Capnography

[rogue medic]

As I mentioned before, capnography does have its place. But, before you make blanket statements, you must take into consideration all the different levels of training and skills abilities as well as the frequency of intubation per month or even per year for different services.

Why would anyone not use the most effective tube confirmation device available?

Look at the RSI cases from Texas. They did not assess carbon dioxide by any means.

Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.

Prehospital use of succinylcholine: a 20-year review.

Wayne MA, Friedland E.

RESULTS: Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

A large number of patients in a system that appears to do an excellent job.

They added capnography and the esophageal tube rate went down.

This is not a bunch of yokels being given a toy to play with. These are medics, who are very good at what they do. They do not turn up their noses at something that will help them to assess placement better.

Capnography is not a substitute for competence. Incompetent medics do not belong in EMS. The medical directors, who allow them to treat patients need to be eliminated.

Bad medical oversight just allows bad medics to kill patients. Adapting the type of ALS to accommodate bad medics is just allowing the incompetence to continue. If you can't afford ALS, BLS works.

Incompetent medics are not better than good basic EMTs.

In both the ED and the ICU, it is used as a diagnostic tool and not an expensive tube sitter.

The only time I have seen it used in the ED was when I provided it. Not many EDs seem to have anything other than the plastic covered litmus paper color change devices, CO2-wise.

So no, these people in the ICUs or EDs may be not ignorant, just better educated and more confident in their training and skills as well as their adjuncts which you may not be aware of.

My comment was that the ED personnel would not go to the ICU and start pulling off equipment that they are unfamiliar with. If you don't know what something is, you ask. You do not disconnect things you do not understand.

If ED personnel go to the ICU and start disconnecting things, because they are in the way, they should not expect to be treated as professionals.

It sounds like you are putting alot of faith into a piece of equipment that can fail you. The wave may not change at the slightest movement. I listed other variables that also mimic similar wave patterns.

What equipment do you have that does not have the possibility of failure? The tube can fail, the bag can fail, the oxygen can fail, the stretcher can fail, the ambulance can fail, . . . . Everything can fail. All of these have happened to me and I have adapted, as I have adapted to capnography problems. Capnography is just one assessment tool, but it is the most effective one.

Anyone relying on only one assessment does not belong in EMS.

You seem to keep trying to justify the untrained and under-supervised medic. These need to be eliminated before they kill and/or injure people. Anything else is just plain dangerous.

National Registry keeps making it easier for people to get medic cards, regardless of their incompetence. For them visualizing the tube going through the cords is a mandatory statement. How many people have they helped to kill with that requirement?

They also teach that you treat the rhythm, not the patient.

Are you going to pull what could be a perfectly good tube if your monitor still says flat line because you don't trust your own self with watching it "pass through the cords". Or, will you ignore the patient and "work the machine" instead?

It is a tool that can fail. Just as I do not start CPR, because there is a flat line (or artifact) on the ECG of a patient with a pulse, I do not make the capnography the only assessment. But I have already stated this a few times. You can keep making the same comments and you will keep getting the same responses.

I never wrote that capnography is, or should be, the only assessment.

I wrote that it is the most reliable, the most effective.

Claiming that I stated anything else is misleading.

Relying on seeing the tube pass through the cords" is not a mistake I make. I assess the patient for signs that the tube is in the esophagus (epigastric sounds with each breath, lack of chest rise, significant belly rise, . . . ) and pull the tube quickly if that appears to be the case.

Are you not using another assessment skill and sense of "feel" for this procedure and relying a little on your human qualities to do this?

Again, you misrepresent what I wrote to claim that I am inconsistent.

Capnography should not be the only assessment. Using a bougie has absolutely nothing to do with not using capnography.

Using the bougie does rely on feel.

Using the standard excuse for esophageal tubes - "I saw it go through the cords" as anything more than a hint of where the tube might be, is wrong. Visualization is even less reliable than the bougie.

Having a lot of tools is important. Understanding their use, and their potentially to mislead is also important. Discouraging people from using tools that can improve their assessment of the airway is bad medicine.

Almost every esophageal tube is accompanied by the statement "I saw it go through the cords." Is there any less reliable means of assessing tube placement?

Just curious, who sold you on capnography and who trained you? How long ago?

I do not remember when I started using capnography. The first several times I saw it used was when working in an ICU. On the ambulance it has been extremely helpful. Several tubes, that were not as secure as I would have liked, were left in place due to the ability to continuously demonstrate good gas exchange.

As I wrote before, I have had a false positive with capnography for longer than the 6 breaths that are supposed to be the maximum. A bystander had been doing mouth-to-mouth for a while. The waveform did not change significantly. The rest of the assessment was ambiguous, but did not agree with the capnography, so the tube was pulled. The patient was reintubated successfully. I should have pulled the tube a few breaths earlier, but I did let the capnography mislead me. This was a very large patient with a very distended belly making assessment difficult. Breath sound/stomach sound, chest rise/belly rise. In spite of all of the air in his belly, he never vomited.

