The Disappearing Endotracheal Tube

[p3medic]

On the topic of waveform capnography, why is it that the vast majority of ED's I transport to (including 4 level 1 trauma centers) don't have capnography in the ED? I can monitor an intubated pt better in the truck than they can in the ED, short of gasses.

[scott33]

On the topic of waveform capnography, why is it that the vast majority of ED's I transport to (including 4 level 1 trauma centers) don't have capnography in the ED? I can monitor an intubated pt better in the truck than they can in the ED, short of gasses.

Probably because their instances of missed tubes (or rather, missed tubes left in situ) are so insignificant as to not warrant it. Probably because RT's and Anesthesiologist do enough tubes to take the guesswork out of intubation and end tidal monitoring. Probably because a hospital bed is a lot less bumpy than an ambulance or a flight of stairs.

[chbare]

Probably because their instances of missed tubes (or rather, missed tubes left in situ) are so insignificant as to not warrant it. Probably because RT's and Anesthesiologist do enough tubes to take the guesswork out of intubation and end tidal monitoring. Probably because a hospital bed is a lot less bumpy than an ambulance or a flight of stairs.

I am not sure. The unfortunate truth is that unrecognized esophageal intubation is most likely more common; however, it may not be talked about as much.

The trend is becoming much more popular in the hospital however. I occasionally work in a tiny rural ER that has 5 beds. Their intubation kit comes complete with LMA's and a monitor that has waveform capnography capabilities. In addition, capnography has been used every time I have been on an intubation.

In fact, I remember one night a patient went into respiratory arrest on their tiny medical/surgical floor. I responded along with a paramedic from the ambulance service (hospital based). The patients doc (Family Specialty), had intubated the patient and taken all the reasonable steps to stabilize the patient. One of the first things he asked was to place the patient on capnography and note the findings.

It is becoming more popular and many places at least have colometric technology. Baby steps. I do not expect ICU's to use this technology as frequent ABG monitoring and chest x-rays on vented patient are fairly standard. In the ER and with code response teams involved with the initial intubation; however, capnography should be standard.

Take care,

chbare.

[Arizonaffcep]

Capnography is not mandated by DHS in AZ (ya ya...we're a little behind the times...), but most departments have moved to include it anyway, as they recognize the importance of it. 4 hospitals in the Tucson area don't have it in the ED, which is troublesome for me. After all, how well can you relay on a pulse ox only...after all, they will show 80 something percent for a POx...when UNATTACHED! I'm disappointed that my service only has CO2 ability for intubated patients. I would like to see it for breathing patients (asthma, COPD, etc.).

[VentMedic]

It is becoming more popular and many places at least have colometric technology. Baby steps. I do not expect ICU's to use this technology as frequent ABG monitoring and chest x-rays on vented patient are fairly standard. In the ER and with code response teams involved with the initial intubation; however, capnography should be standard.

Take care,

chbare.

ETCO2 detection has been pretty much the standard for Emergency Response teams and ICUs during intubation for many years. This question has been asked many times in the RT and/or ICU worlds and is incorporated into their national guidelines. Very few hospitals totally lack the ability to detect ETCO2. A quick check can be done with a calorimetric device or handheld capnometer immediately after intubation. However, not all will continuously monitor the patient and will rely on other diagnostics for disease determine determination.

Since ventilators are now more complex and offer much more ventilation data than in years past, ABGs are not even used that often. For the time a patient spends in the ED and the fact that the indepth diagnostics may start with the intensivitsts in the ICU with the ED physicians stabilizing the patient, a fancy ETCO2 monitor is not always required in the ED. CXRs will be done immmediately and the tube will be secured in place.

ICU ETCO2 machines can cost from $10K to $20K. When you have 20 - 150 ICU beds, that is a huge chunk of money that must fit into the budget. It must be weighed with hypothermia equipment or other types of monitoring devices. Often these devices are not necessary since the ventilators also give a graph as well as many measurements with sensitive alarms for everything. Even the ventilators used in the ED such as the LTVs can sound at alarm if the parameters are set appropriately and they can come with a monitor for graphing each breath.

