental animals.
The major advantages of mainstream sensors are fast response time and elimination of water traps. These devices operate on the principle that the esophagus is composed of soft, floppy musculature while the trachea is held open by rings of cartilage.
End-tidal carbon dioxide measurement is used to assess endotracheal tube positioning and to monitor the adequacy of ventilation. When carbon dioxide is in the presence of water, it forms carbonic acid; the pH sensitive litmus paper in the colorimetric device detects this acid and changes color. The infrared beam and sensor can either be attached directly to the gas exhaust stream, called mainstream or in-line monitoring, or can be housed in a device that takes a small sample from the exhaled gasses, called side-stream or microstream monitoring.
A review of the airway management algorithm clearly demonstrates that, after a third failed endo-tracheal intubation attempt, the Paramedic should strongly consider another approach to airway management. A standard BVM adapter at the end of the device is used to ventilate the patient via small holes located between the balloons. The mask is designed to cover the opening of the larynx and, with the mask inflated, provide a seal. Each has two cuffs: a large proximal cuff designed to seal the hypopharyngeal portion of the airway and a smaller distal cuff designed to seal the esophagus or trachea, depending on the placement. The Combitube has been demonstrated to cause less C-spine movement than conventional endotra-cheal intubation,31 which may be clinically significant in the patient with known or suspected C-spine injury. When the devices are placed in the trachea, the distal cuff serves to seal the trachea (like the cuff of an endotracheal tube) while the proximal cuff helps stabilize the device. For the King airway and Combitube, this is done with the syringes that are prepackaged with the device.
When CO2 diffuses out of the lungs into the exhaled air, a device called capnometer measures the partial pressure or maximal concentration of CO2 at the end of exhalation. The pressure difference of 5 mmHg will cause all the required CO2 to diffuse out of pulmonary capillaries into the alveoli.
Ultimately, ETCO2 can be used as a quantitative index of evaluating adequacy of ventilation and pulmonary blood flow during CPR. The pressure difference of 5 mmHg will cause all the required CO2 to diffuse out of pulmonary capillaries into the alveoli. Ultimately, ETCO2 can be used as a quantitative index of evaluating adequacy of ventilation and pulmonary blood flow during CPR. The CO2 and RR measurements, as well as a trend plot of the end-tidal values, are displayed on the graphics LCD screen.


The heated measurement cell prevents water condensation, even during long-term measurement sessions.
Regardless of the device or technique used to secure the endotracheal tube, it is important that the endotracheal tube not be able to move. Although auscultation of the axilla alone to detect esophageal intubation is only 85% sensitive (and therefore misses 15% of esophageal intubations), the combination of auscultation over the epigastrium and in the axilla, when sounds can be well heard, has been shown to be 100% sensitive (detected all) for detecting esophageal intubation. Therefore, if suction is applied to an endotracheal tube placed in the esophagus, the walls of the esophagus will collapse on the tip and prevent inflation. Although there are reports of the devices failing to detect esophageal intubations in patients with massive gastric insufflations,12 this has not been seen universally.
The three classes of end-tidal carbon dioxide measurement are colorimetric measurement, capnometry, and capnography. Perhaps the most fundamental limit is that the patient must be producing carbon dioxide in order to exhale it. These devices are as reliable as infrared cap-nometry and capnography for detecting esophageal and tra-cheal intubations20 and are reliable in infants and children larger than 15 kg.24 The devices are designed to be attached between the 15 mm adapter on the endotracheal tube or an alternative airway device and the BVM. Although they do not display trends over time nor show a graph of the exhalation curve, if the Paramedic records the peak ETCO2 over time it is possible to collect trending data. One class of rescue devices available are placed blindly and provide an airway that is superior to face-mask ventilation, yet not as protective as an endotracheal tube.
A channel located in the anterior between the two balloons allows the use of an elastic gum bougie or endotracheal tube exchanger to replace the device with a standard endotracheal tube.
The intubating LMA, in addition to placing the mask over the larynx, is designed to pass an endotracheal tube through the lumen and direct it into the trachea.
Since the opening to the larynx lies between these cuffs, ventilatory gasses passing through the proximal lumen can only go into the larynx and subsequently to the lungs.
