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Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Capnography Waveform | Respiratory Compromise: Use of Capnography During Procedural Sedation
Capnography Waveform | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Clinical Implementation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Getting a True Measure of End-Tidal Volume | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Assess for Equipment Issues | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Transcript

thank you Michael thank you to Medtronic for having me and thank you to the AI a your organization for having me today I seem to be having a little trouble advancing my slides so I'm just gonna get started with my introduction here we go

so I'm here's my disclosures basically I am sponsored by Medtronic to provide this Lunch and Learn for you but I am an active clinician I work actively at Yale as a CRNA and I do provide the majority of my anesthesia in what we call our off

floor locations meaning interventional radiology EP lab GI endoscopy r zh' in the operating room so I understand the challenges you face I do you know the sedation in those rooms myself so I understand the positioning concerns the

monitoring concerns and so I'm really I'm honored to be here today and I hope that I add value to your conference while you're having lunch I won't talk about anything that is off-label use everything I will present today is

evidence-based medicine and had been proven I'm not here to sell you any products or talk you into buying anything I just really strictly clinician to clinician so starting out we only have

an hour and I really want to make sure I get through everything today so I'm gonna ask if you have any questions to please hold them to the end and that's for a couple reasons because if you have a question I might even be covering that

material in subsequent slides and I want to make sure I get through the whole presentation the beginning of the talk is going to be some review material for some of you we're gonna move through the first 30 slides pretty quickly because I

understand that the majority of you are already using capnography and I want to spend the majority of our time in this presentation talking about the stuff that the advanced level the problem solving the troubleshooting and the

things that are really pertinent to your practice so that you have value that is gained from attending this presentation today

so reviewing the evidence in relation to respiratory depression and airway

compromise respiratory depressions been identified in ninety and ninety two claims of which seventy seven percent have resulted in severe brain damage or death eighty-eight percent of respiratory

depression events occur within 24 hours of a surgery or sedation related event and 97 percent of these were judged to have been preventable with better monitoring so where does capnography fit in with all of this with with your areas

well if you're starting capnography monitoring in your procedure and carrying that over into the post-operative or the post sedation care unit or in your own recovery units where you're recovering them before you send

these patients to the floor that could be part of a bigger picture they can continue on the capnograph even monitoring onto the floor and be monitored with that so that they are monitored throughout the entire time so

by starting capnography you may be actually implementing a monitoring strategy that hopefully could be carried through for that patient for the next 24-48 hours if they're receiving pain medications and such so when we look at

some of the factors for respiratory compromise we have patient factors right intrinsically they may have diagnosis that we do not know of like obstructive sleep apnea there hasn't been diagnosed polypharmacy some of the treatment

factors things medications that we give illnesses that they're coming in with or lying in bed developing atelectasis maybe have pneumonia they bring in their own illnesses and then the area of care factors right weather monitoring is

continuous or episodic in nature and certainly the interventions and you take all of these things together in this Venn diagram sometimes that can create the perfect storm for creating an adverse event related to either opioids

or sedative use and how do we monitor for that how do we figure out which patients we need to monitor there's so many complex factors we really need to anticipate the consequences right and monitor appropriately so moving on to

etiology and I keep the slide in here and I know it looks very basic oxygenation and ventilation oxygenation process of getting oxygen into the body onto the red blood cells and transported to these cells for cellular metabolism

and Krebs cycle whereas ventilation is removing carbon dioxide from the body these are two separate physiologic processes and sometimes these terms are used appropriately interchangeably they are

related to one another but they are separate processes we can oxygenate patients with ECMO with passive oxygen APNIC oxygenation High Flow oxygen but can we eliminate carbon dioxide without ventilation and the answer is no we need

to ventilate to get the co2 out and the co2 is a very important regulator of pH so how do we monitor ventilation and

hopefully you think capnography right so we are looking for in our waveform is a nice square waveform it's a plot of

magnitude of quantity of carbon dioxide concentration over time and that is what's plotted out the baseline should return to zero in between those little square wave forms and the top of it should be a nice flat alveolar plateau

reflecting the alveolar air that has participated in gas exchange being fully exhaled the end of that point D on the monitor here on the bottom right hand corner that is where you get the value of your end-title carbon dioxide

concentration that's where the number on your monitor comes from that is the highest value and that is the end of your expiration of your full tidal volume that's where that digit comes from so here's where I'm gonna need a

little help with the computer playing some waveforms here so first on the yellow box in the upper left hand corner we have an example of what hypoventilation looks like with somebody who was breathing shallow so you see at

first a square waveform right but the magnitude wasn't that big and then you tell the patient take a deep breath and you see that magnitude goes way up so you probably have seen this in your practice when you're taking care of

somebody you're like why is the end-tidal solo anyone see that yeah to have the patient take a deep breath and you might be surprised by what you see so now moving over to the black box in the upper right hand corner we have

classic hypoventilation and this is usually just opioids like somebody's just purely on opioids and they're taking deep breaths nice big tidal volume but they're only taking like 4 of a minute and that's what that waveform

would look like you see the differences here okay now in the purple box again this is one that you probably have seen quite a bit it is an example we have a nice square wave form and then all of a sudden our

