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Williams EE, Dassios T, Harris C, Greenough A. Capnography waveforms: basic interpretation in neonatal intensive care. Front Pediatr 2024; 12:1396846. [PMID: 38638588 PMCID: PMC11024230 DOI: 10.3389/fped.2024.1396846] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
End-tidal capnography can provide useful clinical information displayed on the ventilator screen or bedside monitor. It is important that clinicians can assess and utilise this information to assist in identifying underlying complications and pulmonary pathology. Sudden change or loss of the CO2 waveform can act as a safety measure in alerting clinicians of a dislodged or blocked endotracheal tube, considering the concurrent flow and volume waveforms. Visual pattern recognition by the clinicians of commonly seen waveform traces may act as an adjunct to other modes of ventilatory monitoring techniques. Waveforms traces can aid clinical management, help identify cases of ventilation asynchrony between the infant and the ventilator. We present some common clinical scenarios where tidal capnography can be useful in the timely identification of pulmonary complication and for practical troubleshooting at the cot-side.
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Affiliation(s)
- Emma E. Williams
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Theodore Dassios
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christopher Harris
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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Nourian MM, Alshibli A, Kamau J, Nabulindo S, Amollo DA, Connell J, Eden SK, Seyoum R, Teklehaimanot MG, Tegu GA, Desta HB, Newton M, Sileshi B. Capnography access and use in Kenya and Ethiopia. Can J Anaesth 2024; 71:95-106. [PMID: 37914969 DOI: 10.1007/s12630-023-02607-y] [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] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Lack of access to safe and affordable anesthesia and monitoring equipment may contribute to higher rates of morbidity and mortality in low- and middle-income countries (LMICs). While capnography is standard in high-income countries, use in LMICs is not well studied. We evaluated the association of capnography use with patient and procedure-related characteristics, as well as the association of capnography use and mortality in a cohort of patients from Kenya and Ethiopia. METHODS For this retrospective observational study, we used historical cohort data from Kenya and Ethiopia from 2014 to 2020. Logistic regression was used to study the association of capnography use (primary outcome) with patient/procedure factors, and the adjusted association of intraoperative, 24-hr, and seven-day mortality (secondary outcomes) with capnography use. RESULTS A total of 61,792 anesthetic cases were included in this study. Tertiary or secondary hospital type (compared with primary) was strongly associated with use of capnography (odds ratio [OR], 6.27; 95% confidence interval [CI], 5.67 to 6.93 and OR, 6.88; 95% CI, 6.40 to 7.40, respectively), as was general (vs regional) anesthesia (OR, 4.83; 95% CI, 4.41 to 5.28). Capnography use was significantly associated with lower odds of intraoperative mortality in patients who underwent general anesthesia (OR, 0.31; 95% CI, 0.17 to 0.48). Nevertheless, fully-adjusted models for 24-hr and seven-day mortality showed no evidence of association with capnography. CONCLUSION Capnography use in LMICs is substantially lower compared with other standard anesthesia monitors. Capnography was used at higher rates in tertiary centres and with patients undergoing general anesthesia. While this study revealed decreased odds of intraoperative mortality with capnography use, further studies need to confirm these findings.
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Affiliation(s)
- Maziar M Nourian
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Amany Alshibli
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - John Kamau
- African Mission Healthcare, ImPACT Africa-Tanzania, Nairobi, Kenya
| | - Susan Nabulindo
- Department of Anesthesiology, University of Nairobi, Nairobi, Kenya
| | - Dennis A Amollo
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahel Seyoum
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Gebrehiwot A Tegu
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Haftom B Desta
- Department of Anesthesiology, Mekelle University, Mekelle, Ethiopia
| | - Mark Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bantayehu Sileshi
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Sweeney T, Deasy A, Linehan R, O'Sullivan EP, Cafferkey A. The Theatre Recovery and Anaesthetic nurse Capnography Education (TRACE) project. Anaesth Rep 2024; 12:e12301. [PMID: 38765554 PMCID: PMC11099708 DOI: 10.1002/anr3.12301] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
The Theatre Recovery and Anaesthetic Nurse Capnography Education (TRACE) project is a multidisciplinary quality improvement project. The overall aim is to educate anaesthetic and recovery nurses on the correct use of capnography and educate non-consultant hospital doctors on the guidelines on Preventing Unrecognised Oesophageal Intubation from the Project for Universal Management of Airways group. This project addresses technical aspects of task performance such as correct waveform identification and interpretation, troubleshooting abnormal waveforms and establishing routine checks of capnography both pre-induction and post-intubation. The pre-induction verification of the correct function of capnography is an essential component of this project. In addition, the project focuses on team aspects of task performance with an emphasis on team psychological safety, empowering nurses to speak up using graded assertiveness and flattening hierarchies. As a result of the project, our nurses' knowledge about capnography and waveform identification improved to over 80% correct answers six months after completion of the project. In addition, over 90% of participants reported feeling confident in speaking up to both consultants and non-consultant hospital doctors when a waveform was not present before induction of anaesthesia or after attempted tracheal intubation.
