Capnography Use During Intubation and Cardiopulmonary Resuscitation in the Pediatric Emergency Department

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review evidence on and devise treatment recommendations for patient monitoring before, during, and following CPR in dogs and cats, and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to peri-CPR monitoring following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by Monitoring Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Thirteen questions pertaining to hemodynamic, respiratory, and metabolic monitoring practices for identification of cardiopulmonary arrest, quality of CPR, and postcardiac arrest care were examined, and 24 treatment recommendations were formulated. Of these, 5 recommendations pertained to aspects of end-tidal CO2 (ETco2) measurement. The recommendations were founded predominantly on very low quality of evidence, with some based on expert opinion.

CONCLUSIONS

The Monitoring Domain authors continue to support initiation of chest compressions without pulse palpation. We recommend multimodal monitoring of patients at risk of cardiopulmonary arrest, at risk of re-arrest, or under general anesthesia. This report highlights the utility of ETco2 monitoring to verify correct intubation, identify return of spontaneous circulation, evaluate quality of CPR, and guide basic life support measures. Treatment recommendations further suggest intra-arrest evaluation of electrolytes (ie, potassium and calcium), as these may inform outcome-relevant interventions.

Physiology-Guided Resuscitation: Monitoring and Augmenting Perfusion during Cardiopulmonary Arrest

Given the high morbidity and mortality associated with cardiopulmonary arrest, there have been multiple trials aimed at better monitoring and augmenting coronary, cerebral, and systemic perfusion. This article aims to elucidate these interventions, first by detailing the physiology of cardiopulmonary resuscitation and the available tools for managing cardiopulmonary arrest, followed by an in-depth examination of the newest advances in the monitoring and delivery of advanced cardiac life support.

Prehospital Use of Waveform Capnography in Intubated Neonates

INTRODUCTION

Routine continuous monitoring of endotracheal tube placement with waveform capnography is considered standard of care in the prehospital setting. However, maintaining this standard in neonatal patients remains a challenge due to low tidal volumes that do not tolerate the additional dead space ETCO2 attachments add. Additionally, continuous ETCO2 can increase the risk of ETT dislodgement or kinking because of the weight and size of the capnography attachments relative to the patient and tube size. We hypothesize that there is a gap in care of intubated neonates when compared to adults in the prehospital setting in terms of continuous monitoring of ETT placement.

METHODS

Data were obtained from a single air medical agency. Through a retrospective chart review, records of intubated neonates (<28 days), children (≥28 days-12 years), adolescents (13-18 years), and adults (aged ≥18 years) were analyzed. Records were available from 11/21/13-1/21/22. The number of intubation attempts, whether an intubation was successful, and the use of capnography were recorded in RedCap. Statistical analysis was performed in Microsoft Excel via Chi Square Goodness of Fit Tests.

RESULTS

During the study period, 674 intubation attempts were identified, and 28 charts were excluded due to missing patient age. Continuous waveform ETCO2 monitoring was used on 62%, 94%, 95%, and 97% of successfully intubated neonates, children, adolescents, and adults, respectively. There was a statistically significant difference between use of continuous waveform capnography in adults and neonates (p-value = 0.013). There was also a statistically significant difference between use of continuous waveform capnography in intubated neonates, children, and adolescents (p-value = 0.049).

CONCLUSION

Continuous ETCO2 monitoring is underutilized in intubated neonates compared to children, adolescents, and adults in the prehospital setting in this study population. This suggests a gap in the standard of care provided to neonates. Additional studies are needed to determine if these results are consistent around the industry and if there is a higher rate of undetected tube displacement in neonates who are transported without waveform capnography.

Navigating Pediatric Capnography: A Comprehensive Review of Scope and Limitations

This review comprehensively explores pediatric capnography, a vital tool in contemporary respiratory monitoring. The overview encompasses the foundational principles of capnography, elucidating its real-time measurement of carbon dioxide (CO2) in respiratory gases. The review emphasizes its paramount role in pediatric care and underscores capnography's significance in detecting respiratory abnormalities and guiding timely interventions. The distinctions between mainstream and sidestream capnography, the key to understanding their applications, are meticulously outlined. Addressing the importance of ongoing research and education, the review advocates for a dynamic approach to refine guidelines and optimize capnography utilization in pediatric settings. The conclusion reflects on the scope and limitations of pediatric capnography, acknowledging its transformative impact while advocating for a judicious recognition of constraints. As we navigate the future of pediatric respiratory care, the synergy of research, education, and clinical application emerges as the cornerstone for advancing pediatric capnography to new horizons.

Implementation of a Pediatric Emergency Department Cardiopulmonary Resuscitation Quality Bundle

BACKGROUND AND OBJECTIVES

We have previously demonstrated that standardized handoff from prehospital to hospital clinicians can improve cardiopulmonary resuscitation performance for out-of-hospital cardiac arrest (OHCA) patients in a pediatric emergency department (ED). We leveraged our previous quality improvement initiative to standardize performance of a bundle of 5 discrete aspects of resuscitation for OHCA patients: intravenous or intraosseous catheter (IV/IO) access, epinephrine administration, advanced airway placement, end-tidal capnography (ETCO2) application, and cardiac rhythm verbalization. We aimed to reduce time to completion of the bundle from 302 seconds at baseline to less than 120 seconds within 1 year.