I have talked with Dr. Baruch Krauss of Boston Children's Hospital. He attends a lot of conferences and is always looking to hear how capnography can be used better, how capnography malfunctions, and anything else that affects the use of capnography.

His name is on about half of the capnography literature. He also has written a lot of the literature on pediatric sedation, pediatric PSA, and pediatric analgesia.

These two are related. Capnography is used some places for any heavy sedation. It gives a clear, objective, assessment of ventilation. That does not mean that you ignore other assessment skills.

Who sold me on capnography? The research. The research is very clear about the value of capnography.

[VentMedic]

When I arrive at the ED and they pull the capnography tubing that they do not like, they are only demonstrating profound ignorance. The ED personnel would not do that in the ICU, but they are removing equally valuable equipment.

My comment was that the ED personnel would not go to the ICU and start pulling off equipment that they are unfamiliar with. If you don't know what something is, you ask. You do not disconnect things you do not understand.

If ED personnel go to the ICU and start disconnecting things, because they are in the way, they should not expect to be treated as professionals.

You are in their ED. They have every right to remove your stuff and apply whatever equipment they want or not. Your stuff may not be compatible with their stuff. They may not want more lines to get tangled when moving the patient and prepping them for procedures. They may not want extra deadspace in the circuit if it is no longer performing a function. Maybe they want to use only the equipment that belongs to them that is properly calibrated by them if they are putting their licensed signature on it. If you have any ICU experience, you should already know some of these things.

I don't know what your argument here is, but there are still some acceptable standards in the field that are also dictated by well known authors, researchers and medical directors. Name dropping can be impressive but not an end all for all research. I already said it was a valuable tool but care does not have to stop if you don't have one. Even hospital ICUs don't fall apart without one.

I do not remember when I started using capnography. The first several times I saw it used was when working in an ICU.

Believe it or not but I do remember when I was first introduced to ETCO2. I also remember how it was integrated into my life at work both in and outside of the hospital.

Several tubes, that were not as secure as I would have liked, were left in place due to the ability to continuously demonstrate good gas exchange.

Is the machine also holding those tubes in place for you? The transport environment is not always a smooth ride.

You seem to keep trying to justify the untrained and under-supervised medic.

That is not at all what I stated anywhere. Just because a service does not have ETCO2 does not make the paramedics working for it any less competent than those that do.

After seeing your other posts on another forum and your blogspot, are a rep for an ETCO2 company selling to EMS?

[rogue medic]

You are in their ED. They have every right to remove your stuff and apply whatever equipment they want or not.

Disconnecting stuff that you don't understand is bad patient care regardless of where it takes place. Ask before you disconnect. Also, it might be a good idea to ask before you cut a capnography cable that is not disposable. But, I'm sure there is a good reason for the ED staff to be destroying EMS equipment. Maybe, it just demonstrates that a person was acting without thinking.

Maybe they want to use only the equipment that belongs to them that is properly calibrated by them if they are putting their licensed signature on it.

What licensed signature? They just start pulling on things. Good thing I haven't seen them do this to a PICC line, yet.

If you don't know what it is, ask. If you want it removed, don't panic and start grabbing things you don't understand, ask someone to remove it.

I don't know what your argument here is, but there are still some acceptable standards in the field that are also dictated by well known authors, researchers and medical directors.

Please explain what you are talking about. What argument? What standards? It looks as if you clipped part of a comment and did not get all of it.

Name dropping can be impressive but not an end all for all research.

I was just answering the who part of your question:

Just curious, who sold you on capnography and who trained you? How long ago?

Since I put your quote in front of my answer, I thought you might see the connection.

Believe it or not but I do remember when I was first introduced to ETCO2. I also remember how it was integrated into my life at work both in and outside of the hospital.

And your point is that I have a bad memory? :roll:

After seeing your other posts on another forum and your blogspot, are a rep for an ETCO2 company selling to EMS?

Really, I sell rose tinted glasses for people who believe that "seeing the tube go through the cords" is a dependable assessment.

If I were selling something, I would have some way for you to order it.

I might even identify a particular product.

I do not sell anything.

I do not advertise anything.

I have links to tinyURL, dictionary.com, and Epocrates. I do not receive any money from them. These are there to make it easier for people to find information. If someone goes to one of these sites and purchases something, I do not receive anything for it. I have never plugged any of these on my blog, other than to provide access to them on the side bar.

I have links to several blogs. Many of them do not have any kind of advertising. The blogs that do have advertising are probably not making any significant money from the ads. Certainly not when you break it down per hour devoted to keeping the blogs going. The links are there to provide ideas for interesting and informative reading.