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Affiliation(s)
- T. Sweeney
- Department of AnaesthesiologySt James's HospitalDublinIreland
| | - A. Deasy
- Department of AnaesthesiologySt James's HospitalDublinIreland
| | - R. Linehan
- Department of AnaesthesiologySt James's HospitalDublinIreland
| | | | - A. Cafferkey
- Department of AnaesthesiologySt James's HospitalDublinIreland
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Edmark L, Englund EK, Jonsson AS, Zilic AT, Cajander P, Östberg E. Pressure-controlled versus manual facemask ventilation for anaesthetic induction in adults: A randomised controlled non-inferiority trial. Acta Anaesthesiol Scand 2023; 67:1356-1362. [PMID: 37476919 DOI: 10.1111/aas.14308] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Pressure-controlled face mask ventilation (PC-FMV) with positive end-expiratory pressure (PEEP) after apnoea following induction of general anaesthesia prolongs safe apnoea time and reduces atelectasis formation. However, depending on the set inspiratory pressure, a delayed confirmation of a patent airway might occur. We hypothesised that by lowering the peak inspiratory pressure (PIP) when using PC-FMV with PEEP, confirmation of a patent airway would not be delayed as studied by the first return of CO2 , compared with manual face mask ventilation (Manual FMV). METHODS This was a single-centre, randomised controlled non-inferiority trial. Seventy adult patients scheduled for elective day-case surgery under general anaesthesia with body mass index between 18.5 and 29.9 kg m-2 , American Society of Anesthesiologists (ASA) classes I-III, and without anticipated difficult FMV, were included. Before the start of pre-oxygenation and induction of general anaesthesia, participants were randomly allocated to receive ventilation with either PC-FMV with PEEP, at a PIP of 11 and a PEEP of 6 cmH2 O or Manual FMV, with the adjustable pressure-limiting valve set at 11 cmH2 O. The primary outcome variable was the number of ventilatory attempts needed until confirmation of a patent airway, defined as the return of at least 1.3 kPa CO2 . RESULTS The return of ≥1.3 kPa CO2 on the capnography curve was observed after mean ± SD, 3.6 ± 4.2 and 2.5 ± 1.9 ventilatory attempts/breaths with PC-FMV with PEEP and Manual FMV, respectively. The difference in means (1.1 ventilatory attempts/breaths) had a 99% CI of -1.0 to 3.1, within the accepted upper margin of four breaths for non-inferiority. CONCLUSION Following induction of general anaesthesia, PC-FMV with PEEP was used without delaying a patent airway as confirmed with capnography, if moderate pressures were used.