wave form just the amplitude decreases and the overall shape becomes that that nice square wave form and this is a patient who's partially obstructing right there exhaling some but there's some flow the monitor is not getting the

full flow of carbon dioxide and then finally on the right hand side lower box we have an example of a complete airway obstruction and this is where we're ventilating and then all of a sudden something has happened whether the

monitor has become dislodged the nasal cannula has moved there's some secretions in the line but that's worthy of checking right because ventilation we can detect immediately and we can check on that before there spo2 other

oxygenation values drop so let's look at

some of the contributing factors to hypoventilation well certainly will we give sedation we give you know a benzodiazepine we give other medications we combine those with opioids right that

decreases our responsiveness to elevated co2 levels but we also have muscle relaxation certainly in patients with obstructive sleep apnea history undiagnosed or undiagnosed they lose their muscle tone in the airway patency

kind of diminishes very very quickly and they also have a decreased response to hypoxia all again creating that perfect storm of an adverse event waiting to happen and even patients that have don't normally have obstructive sleep apnea

can have it under our sedation so the key signs and symptoms you know clearly respiratory rate is one that we monitor but we also want to monitor the quality of ventilation right one look at patients tidal volumes and how much

they're expiring with each breath we want to look at their sedation scores whether you're using the rasp score or any of the other standardized scores spo2 less than 90 for at least thirty seconds that's pretty significant

hypoxia especially if somebody's on oxygen and hopefully you would detect somebody who's deteriorating much earlier than that but that certainly would be a terminal sign before they became bradycardic and you were pulling

out the code card but certainly using capnography you could tell breath by breath right instantaneous looking at those waveforms and look to see if the patient is not only taking enough breaths per minute but are they

taking quality ones so let's look at a little bit of a case study here we're gonna kind of look at this case study throughout so this is Jane Doe she's 39 years old she's being worked up for a nonspecific abdominal pain they've ruled

her out for gallbladder issues and appendicitis and they want to do an upper endoscopy in a colonoscopy she's treated with chronic pain medications gabapentin and oxycodone and she's had some surgeries in the past no allergies

to anything so concerns with this patient so what risk factors does this Jane Doe have for during for at risk for respiratory compromise during sedation possibility of undiagnosed OSA be a bio t mass index obesity high risk

comorbidities medical condition or advanced age there's more than one right answer so just make mental note here and these are the correct ones so she potentially has obstructive sleep apnea she does have an elevated BMI and she

has medical conditions she's sick acutely and she has pain medications as part of her chronic therapy so now let's look into solutions so again with our case studies after we give her some versed and a hundred Mike's of fentanyl

the patient develops the following pattern on the monitor so what should your first step be in this scenario nothing because her pulse oximetry is normal be stimulate the patient to take a deep breath perform jaw thrust and

place patient at a sniffing position to open the airway give a reversal agent or D intubate the patient good B you guys are all anesthetists now we have a bunch of positions open at Yale if you're

interested okay let's look at the

literature so when we look at the AAA say they were the ones that you know they look at a lot of sedation claims and the close claims are what they look at the causative factors of adverse incidents and when they look at sedation

claims that occurred outside the o.r it's sometimes it's been referred to as the wild wild west of anesthesia yeah when you're outside the o.r environment and you're in remote locations the incidence of things going really wrong

increases significantly and I'm sure you guys are no stranger to that right but in remote locations a lot of the claims were judges being preventable thirty-two percent of the time versus eight percent of the times

that that happens in the operating room 62 percent of claims with over sedation as their cause could have been prevented by better monitoring and these are anesthesia providers that are looking at this right and we're seeing the

anesthesia providers have been using capnography and other advanced monitoring as their standard of care for a very long time certainly sedation and claims in monitored anesthesia care these are you

know cases where we're not into baiting the patient very common 21 percent in the specific claims related to Mac anesthesia and again the common denominator here was lack of monitoring or better monitoring could have improved

outcomes so when we look at the professional associations we have UAS a we have the European Society of anesthesiology the Society of gastroenterology nurses and then certainly your organization right the

association of radiology and imaging nursing and what your statement is with capnography it's a RN endorses the routine use of capnography for all patients who receive moderate sedation and analgesia during procedures in your

imaging environments right and and there's certainly there's their statements from many organizations that are all along these lines one of the questions I often get is - well how come we have these recommendations we have

these you know endorsements and such but we're not you know mandated to use it and a lot of that is political there's a lot of pushback from organizations that are gonna come out and say you must use this you know or else they could

strongly recommend things in the anesthesia world it is one of those things that but it's been a long time and I think in time you're gonna see the movement become more strong as far as recommendations go but for now that's

where a lot of the claims are strongly encouraged strongly recommend and such but that means that we should be doing it because the evidence is proven that that it is safer for patients so let's look back at our case study so later in

the procedure our patient develops the following pattern on the monitor you stimulate the patient and position the airway and you have no response what should your next step be nothing because the pulse oximetry is

normal hold additional sedation meds until breathing normalized supplement breathing with a BVM if if required to maintain acceptable and tidal co2 give a reversal agent or intubate the patient well the correct answer would be