I also link to the web sites of these people and organizations. They do not endorse my blog. They do not pay me. They are there to make it easy for readers to find reputable information. EMT City might have links to some, or all, of them somewhere.

* Dr. Bryan Bledsoe

* EMS House of DeFrance

* EMS1.com

* EMStock

* EMSunites.com

* National Association of EMS Educators

* National Association of EMS Physicians

* National Association of EMTs

* National Association of State EMS Officials

* National EMS Museum Foundation

* Prehospital Emergency Care

* SLAM - Street Level Airway Management

My blog is Rogue Medic.

I am not hiding or selling anything. If you want to come and read and laugh at me, go ahead. If you want to come and disagree, you are welcome, also. If you want to come and agree, I have to warn you that VentMedic is watching and will be taking names. :shock:

Actually, I do sell one thing - ideas.

Those ideas are free. Some might say that they aren't even worth that much. Oh, well.

Ad hominem attacks generally indicate that the critic has no other way of making a point, no valid argument.

VentMedic does not have any research that shows that a medic, or nurse, or doctor, claiming to "see the tube go through the cords" is an effective way to determine tube placement. This is just wishful thinking on VentMedic's part.

[DwayneEMTP]

I swear to God...I have an almost perfect record for posting something like, "I like you're posts, thanks for sharing!" with a n00bie and then changing threads to find them make a complete ass of themselves.

Rogue, you sound to me like a very smart medic, how then can you not be smart enough to see that Vent made her points very clearly, yet you insist on changing them, and then arguing against the point you claim she made, but didn't?

It's not uncommon that n00bs want to get into a penis measuring contest with vent. What's sad, is that she always wins, despite the fact that she doesn't have one!

Her points were pretty clear to me. The fact that you're attempting to claim that she advocates cord visualization as the only necessary means of tube verification is ignorant and laughable. I can only guess that you are hoping the rest of us here are too stupid to understand this conversation and therefore not see it for what it is. If you choose that logic strategy here you will often, if not always be found lacking and exposed as a logically and intellectually weak.

I really like your attitude about prehospital medicine. I believe that I have much to learn from you, and look forward to doing so in the future. It's just simply hard to respect your intelligence when you spin ideas in a way that allows you to be offended and agressive.

On a different note. I notice that it's often a habit to simply used the quotes without adding the posters name. Can we change that? It's kind of a pain to see a quote and then have to research where it came from before being able to decide on it's contextual validity and responding.

Have a great day all.

Dwayne

[rogue medic]

Dwayne,

I don't believe I ever stated that VentMedic claimed it was the only method of confirming placement. I disagreed with her claim that it is an effective part of assessing placement.

It is a very ineffective means of assessing placement. It does not contribute to assessment. It misleads people into keeping tubes in place that should be pulled.

People think that what they see is what is happening. People see what they want to believe.

Why is it that so many people state that they saw the tube go through the cords, when the tube is actually in the esophagus?

I am critical of cord visualization and strongly encourage waveform capnography.

VentMedic is critical of waveform capnography in the prehospital setting and feels that visualizing the tube going through the vocal cords is an important component of tube placement confirmation, unless I misunderstand her position.

Neither of us was suggesting that these be the only method of confirmation.

One is supported by plenty of research, especially in the prehospital setting. The other is not. How do you come to the conclusion that cord visualization has a place in assessment and capnography does not?

Perhaps you can explain where I am not getting VentMedic's argument.

[VentMedic]

VentMedic is critical of waveform capnography in the prehospital setting and feels that visualizing the tube going through the vocal cords is an important component of tube placement confirmation, unless I misunderstand her position.

Did you even read the beginning or middle of this thread? I posted educational information and links to additional sites. And, I posted all this on a prehospital forum with EMTs and Paramedics as the intended audience.

You even posted on another forum where I started the Texas RSI thread and where I was pro proper protocol and procedure.

rogue medic

Why is it that so many people state that they saw the tube go through the cords, when the tube is actually in the esophagus?

If not properly secured, as you stated earlier to being guilty of, the tube can migrate during transport or transfer.

How do you come to the conclusion that cord visualization has a place in assessment and capnography does not?

Conclusion? ... Once again, did you actually read my posts? Or, is this just a snip at those who do not have ETCO2 monitors?

When you intubate, the first thing you look at is the vocal cords. You do not close your eyes but rather you watch the tube to pass through the cords. You can also use the vocal cord marks on some of the smaller uncuffed tubes to determine placement. If you have any neo/peds experience, you should be aware of that already. You can also do a quick check for the tube before you yank out the tube especially if it is just a cuff above the cords which can be fairly easily remedied. Direct visualization with a laryngoscope is only of my many favorite methods in the ED, ICU or on transport.