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Affiliation(s)
- Lennart Edmark
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
| | - Emma-Karin Englund
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
| | | | | | - Per Cajander
- Department of Anaesthesia and Intensive Care, Örebro University Hospital, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Erland Östberg
- Department of Anaesthesia and Intensive Care, Västmanland Hospital Köping, Köping, Sweden
- Region Västmanland-Uppsala University, Centre for Clinical Research, Västmanland Hospital Västerås, Västerås, Sweden
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Campos MD, Palazzi LH, Böhm SH, Tusman G. Effects of apparatus dead space on volumetric capnograms in neonates with healthy lungs: a simulation study. Paediatr Anaesth 2023; 33:973-982. [PMID: 37403466 DOI: 10.1111/pan.14724] [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: 04/15/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Volumetric capnography in healthy ventilated neonates showed deformed waveforms, which are supposedly due to technological limitations of flow and carbon dioxide sensors. AIMS This bench study analyzed the role of apparatus dead space on the shape of capnograms in simulated neonates with healthy lungs. METHODS We simulated mechanical breaths in neonates of 2, 2.5, and 3 kg of body weight using a neonatal volumetric capnography simulator. The simulator was fed by a fixed amount of carbon dioxide of 6 mL/kg/min. Such simulator was ventilated in a volume control mode using fixed ventilatory settings with a tidal volume of 8 mL/kg and respiratory rates of 40, 35, and 30 breaths per minute for the 2, 2.5 and 3 kg neonates, respectively. We tested the above baseline ventilation with and without an additional apparatus dead space of 4 mL. RESULTS Simulations showed that adding the apparatus dead space to baseline ventilation increased the amount of re-inhaled carbon dioxide in all neonates: 0.16 ± 0.01 to 0.32 ± 0.03 mL (2 kg), 0.14 ± 0.02 to 0.39 ± 0.05 mL (2.5 kg), and 0.13 ± 0.01 to 0.36 ± 0.05 mL (3 kg); (p < .001). Apparatus dead space was computed as part of the airway dead space, and therefore, the ratio of airway dead space to tidal volume increased from 0.51 ± 0.04 to 0.68 ± 0.06, from 0.43 ± 0.04 to 0.62 ± 0.01 and from 0.38 ± 0.01 to 0.60 ± 0.02 in the 2, 2.5 and 3 kg simulated neonates, respectively (p < .001). Compared to baseline ventilation, adding apparatus dead space decreased the ratio of the volume of phase III to VT size from 31% to 11% (2 kg), from 40% to 16% (2.5 kg) and from 50% to 18% (3 kg); (p < .001). CONCLUSIONS The addition of a small apparatus dead space artificially deformed the volumetric capnograms in simulated neonates with healthy lungs.
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Affiliation(s)
- Marcelo D Campos
- Department of Anesthesiology, Sanatorio Finochietto, Buenos Aires, Argentina
| | - Lucio H Palazzi
- Department of Anesthesiology, Children Hospital Dr. Orlando Alassia, Santa Fe, Argentina
| | - Stephan H Böhm
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Rostock University Medical Center, Rostock, Germany
| | - Gerardo Tusman
- Department of Anesthesia, Hospital Privado de Comunidad, Mar del Plata, Argentina
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Smida T, Menegazzi JJ, Crowe RP, Salcido DD, Bardes J, Myers B. The Association of Prehospital End-Tidal Carbon Dioxide with Survival Following Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:478-484. [PMID: 37751228 PMCID: PMC10963336 DOI: 10.1080/10903127.2023.2262566] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE End tidal carbon dioxide (ETCO2) is often used to assess ventilation and perfusion during cardiac arrest resuscitation. However, few data exist evaluating the relationship between ETCO2 values and mortality in the context of contemporary resuscitation practices. We aimed to explore the association between ETCO2 and mortality following out-of-hospital cardiac arrest (OHCA). METHODS We used the 2018-2021 ESO annual datasets to query all non-traumatic OHCA patients with attempted resuscitation. Patients with documented DNR/POLST, EMS-witnessed arrest, ROSC after bystander CPR only, or < 2 documented ETCO2 values were excluded. The lowest and highest ETCO2 values recorded during the total prehospital interval, in addition to the pre- and post-ROSC intervals for resuscitated patients, were calculated. Multivariable logistic regression models adjusted for age, sex, initial rhythm, witnessed status, bystander CPR, etiology, OHCA location, sodium bicarbonate administration, number of milligrams of epinephrine administered, and response interval were used to evaluate the association between measures of ETCO2 and mortality. RESULTS Hospital outcome data were available for 14,122 patients, and 2,209 (15.6%) were classified as surviving to discharge. Compared to patients with maximum prehospital ETCO2 values of 30-40 mmHg, odds of mortality were increased for patients with maximum prehospital ETCO2 values of <20 mmHg (aOR: 3.5 [2.1, 5,9]), 20-29 mmHg (aOR: 1.5 [1.1, 2.1]), and >50 mmHg (aOR: 1.5 [1.2, 1.8]). After 20 minutes of ETCO2 monitoring, <12% of patients had ETCO2 values <10 mmHg. This cutpoint was 96.7% specific and 6.9% sensitive for mortality. CONCLUSION In this dataset, both high and low ETCO2 values were associated with increased mortality. Contemporary resuscitation practices may make low ETCO2 values uncommon, and field termination decision algorithms should not use ETCO2 values in isolation.
