Get Part 1 of this discussion at MedicCast.com/innovations
Capnography Uses and Discussion with Peter Canning and Tom Bouthilett
Transcript of main discussion (Part 2)
Jamie: Let’s move in and talk a little bit—we talked about perfusion and the ways that capnography really gives us an idea of what’s going in the respiratory system and perfusion and gas exchange. Peter previously said that it’s an opportunity to see perhaps why someone has collapsed if it’s been related to choking or some of the other respiratory issues. There are really a lot of different ways that capnography can be used for that live patient. Patients with respiratory difficulties to help confirm based on the waveform, based on the capnography numbers that are coming back, the values for carbon dioxide that we’re seeing. We can correlate that with specific problems. I know, Peter, you’ve been talking about this for a long time on how we can use this to identify effectiveness of interventions for asthma. Identifying a patient with an asthma attack versus an anxiety attack just based on the shape of the waveform. We’d like to share a little bit about how you think that is just something that were missing and not doing enough of.
Peter: Yes. I have found it very useful in some cases. One caution as far as the number when you’re using the nasal prongs is a low number is harder to take for granted than a high number. If you get a high number then you know there’s a problem. There’s a lot of carbon dioxide there. But the low number sometimes it can just be the way the person’s breathing or the way the thing is positioned. What I like to use it for is if I have a patient that’s like an unresponsive. I show up and they don’t arouse very well. If I slap one of those things on right away, I can tell whether this patient’s obtunded or whether they’re ventilating properly. If I put the thing on and I get 35 for an end-tidal then I’m relatively calm. If this person I put it on and I’m getting 60’s or 70’s then I have to start thinking, “Maybe this patient’s going to need to be intubated.” I find that I’m not using as much as I used to use it on some of the respiratory calls. If I show up and the person had COPD or an asthmatic, confirmed with a history of it, and they’re having a hard time breathing and I can hear their wheezes, I just go ahead and treat them. The capnography, while providing some interesting information, isn’t going to change my treatment that much. Being a single medic, I don’t always have the time to put it on. As you mentioned, sometimes if I’m not certain what the cause is, if this person is—they’re going, “I can’t breathe. I can’t breathe. I have asthma. I can’t breathe.” I put the capnography on and I see a nice upright waveform then I may think this is more anxiety or if I put it on and I see the big shark fin, then I know it’s more of the asthma.
Tom: I find the shark fins very interesting. We had a gentleman named Robbie Murray who is the Operations Chief for Sussex County EMS that came down and taught our capnography class on Hilton Head. For anyone that doesn’t understand what we mean when we talk about a “shark fin” waveform is what’s called the, I guess, the leading edge of the alveolar plateau, so the flat top on top of the waveform is referred to as the alveolar plate. The leading edge of it becomes obliterated in the presence of bronchospasm. Because that leading edge gets rounded out, it really does take on the general appearance of a shark fin. I’m sure that a field-hardened paramedic like Peter can identify a patient who is wheezing without the assistance of capnography. Peter, one thing, I though was so cool in this presentation was seeing the improvement in the waveform after the treatment. I thought that was kind of neat.
Peter: Right. Yes. You can really do that. I have a website called “Capnography for Paramedics.” I’ve got some of these waveforms on there. It’s “emscapnography.blogspot.com.” On there, I have strips from COPD that I treated. The first strip you hardly see any waveform at all. They’re having such difficulty breathing. The next strip, after I started giving them breathing treatments, you can see the clear shark fin. The last one after the two combivents, it’s almost upright. It’s really a marked improvement that can be documented. You can go to the hospital and say, “Look, this person really was having a hard time.”
Tom: Peter, I’m glad you brought up capnography for paramedics because for anyone who doesn’t know, back in October 2008, the capnography for paramedics blog was my inspiration for starting the “Prehospital 12-lead ECG” blog.
Peter: Well, I can say, you’ve done a lot more with your blog than I have with the capnography one. I haven’t really kept up with it too much. I am planning to go in and update it. My last update I did was at the end of 2007. There certainly are some updates that could be done there. There’s a nice handout that anybody’s free to use and to copy. I have to say your 12-lead blog is just outstanding. I know we’re talking about capnography today but there so much that can be learned about 12-lead interpretation that is on your blog. I’m a regular reader of that and I really enjoy it.
Tom: Thanks, Peter. I appreciate that. Of course, your capnography blog was side-project for you because your main blog is the Medicscribe. Anyway, anyone who wants a basic primer to understand capnography waveforms and what capnography can do for you, I would definitely recommend capnography for paramedics. All you have to do is just go to Google and type in “capnography for paramedics” and I’m sure it’ll take you straight there.
Jamie: Peter, I’ll make sure we give you a link to the MP3 for these series of episodes so that you can improve that.
Peter: Like I said, I’m going to try to get sometime and update the blog with some of that newer research and certainly with the new American Heart recommendations on it.
