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Shah D, Tracy M, Hinder M, Badawi N. Quantitative end-tidal carbon dioxide at initiation of resuscitation may help guide the ventilation of infants born at less than 30 weeks gestation. Acta Paediatr 2023; 112:652-658. [PMID: 36541873 DOI: 10.1111/apa.16639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/18/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
AIM Estimation of end-tidal carbon dioxide (EtCO2 ) with capnography can guide mask ventilation in infants born at less than 30 weeks of gestation. Chemical-sensitive colorimetric devices to detect CO2 are widely used at resuscitation. We aimed to quantify EtCO2 in the first breaths following initiation of mask ventilation at birth and correlated need for endotracheal intubation. METHODS Infants <30 weeks gestation receiving mask ventilation were randomised into two groups of mask-hold technique (one-person vs. two-person). Data on EtCO2 in the first 30 breaths, time to achieve 5 mmHg, 10 mmHg and 15 mmHg CO2 using a respiratory function monitor was determined. RESULTS Twenty-five infants with a mean gestation of 27.3 (±3 weeks) and mean birth weight 920.4 (±188.3 g) were analysed. The median EtCO2 was 5.6 mmHg in the first 10 breaths, whereas it was 12.6 mmHg for 11-20 breaths and 18 mmHg for 21-30 breaths. There was no significant difference in maximum median EtCO2 for the first 20 breaths, although EtCO2 was significantly lower in infants who were intubated (32.0 vs. 15.0, p = 0.018). CONCLUSION EtCO2 monitoring in infants <30 weeks gestation at birth is feasible and reflective of alveolar ventilation. EtCO2 may help guide ventilation of preterm infants at birth.
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Affiliation(s)
- Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Mark Tracy
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Murray Hinder
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Nadia Badawi
- University of Sydney, Sydney, New South Wales, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Cerebral Palsy Research Institute, Cerebral Palsy Alliance, University of Sydney, Sydney, New South Wales, Australia
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Takahashi D, Goto K, Goto K. Effect of tidal volume and end tracheal tube leakage on end-tidal CO 2 in very low birth weight infants. J Perinatol 2021; 41:47-52. [PMID: 32753707 PMCID: PMC7399592 DOI: 10.1038/s41372-020-0758-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/02/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To examine the extents to which low tidal volume (VT) and endotracheal tube (ETT) leakeage influence the accuracy of ETCO2 for estimating arterial PCO2 (PaCO2) in very low birth weight (VLBW) infants with mechanical ventilation. STUDY DESIGN An observational study. We evaluated a total of 287 paired ETCO2 and PaCO2 values as well as VTs obtained from 22 VLBW infants with ventilation. Deming regression, quadratic discriminant analysis, and Bland-Altman analysis were performed. RESULT ETCO2 and PaCO2 were correlated (r2 = 0.5897, p < 0.0001). A quadratic discrimination analysis of the VT and the percentage of leak yielded 70.4% [95%CI, 65.1 to 75.7] discrimination for the agreement between ETCO2 and PaCO2. ETCO2 was strongly correlated with PaCO2 in the discriminant function Z > 0 group (r2 = 0.7234, p < 0.0001). CONCLUSION Our results indicate that ETCO2 is a good surrogate for PaCO2 when VT is high and ETT leak is low.
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Affiliation(s)
- Daijiro Takahashi
- Division of Neonatology, Fukuda Hospital, Kumamoto, Japan. .,Division of Pediatrics, Fukuda Hospital, Kumamoto, Japan.
| | - Koko Goto
- Division of Neonatology, Fukuda Hospital, Kumamoto, Japan
| | - Kei Goto
- Division of Pediatrics, Fukuda Hospital, Kumamoto, Japan
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Cook TM, Kelly FE, Foy K, Mew E, Bower J, Marden B, Dean S, Knight P, Herneman K. The PIC-NIC survey: capnography and neonatal intensive care - a reply. Anaesthesia 2019; 74:118-120. [PMID: 30511756 DOI: 10.1111/anae.14529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- T M Cook
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - F E Kelly
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - K Foy
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - E Mew
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - J Bower
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - B Marden
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - S Dean
- Bristol Royal Hospital for Children, Bristol, UK
| | - P Knight
- Bristol Royal Hospital for Children, Bristol, UK
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Abstract
Although capnography is a standard tool in mechanically ventilated adult and pediatric patients, it has physiological and technical limitations in neonates. Gas exchange differs between small and adult lungs due to the greater impact of small airways on gas exchange, the higher impact of the apparatus dead space on measurements due to lower tidal volume and the occurrence of air leaks in intubated patients. The high respiratory rate and low tidal volume in newborns, especially those with stiff lungs, require main-stream sensors with fast response times and minimal dead-space or low suction flow when using side-stream measurements. If these technical requirements are not fulfilled, the measured end-tidal CO2 (P et CO 2 ), which should reflect the alveolar CO2 and the calculated airway dead spaces, can be misleading. The aim of this survey is to highlight the current limitations of capnography in very young patients to avoid pitfalls associated with the interpretation of capnographic parameters, and to describe further developments.