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Affiliation(s)
- Tanner Smida
- West Virginia University Department of Emergency Medicine, Division of Prehospital Medicine, Morgantown, WV, USA
| | - James J. Menegazzi
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, USA
| | | | - David D. Salcido
- University of Pittsburgh Department of Emergency Medicine, Pittsburgh, PA, USA
| | - James Bardes
- West Virginia University Department of Surgery, Morgantown, WV, USA
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Cruces P, Moreno D, Reveco S, Améstica M, Araneda P, Ramirez Y, Vásquez-Hoyos P, Díaz F. Capnometry after an inspiratory breath hold, PLAT CO 2 , as a surrogate for P aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ in mild to moderate pediatric acute respiratory distress syndrome: A feasibility study. Pediatr Pulmonol 2023; 58:2899-2905. [PMID: 37594148 DOI: 10.1002/ppul.26610] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Accurate and reliable noninvasive methods to estimate gas exchange are necessary to guide clinical decisions to avoid frequent blood samples in children with pediatric acute respiratory distress syndrome (PARDS). We aimed to investigate the correlation and agreement between end-tidalP CO 2 ${P}_{{\mathrm{CO}}_{2}}$ measured immediately after a 3-s inspiratory-hold (PLAT CO2 ) by capnometry andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ measured by arterial blood gases (ABG) in PARDS. DESIGN Prospective cohort study. SETTING Seven-bed Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Chile. PATIENTS Thirteen mechanically ventilated patients aged ≤15 years old undergoing neuromuscular blockade as part of management for PARDS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients were in volume-controlled ventilation mode. The regular end-tidalP CO 2 ( P ETCO 2 ) ${P}_{{\mathrm{CO}}_{2}}({P}_{{\mathrm{ETCO}}_{2}})$ (without the inspiratory hold) was registered immediately after the ABG sample. An inspiratory-hold of 3 s was performed for lung mechanics measurements, recordingP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ in the breath following the inspiratory-hold. (PLAT CO2 ). End-tidal alveolar dead space fraction (AVDSf) was calculated as[ ( P aCO 2 - P ETCO 2 ) / P aCO 2 ] $[({P}_{{\mathrm{aCO}}_{2}}\mbox{--}{P}_{{\mathrm{ETCO}}_{2}})/{P}_{{\mathrm{aCO}}_{2}}]$ and its surrogate (S)AVDSf as[ ( PLAT CO 2 - P ETCO 2 ) / PLAT CO 2 ] $[{(}_{\mathrm{PLAT}}{\mathrm{CO}}_{2}\mbox{--}{P}_{{\mathrm{ETCO}}_{2}}){/}_{\mathrm{PLAT}}{\mathrm{CO}}_{2}]$ . Measurements ofP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ were considered the gold standard. We performed concordance correlation coefficient (ρc), Spearman's correlation (rho), and Bland-Altmann's analysis (mean difference ± SD [limits of agreement, LoA]). Eleven patients were included, with a median (interquartile range) age of 5 (2-11) months. Tidal volume was 5.8 (5.7-6.3) mL/kg, PEEP 8 (6-8), driving pressure 10 (8-11), and plateau pressure 17 (17-19) cm H2 O. Forty-one paired measurements were analyzed.P aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was higher thanP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ (52 mmHg [48-54] vs. 42 mmHg [38-45], p < 0.01), and there were no significant differences with PLAT CO2 (50 mmHg [46-55], p > 0.99). The concordance correlation coefficient and Spearman's correlation betweenP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ and PLAT CO2 were robust (ρc = 0.80 [95% confidence interval [CI]: 0.67-0.90]; and rho = 0.80, p < 0.001.), and forP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ were weak and strong (ρc = 0.27 [95% CI: 0.15-0.38]; and rho = 0.63, p < 0.01). The bias between PLAT CO2 andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was -0.4 ± 3.5 mmHg (LoA -7.2 to 6.4), and betweenP ETCO 2 ${P}_{{\mathrm{ETCO}}_{2}}$ andP aCO 2 ${P}_{{\mathrm{aCO}}_{2}}$ was -8.5 ± 4.1 mmHg (LoA -16.6 to -0.5). The correlation between AVDSf and (S)AVDSf was moderate (rho = 0.55, p < 0.01), and the mean difference was -0.5 ± 5.6% (LoA -11.5 to 10.5). CONCLUSION This pilot study showed the feasibility of measuring end-tidal CO2 after a 3-s end-inspiratory breath hole in pediatric patients undergoing controlled ventilation for ARDS. Encouraging preliminary results warrant further study of this technique.
