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1037279_capnohrfcasestudy.qxd [ 2 ], page 1 @ normalizeC A S E S T U D Y
The Use of Capnography and NPPV in
Hypercapnic Respiratory Failure
Jhaymie L. Cappiello, RRT RCP
Duke University Medical Center, Durham, NC
A 73-year-old male with a complex history of COPD, hypertension and previous myocardial infarctions presented to the emergency department in severe respiratory distress. The patient was placed on Noninvasive Positive Pressure Ventilation (NPPV) using a Respironics BiPAP® Vision® Ventilatory Support System. To evaluate the adequacy of NPPV, End-Tidal C02 (ETC02) was continuously monitored via nasal cannula using the Respironics CO2SMO® Capnograph with the CAPNOSTAT® CO2 sensor in the sidestream mode.
The patient continued to improve. At 1135 with an RR of 28 and an ETCO2 of 38 mmHg, the patient was removed from NPPV and The patient presented to the emergency department at 0955 in placed on a mask with 40% FIO2 (Figure 3).
severe respiratory distress. Although the patient was unable to speak more than two words, he was alert and cooperative. The patient received nebulized albuterol and atrovent with oxygen.
Initial vital signs at 1000 were: RR 36, HR 101, BP 168/73, O2 saturation 95% on 8 L/min O2, and an End-Tidal CO2 (ETCO2)of 26 mmHg (Figure 1). The capnogram was indicative of alveolar hypoventilation and an incomplete expiratory phase.
Patient monitoring with capnography was continued. Changes in both the waveform and ETCO2 level were assessed. At 1205, the vital signs were: RR 24, HR 96, BP 131/52, 95% saturation on 40% FIO2, and ETCO2 36 mmHg with no changes in waveform. The patient was placed on 4 L/min of oxygen via nasal cannula and 90 minutes later was transferred to a general care monitored room. DISCUSSION
of 87 mmHg. At 1005 the patient was placed on NPPV with an Capnography depicts ETCO2 trends and enables alveolar IPAP of 10 cm H2O, EPAP of 5 cm H2O, and a FIO2 of 0.40. assessment in real time. In this case, the baseline ETCO2 - At 1020, the respiratory rate had decreased to 30 and the ETCO2 PaCO2 was large, which is often indicative of a COPD patient. had increased to 45 mmHg. The capnogram changed, revealing With capnography, alveolar ventilation changes can be detected a longer expiratory limb (Figure 2).
without the need for serial arterial blood gas draws. Additionally, capnographic waveform analysis enables an accurate assessment of alveolar progression. The combination of capnography with NPPV can permit the rapid stabilization of the patient’s respiratory condition and shorten the time needed for The respiratory rate had further decreased to 28 by 1035 with an ETCO2 of 43 mmHg and a full expiratory waveform. At 1105 the Customer Service: 800-345-6443 or 724-387-4000 vital signs were: RR 22, HR 102, BP 121/88, 97% O Respironics Europe, Africa, Middle East: +33-1-47-52-30-00 on 40% O2, NPPV 10/5, and ETCO2 38 mmHg. At this point, thepatient was able to speak in complete sentences. An ABG revealed “Respironics”, “BiPAP”, “Vision”, “CO SMO” and “CAPNOSTAT” are registered trademarks of Respironics, Inc.and its affiliates. 2006 Respironics, Inc. and its a pH of 7.34, a PaCO2 of 52 mmHg, and a PaO2 of 80 mmHg.
12 and 15 lead ECG Interpretation Lead Placement: even if you are not performing the test itself, knowledge of the correct lead placement is useful in troubleshooting an ECG test. V2 : feel for the space between the left clavicle and the rib beneath, place your baby finger there and feel down with subsequent fingers until your index is resting on the 4th rib space (4th intercostal spac