Jamie: We should stress that even though it says “capnography for paramedics” it’s primarily because we’re the ones using it more than anybody else right now. I got to say that for anyone in the hospital setting: ER nurses, critical care nurses that want to learn a little bit more about capnography and how to read these waveforms and see what we’re talking about when we talk about that shark fin which really, again, being able to see the effects of our intervention. That’s like, Tom, you do it. You talk about watching those subsequent 12-leads as your interventions have a positive effect when you’re watching ST-elevations change either for better or for worse depending on how the patient’s trending. Certainly, as on-going tool, to see real-time effects of respiratory treatment, capnography is pretty amazing to see that change.
Tom: Absolutely. How many times have you found a patient, let’s say, in CHF, and maybe even having those reflex bronchospasms, the so-called “cardiac asthma” to where the patient was breathing at a rate of 40 and so shallow or maybe it was so tight that you could scarcely auscultate any breath sounds. You gave the patient the nitroglycerine and maybe you even stood up behind the patient in the days before CPAP and try to sort of handbag them and keep them or give them your own positive-pressure ventilations and they had a miraculous turn-around. By the time you got into the emergency department and you kind of get this look from the nurse or the doctor that the patient wasn’t quite as bad as you said they were. I think capnography is just one more tool where we can say, “Oh, yes, they were. Here is an instrument documentation of the respiratory rate.”
Jamie: Well, I’ve been tweeting while we’ve been doing this interview and everybody’s saying please tell Peter Canning that you are their hero from several of my Twitter followers. Just as we conclude here, what would your recommendation be to any medical professional listening to this about bringing more use of capnography into monitoring your patients whether it’s pre-hospital or in the hospital setting even if they had one of those pocket devices they can bring by and put a cannula on somebody and just monitor their respiratory effectiveness when they got an asthmatic patient that’s problematic. What would you say to those individuals, Peter, about getting started and just utilizing this new tool?
Peter: Well, I don’t know, I just have them try to do some preliminary reading about it. I’m not that familiar with the in-hospital setting on a longer term basis. As far as in the ER, I think it’s great to get a quick snapshot of what’s going on with your patient. Certainly, if you’re doing a cardiac arrest or you’re intubating somebody in the ER, it would be absolutely essential. On a longer term basis, I think there’s other types of stuff that they can use.
Jamie: They got the respiratory therapist that are usually available in the hospital setting, pulmonologists and things. I work in a small hospital and often, in nighttime, there was one physician in the hospital, one respiratory therapist to cover an entire hospital with a regular med-surg floor, an ICU, and in ER. I think familiarizing yourself with these tools even if you’re a floor RN, familiarizing yourself with understanding of what capnography waveforms mean, recognizing them if you are looking at a ventilator, talking to your respiratory therapist, and encouraging perhaps that they come in and do some education on capnography for the facility would be a great thing. Or talk to your paramedic educators because I think we are using this more and more and have a great understanding. So bring those paramedic educators in to educate the nurses in the facility about this.
Peter: Yes. Actually one of our local hospitals had me come in to their regular staff skill sessions and do a little module on capnography. It was very interesting that people are very excited to learn about it and it was something that they weren’t very familiar with.
Jamie: Well, this has been a really fascinating and I want to thank both of you for taking time out of your busy schedules to come in here and share this with the listeners here of the brand-new Innovations in Patient Care podcasts that actually should be showing up at iTunes by the time they listen to this, we should have it posted there. I got a bunch of episodes already in the can with some variety of different topics. Capnography is one of those things that we’re going to continue to bring up here as one of those monitoring tools that can provide just a different window, an insight into many things going on with our patients. Tom, any final thoughts?
Tom: I just think if there is an EMS system that is ready to pull the trigger and implement capnography, just get with your vendor and they probably have someone that delivers education for them. I think that’s how we did it on Hilton Head and I was very pleased with the result.
Jamie: The same thing goes for the hospital ERs and other settings. I think that there are good educators out there that can come in associated with a vendor or with other organizations in your region that could come in and talk about capnography and its uses in your specific setting. There may be applications beyond what we’ve talked about in a specific patient care environment depending on the patient type and issues that you’re dealing with, so definitely for that. Peter, where can people find more of you online so that they can catch your blog if they haven’t already been reading?
Peter: A year or so ago, I moved my regular blog from Blogspot to the Fire EMS blog site. You can go there now on www.medicscribe.com. I’ve been busy with lots of other stuff lately so I haven’t been posting nearly as much as I used to. I do post there. I try to post as much as I can which is only probably about a couple of times a month right now. There’s links there to the capnography blog and links to where you can get copies of my book if you’re interested in that.
Jamie: Thank you very much, Peter, and I would urge everybody even if he hasn’t posted anything recently, you will find a wealth of information just by reading any of the particular posts. You’re a gifted author. If you haven’t checked out his novels to learn about what brought him into the EMS setting. You should check out his books and they’re available over in his site. You can find them on Amazon. I think in other places as well. But just a fantastic read. Peter, thanks a lot for joining us today.
Peter: Great. Thanks, Jamie. Thanks for having me.
Jamie: Tom Bouithilett, where we can find more of you online?
Tom: My website is the “Pre-hospital 12-lead ECG” blog and that is located at ems12lead.com. You can email me at Gmail which is firstname.lastname@example.org and you can find me on Twitter at ems12lead.
Jamie: Great, guys. Well, thanks a lot and we’ll be continuing this discussion and other discussions and I hope we can have you on again to talk about some other things in the future