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Affiliation(s)
- Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Colombia
| | - Diego Moreno
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Sonia Reveco
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Marjorie Améstica
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Patricio Araneda
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Yenny Ramirez
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
| | - Pablo Vásquez-Hoyos
- Departamento de Pediatría, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
- Departamento de Pediatría, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Colombia
- Unidad de Investigación y epidemiología clínica, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
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Ramesh M, Brooks AC, Thomovsky E, Johnson P, Fulkerson C, Parnell N, Weng HY. Comparison of 4 point-of-care techniques to detect correct positioning of nasogastric tubes in dogs (2020-2021). J Vet Emerg Crit Care (San Antonio) 2023; 33:501-508. [PMID: 37561112 DOI: 10.1111/vec.13327] [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] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To compare 4 point-of-care (POC) techniques to assess nasogastric (NG) tube placement versus radiographs as a reference standard. POC methods included air inflation with auscultation, fluid aspiration with pH measurement, ultrasonography, and capnography. DESIGN Prospective observational study in hospitalized dogs between 2020 and 2021. SETTING University teaching hospital. ANIMALS Fifty-one dogs requiring NG tube placement as part of their normal care. INTERVENTIONS After standard blind NG tube placement, each POC method was performed following standardized instructions. All POC methods were scored as to whether the investigator believed the tube to be in the gastrointestinal tract (as indicated by positive auscultation of borborygmus during insufflation, positive fluid aspiration with pH ≤5, presence of hyperechoic shadow in the esophagus, or absence of capnographic waveform). Subsequently, radiographs were taken to determine NG tube position as a gold standard. The sensitivity, specificity, and accuracy of each test as compared to 2-view thoracic radiographs were determined. MEASUREMENTS AND MAIN RESULTS Sensitivity, specificity, and accuracy for each POC technique were as follows: air auscultation (84.4%, 50.5%, and 80.4%, respectively), neck ultrasound (95.6%, 83.3%, and 94.1%, respectively), capnography (91.1%, 33.3%, and 84.3%, respectively), and fluid aspiration with pH measurement (22.2%, 100%, and 31.4%, respectively). CONCLUSIONS Among the 4 techniques evaluated, neck ultrasound had the best overall performance for assessing NG tube placement. Fluid aspiration with pH measurement might also have potential due to perfect specificity, but its clinical utility may be limited by low sensitivity and accuracy. Nonetheless, 2-view thoracic radiography should still be considered the standard method for confirmation of NG tube placement as none of the 4 POC techniques investigated showed both high sensitivity and perfect specificity.
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Affiliation(s)
- Meera Ramesh
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Aimee C Brooks
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Elizabeth Thomovsky
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Paula Johnson
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Carrie Fulkerson
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Nollie Parnell
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Hsin-Yi Weng
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
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İşat G, Cimilli Öztürk T, Ecmel Onur Ö, Özdemir S, Ünal Akoğlu E, Tokgöz Akyıl F, Kuzu Okur H. Comparison of the Arterial PaCO 2 Values and ETCO 2 Values Measured with Sidestream Capnography in Patients with a Prediagnosis of COPD Exacerbation. Avicenna J Med 2023; 13:182-186. [PMID: 37799184 PMCID: PMC10550360 DOI: 10.1055/s-0043-1771179] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background Aim of this study is to investigate whether end-tidal carbon dioxide (ETCO 2 ) values can be used instead of partial pressure of carbon dioxide (PaCO 2 ) values in guiding treatment, and determining treatment benefits in patients that received a pre-diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation at the emergency department. Methods This observational prospective study was conducted with patients who presented to the emergency department with the complaint of shortness of breath and were diagnosed with COPD exacerbation. ETCO 2 was measured with the sidestream method during blood gas analysis in patients with indications for this analysis. Measurements were repeated at hour 1 after treatment. Results The study included a total of 121 cases. There was a positive correlation between the PaCO 2 and ETCO 2 values measured before and after treatment ( r = 0.736, p < 0.01 and r = 0.883, p < 0.01, respectively). High ETCO 2 values were accompanied by high PaCO 2 values. When the measurements before and after treatment were evaluated using the Bland-Altman method, most of the result were within the limits of agreement (-4.9 and +31.4/- 2.6 and +9.4), with mean differences being calculated as 13.2 and 8.4, respectively. Conclusions Although ETCO 2 and PaCO 2 were statistically consistent according to the results of our study, due to the high averages of differences between these two parameters, the ETCO 2 value has limited clinical use in COPD cases compared to PaCO 2 . However, high ETCO 2 values may indicate that noninvasive mechanical ventilation should be included in the treatment of COPD cases without waiting for the results of blood gas analysis, and they can also be when needed for inpatient treatment.