to hold additional meds monitor the breathing and supplement the breathing with a BVM see if you can increase the ventilation to maintain acceptable levels well now we're further deteriorating so our same Jane Doe

patient is does not respond to your previous efforts and the end tidal co2 continues to rise followed by a sharp drop in our spo2 concentration despite being on oxygen then the following waveform appears what do we do nothing

decrease our oxygen give a reversal agent or intubate okay I heard some C's what do we want to immediately do she's kind of acutely dropping so yes C would've been correct maybe a slight ago you know before she's really started to

desaturate and certainly that would be correcting the problem but immediately before she decreases her SATs any further becomes any further hypoxic recommendation is to establish an airway

all right so now here's what I want to

spend some more time digging a little deeper and talking about our clinical implementations this is where I get why I do a lot of these events and a lot of speaking with clinicians and this is where I'm gonna address a lot of the

questions that I get very frequently about using capnography and hopefully you leave with a little bit more knowledge and some troubleshooting tips so capnography traditionally when it first came out was used on intubated

patients right for establishing that they have a pain airway the endotracheal tubes in the right place and it's staying in the right place and that was placed in line with the endotracheal tube via adapter but now we're using

more and more capnography with patients who are spontaneously breathing and maintaining their own air and we have this breathing patients who are breathing between their nose in their mouth so they've developed

monitors where we can monitor patients who are exhaling through their nose and/or mouth we are looking at is again that non-invasive continuous plot concentration overtime of the co2 concentration that is being exhaled at

any given moment which is going to tell us instantaneously if there's any change in the patient's ventilation it just this is just a blown up view for those in the back saying if some of this can be difficult to see but what we have

here on the left side of the screen is an image and Michaels gonna start to hand out some of these just so you guys could put your hands on them and feel them and touch them because there's a lot of different advices that have come

out even in the last year that I haven't seen yet that I'm starting to see so we brought some samples that you guys can just touch and play with and such but what we have on the left is a sampling a filter line set which delivers oxygen

through in both nares both nasal you know prongs and also samples out of the nose but also out of the mouth and this is important because we all don't breathe just through our nose and mouth right we we we switch breathe Leone

where I'm talking I'm exhaling through my mouth sometimes I have a stuffy nose and I can't breathe through my mouth through my nose so sometimes when we're monitoring these things we can't if a patient is breathing just through one

air you're not going to get an adequate sample we're using capnography and I think it's more important to use capnography in the patients that have their own airway and our risk for losing their airway rather than ones that

already have an airway established and we're using it certainly in our sedation Suites we're using it pediatrics and neonates all the way up through adult right and we're using it more and more to with non-invasive ventilation with

our CPAP and our BiPAP patients that's another question I get a lot and we're gonna dig into that a little bit more but as you see on the picture on the right when we have patience with our non-invasive ventilation there's

different sampling sites that we can use we can have on the top there this patient is actually wearing a nasal and oral monitor underneath the mask there's also a mask port so a port that can be just plugged right into the

and then there's also ports that are on the circuit the mask ventilator connection which is a little bit more downstream so there's three places that you can attach capnography monitoring to and we're going to talk about the

differences with those as we go through here so let's look at physiology so why

is my cap nog Rafi reading actually I want to back up a little bit here do I want to back up no I don't I don't want to back up so um let's look at the first

question why is my cap nog Rafi reading abnormal so let's first talk about physiology so a question I get a lot of times is sue the patient comes down for a procedure to the floor I put a sample line set on

them I plug them into the monitor and I'm getting a value of 28 29 30 why are my values abnormal anyone ever see this is anyone still awake okay so there's a few reasons the patients that we are dealing with generally aren't

healthy right I mean sometimes I go to work and I get chest pain I'm like can I just be in an ambulatory gallbladder room today because the patients that are coming from down to IR are sick what their physiology is sick too so we have

Krebs cycle we take oxygen in right it circulates to ourselves it participates in aerobic metabolism we get the byproducts of heat and energy and we get carbon dioxide as a by-product carbon dioxide really diffuse about diffuses

into our blood travels to the lungs and gets exhaled where we measure it so let's talk metabolism really quickly so if someone has a fever if their metabolism is ramped up you think they're gonna be producing more carbon

dioxide yes let's say they're a little hypothermic maybe they're gonna be producing a little bit less you see it for sure in the car patients who are cardiac arrest that are cool to status post cardiac

arrest right those values go way down normal physiology normal physiologic response somebody comes down and they're mildly hypoxic they've got pneumonia or some sort of VQ mismatch and they're hyperventilating to UM debeso

compensate for their hypoxia do you think there's co2 values gonna be a little lower at baseline yeah so these are the patients that you're seeing right so we have reasons that patients could be hyper cap neck like metabolism

right somebody who's in pain someone who's developing a fever early stages of sepsis they may actually have a little bit of a higher value somebody who's sedated or hypoventilating may have a higher value and when we talk about

perfusion is the blood moving round and round is that circulating co2 coming back to the core do we have increased cardiac output with continuous constant ventilation and certainly we can we're gonna look at equipment issues next and