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Affiliation(s)
- Gerd Schmalisch
- Department of Neonatology, Charité University Medical Center, Charitéplatz 1, 10117, Berlin, Germany.
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Hawkes GA, Kelleher J, Ryan CA, Dempsey EM. A review of carbon dioxide monitoring in preterm newborns in the delivery room. Resuscitation 2014; 85:1315-9. [PMID: 25086296 DOI: 10.1016/j.resuscitation.2014.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements. AIM To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room. METHODS Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials. RESULTS The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B. DISCUSSION CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.
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Affiliation(s)
- G A Hawkes
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland
| | - J Kelleher
- Department of Neonatology, University Maternity Hospital Limerick, Ireland
| | - C A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland
| | - E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland.
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Trevisanuto D, Giuliotto S, Cavallin F, Doglioni N, Toniazzo S, Zanardo V. End-tidal carbon dioxide monitoring in very low birth weight infants: correlation and agreement with arterial carbon dioxide. Pediatr Pulmonol 2012; 47:367-72. [PMID: 22102598 DOI: 10.1002/ppul.21558] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 09/08/2011] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We aimed to determine the correlation and the agreement between end-tidal carbon dioxide (ETCO(2)) and partial pressure of arterial carbon dioxide (PaCO(2) ) in very low birth weight infants (VLBWI); furthermore, we assessed factors that could affect the ETCO(2)-PaCO(2) relationship. METHODS Simultaneous end-tidal and arterial CO(2) pairs were obtained from ventilated VLBWI who were monitored by mainstream capnography and had umbilical arterial catheter. Correlation and agreement between ETCO(2) and PaCO(2) were evaluated by using Spearman test and Bland-Altman method, respectively. RESULTS A total of 143 simultaneous ETCO(2)-PaCO(2) pairs were analyzed from 45 ventilated VLBWI. There was a significant correlation (r = 0.69; P < 0.0001) between ETCO(2) and PaCO(2) values. The ETCO(2) value was lower than the corresponding PaCO(2) value in 94% pairs, with a mean bias of 13.5 ± 8.4 mmHg (95% agreement levels, -3.0 to 29.9 mmHg). Mean PaCO(2)-ETCO(2) bias was similar between ELBWI (13.1 ± 7.7 mmHg; 95% agreement levels, -1.9 and 28.2 mmHg) and infants with birth weight 1,001-1,500 g (14.8 ± 9.7 mmHg; 95% agreement levels -4.3 and 33.8 mmHg). The bias between ETCO(2) and PaCO(2) was significantly increased with increasing FiO(2), mean airway pressure and oxygenation index. Within each patient, there was a positive correlation (r = 0.78, P < 0.0001) between the changes in PaCO(2) and the simultaneous changes in ETCO(2). CONCLUSIONS In ventilated VLBWI, the correlation between mainstream ETCO(2) and PaCO(2) is good, but the agreement is poor and negatively influenced by the severity of pulmonary disease. Capnography is feasible in ELBWI. ETCO(2) should not replace PaCO(2) measurements in ventilated VLBWI, but may have a role to detect trends of PaCO(2).
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Affiliation(s)
- Daniele Trevisanuto
- Pediatric Department, Medical School, University of Padua, Azienda Ospedaliera Padova, Padua, Italy.
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de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e213-59. [PMID: 20956041 DOI: 10.1016/j.resuscitation.2010.08.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Allan R de Caen
- Stollery Children's Hospital, University of Alberta, Canada.
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Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261-318. [PMID: 20956433 PMCID: PMC3784274 DOI: 10.1542/peds.2010-2972a] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466-515. [PMID: 20956258 PMCID: PMC3748977 DOI: 10.1161/circulationaha.110.971093] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.
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Abstract
Rabbits, guinea pigs, chinchillas and many other small exotic mammals are not intubated routinely, because intubation requires specialized equipment and is difficult to perfect. Using a face mask for these species solely on the basis that they are unable to regurgitate ignores the numerous other benefits of airway control. This article summarizes the many advantages of endotracheal intubation and the various methods of intubation that have been reported. It introduces endoscopic intubation as a method that overcomes many of the difficulties associated with other methods and describes the equipment needed, how to intubate with an endoscope, how to confirm proper endotracheal tube placement, and possible complications. Over-the-endoscope intubation is discussed in detail, as it appears to provide the most versatile and reliable method of intubating exotic companion mammals.
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Affiliation(s)
- Dan H Johnson
- Avian and Exotic Animal Care, 8711 Fidelity Boulevard, Raleigh, NC 27617, USA.