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Affiliation(s)
- Gökhan İşat
- Department of Emergency Medicine, University of Health Sciences Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Tuba Cimilli Öztürk
- Department of Emergency Medicine, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Özge Ecmel Onur
- Department of Emergency Medicine, Marmara University, Istanbul Turkey
| | - Serdar Özdemir
- Department of Emergency Medicine, University of Health Sciences Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Ebru Ünal Akoğlu
- Department of Emergency Medicine, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Fatma Tokgöz Akyıl
- Yedikule Center for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
| | - Hacer Kuzu Okur
- Department of Pulmonary Medicine, Altunizade Acibadem Hospital, Istanbul, Turkey
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10
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Sharp SM, Gomez FM, Meegan JM, Rowles TK, Townsend F, Schwacke LH, Smith CR. Using Blood Gas Analysis and Capnography to Determine Oxygenation Status in Bottlenose Dolphins ( Tursiops truncatus) Following the Deepwater Horizon Oil Spill. Toxics 2023; 11:toxics11050423. [PMID: 37235238 DOI: 10.3390/toxics11050423] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Abstract
Following the Deepwater Horizon (DWH) oil spill in 2010, poor pulmonary health and reproductive failure in bottlenose dolphins (Tursiops truncatus) in the northern Gulf of Mexico were well-documented. One postulated etiology for the increased fetal distress syndrome and pneumonia found in affected perinatal dolphins was maternal hypoxia caused by lung disease. The objective of this study was to evaluate the utility of blood gas analysis and capnography in determining oxygenation status in bottlenose dolphins with and without pulmonary disease. Blood and breath samples were collected from 59 free-ranging dolphins in Barataria Bay, Louisiana (BB), during a capture-release health assessment program, and from 30 managed dolphins from the U.S. Navy Marine Mammal Program in San Diego, CA. The former was the oil-exposed cohort and the latter served as a control cohort with known health histories. Capnography and select blood gas parameters were compared based on the following factors: cohort, sex, age/length class, reproductive status, and severity of pulmonary disease. Animals with moderate-severe lung disease had higher bicarbonate concentrations (p = 0.005), pH (p < 0.001), TCO2 (p = 0.012), and more positive base excess (p = 0.001) than animals with normal-mild disease. Capnography (ETCO2) was found to have a weak positive correlation with blood PCO2 (p = 0.020), with a mean difference of 5.02 mmHg (p < 0.001). Based on these findings, indirect oxygenation measures, including TCO2, bicarbonate, and pH, show promise in establishing the oxygenation status in dolphins with and without pulmonary disease.
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Affiliation(s)
- Sarah M Sharp
- National Marine Mammal Foundation, San Diego, CA 92106, USA
- International Fund for Animal Welfare, Yarmouth Port, MA 02675, USA
| | | | - Jenny M Meegan
- National Marine Mammal Foundation, San Diego, CA 92106, USA
| | - Teresa K Rowles
- Marine Mammal Health and Stranding Response Program, National Oceanographic and Atmospheric Administration, Silver Spring, MD 20910, USA
| | - Forrest Townsend
- College of Veterinary Medicine, Auburn University, Auburn, AL 36832, USA
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11
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Pelchat J, Desprez I, Beaufrère H, Beazley SG, Duke-Novakovski T. Comparison between mainstream (Capnostat 5) and a low-flow sidestream capnometer (Capnostream) in mechanically ventilated, sevoflurane-anesthetized rabbits using a Bain coaxial delivery system. Vet Anaesth Analg 2023; 50:81-90. [PMID: 36517354 DOI: 10.1016/j.vaa.2022.11.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate agreement between end-tidal carbon dioxide (Pe'CO2) and PaCO2 with sidestream and mainstream capnometers in mechanically ventilated anesthetized rabbits, with two ventilatory strategies. STUDY DESIGN Prospective experimental study. ANIMALS A total of 10 New Zealand White rabbits weighing 3.6 ± 0.3 kg (mean ± standard deviation). METHODS Rabbits anesthetized with sevoflurane were intubated with an uncuffed endotracheal tube (3.0 mm internal diameter) and adequate seal. For Pe'CO2, the sidestream capnometer sampling adapter or the mainstream capnometer was placed between the endotracheal tube and Bain breathing system (1.5 L minute-1 oxygen). PaCO2 was obtained from arterial blood collected every 5 minutes. A time-cycled ventilator delivered an inspiratory time of 1 second and 12 or 20 breaths minute-1. Peak inspiratory pressure was initially set to achieve Pe'CO2 normocapnia of 35-45 mmHg (4.6-6.0 kPa). A total of five paired Pe'CO2 and