the same goes true more probably in your cases of the hypocapnia patient so someone who is not fully exhaling someone who's in bronchospasm or a COPD or you're not getting that nice square waveform you're only getting some of the

mixed gas ventilation that they're exhaling rights and the conducting airway is mixing with the alveolar gases someone's a little hypothermic someone who's been NPO for 24 hours right it's the opposite of carb-loading right so

you kind of throw them into a little bit of like acidosis you know they're kind of not burning carbs for fuel are they gonna be producing as much carbon dioxide not so much right so when you're coming so when

patients come down to you and you put them on the monitor consider these things so ventilation perfusion gradients so we have what we call our VQ matches and our body is designed beautifully right so when everything is

working great it works great so the way we ventilate all of our lungs owns is very closely matched to the perfusion of all of our lungs ohms so by me standing up here I'd like to think I'm pretty healthy if you did a blood gas and you

put me on one of those filter line sets right now you would hopefully see a gradient that's very small the normal gradient between a PA co2 on a blood gas so the level of carbon dioxide on a blood gas in the arterial blood and what

you see when I fully exhale into the monitor should be between two and five millimeters so these are your patients come down healthy physiology you put them on and you get a value of like 32 then you

could assume that if they were healthy two to five millimeters okay their blood gas would probably like 35 for POC to everyone follow now does any of our patients read the physiology tech books textbooks no they typically don't so

when you have patients come down they may have shunt right so they may have we have our little airway here a and B you're out like picture them as lungs and lung a is blocked so we have no ventilation going to lung a but blood is

still chugging through right so blood is still going through the pulmonary circuit so we're gonna have Patapsco a dia depending on the size of the shunt is this the end of the world are we gonna cancel the case no but just being

aware of the patient's physiology would explain to you why I put this patient on this and I'm getting a value of 30 you follow and it's not the end of the world you document 30 and you monitor for trends as you're going along with your

sedation same thing goes through with dead space dead spaces were ventilating but we have an area of the lung that is not being perfused pulmonary emboli other circulations some medications hypovolemia shocky patients same thing

the VQ mismatch not the end of the world it's part of the patient's physiology maybe part of the reason why they're down there just being aware of these things though so the technology works right our equipment works if just amazed

it's picking up something that we don't connect all the dots on physiologically that sometimes confuses us a little bit so I hope that clears up part of it so when we're monitoring capnography certainly ventilation is what we think

of first and it's important co2 being expired by the lungs that's what we're looking for but if we back up and look at the physiology of carbon dioxide production in the body we are also inferring that

it's being metabolized and being created from Krebs cycle and aerobic metabolism and that we have perfusion occurring okay I'm sure if some of us have seen in our you know nursing careers patients who are kind of peri-arrest and

the capnography kind of drops off it's like a poor man's swan you're watching cardiac output drop in real time because carbon carbon dioxide is not being delivered to the lungs so when we're looking at our patients when

they first come down we first want to establish a baseline value we want to put on a monitor have a patient take some nice deep breaths full ventilations not just one but a few you want to you know have them take a few and look at

their other vital signs their mental baseline status and we're gonna look for trends in their carbon dioxide value so if someone starts off at twenty nine I don't care that they're not 35 to 45 which is textbook normal this person may

not have the stimulus to breathe if I let too much co2 accumulate so we're really looking for the trends okay now somebody will say well how much of you know how much should we look for 10 to 20 percent change from your baseline is

somewhere where you want to start paying attention to what's going on okay maybe like titrating your sedation or just being a little bit more cautious with how much more sedation but again it's more important to look at the trend

value behavior of your carbon dioxide than it is the absolute numbers themselves so first you having a problem let's consider the patient's physiology

okay second why is my camp nog raphy reading abnormal now let's look are you

measuring a true sample of the patients and tidal volume so again we have some of these campin ography waveforms here and in the yellow blocks I'm gonna play it again we're gonna play it again in the back we're gonna look at the

hypoventilation again nice square waveform but you tell the patient take a deep breath and all of a sudden you see the amplitude go up so just because we see little boxes yeah the patient's breathing but are they really taking a

full deep breath this is the patient that you got a baseline on and they were normal and now you started your procedure and now your values are like 28 29 guess what the value probably didn't drop in their blood

it's just a probably not exhaling as well did you flip them prone are they on their side you follow did you change something with their airway so now looking again at the classic hypoventilation okay this is somebody

who is taking deep breaths so we have our normal waveforms here on the top okay that would you hopefully you'd see before sedation and you know what you might see that drop off a little bit during your sedation is at the end of

the world no because you're watching trends every now and then you might tap them on and say okay take a deep breath but you know that they're still ventilating right but if we start to see examples of partial airway obstructions

or complete airway obstructions that's when we want to intervene on the bottom I included the hype optic hypoventilation this is what we see a lot of you see some squiggles and you're like okay airs moving in and out but how

come my numbers aren't adequate that's where you're like are they effectively exchanging are they emptying out their full tidal volume and you give them an Ambu bag breath or you stimulate them and you are you give them that chin lift

and they take that big deep breath and that's what you see is the actual waveform going up that's more of a representative sample and you got to be careful with that they get too much co2 retained again the sedation gets worse

