Use of ETCO2 Monitors

[Ridryder 911]

Afer watching a 2 hour video that Dr Krauss, (Harvard Emergency Professor) produced for Medtronics. A very informative lecture. I had used ETC[sub:14b60c3322]o[/sub:14b60c3322]2, for a period of time, but it was a good review.

My question how often do you use ETC[sub:14b60c3322]o[/sub:14b60c3322]2 ?... And to what degree do you use them ? Do you use them to verify endotracheal intubations, determine CPR is effective, check for capturing of pacemaker, or to cease or not to perform codes, etc... ? Does your medics fully understand capnography waveforms ?

As well do you use side stream... to determine depth of bronchial spasms?

Be safe,

R/R 911

[medic001918]

We use capnography in my system and I use it often. We have it for intubated and non-intubated patients. I find it to be a far better indicator of ventilation than pulse oximetry. I look for wave forms to aid in seeing how effective my patient is breathing, as well as to determine a greater need for intubation since as the numbers rise, resp failure is immenent. It's great for trending. We're required on all intubated patients to use it as well. I'd like to see it used more frequently than it is though. It's a great tool.

Shane

NREMT-P

[Ridryder 911]

Yeah, I find it ironic with all the talk of missed ETI , using this would reduce the number immediately. Using it would determine 100% your in proper place or not.... no guessing, estimating. It also can tell you if you have displaced into oropharynx, as well. No waveform... no intubation short and simple ... waveform drops within 2 seconds, not like SpO2 which can be continuous u to 4-6 minutes. Also, you should not use SpO2 for determination for intubation.

Remembering ventilation and tissue oxygenation are totally separate issues. The process of ventilation is just as important as tissue perfusion. This is something we can assist or even control, the other we can't...

I believe within 5 years, we will understand capnography will be just as important in respiratory as the EKG is in cardiac care. the neat thing is can be used on any age from neonate to adult. .

Once you have mastered understanding it, you can determine many things. Co2 entrapment. Those nasty asthmatics, is your up-drafts really working?.. determination way before lung sounds change, also we all know that intubating asthmatics is not the best thing since they don't really have airway obstruction more it is an entrapment. You can tell how much...

Ironically, many EMS is looking at the new device to determine if CPR is effective, when you can also determine this with ETCo2 as well, immediately, the same is true on capturing with pacemaker, with those patients that pulse is hard to determine.

Like I said, this device is not being utilized in its full range it has so many uses and many are not using it, which is a shame. It is one of the few if any device that is an absolute..

Be safe,

R/R 911

[nsmedic393]

Right now we only use the colormetric ETC02 detectors to assist in verification of intubation. Rumor has it that we will be getting ETC02 monitoring when we get our new LP12s sometime in the next six months. I would love to have it.

[kevkei]

Rid, I personally use it to: evaluate treatment, effectiveness of CPR, monitor for ROSC, monitor patency of ETI, sometimes to assess/confirm ETI, to maintain PETCO2 in a certain theraputic range depending on patient and pathological process. And yes I like to assess capnographic waveforms although it's not often an issue.

[Dustdevil]

We need a Dubin style capnography book!

[flight-lp]

I use it regularly on the ground and in the air. My ground service used to use the sidestream, however they recently removed it from the trucks. Personally I like the sidestream because you can utilize it on your COPD'r with a NC and get a fairly accurate CO2 level. But supposibly there is some inaccuracy with the sidestream, I have yet to see substantiating evidence supporting it. Besides, even if it is off some, it still allows a reasonable baseline............

[Ridryder 911]

Apparently Harvard and Duke, Yale, etc.. has done substantial research showing it is one of the few tools that is absolute. Yes, there is some equipment failure occasional like any other equipment, but you can detect that easy by blowing into the monitor yourself & check variation. The cost is nominal in comparrisonto other equipment we use.

I personally believe this tool will be an asset, once we learn it, in comparison to an ECG. This definitely does not replace clinical skills but really enhances, them on things either your are unable to detect or will display before clinical findings can occur. For example tube displacement within 2 seconds .. showing either into posterior pharynx or totally out.

I have developed a power point presentation, and trying to up-date it with more factual points. For thos interested.

In the days of controversy of percentage intubation per Paramedics.. this would solve it. If you show ETCo2 wave form appropriate there is no dispute... short & simple. You cannot fake it or have false readings.... this is why anesthesiologist use this so much. For TQI purposes this really will justify our skills percentage, if you do not have a wave form alternate airway should be tried if intubation techniques have failed.

I will try to post links for journal research later...

The colormetric is really non-valuable due to high percentage of poor readings and only use is to detect either tube confirmation or not, unfortunately you have nothing to place in documentation.

Be safe,

R/R

[Ridryder 911]

Here is some links, with interesting findings of ETCo2 in the field.