METHODS

A multidisciplinary team performed video-based review of actual OHCA resuscitations in our pediatric ED. We designed interventions aimed at key drivers of bundle performance. Interventions included specific roles and responsibilities and a standardized choreography for each bundle element. To assess the effect of the interventions, time to performance of each bundle element was measured by standardized review of video recordings from our resuscitation bay. Balancing measures were time off the chest and time to defibrillator pad placement.

RESULTS

We analyzed 56 cases of OHCA from May 2019 through May 2021. Time to bundle completion improved from a baseline of 302 seconds to 147 seconds. Four of 5 individual bundle elements also demonstrated significant improvement. These improvements were sustained without any negative impact on balancing measures.

CONCLUSIONS

Standardized choreography for the initial minutes of ED cardiac arrest resuscitation shows promise to decrease time to crucial interventions in children presenting to the pediatric ED with OHCA.

Improving Capnography Use for Critically Ill Emergency Patients: An Implementation Study

OBJECTIVES

Capnography has established benefit during intubation and cardiopulmonary resuscitation (CPR). Implementation within emergency departments (EDs) has lagged. We sought to address barriers to improve documented capnography use for patients requiring intubation or CPR.

METHODS

A controlled before- and after-implementation study was performed in 2 urban EDs. The control site had an existing policy for capnography use. Interventions for the experimental site included a 5-minute informational video, placement of capnography monitors with a shortened warm-up period in all resuscitation rooms, laminated reminder cards, and feedback during staff meetings. Staff members were surveyed about knowledge before and after the intervention. Records were reviewed for documented capnography use for 3 months before and 6 months after the intervention. Change in documented use at the experimental site was compared with the control site.

RESULTS

At the experimental site, 118 providers participated and 190 records were reviewed; 544 records were reviewed from the control site. There was a significant increase in the proportion of documented capnography use at the experimental site (8% versus 19%, P = 0.04) compared with the control site (64% versus 71%, P = 0.10). However, there was no significant trend over time at the experimental site after the intervention (P = 0.86). Despite high baseline knowledge about capnography, providers had improvements in survey responses regarding indications for intubation and CPR, normal values, and minimum effective values during CPR.

CONCLUSIONS

Documented capnography use increased with simple interventions but with no positive trend. Additional work is needed to improve use, including further evaluation of capnography's implementation in the ED.

Just Breathe: Tips and Highlights for Managing Pediatric Respiratory Distress and Failure

Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.

Identification of return of spontaneous circulation during cardiopulmonary resuscitation via pulse oximetry in a porcine animal cardiac arrest model

In this prospective study we investigated whether the pulse oximetry plethysmographic waveform (POP) could be used to identify return of spontaneous circulation (ROSC) during cardio-pulmonary resuscitation (CPR). Tweleve pigs (28 ± 2 kg) were randomly assigned to two groups: Group I (non-arrested with compressions) (n = 6); Group II (arrested with CPR and defibrillation) (n = 6). Hemodynamic parameters and POP were collected and analyzed. POP was analyzed using both a time domain method and a frequency domain method. In Group I, when compressions were carried out on subjects with a spontaneous circulation, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method. In Group II, after the period of ventricular fibrillation was induced, the POP waveform disappeared. With compressions, POP showed a regular compression wave. After defibrillation, ROSC, and continued compressions, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method, similar to Group I. Analysis of POP using the time and frequency domain methods could be used to identify ROSC during CPR.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

OBJECTIVE

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.

DESIGN

A multicenter retrospective cohort study.

SETTING

Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

PATIENTS

Primary tracheal intubation in children younger than 18 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

CONCLUSIONS

Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations

BACKGROUND

Capnography has many uses in the emergency department (ED) and critical care setting, most commonly cardiac arrest and procedural sedation.

OBJECTIVE OF THE REVIEW

This review evaluates several indications concerning capnography beyond cardiac arrest and procedural sedation in the ED, as well as limitations and specific waveforms.

DISCUSSION

Capnography includes the noninvasive measurement of CO₂, providing information on ventilation, perfusion, and metabolism in intubated and spontaneously breathing patients. Since the 1990s, capnography has been utilized extensively for cardiac arrest and procedural sedation. Qualitative capnography includes a colorimetric device, changing color on the amount of CO₂ present. Quantitative capnography provides a numeric value (end-tidal CO₂), and capnography most commonly includes a waveform as a function of time. Conditions in which capnography is informative include cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Patients with seizure, trauma, and respiratory conditions, such as pulmonary embolism and obstructive airway disease, can benefit from capnography, but further study is needed. Limitations include use of capnography in conditions with mixed pathophysiology, patients with low tidal volumes, and equipment malfunction. Capnography should be used in conjunction with clinical assessment.

CONCLUSIONS

Capnography demonstrates benefit in cardiac arrest, procedural sedation, mechanically ventilated patients, and patients with metabolic acidemia. Further study is required in patients with seizure, trauma, and respiratory conditions. It should only be used in conjunction with other patient factors and clinical assessment.