and they may eventually stop breathing from that so look at this waveform here we have an amplitude of five we have us reading to five and a bunch of these square little boxes that's an example of somebody who is making some effort but

are they effectively ventilating not so much so this is the patient that you again you give a you know good breath open the airway stick an oral airway in or do something to stimulate them and then you see that you're like now I'm

ventilating appropriately so looking at another troubleshooting this is really common in the IR Suites from what I seen and I'm sure you guys have seen as well is co2 re breathing so patients are exhaling and what you're seeing here

notice how the baseline in that waveform is not returning to zero so patients are exhaling and then they're inhaling exhaling inhaling they're not clearing the carbon dioxide that they're exhaling out so how

is this happening well what do we do to pee like you guys are working in environments that are certainly not pristine we are flipping patients over there on their side they're draped so we have this beautiful little tent of

oxygen don't even get me started on the combustion cycle right but we have this beautiful Lake draping of a tent and patients are exhaling and where is that going so the last thing we want is somebody who's potentially going to be

hypoventilating then rien hailing carbon dioxide because not enough fresh gas flow so this is also patients who are just shallow breathing right they're inhaling exhaling and they're really exchanging

mostly dead space or this is someone that you put the oxygen mask or maybe you start with a nasal cannula and then you want to increase their fio2 so you put a mask on but you forget to plug the mask in instead of a nasal cannula it

happens right or the oxygen mask gets unplugged or the tubing gets runned over or the connection because it's like a mile away gets disconnected these things happen but if you see a waveform like that these are things to start to think

about right what's going on where my patient is rebreathing carbon dioxide so first we're gonna look at physiology do we understand the physiology of our patient and what our patient is trying to tell us second are we really

assessing an effective ventilation are we really assessing the adequacy of ventilation so instead of just skiing square bumps on our monitor are we seeing something that we saw the beginning of our case or are they

hypoventilating are they not effectively exchanging so that's the second thing we

want to look at now third this is the area that I really wanted to get to today did we pass along out no yeah hand me up one if you don't mind

so third let's look for equipment issues anyone in here do yoga a couple hands okay so some of this is from a yoga exercise and it will play into what we're gonna discuss here but on the left here this is an example

of some of there's all different products out there so on the Left we have a nasal cannula that on one side is delivering oxygen and on the other side is monitoring our carbon dioxide so everyone just humor me if you're not

eating take your finger and plug your right nostril and just take a few breaths in and out through your left okay now let's do the other side so plug the other side it's supposed to be calming we do this in yoga anyone having

trouble breathing through one nostril over the other okay I see a quite a bit of hands so physiologically we have deviated septums we have nasal congestion we have you know our blood capillaries getting gorged on one side

you know I know if I sleep on one side I wake up all stuffed up I have to take a nap on the other side to even it out at least that's what I tell myself right but we preferentially breathe through different nostrils so if we have a

patient on a monitor there's only monitoring from one side do you think that's the most effective monitor we can use probably not just take notice right now who's breathing through their mouths because a lot of us breathe through our

mouths especially patients who are respiratory compromise under sedation or are sick and these are the patients we take care of so for monitoring just through the nose are we doing the best job of monitoring we could be doing no

and we found this out I mean there's all different products out there but what we have found that is most effective is using something that is delivering oxygen through both nares but also monitoring exhaled gases from both nares

but also from the mouth and evidence proves us so I'm not just making this up so we're looking at here is a study that was looking at the accuracy of non intubated capnography patients different sampling lines and what we see in the

navy blue on the left is the first is when they had patients just under a mer and then they put patients on a couple liters of oxygen per minute and you can see use the nasal canula with a scoop was pretty

accurate for both those patients who are breathing room air and supplemental oxygen when we look at two different other designs of nasal canula that just had like a little like a little port to kind of hung down the accuracy not as

great okay same patient group but what happens when we add oxygen to those nasal canula they just they dipped in their accuracy so I'm not saying not to use whatever you have you know if you may only have those kind of nasal canula

but just know that you might not be getting a full sample especially if you're adding oxygen if you're just using a nasal cannula port you follow so just knowing the limitations of your equipment so the monitor the little

machine can only evaluate the gas analyzer can only evaluate what's being delivered to it so if the sample line is not receiving an adequate sample it's going to give you an a waveform that is certainly not accurate so we want to

consider a few things are you connecting multiple tubes to get like multiple you know sampling lines together and connecting them with a stopcock yes no I see some nods of heads and sometimes we have to do what we have to

do right to reach the monitor to the patient but if you're connecting those sampling lines is the connector tight I've seen a number of times where I've seen abnormal waveforms and someone stepped on the stopcock that was

connecting two pieces of tubing and then you just correct the stopcock or tighten up the connection and then all of a sudden your waveform improves but also where the sampling port is located on the patient is important so remember

that picture I showed you of the non-invasive ventilation and the person had the oral and nasal scoop on and they also had the port on the mask and the port on the circuit three different locations we're gonna look at that a

little closer but where is the sampling port located doesn't it make sense to have the sampling port located right where the patient's exhaling especially for delivering oxygen and especially if we're delivering oxygen and kind of

