Applications of capnography in airway management outside the operating room

The capnograph is vital for patient monitoring in the operating room. Its clinical applications for airway management outside the operating room are being increasingly recognized due to its role in the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guidelines. Capnography can be used for the detection of respi-ratory depression during procedural sedation, verification after emergency endotracheal tube intubation, assessment of the airway and circulation during cardiopulmonary resuscitation, and continuous monitoring during patient transportation and in intensive care settings. This can be especially beneficial for pediatric patients, those who are critically ill, and patients with a difficult airway.

Capnography; Capnometer; Airway management; Patient transport; Difficult airway

[1] Bhavani-Shankar K, Moseley H, Kumar AY, Delph Y. Capnometry and anaesthesia. Canadian Journal of Anaesthesia. 1992; 39: 617–632.

[2] Long B. Interpreting waveform capnography: pearls and pitfalls. 2016. Available at: http://www.emdocs.net/interpreting-waveform-capnography-pearls-and-pitfalls (Accessed: 30 May 2016).

[3] Gravenstein JS, Jaffe MB, Gravenstein N, Paulus DA. Capnography. 2nd ed. New York: Cambridge University Press. 2011; 461–465.

[4] Smalhout B, Kalenda Z. An atlas of capnography. 2nd edn. Utrecht: Kerckebosch-Zeist. 1981.

[5] Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. Journal of the American Medical Association. 1986; 256: 1017–1020.

[6] Jooste R, Roberts F, Mndolo S, Mabedi D, Chikumbanje S, Whitaker DK, et al. Global Capnography Project (GCAP): implementation of capnography in Malawi-an international anaesthesia quality improvement project. Anaesthesia. 2019; 74: 158–166.

[7] Gelb AW, Morriss WW, Johnson W, Merry AF. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) international standards for a safe practice of anesthesia. Canadian Journal of Anesthesia. 2018; 65: 698–708.

[8] Long B, Koyfman A, Vivirito MA. Capnography in the emergency department: a review of uses, waveforms, and limitations. The Journal of Emergency Medicine. 2017; 53: 829–842.

[9] Ward KR, Yealy DM. End-tidal carbon dioxide monitoring in emergency medicine, part 2: clinical applications. Academic Emergency Medicine. 1998; 5: 637–646.

[10] Smits GJ, Kuypers MI, Mignot LA, Reijners EP, Oskam E, Van Doorn K, et al. Procedural sedation in the emergency department by Dutch emergency physicians: a prospective multicentre observational study of 1711 adults. Emergency Medicine Journal. 2017; 34: 237–242.

[11] Krauss B, Hess DR. Capnography for procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 2007; 50: 172–181.

[12] Dobson G, Chong MA, Chow L, Flexman A, Hurdle H, Kurrek M, et al. Procedural sedation: a position paper of the Canadian Anesthesiologists’ Society. Canadian Journal of Anaesthesia. 2018; 65: 1372–1384.

[13] Veazie S, Vela K, Mackey M. Evidence brief: capnography for moderate sedation in non-anesthesia settings. Washington: Department of Veterans Affairs. 2020.

[14] Vaghadia H, Jenkins LC, Ford RW. Comparison of end-tidal carbon dioxide, oxygen saturation and clinical signs for the detection of oesophageal intubation. Canadian Journal of Anaesthesia. 1989; 36: 560–564.

[15] Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Medicine. 2002; 28: 701–704.

[16] Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Annals of Emergency Medicine. 2005; 45: 497–503.

[17] Pokorná M, Nečas E, Kratochvíl J, Skřipský R, Andrlík M, Franěk O. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. The Journal of Emergency Medicine. 2010; 38: 614–621.

[18] Ornato JP, Shipley JB, Racht EM, Slovis CM, Wrenn KD, Pepe PE, et al. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Annals of Emergency Medicine. 1992; 21: 518–523.

[19] Jaber S, Jung B, Corne P, Eledjam JJ, Lefrant JY. Making intubation in ICU safer with intubation guidelines: a before-after multicenter study. Anesthesiology. 2007; 107: A942.

[20] Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785–799.

[21] Cereceda-Sánchez FJ, Molina-Mula J. Systematic review of capnography with mask ventilation during cardiopulmonary resuscitation maneuvers. Journal of Clinical Medicine. 2019; 8: 358.

[22] Urman R, Kodali B. Capnography during cardiopulmonary resuscitation: current evidence and future directions. Journal of Emergencies, Trauma, and Shock. 2014; 7: 332.

[23] Morisaki H, Takino Y, Kobayashi H, Ando Y, Ichikizaki K. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation in patients with pre-hospital cardiac arrest. Masui. 1991; 40: 1048–1051.

[24] Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. Journal of the American Medical Association. 1987; 257: 512–515.

[25] Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G. Recommenda-tions for the intra-hospital transport of critically ill patients. Critical Care. 2010; 14: R87.