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11339734&dopt=Abstract

www.jpgmonline.com/article.asp?issn=0022-year=2001;volume=47;issue=2;spage=153;epage=6;aulast=Bhende

www.enw.org/ETCO2inCPR.htm

www.medscape.com/viewarticle/464505

www.medtronic-ers.com/documents/Capno_It's_a_Gas.pdf

Journals:

Gravenstein JHS, Paulus DA, Hayes TJ. Clinical indications. In: Gravenstein JS, Paulus DA, Hayes TJ, editors. Capnography in clinical practice. Stoneham, MA: Butterworth; 1989, pp 43-49.

2. Bhende MS. Capnography in the pediatric emergency department. Pediatr Emerg Care 1999; 15:64-69.

3. Sanders AB. Capnometry in emergency medicine. Ann Emerg Med 1989; 18:1287-1290.

4. Santos LJ, Varon J, Pic-Aluas L, Combs AH. Practical uses of end-tidal carbon-dioxide monitoring in the emergency department. J Emerg Med 1994; 12:633-644.

5. Ward KR, Yealy DM. End-tidal CO2 monitoring in emergency medicine. Part I: Basic principles. Acad Emerg Med 1998; 5:628-636.

6. Falk JL. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. Advances in Anesthesia 1993; 10:275-285.

7. Gonzalez del Ray JA. End tidal CO2 monitoring. In: Henretig FM, King C, editors. Textbook of pediatric emergency procedures. Baltimore: Williams & Wilkins; 1997, pp 829-837.

8. Bhende MS, LaCovey D. End-tidal carbon dioxide monitoring in the prehospital setting. Prehospital Emerg Care 2001; 5:208-213.

9. Bhavani-Shankar K, Moseley H, Kumar AY, Delph Y. Capnometry and anaesthesia. Can J Anaesth 1992; 39:617-632.

10. Nobel JJ. Carbon dioxide monitors: exhaled gas, capnographs, capnometers, end-tidal CO2 monitors. Pediatr Emerg Care 1993; 9:244-246.

11. Microstream Technology, Oridion Medical, Danville, CA.

12. Singh S, Venkataraman ST, Saville A, Bhende MS. NPB-75â„¢: a portable quantitative microstream capnometer. Am J Emerg Med 2001; 19:208-210.

13. Bhende MS. End-tidal carbon dioxide detectors: are they useful in children? J Postgrad Med 1994; 40:78-82.

14. Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol 1999; 19:110-113.

15. Gonzalez del Ray JA, Poirier MP, Digiulio GA. Evaluation of an ambu-bag valve with a self-contained, colorimetric CO2 system in the detection of airway mishaps: an animal trial. Pediatr Emerg Care 2000; 16:121-123.

16. Bhende MS, Allen WD. Utility of a Capnoflo resuscitator during transport of critically ill children. Pediatr Emerg Care (In press).

17. Cummins RO, Hazinski MF. New guidelines on tracheal tube confirmation and prevention of dislodgement. Circulation 2000; 102(Suppl 2):I-380-I-384.

FYI...

Be safe,

R/R 911

[Ace844]

(Acad Emerg Med Volume 13 @ Number 5 500-504,

published online before print March 28, 2006, doi: 10.1197/j.aem.2005.12.017

© 2006 Society for Academic Emergency Medicine CLINICAL INVESTIGATION

Does End-tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices?

John H. Burton, MD, John D. Harrah, MD, Carl A. Germann, MD and Douglas C. Dillon, MD

From the Department of Emergency Medicine, Maine Medical Center (JHB, JDH, CAG, DCD), Portland, ME; and the Department of Emergency Medicine, Albany Medical Center (JHB), Albany, NY.

Address for correspondence and reprints: John H. Burton, MD, Emergency Department, MC-139, 47 New Scotland Avenue, Albany, NY 12208. Fax: 518-262-3236; e-mail: burtonj@mail.amc.edu.)

Objectives: The value of ventilation monitoring with end-tidal carbon dioxide (ETCO2) to anticipate acute respiratory events during emergency department (ED) procedural sedation and analgesia (PSA) is unclear. The authors sought to determine if ETCO2 monitoring would reveal findings indicating an acute respiratory event earlier than indicated by current monitoring practices.

Methods: The study included a prospective convenience sample of ED patients undergoing PSA. Clinicians performed ED PSA procedures with generally accepted patient monitoring, including oxygen saturation (SpO2), and clinical ventilation assessment. A study investigator recorded ETCO2 levels and respiratory events during each PSA procedure, with clinical providers blinded to ETCO2 levels. Acute respiratory events were defined as SpO2 92%, increases in the amount of supplemental oxygen provided, use of bag-valve mask or oral/nasal airway for ventilatory assistance, repositioning or airway alignment maneuvers, and use of physical or verbal means to stimulate patients with depressed ventilation or apnea, and reversal agent administration.

Results: Enrollment was stopped after independent review of 20 acute respiratory events in 60 patient sedation encounters (33%). Abnormal ETCO2 findings were documented in 36 patients (60%). Seventeen patients (85%) with acute respiratory events demonstrated ETCO2 findings indicative of hypoventilation or apnea during PSA. Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events.

Conclusions: Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 abnormalities that occurred before oxygen desaturation or observed hypoventilation.