[RT_TLP]

We're touching on capnography right now for my critical care monitoring course, and I'd like to hear your input and experiences using capnography. Our hospital rarely uses devices to monitor ETCO2; the extent is the EZ-Cap for OET tube placement. However, having read some articles, I would like to see capnography being use more frequently in the ICU settings. I have even come across literature that suggests ETCO2 monitoring is more valuable than pulse oximetry.

Here's an article about capnography and the asthmatic patient. http://www.ncbi.nlm....pubmed/20157449

Where do you stand? Do you feel that capnography deserves more respect in the clinical environment?

[old school]

Capnography is great technology that can give you a lot of info if you know what you are looking at.

However, for something relatively new like this to become common practice requires demonstration that it can positively impact patient outcomes and/or reduce costs. I'm not sure that's been demonstrated yet. The fact that it's cheap and noninvasive works heavily in favor of capnography, but how how does it actually improve outcomes? (and actually, it's NOT cheap to start using if your current monitors don't already have capnography capability)

Might be the topic of a great thesis though....

[MSDeltaFlt]

RT_TLP, on 25 January 2012 - 10:11 AM, said:

We're touching on capnography right now for my critical care monitoring course, and I'd like to hear your input and experiences using capnography. Our hospital rarely uses devices to monitor ETCO2; the extent is the EZ-Cap for OET tube placement. However, having read some articles, I would like to see capnography being use more frequently in the ICU settings. I have even come across literature that suggests ETCO2 monitoring is more valuable than pulse oximetry.

Here's an article about capnography and the asthmatic patient. http://www.ncbi.nlm....pubmed/20157449

Where do you stand? Do you feel that capnography deserves more respect in the clinical environment?

Back in my RT days when I worked in my state's burn center we'd sometimes have to use high frequency oscillating ventilation on our pts with ARDS. We'd use EtCO2 monitoring on them to assist in the hourly changing ABG's and to also monitor against plugging. It was very very useful. Loved it. Miss using the VDR4.

[Tmed725]

In the transport environment I don't feel comfortable without it. In the mid 90's when I started we did not have it let alone a nice transport vent other than the pos auto vent. I don't know how we ever lived without it looking back.

[SerendepitySaki]

Tom... i lecture on this at state and national levels... ETCO2 monitoring IS more valuable than pulse oximetry, but most folks don't utilize EITHER to their fullest extent....in fact, i submitted proposals on BOTH for the AARC IC this year....as always, old school introduces salient points into the dialogue....no time to type...if you like, we can try to discuss mano a mano over drinks before i head off into the wild blue yonder yet again... FB me and we'll hash out the details....

[JLP]

having used live-time capnography in the field for years, I think it's one of the most informative tools we have if you understand how it works (which is important, and not everyone does understand how it works); moreover, I find that hospital staff are often envious of our ability to so when they see what it tells us. A few times, I've stayed and done my paperwork in the ER so that the patient could stay on our end-tidal monitor.

[RT_TLP]

This would make a great Capstone project during my final semester. I'll have to really learn the dirty behind capnography so I can make a good presentation of it. Looking forward to exploring this further.

Sean, if I can find some time between our schedules I'll take you up on your offer. Working 5-6 12's / week leaves me with little time.

[fltpuke]

RT_TLP, on 25 January 2012 - 12:11 PM, said:

We're touching on capnography right now for my critical care monitoring course, and I'd like to hear your input and experiences using capnography. Our hospital rarely uses devices to monitor ETCO2; the extent is the EZ-Cap for OET tube placement. However, having read some articles, I would like to see capnography being use more frequently in the ICU settings. I have even come across literature that suggests ETCO2 monitoring is more valuable than pulse oximetry.

Here's an article about capnography and the asthmatic patient. http://www.ncbi.nlm....pubmed/20157449

Where do you stand? Do you feel that capnography deserves more respect in the clinical environment?

VERY useful.
If the opportunity presents itself, get the technology.

There is a reason it is in our standard of care. It works.

My .02 worth, actual mileage may vary.
Tax, tag, title extra.


Jeff

[Speed]

In my facility we've changed our conscious sedation protocol to include ETCO2 (and BIS) which both have helped guide drug dosages and has increased the safety margin, comfort, and recall for procedural sedation. ETCO2 IS better than SpO2 period. This parameter also shows so much more of a bigger picture in a lot of high acuity situations. It's reflective of temp, metabolism, onset of MH, so many things other than just pulmonary function/exchange...

[pureadrenalin]

Speed, can you explain the temp, MH, thing? That's new to me.

On that note, anyone have any good resources for capnography for field providers? My knowledge is limited to numbers, and confirming tube placement and effective respiration/ventilation. It's a shortcoming...I'll admit it.

[RT_TLP]

For those who have experience using capnography - more specifically with intubated patients - is mainstream or side stream the way to go, and why?

[SerendepitySaki]

think about what MH is.... and where CO2 comes from....

CO2 = byproduct of metabolism.... MH = HYPERmetabolic state....

basically, considered in isolation, any HYPERmetabolic state will produce an increase in ETCO2 and any HYPOmetabolic state will produce a decrease....

MH produces a very rapid rise to well above "normal" increases in ETCO2 seen in other hypermetabolic states....

here is a good starter link for ETCO2 in general... which addresses most, if not all, of the topics brought up so far...including mainstream vs. sidestream...

http://www.capnography.com/new/

[old school]

RT_TLP, on 26 January 2012 - 05:36 PM, said:

For those who have experience using capnography - more specifically with intubated patients - is mainstream or side stream the way to go, and why?

