RESP 2533 CRITICAL CARE

Module 2: Respiratory Monitoring in the Intensive Care Unit

OVERVIEW
Defined as repeated or continuous observations or measurements of the patient, his or her physiologic function, and the function of support equipment, for the purpose of guiding management decisions, including when to make therapeutic interventions and assessment of those interventions
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OVERVIEW
Respiratory monitoring - continuously evaluating the cardiopulmonary status of patients for the purpose of improving clinical management

OVERVIEW
Goals
alert clinician to changes in patients condition improve understanding of pathophysiology diagnosis cost-effective clinical management

OVERVIEW
Goals accomplished by
physical assessment measurements and calculations i.e., lab values alarms

VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Capnometry (measurement of exhaled CO2) can detect changes in
metabolic rate as a result of increased cardiac output, fever, shivering, seizures, trauma, and high carbohydrate infusion

VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

CO2 elimination depends on
cardiac output V/Q ratio emptying times of various regions of the lung
lung apex - alveoli open first and close last
high V/Q low alveolar CO2 concentrations

lung bases - open last and close first

low V/Q alveolar CO2 concentrations approach mixed venous blood
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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Exhaled carbon dioxide concentration highest at end of exhalation due to dependent alveoli closing last End-tidal CO2 (PETCO2) used to indicate the highest concentration

VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

PETCO2 (abbreviation used by the NBRC) correlates well with PaCO2 in healthy individuals Conditions that alter V/Q such as mechanical ventilation, pulmonary disease, and a decrease in perfusion increase the arterial to PETCO2 ratio

VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Indications - refer to AARC CPG

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Methods
infrared analysis partial-pressure analysis mass spectrometer generally use infrared analysis

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Methods
mainstream - infrared sensing devise located at the airway, usually attached directly to ET tube
infrared light passed through gas stream and the greater the difference between value sent and value received, the greater the concentration of carbon dioxide may be adversely affected by moisture and secretions

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Mainstream - all exhaled and inhaled gases pass through the photodetector

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Methods
sidestream - small bore tubing aspirates gas and transports it to a remote measuring chamber water and secretions must be removed before entering the chamber

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Sidestream - capillary tube placed into ventilator circuit to sample exhaled and inhaled gases

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Methods
gas may be measured breath-by-breath or as a mean concentration

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

CO2 production
VCO2 = CO2 produced and excreted over 1 minute can assess changes in metabolic rate and transport of CO2

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

VCO2 increases in
fever (10% per 1 degree C increase) trauma peritonitis (25 - 50%) head trauma rewarming after hypothermia high carbon dioxide loading during parenteral nutrition (as much as 75%)
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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Single breath tracing over time Three phases
I contains no CO2 dead space II shows rapid increase in CO2 III continues to rise due to sequential emptying of alveoli and release of CO2 into alveoli during exhalation
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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

slow speed

fast speed
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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Normal ABG and Capnography PaCO2 ~ 40 torr PVCO2 ~ 46 torr PACO2 ranges from 40 - 46 torr varying between the arterial and mixed venous levels PETCO2 40 - 46 torr and correlates with PaCO2 end-tidal FACO2 5.3% - 6.1% and correlates with PaCO2

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Interpreting end-tidal arterial carbon dioxide gradient [ET (A - a) CO2] Useful once reliability determined
can monitor ventilatory condition without drawing ABG

Normal gradient < 6 torr Unstable patients range from - 6 to + 20 torr

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Patient breathing shallowly may have endtidal CO2 < than arterial because patient is not completely emptying alveoli

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Relationship between alveolar ventilation, PaCO2, and CO2%

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Dead Space-Tidal Volume Ratio VD/VT = PaCO2 - PECO2 PaCO2
exhaled gas is collected in a Douglas bag while ABG is drawn simultaneously

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Normal shape

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Poor plateau
kinked tube herniated cuff bronchospasm i.e., any obstruction that limits expiration

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Unequal emptying of lungs
lateral position
lube touching carina

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Slow decrease in CO2
hyperventilation decreasing body temperature decreasing lung or body perfusion

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

A sudden drop in end tidal CO2 to zero.

Spontaneous breathing intubated patient

kinked ET tube kinked or disconnected sampling tube patient extubated total anaesthetic circuit disconnect

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

A sudden drop in end tidal CO2 to zero.

In a ventilated patient
all of former and ventilator failure

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

A sudden drop in end tidal CO2 but not to zero
leak in circuit, i.e., deflated cuff

obstruction, i.e., acute bronchospasm

leak in sampling tube drawing in room air
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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

An exponential decrease in CO2
circulatory arrest: cardiac or hypovolaemic
embolism: air or clot

sudden severe hyperventilation

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Gradual increase in CO2
hypoventilation
rapidly rising body temperature

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Progressive rebreathing causing a rise in baseline PETCO2

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Esophageal intubation

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Leak in sample line or around ET tube cuff

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VENTILATORY ASSESSMENT EXHALED CARBON DIOXIDE

Ventilator disconnect causing a sudden drop in end-tidal CO2 to zero

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