Ventilation is performed through the distal lumen that opens at the end of the tube, distal to the smaller cuff.
The distal end of the tube should be lubricated with a water-soluble lubricant and the devices returned to the packaging. During CPR, the amount of CO2 excreted by the lungs is proportional to the amount of pulmonary blood flow.
Windows-based monitoring software is included, which allows display of the measurements, and saving the data to a disk file. This is considered “functional” oxygen saturation which identifies oxyhemoglobin and deoxyhemoglobin. Although taping the endotracheal tube to a patient’s face may be an acceptable practice in an operating room setting where the patient is not moved during the procedure, it is not sufficient for the prehospital environment. The greatest limitation seems to be that the devices will often indicate an esophageal intubation when, in fact, the tube is actually in the trachea. In patients in cardiac arrest, the lack of exhaled carbon dioxide may be mistaken for an esophageal intubation.20 Of much more concern, however, is the risk of mistaking an esophageal intubation for a tracheal intubation. Some manufacturers produce bag-mask assemblies with colorimetric ETCO2 devices built into the exhalation valves. In addition, these devices are usually equipped with an apnea alarm and can alert the Paramedic to sudden changes in ventilatory function.
These devices are collectively called supraglottic airway devices or blind insertion airway devices (BIADs). Finally, a posterior lumen allows for passage of a nasogastric tube into the stomach once the King airway is in place, allowing stomach decompression. The LMA Unique®, as a disposable device, is most likely to be used in the prehospital environment.
Tracheal placement allows the device to function as an endotracheal tube and all procedures and medications normally performed with an endotracheal tube can be performed with the Combitube.
Therefore, the esophageal intubation detection device should inflate rapidly and completely with air.
This can occur when the tip of the tube is on the carina or pushed against the trachea’s wall. Bag-mask assembly ventilation with gastric insufflations,21 ingestion of carbonated beverages and antacids,22 and hypopharyn-geal endotracheal tube placement23 have all been shown to produce waveforms that would indicate tracheal intubation. The most common supraglottic devices are the King LTS-D airway, the esophageal tracheal Combitube (ETC or Combitube), and the laryngeal mask airway (LMA).
They must be inserted orally and, when placed in the esophagus, are difficult to intubate around, owing to their large size and rigidity. Most importantly, epiglottic, perilaryngeal, and laryngeal injury or deformity (burns, trauma, edema, etc.) can prevent effective ventilation.
Not only is it important to secure the tube with an adequate device or technique, but it is also important to place a cervical collar to minimize neck extension and flexion.6 However the Paramedic plans to secure the neck, it is important that the equipment be prepared prior to the intubation. In addition, in patients with limited functional residual capacity—such as those in CHF, adult respiratory distress syndrome, or the morbidly obese—the devices may inflate slowly or with resistance.11,13 Therefore, the devices must be used in conjunction with other methods. However, with the exception of hypopharyngeal placement, after six ventilations (approximately 30 to 60 seconds of ventilation), the waveforms diminish and eventually vanish.
For a mainstream device, the probe must be attached to the monitor and an adapter that connects to the endotra-cheal tube (or alternative airway device) which should be attached to the probe. Although the esophageal obturator airway (EOA) and esophageal gastric tube airway (EGTA) were commonly used before the advent of the supraglottic airways, the need to maintain an adequate mask seal and inability to protect the trachea have decreased the use of the EOA and EGTA. Once it is removed from the package, the mask should be inflated to assure that it holds air.
Furthermore, caustic ingestions and known esophageal trauma or disease are contraindications to use of these devices.
Therefore, end-tidal carbon dioxide measurements should always be accompanied by other methods of assessing endo-tracheal tube placement. Sidestream and microstream monitors will have an adapter with a sampling tube that attaches to the exhalation stream.
The LMA mask must then be pressed against a firm surface and the air aspirated from the mask. Finally, medication administration and deep suctioning of the lungs are not possible with esophageal placement.
Over time (approximately two hours for most in-line devices), the paper turns permanently yellow.
Exposure to water, vomit, pulmonary secretions, medications, and so on, will hasten the deactivation of the device. Preparation of the colori-metric end-tidal CO2 monitor involves simply opening the packaging.



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