Edited March 14, 2009 by VentMedic

[Arizonaffcep]

ICU ETCO2 machines can cost from $10K to $20K.

When (edit for spelling) I was FT at UMC, we had the Phillips monitors, which ETCO2 was incorporated into them. I would assume that the separate machine is because it's not part of the Pt. monitor? At that point, are the monitors that are used outdated-or they just opted out of the ETCO2 portion?

Edited March 14, 2009 by Arizonaffcep

[VentMedic]

When (edit for spelling) I was FT at UMC, we had the Phillips monitors, which ETCO2 was incorporated into them. I would assume that the separate machine is because it's not part of the Pt. monitor? At that point, are the monitors that are used outdated-or they just opted out of the ETCO2 portion?

Several reasons for the way things are done:

1. Who's budget? RT? Nursing? Or a separate ICU, ED, CCU, SICU, TICU etc?

2. Consistency of equipment... You might recall some of the problems hospitals have with adapting different defibrillator equipment if each department does its own thing.

3. Some ICU monitors may not be set up to give all the graphics required or have too much already connected and the ETCO2 display becomes a little number down in a lower corner.

4. Versatility for downloading and integrating with various research programs.

5. Some ventilators can have an ETCO2 package as an extra but costly accessory.

6. Biomed contracts.

7. Type of uses for the monitor.

8. Some ventilator patients may be in an area that does not have an ICU monitor or one that is compatible with that equipment.

9. Portability to be used on patients that are not on ventilators.

10. Vendors the hospital has contracts with which determines what equipment is easily approved for purchase.

11. May want a multifunction machine that also includes respiratory profile monitor. (You may be familiar with these if the Philips' reps have tried to up grade your equipment.) Sidenote: Philips acquired or "inhaled" Respironics a couple of years ago.

12. Level of expertise and knowledge of the doctors, RRTs and RNs. Like some Paramedics, they may just want to look at a pretty wave to see if the patient is intubated but don't understand much about the wave or the correlation of the numbers to different clinical conditions. Or, they may be serious clinicians that want to explore all options when it comes to patient care if it can be of some benefit.

[chute]

Very interesting topic and responses as well. My experience in LV, ATL, LA, and other states is that there were many times when it was better to book to the ED instead of intubating at the scene. In my opinion, it's all about making a good fast assessment with regards to where you are at, what do you have, and where you are going + time to get there. Also, it is my opinion that it will depend on the type of service and EMS system you work in. The two tier systems used in many states out west waste alot of patient time in my opinion - too many cooks in the kitchen!

One thing I do believe, until EMS gets the education and training standards implemented to enable true licensure leading to a scope of practice and a national standard for us all, then I think EMS is doomed to remain like it has been for the past ten years. A low pay, no respect, stepping stone medical job!

Dr. Bledsoe's article and many posts on here by veteren members are spot on regarding this post,

Thanks.

[Doczilla]

[iam sorry but I had to jump here on th one comment that was made about who would you rather have put a tube in?

Well I was in he hosp for the past two weeks and the so called peope standing around that hae just ONE job to do intead of 5 different skills, well they messed up big time. I was getting a line in the neck and they totally blew it and sent a bleed into my neck and what the docs no thought to be a bleed into my chest. So whom is ready for what want to know?

Stop posting.

'zilla

[ncmedic309]

I just attended our monthly continuing education last night and I got the impression that the service is working towards eventually eliminating endotracheal intubation. The most notable change is our new cardiac arrest guidelines where first responders (EMTs) will be putting in the LMA and “managing” the airway while paramedics initiate vascular access and focus on ACLS and induced hypothermia should the patient meet the criteria. This is one of the first steps that I see them taking to weed out field intubations. Aside from that though, since this does appear to be around the corner for some providers, what will be the best means of managing the airway without endotracheal intubation?