higher flow rates right greater than 12 or greater than 8 and P because it's gonna do potentially dilute our samples and these are some of the challenges that when I talk to people that they are bringing to me like it

just doesn't seem accurate when I have patient on oxygen how can I know that it's accurate so that's what we're going to look at a little bit more here so the farther the sampling ports are from where the patient is exhaling the higher

the chance of your sample being diluted and not being completely accurate when you're looking at your exhaled gas and you may see something like this picture here so there's some challenges like I said we can do the exhaled co2 can be

diluted the masks we're passing around some masks here some of the masks may allow for rebreathing so when I started and you know in healthcare and especially in anesthesia and such and providing sedation we used to take a

non-rebreather put on the patient and then cut tubing and stick the tubing in one of the little holes okay see a couple of nods of heads here right we make our own and that's how we monitored air going in now but do you think those

non rebreather czar really allowing patients to exhale fully and to get all that co2 out where it's all that carbon dioxide going you you see the mask fog up right now they at risk for rebreathing co2 absolutely so we're

looking at all these challenges right and do you think that little like rigged up mask design was getting a really accurate sample really close to the airway not so much so and you guys are assuming do you guys do T E's and

things where you're putting mouth guards and patients yes no some their sampling issues with that right how do we sample when someone's working in the airway well there are bite blocks now that are integrated and I think we may even have

some here that we can actually capture an accurate sample so knowing the

physiology knowing that we want to measure true ventilation let's kind of dive deeper into the equipment issues so looking at some studies here this is a

study that compared the different techniques for interfacing capnography with adult and pediatric supplemental oxygen masks in really the main finding of this study was regardless of the measuring device that was used this

signal for the of the entitled carbon side it varies as the oxygen concentration varies especially in very high levels so levels and adults that are less than 15 if you have a good location of your sampling you're going

to get a pretty accurate sample of your carbon dioxide but what this study found is an extremely high flow rates and that's adults greater than 15 liters per minute and in Pediatrics greater than 8 liters per minute that's when you're

gonna start to see some data quality decrease and I'm gonna tell you a little secret if you have an adult that's on 15 liters per minute and you're having oxygenation issues your problems are bigger than that okay no one should

really be on that much oxygen right you know there's a certain point where you have to change the ventilation or maybe they have a perfusion mismatch or they need peep or they need some other physiologic intervention camp Nagato

masks they provide really stable measurements without significantly breathing with commonly used oxygen flows and these are capnography masks that were designed for that not the rigged up ones that we sometimes you'll

have creatively used in the past and because and if you've seen some of the masks coming by some of because of the open design the carbon dioxide measured with the High Flow oxygen rates if we need to use higher flow rates you make

it artificially lower readings a greater again greater than 15 liters per minute and they may not reflect adequately like that gradient may be much bigger than compared with lower flows so using a standard o2 mask the one we pick up off

the shelf in combination with our you know nasal oral scope monitor can provide us with really good monitoring because it's going to be right close to the patient where they're exhaling but you have to watch the risk of patients

rebreathing okay so this is a little bit of a change in practice because we've recommended this for a long time now you put your sampling line on you use your regular oxygen but just by doing these studies we've found that

patients are rebreathing carbon dioxide more than we thought just something to be aware of you're looking at your baseline and if your monitor is calibrated appropriately and I've been doing

for 15 years and I've never seen a Capon ography monitor you know when you turn it on and it calibrates itself where the baseline was not zero okay so usually it's something related to the patient rebreathing and such so again food for

thought this is just the comparisons okay so when we have patients that are breathing I know it's a little hard to see from the back so we're comparing the end tidal co2 concentration between devices and at our supplemental oxygen

rates as we're going up on our flow rates so with patients that were normal ventilating their co2 on a blood gas was 39:39 on the monitor so very very little change and that's actually true for the cap one mask the oxy mask and the

different capital lines that's what they looked at they looked at for when they went up to five liters per minute 38 plus or minus point five 38 plus or minus point seven and then no change for the capital line the two different

capital lines so again nothing's statistically significant as far as using five liters per minute and same thing with ten liters per minute with normal ventilation really no change in the monitoring from no oxygen to oxygen

where you start to see some changes in normal ventilation with using all four of those the cap one the oxy mask and the capital lines very very little difference even at 20 but when you looked at the regular oxygen mask that

wasn't designed for it that's when you see the statistic differences and certainly the same goes true for patients who are a hypoventilating and hyperventilating to using the proper equipment again with normal flows and

even higher flows you really don't see a whole lot of changes and this is just a this in a graphical form here so we have patients with a simple mask on the first column cap one and then the oxy mask and you can see the simple mask between no

flow and flow there's a difference in our siege of co2 readings where the cap one and the oxy mask not as much of a difference right and then the same things when we I'm sorry I'm the right when we

turn the oxygen on and the flow rates go up minimal difference in the concentration that we're monitoring there so careful attention to positioning the mask where the mask is located on the patient the inspired

concentration of carbon dioxide and the waveform itself right the quality of the waveform should be looked at very carefully and then looking at the location the gas sampling should be right over where the patient is exhaling