Zoll would probably tell you that "ABC studies" showed mainstream is better for some reason, and Physio would tell you that "XYZ studies" showed that sidestream is superior.

At the engineering level, sidestream is more complicated as it requires the device to actually sample a small volume of exhaled gas, which in theory may add to the weight or fragility or maintenance requirements of the device. Mainstream is simpler as the photometric analysis is carried out right at the ET tube and the analyzer cable is easy (though probably expensive) to replace.

At the clinical level, I doubt there is any difference, really. I used to use Zolls (mainstream) and the capnography took forever to warm up and simply didn't work right half the time, but I'm pretty sure that was a problem our machines and not with mainstream. The LP-15's (sidestream) that we have now start almost instantly and are very reliable, but again I think that's just the machine working better rather than an inherent advantage of sidestream.

One downside of the Zolls was that you need two pieces of equipment (the hard cable with the analyzer at the end, and the disposable ETT adapter that the analyzer snaps on to), vs. the LP-15 which just has a single, disposable sampling line with adapter built in. Also, with the LP's sidestream technology you can use nasal cannula probes to sample gas and get a capnograph, which I don't think mainstream technology allows for yet.

[old school]

Speed, on 26 January 2012 - 04:23 PM, said:

In my facility we've changed our conscious sedation protocol to include ETCO2 (and BIS) which both have helped guide drug dosages and has increased the safety margin, comfort, and recall for procedural sedation. ETCO2 IS better than SpO2 period. This parameter also shows so much more of a bigger picture in a lot of high acuity situations. It's reflective of temp, metabolism, onset of MH, so many things other than just pulmonary function/exchange...

Where are you working and what are you doing now, Speed?

[Speed]

Respectfully an unnamed teaching level 1 in my home state. New job title for them: "hospital paramedic"(full scope ++), was their first hire, CCEMTP recognized, working/learning/teaching. It's exhausting work, but the toys are nice. I'm a little tiny bit scared of helicopters now, maybe?

[pureadrenalin]

SerendepitySaki, on 26 January 2012 - 06:10 PM, said:

think about what MH is.... and where CO2 comes from....

CO2 = byproduct of metabolism.... MH = HYPERmetabolic state....

basically, considered in isolation, any HYPERmetabolic state will produce an increase in ETCO2 and any HYPOmetabolic state will produce a decrease....

MH produces a very rapid rise to well above "normal" increases in ETCO2 seen in other hypermetabolic states....

here is a good starter link for ETCO2 in general... which addresses most, if not all, of the topics brought up so far...including mainstream vs. sidestream...

http://www.capnography.com/new/

Ah, thanks..

I thought it was something more complex than that.

[QANIK]

I honestly have to say I am a bit shocked by the post. I have not worked in an ICU, ER, OR or transport program that hasnt used capnography since 1990. It is even a mandatory standard in the ER's here for any intubated patient. I can not believe that there actually are transport programs not using it? There is absolutely no excuse for not using and knowing capnography and shame on any medical director who would think otherwise. It is a standard of care.

Qanik

[Jwade]

QANIK, on 27 January 2012 - 04:09 PM, said:

I honestly have to say I am a bit shocked by the post. I have not worked in an ICU, ER, OR or transport program that hasnt used capnography since 1990. It is even a mandatory standard in the ER's here for any intubated patient. I can not believe that there actually are transport programs not using it? There is absolutely no excuse for not using and knowing capnography and shame on any medical director who would think otherwise. It is a standard of care.

Qanik

What he said ^ !

Nice to see you back on the forums Qanik! Hit me up offline and catch me up on what's going on!

JW

[old school]

QANIK, on 27 January 2012 - 07:09 PM, said:

I honestly have to say I am a bit shocked by the post. I have not worked in an ICU, ER, OR or transport program that hasnt used capnography since 1990. It is even a mandatory standard in the ER's here for any intubated patient. I can not believe that there actually are transport programs not using it? There is absolutely no excuse for not using and knowing capnography and shame on any medical director who would think otherwise. It is a standard of care.

Qanik

There are many ICU's and ED's that use capno only rarely if ever, even in large, well respected facilities.

Not saying its right, just saying that's how it is....

[pureadrenalin]

QANIK, on 27 January 2012 - 06:09 PM, said:

I honestly have to say I am a bit shocked by the post. I have not worked in an ICU, ER, OR or transport program that hasnt used capnography since 1990. It is even a mandatory standard in the ER's here for any intubated patient. I can not believe that there actually are transport programs not using it? There is absolutely no excuse for not using and knowing capnography and shame on any medical director who would think otherwise. It is a standard of care.

Qanik

While I completely agree, it's pretty commonplace here to not see capnography on anyone who isn't in the OR or ICU. I worked at a major urban hospital for sometime, and of all of the patients that were tubed and on a blower, it was rarely, if ever done. Repeat ABG's were their choice. I dont' agree with it in the least. I think it's very underused as many don't fully understand it. I am one of those. Though, having said that. Every tubed patient I transport, every sever respiratory distress, or person I use a BVM on, gets a capnoline of some sort.

I don't have any excuses for not knowing it. Quite honestly, we never even talked about it in my initial paramedic training, other than the act that it exists. Why? There is only two services in the county who have it. Mine being one, and the other doesn't use it unless they are intubated which is their standard of care.