I can give you many examples of things that can skew just about any assessment scenario and that is why it is not good to rely on something electronic but also to have several alternatives that require physical assessment. But then, I have already stated this earlier in the thread. I also posted an extensive list of things that can present similar waveforms which may require a physical assessment to determine the cause.

It is going to be a long time before all of EMS is on the same page in this country. Protocols and equipment differ from state to state, county to county and city to city. I do not criticize those that do not have all the latest and greatest gadgets. That includes ETCO2 monitors. The exception, of course, is if they are doing advanced procedures such as RSI or IFT - CCT with ventilators. But, I am just repeating what I have already said.

BTW: This thread was not even about pro or con Capnography in the field. There was not a question as to its usefulness. It was started by the OP asking for some information to learn more about Capnography in the field.

[ccmedoc]

Disconnecting stuff that you don't understand is bad patient care regardless of where it takes place. Ask before you disconnect. Also, it might be a good idea to ask before you cut a capnography cable that is not disposable. But, I'm sure there is a good reason for the ED staff to be destroying EMS equipment. Maybe, it just demonstrates that a person was acting without thinking.

What licensed signature? They just start pulling on things. Good thing I haven't seen them do this to a PICC line, yet.

If you don't know what it is, ask. If you want it removed, don't panic and start grabbing things you don't understand, ask someone to remove it.

I find it laughable that you believe that the staff in an ED do not understand the monitoring equipment on an ambulance, especially capnography. I would venture that any airway equipment would be tended to by a respiratory therapist or physician anyhow.

If the approach in the ED is in any way as arrogant or conceded as your tone here, I wonder why they don't respect your equipment.

It has been stated here, ad nauseam, that capnography is a very valuable tool in the prehospital, as long as the equipment and education is there. This is not the case in the majority of areas in the U.S.

I believe that physical examination and assessment is by far the most reliable and "technical" tools we have. To correlate this with an adjunct such as capnography is only a bonus. If you have them, absolutely use them..When RSI is in the picture, they are standard. Most people don't RSI, however.

Bottom line, if you can't get the tube, what good is capnography. Even if the tube is verified, there is more than one lung pathology that would indicate possible placement error. At that point...who or what do you trust??

I agree with Vent on this one..seems a bit one sided.

[rogue medic]

rogue medic

Quote:

Why is it that so many people state that they saw the tube go through the cords, when the tube is actually in the esophagus?

VentMedic:

If not properly secured, as you stated earlier to being guilty of, the tube can migrate during transport or transfer.

Quote:

The "proper" ways were not working. The tube did not migrate. I was able to continually confirm that because of the waveform capnography. This was an unusual situation, the patient had consumed a large amount of some extremely slippery substance. Nothing was sticking.

Why do you believe that tube migration is a problem, rather than these being cases of misplacement?

When "I saw the tube go through the vocal cords," is followed by "it must have become dislodged," why does anyone believe that the tube was ever in the trachea?

I am not claiming that tubes never become dislodged, but that the rate of tracheal intubation followed by dislodgement, is wildly exaggerated.

The tube was never in the trachea.

The medic has been trained to say "I saw the tube go through the vocal cords," because if the medic does not state that, the testing body will punish the medic for a critical failure.

This is teaching bad airway management. It teaches the student to say that the student sees something the student doesn't see.

It is rare for a properly managed tube to leave the trachea.

Even with the parts of my tube separating and nothing sticking, my tube was never dislodged.

"Winged Migration" was not a movie about endotracheal tubes.

The true dislodged tube is rare. The research I quoted showed that in an excellent system the rate of unrecognized esophageal tubes was 0.3 % and decreased with the addition of capnography.

Other systems claim to have equal success at intubating, just an extremely high rate of dislodged tubes.

Some people believe that.

The word for that is gullible.

[firedoc5]

For me, they were tubed correctly or not at all. Either I monitored the airway or someone I totally trusted did. Had very, very few dislodgings. A new doc (who turned out to be the new Medical Director) and I had a side chat about that. When they were moving the pt. from our cot onto the ER bed the tube did get moved, but not displaced, just got moved up a little. The RT didn't catch it, but the doc was standing right there and he saw it when it got moved. The RT rolled his eyes almost like he was going to blame me. Afterwards I made it clear to the doc that the tube was correct. He said he knew it was, and we became close friends after that. He liked that I spoke up.

But for me, airway is almost an obsession. So whether a pt. was tubed or not, they had a patent airway, and I made sure of that. It always burns be when some one is complacent about an airway and does not make 100% sure it's good. Then has excuses why it was not.

(I'm jumping off my little soap box now)

[IUemt]

A little late..but

woot

http://youtube.com/watch?v=9lrja6C0Quc