right you want to avoid having any distance between the two of those which I know can be a challenge in the environments that you're working in so

now let's look at non-invasive ventilation and I know about like five

percent of the patient population that you are seeing is on some form of non-invasive whether they're on by level ventilation or continuous positive airway pressures right so see if HAP using to stent the Airways open and

maintain a pro a Peyton airway and improving oxygenation but BiPAP and patients that need co2 elimination right need help with the by level support so there's a lot of questions that come up when we give

these talks I'm like how does capnography work effectively with these different technologies of non-invasive ventilation and especially because more and more of our patients are requiring these so we're gonna look at some of the

comparisons of co2 capnography data from three different sample sites and remember I showed you that picture so that picture I showed you with the patient wearing the sampling line with a nasal oral scoop and then there was the

mask sampling port and then there was the port on the ventilator circuit distally so that's what we're looking at here so the diamonds that go I wish I had a pointer I don't have a laser pointer I'm sorry but across the top the

diamonds represent our end tidal capnography values from one liter all the way up to eight liters so as the props are as the pressures go up for CPAP they were monitoring leak rates and what they found is the cat nog rafi

values across all of those were pretty accurate when we're monitoring right here the squares and the diamonds represent the mask sampling port and the the ventilator in the circuit distal to the mask and as you could see that

quality of our monitoring goes down as we progress okay to use yes but just know the limitations of your equipment right and again this is the same thing for our BiPAP Dave data are by level ventilation we're seeing again

across the top if we're sampling right at the airway we have pretty consistent readings but then they start to fall off and we look at the other devices that are further down the downstream what we're seeing here is our end tidal

measurements again with CPAP data and what we're looking at is the patient leak so there's always leaks right when we have these devices on and that's a question well sue if I have a leak how accurate am i okay so now the red is our

nasal oral scoop and if you look at the red graph all the way across depending on the leak rate pretty consistent values right the charcoal color is the mask sampling port and that's pretty consistent probably until about like 10

right until our patient like leak rate 10 liters per minute coming out of that mast and then that value starts to fall off and even more so even further distal down our circuit when we're sampling from the circuit at the past the mask

that's the cream color pretty accurate when there's a minimal leak but as the leak goes up that falls off pretty significantly and the same holds true for our by level ventilation pretty similar distribution here with the

patient leak and the sampling so when we're using non-invasive ventilation yes it's accurate and yes it's accurate we're using high flows and yes it's accurate if we have a huge leak only if we're sampling right where the patient

is exhaling so now I hope that clears that up with the patients that are getting supplemental pressure support with your sampling and you know in those just whatever it can sample from the mouth and the nose right at the source

of exhalation has proven to be the most reliable out of all of the different sampling devices so third evaluate your

equipment so first when you have a patient that comes down look at your patient look at

the vital signs Mental Status baseline lung sounds baseline ventilation status do they have a blood gas that's on record do they have they been monitored of capnography are you putting them on it for the first time yourself and

putting the sample line on get your baseline breathing get your baseline reading after a few breaths have them take some nice deep breaths look at their baseline waveform look at their baseline values but consider the

physiology it's okay if they come down and they have a low value or a high value because you're looking for changes and trends in the value second look at the effectiveness of your ventilation so that's a problem sometimes people will

come up to me and say you know this stuff doesn't work yeah I put this thing on the patient and I see their chest going up and down but I'm not getting anything in the monitor well guess what you know and I see this in the recovery

rooms and then I go and like well let's go if I'm clinical well let's go look at the patient and the patient is like slumped down in the bed your head is like this and they're snoring I was like well how about we boost the patient up

we prompt the patient's airway open and all of a sudden our waveform improves so look at your patients right look at the effectiveness of ventilation you know do you need to supplement their ventilation all of a sudden you see their waveform

come right back up right and then finally equipment okay it's not it's it's a little cut and dry yes we use capnograph we put capnography on the gas does the analyzing of the gases for us but you need to understand the the

mechanics of it right and using now capnography with different flow rates and with BiPAP and leak rates and different measures of you know different flow rates of oxygen blowing by so look at your equipment what are the

limitations of the equipment that you're using are your connections tight are you sampling right at the airway or are you sampling distal to the airway some of you may not have a choice right you might only have the mask connections or

for whatever reason you can't you if you have a burn patient or somewhere where you can't put something a patient it's okay but just think about the equipment think about the limitations think about the challenges

you may have with somebody you're doing a te eon or you're flipping somebody prone and they're breathing kind of sideways you're looking at the equipment in conjunction with the patient and the challenges you face so I hope that

putting it together in a format of first looking at physiology second looking at the quality of ventilation but third looking at the equipment interfaces and then passing around some of these devices and such kind of helps to take

it to an advanced level and put some troubleshooting and with that we have time we actually have if we have at least five minutes for questions I'm gonna leave this up on the screen and these are some really great resources so

there are plenty of things online they're free there's no charge some things have C II credits affiliated with them the California burden Board of Nursing but the pace website has a ton of information I apologize I don't have

a handout for you but you can come up take pictures of this go online see any of us after at the booth we can show you some of the equipment we could to answer more questions if you have another session you want to run off to but now