[26] Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Annals of Emergency Medicine. 2005; 45: 497–503.

[27] Langhan ML, Ching K, Northrup V, Alletag M, Kadia P, Santucci K, et al. A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement. Academic Emergency Medicine. 2011; 18: 590–596.

[28] Rückoldt H, Marx G, Leuwer M, Panning B, Piepenbrock S. Pulse oximetry and capnography in intensive care transportation: combined use reduces transportation risks. Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie. 1998; 33: 32–36. (In German)

[29] Bhende MS, Thompson AE, Orr RA. Utility of end-tidal carbon dioxide detector during stabilization and transport of critically ill children. Pediatrics. 1992; 6: 1042–1044.

[30] Kerslake I, Kelly F. Uses of capnography in the critical care unit. British Journal of Anaesthesia Education. 2017; 17: 178–183.

[31] Young A, Marik PE, Sibole S, Grooms D, Levitov A. Changes in end-tidal carbon dioxide and volumetric carbon dioxide as predictors of volume responsiveness in hemodynamically unstable patients. Journal of Cardiothoracic and Vascular Anesthesia. 2013; 27: 681–684.

[32] Schramm WM, Bartunek A, Gilly H. Effect of local limb temperature on pulse oximetry and the plethysmographic pulse wave. International Journal of Clinical Monitoring and Computing. 1997; 14: 17–22.

[33] Nesseler N, Frénel J, Launey Y, Morcet J, Mallédant Y, Seguin P. Pulse oximetry and high-dose vasopressors: a comparison between forehead reflectance and finger transmission sensors. Intensive Care Medicine. 2012; 38: 1718–1722.

[34] Roberts WA, Maniscalco WM, Cohen AR, Litman RS, Chibber A. The use of capnography for recognition of oesophageal intubation in the neonatal intensive care unit. Pediatric Pulmonology. 1995; 19: 262–268.

[35] Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detector during paediatric cardiopulmonary resuscitation. Pediatrics. 1995; 95: 395–399.

[36] Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, et al. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73: 1337–1344.

[37] Eipe N, Doherty DR. A review of pediatric capnography. Journal of Clinical Monitoring and Computing. 2010; 24: 261–268.

[38] Riley CM. Continuous capnography in pediatric intensive care. Critical Care Nursing Clinics of North America. 2017; 29: 251–258.

[39] Wong E, Ng Y. The difficult airway in the emergency department. International Journal of Emergency Medicine. 2008; 1: 107–111.

[40] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827–848.

[41] Dohi S, Inomata S, Tanaka M, Ishizawa Y, Matsumiya N. End-tidal carbon dioxide monitoring during awake blind nasotracheal intubation. Journal of Clinical Anesthesia. 1990; 2: 415–419.

[42] Spencer RF, Rathmell JP, Viscomi CM. A new method for difficult en-dotracheal intubation: the use of a jet stylet introducer and capnography. Anesthesia and Analgesia. 1995; 81: 1079–1083.

[43] Williamson JA, Webb RK, Szekely S, Gillies ER, Dreosti AV. The australian incident monitoring study. Difficult intubation: an analysis of 2000 incident reports. Anaesthesia and Intensive Care. 1993; 21: 602–607.

[44] Miller RD. Miller’s anesthesia. 8th edn. New York: Churchill Livingstone Inc. 2015.

[45] Lim KS, Nielsen JR. Objective description of mask ventilation. British Journal of Anaesthesia. 2016; 117: 828–829.

[46] Wilkinson KA, Martin IC. Tracheostomy care: on the right trach?National Confidential Enquiry into Patient Outcome and Death. 2014.

[47] Lai MF, Wu ZF, Lin CY, Huang YS. Absence of capnography from tracheostomy: an indicator of tracheostomy tube dislodgement. Journal of Medical Sciences. 2019; 39: 102–104.

[48] Cummins RO, Hazinski MF. New guidelines on tracheal tube confirma-tion and prevention of dislodgement. Circulation. 2000; 102: 380–384.

[49] Saunders R, Struys MMRF, Pollock RF, Mestek M, Lightdale JR. Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis. BMJ Open. 2017; 7: e013402.

[50] Parker W, Estrich CG, Abt E, Carrasco-Labra A, Waugh JB, Conway A, et al. Benefits and harms of capnography during procedures involving moderate sedation: a rapid review and meta-analysis. Journal of the American Dental Association. 2018; 149: 38–50.

[51] Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. British Journal of Anaesthesia. 2016; 117: 182–190.

[52] Wollner E, Nourian MM, Booth W, Conover S, Law T, Lilaonitkul M, et al. Impact of capnography on patient safety in high- and low-income settings: a scoping review. British Journal of Anaesthesia. 2020; 125: 88–103.

[53] Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, et al. Part 1: executive summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142: S337–S357.

[54] Nikolova-Todorova Z. Clinical applications of capnography. Signa Vitae. 2008; 3: 44–45.