PaCO2 measurements were obtained with each ventilation mode for each capnometer. Anesthetic episodes were separated by 7 days. Agreement was assessed using Bland-Altman analysis and linear mixed models; p < 0.05. RESULTS There were 90 and 83 pairs for the mainstream and sidestream capnometers, respectively. The mainstream capnometer underestimated PaCO2 by 12.6 ± 2.9 mmHg (proportional bias 0.44 ± 0.06 mmHg per 1 mmHg PaCO2 increase). With the sidestream capnometer, ventilation mode had a significant effect on Pe'CO2. At 12 breaths minute-1, Pe'CO2 underestimated PaCO2 by 23.9 ± 8.2 mmHg (proportional bias: 0.81 ± 0.18 mmHg per 1 mmHg PaCO2 increase). At 20 breaths minute-1, Pe'CO2 underestimated PaCO2 by 38.8 ± 5.0 mmHg (proportional bias 1.13 ± 0.10 mmHg per 1 mmHg PaCO2 increase). CONCLUSIONS AND CLINICAL RELEVANCE Both capnometers underestimated PaCO2. The sidestream capnometer underestimated PaCO2 more than the mainstream capnometer, and was affected by ventilation mode.
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Affiliation(s)
- Jennifer Pelchat
- Department of Small Animal Clinical Studies, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Isabelle Desprez
- Department of Small Animal Clinical Studies, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Hugues Beaufrère
- Department of Veterinary Medicine and Epidemiology, University of California Davis School of Veterinary Medicine, Davis, CA, USA
| | - Shannon G Beazley
- Department of Small Animal Clinical Studies, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Tanya Duke-Novakovski
- Department of Small Animal Clinical Studies, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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12
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Karlsson J, Lönnqvist PA. Capnodynamics - noninvasive cardiac output and mixed venous oxygen saturation monitoring in children. Front Pediatr 2023; 11:1111270. [PMID: 36816378 PMCID: PMC9936087 DOI: 10.3389/fped.2023.1111270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Hemodynamic monitoring in children is challenging for many reasons. Technical limitations in combination with insufficient validation against reference methods, makes reliable monitoring systems difficult to establish. Since recent studies have highlighted perioperative cardiovascular stability as an important factor for patient outcome in pediatrics, the need for accurate hemodynamic monitoring methods in children is obvious. The development of mathematical processing of fast response mainstream capnography signals, has allowed for the development of capnodynamic hemodynamic monitoring. By inducing small changes in ventilation in intubated and mechanically ventilated patients, fluctuations in alveolar carbon dioxide are created. The subsequent changes in carbon dioxide elimination can be used to calculate the blood flow participating in gas exchange, i.e., effective pulmonary blood flow which equals the non-shunted pulmonary blood flow. Cardiac output can then be estimated and continuously monitored in a breath-by-breath fashion without the need for additional equipment, training, or calibration. In addition, the method allows for mixed venous oxygen saturation (SvO2) monitoring, without pulmonary artery catheterization. The current review will discuss the capnodyamic method and its application and limitation as well as future potential development and functions in pediatric patients.
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Affiliation(s)
- Jacob Karlsson
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Dept of Physiology & Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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13
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Shirane S, Funakoshi H, Takahashi J, Homma Y, Norii T. Association between capnography and recovery time after procedural sedation and analgesia in the emergency department. Acute Med Surg 2023; 10:e901. [PMID: 37900991 PMCID: PMC10604570 DOI: 10.1002/ams2.901] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 09/09/2023] [Accepted: 10/05/2023] [Indexed: 10/31/2023] Open
Abstract
Aim Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED). Methods This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no-capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log-rank test and multivariable analysis using clustering for institutions were performed. Results Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography (n = 150, 16%) and no-capnography (n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25-63) min in the capnography group and 30 (IQR: 14-55) min in the no-capnography group. In the log-rank test, the recovery time was significantly longer in the capnography group (p = 0.03) than in the no-capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77-1.17; p = 0.61). Conclusion In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.