we have time for any questions and the microphones in the middle so don't be shy I don't have any prizes like like prices right but I'd be happy to answer some questions

so I actually work mostly in

interventional radiology in CT and ultrasound which is actually on a different floor that where we have our cath lab and I our stuff upstairs so that I our doctors are each going between two floors and one of my biggest

concerns is when we're doing moderate sedation the nurses are down in CT and ultrasound it doesn't matter how many comorbidities the patients have the aasa' is always three or less because they want to justify doing it downstairs

with just one nurse and the procedure list and I just and then you have somebody who obviously needs to be having anesthesia involved and now the anesthesiologist or the nurse anesthetist they get a circulating nurse

with them and I'm just wondering is there a cut-off that anesthesiologists or nurse and necess use for saying okay the a SA when it's this you have to consult with an anesthesiologist before you proceed with a nurse just giving

sedation that's a great question and that's institution unfortunately that's one of those things that is like institution dependent policy and procedure politics finances you know sometimes you'll see patients who really

are in a sa three four or four and a half that are made to be an a sa to write you know so they could be done during off-hours without anesthesia unfortunately it's a symptom so the organization's ever sit together and say

let's look at this globally for the patient safety and if we're doing sedation in this scenario we should still have somebody there who's trained to do the backup for that person I can't speak to your organization's policies

because I don't know them I know that they recommend catalog' Rafi I do know that the avenues to look at would be the Joint Commission in the anesthesia patient safety foundation you know for guidelines and again guidelines are just

that they're guidelines they're not mandates especially you know when institutions develop policies procedures protocols and such I do know on the third bullet down is we have a whole implementation project that we've rolled

out so one of the questions in addition to technical questions we get is how do I go to my institution and kind of change practice a little bit and usually the question is like implementing capnography but it it's a three-part

series that we did on how to implement change in an organization who are the stakeholders who are the champions who can you really talk to that would create change and whether it's the chief of anesthesiology is the person who's your

roadblock or your best friend is it the VP in nursing is it the safety committee you know cuz it takes one adverse event one Sentinel event unfortunately sometimes to change culture it takes more than that I know I know we're

trying a little at a time though but think it was a great comment in question was just made in our institution anesthesia kind of hit at this because the nurses were concerned about what she was just saying and so they worked with

the directors of like IR cath lab the medical directors to you say let's come together and figure out you know if it's a four it doesn't mean that every four needs to be you know it can be given sedation can be given by nurses but at

least get an assessment or things like that and in our institution nurses are able to if they feel like they needed anesthesia consult they can do the anesthesia console it doesn't mean they're gonna have anesthesia but

anestis you can tell you what to give and what not to give mm-hmm but that's that's what they're trying to do they have done for cath they're doing it for IR too and that is I forget them term for it but that's a team collaboration

and so and I must said where we work we actually screen the charts ahead of time because we have some really remote places and some not as remote and it's like the litmus test you know somebody with a BMI 55 is not going to be done

down the street they're gonna be done where emergent resuscitation is right upstairs if needed and same thing holds true like in our institution like anybody can call a patient safety stop meaning like I don't

feel comfortable with this let's not go forward and and again the procedure lists are another list of those champions because procedure lists they care about their pain you know they don't want to see adverse outcomes and

they're so focused sometimes on what they're doing that they kind of black you blank out on some of the peripheral factors and no one wants to see something bad happen on their watch so the procedure lists can be

instrumental in getting better monitoring or advocating for advanced levels of care or at least support for the nurses to have there's another question in your experience are the waveforms the same as far as a

ventilated patient versus a non ventilated patients have you seen any discrepancy in the actual performance that waveform itself yes and no okay so so I'm ventilated patients somebody who's really hyper dynamic I mean I've

seen like you could see sometimes their heart beating you know like just some of the little fluctuations or oscillations for the most part no difference if the non-invasive ventilation patient is getting monitored really right where the

gas is being exhaled like right here you may see some other you know and somebody is intubated so if there's secretions you might see like a little you know blip and such but when things are perfectly working the way they should be

working in both the intubated patient or the patient with an artificial airway versus not the waveform should be spot-on but if you're not seeing that is it a COPD or is it somebody who's got you know bronchitis in there yeah if

you're not seeing that full square waveform the question should be why not is my equipment not working good question great questions did the sign-in sheet make its way I know the spiral bound notebook is over

here but please do make sure that you put your name your email address and you'll be emailed because so you could fill out an evaluation and make sure that you get c e for attending this opportunity today I hope you guys

enjoyed it I hope you took something out of it I hope this just wasn't the basics for you today I hope that there was some value added in to coming today please do hang around we'll be here we'll be in the exhibit hall I know that there's

going to be many more events that are have this afternoon but the rest of the team will be here and we really do look yeah I love working with nurses that are providing sedation's I feel like you're the you're my people you know but you're

the people that are doing this day in and day out and you really are that that patient safety advocate and I feel like when I speak to a roomful of people that you guys go out and teach your precept ease and create change that's going to

impact patient safety so thank you for your attention today and thank you for attending [Applause]

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