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Lopez E, Grabar S, Barbier A, Krauss B, Jarreau PH, Moriette G. Detection of carbon dioxide thresholds using low-flow sidestream capnography in ventilated preterm infants. Intensive Care Med 2009; 35:1942-9. [PMID: 19760396 DOI: 10.1007/s00134-009-1647-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Accepted: 07/27/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND Monitoring CO2 levels in preterm infants receiving mechanical ventilation is designed to avoid the harmful consequences of hypocapnia or hypercapnia. Capnography is of questionable accuracy for monitoring PCO2 in preterm infants. OBJECTIVES To determine the accuracy of sidestream capnography in ventilated preterm infants by comparing end-tidal carbon dioxide (EtCO2) values to mixed venous carbon dioxide pressure (PvCO2) and to transcutaneous carbon dioxide pressure (TcPCO2). METHODS Simultaneous recordings of EtCO2, TcPCO2 and PvCO2 in 37 ventilated preterm infants. The PvCO2-EtCO2 gradient was calculated. The Bland-Altman technique and the intra-class correlation coefficient (ICC) were used to assess agreement between methods. The area under the curve (AUC) was calculated. RESULTS Ninety-nine EtCO2/PvCO2 pairs were studied from 37 preterm infants with a mean gestational age of 27.7 +/- 1.9 weeks and a mean birth weight of 1,003 +/- 331 g. The mean PvCO2-EtCO2 gradient was 11.2 +/- 8.0 mmHg, and the ICC was 0.28. The mean PvCO2-TcPCO2 gradient was 0 +/- 7.8 mmHg, and the ICC was 0.78. AUCs for EtCO2 and TcPCO2 were similar in detecting high or low PvCO2. CONCLUSION Despite an insufficient correlation between EtCO2 and PvCO2, capnography was able to detect low and high CO2 warning levels with a similar efficacy to that of TcPCO2, and may therefore be of clinical interest.
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Abstract
PURPOSE OF REVIEW Numerous recent reports have described limitations in the quality of cardiopulmonary resuscitation. Thus, there has been increasing interest in the techniques available to monitor quality. This review focuses on the major publications since the review published by the International Liaison Committee on Resuscitation in 2005. Some key articles published prior to this time period have also been included. RECENT FINDINGS A number of devices can monitor various components of the quality of cardiopulmonary resuscitation. End-tidal CO2 measurement assists in confirming placement of endotracheal tubes, correlates with cardiac output and detects the return of spontaneous circulation. Turbine flow-meters monitor respiratory rate and tidal volume. Transthoracic impedance monitoring measures respiratory rate, and may assist in confirmation of endotracheal tube placement. A new mechanical device (CPREzy) and a new defibrillator/monitor allow estimation of depth (and rate) of compressions. Ventricular-fibrillation waveform analysis may facilitate better timing of defibrillation. Echocardiography detects conditions that may impair the quality of cardiopulmonary resuscitation. SUMMARY Many options are available to monitor the quality of cardiopulmonary resuscitation. Some have significant limitations, and others are only readily available in hospital. The use of the information from this more intensive monitoring promises to improve outcomes of cardiopulmonary resuscitation.
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Affiliation(s)
- Peter T Morley
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Garey DM, Ward R, Rich W, Heldt G, Leone T, Finer NN. Tidal volume threshold for colorimetric carbon dioxide detectors available for use in neonates. Pediatrics 2008; 121:e1524-7. [PMID: 18458036 DOI: 10.1542/peds.2007-2708] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Colorimetric carbon dioxide detectors are used for confirmation of endotracheal intubation. The colorimetric carbon dioxide detectors that are used for neonates are labeled for use with infants and small children >1 and <15 kg. The objective of this study was to determine the minimal tidal volume that causes a breath-to-breath color change on 2 colorimetric carbon dioxide detectors. METHODS Using an artificial-lung model, we determined the tidal volume threshold of 2 colorimetric carbon dioxide detectors (Pedi-Cap [Nellcor, Pleasanton, CA] or Mini StatCO(2) [Mercury Medical, Clearwater, FL]) during ventilation with a T-piece resuscitator or neonatal ventilator. Digital video recordings of the colorimetric carbon dioxide detectors were made during 20 seconds of ventilation at each tidal volume. Seven clinicians who were blinded to the tidal volume reviewed the videos in random order and graded the color change to determine adequacy for clinical application. RESULTS The Mini StatCO(2) tidal volume threshold was 0.83 mL, and the Pedi-Cap tidal volume threshold was 1.08 mL. CONCLUSIONS The lung model revealed that the tidal volume threshold for the tested colorimetric carbon dioxide detectors is less than the expected tidal volume of a 400-g infant and suggests that these devices are appropriate for use with any neonate to confirm intubation.
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Affiliation(s)
- Donna M Garey
- University of California, Division of Neonatology, 402 Dickinson St, MPF 1-140 #8774, San Diego, CA 92103-8774, USA.
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Current World Literature. Curr Opin Anaesthesiol 2007; 20:605-613. [DOI: 10.1097/aco.0b013e3282f355c3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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