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Affiliation(s)
- Shogo Shirane
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Jin Takahashi
- Department of Emergency and Critical Care MedicineTokyobay Urayasu Ichikawa Medical CenterChibaJapan
| | - Yosuke Homma
- Department of Emergency MedicineChiba Kaihin Municipal HospitalChibaJapan
| | - Tatsuya Norii
- Department of Emergency MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
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14
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Kor JJ, Sprung J, Khanna AK, Weingarten TN. Continuous Monitoring Detected Respiratory Depressive Episodes in Proximity to Adverse Respiratory Events During the PRODIGY Trial. J Patient Saf 2022; 18:738-741. [PMID: 35405725 PMCID: PMC9698081 DOI: 10.1097/pts.0000000000001003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial was a multicenter prospective trial conducted to develop a risk prediction score for opioid-induced respiratory depressive (OIRD) episodes. Several subjects in the PRODIGY trial developed critical respiratory depressive events, which were qualified as reportable adverse events (AEs). In this study, we determine whether those patients also had an episode of OIRD as detected by continuous capnography and pulse oximetry leading up to the critical clinical event. METHODS Blinded capnography and pulse oximetry data from PRODIGY patients who had critical respiratory depressive AE were reviewed. The occurrence and timing of OIRD episodes were recorded in relationship to the AE. RESULTS Of the 1335 subjects in PRODIGY, 7 patients had 8 reportable pulmonary AE and 187 OIRDs (150 apnea episodes, 14 bradypnea episodes, 23 hypoxic episodes) with median 12 (5-19.5) OIRDs per patient. Five patients were monitored before the AE, and multiple preceding OIRD episodes were detected. One patient had 2 AE, the first (hypoxemia) was recognized upon application of pulse oximetry. This patient subsequently had multiple OIRDs until the second AE occurred (somnolence requiring naloxone administration). Another patient's AE (hypotension and bradypnea) was recognized upon monitor application and subsequently had many OIRD episodes. CONCLUSIONS In the PRODIGY trial, patients who had a pulmonary AE had multiple preceding OIRDs detected by continuous capnography and pulse oximetry. When monitoring was initiated before the AE, numerous OIRDs, mostly apneic episodes preceded AE, suggesting continuous monitoring of both ventilation and oxygenation may allow for early detection and possible prediction of future clinical decompensation.
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Affiliation(s)
- Jennifer J. Kor
- From the Kentucky College of Osteopathic Medicine, Pikeville, Kentucky
| | - Juraj Sprung
- Departments of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ashish K. Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
| | - Toby N. Weingarten
- Departments of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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15
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Chrimes N, Higgs A, Hagberg CA, Baker PA, Cooper RM, Greif R, Kovacs G, Law JA, Marshall SD, Myatra SN, O'Sullivan EP, Rosenblatt WH, Ross CH, Sakles JC, Sorbello M, Cook TM. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia 2022; 77:1395-1415. [PMID: 35977431 DOI: 10.1111/anae.15817] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 01/07/2023]
Abstract
Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of 'sustained exhaled carbon dioxide' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Affiliation(s)
- N Chrimes
- Department of Anaesthesia, Monash Medical Centre, Melbourne, Australia
| | - A Higgs
- Department of Anaesthesia and Intensive Care, Warrington Teaching Hospitals NHS Foundation Trust, Cheshire, UK
| | - C A Hagberg
- Department of Anaesthesiology and Peri-operative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P A Baker
- Department of Anaesthesiology, University of Auckland, New Zealand.,Department of Anaesthesiology, Starship Children's Hospital, Auckland, New Zealand
| | - R M Cooper
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - R Greif
- Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Switzerland.,Department of Medical Education, Sigmund Freud University, Vienna, Austria
| | - G Kovacs
- Departments of Emergency Medicine, Anesthesia, Medical Neurosciences and Division of Medical Education, Dalhousie University, Halifax, Canada
| | - J A Law
- Department of Anesthesia, Pain Management and Peri-operative Medicine, Dalhousie University, Halifax, Canada
| | - S D Marshall
- Department of Critical Care, University of Melbourne, VIC, Australia.,Department of Anaesthesia and Peri-operative Medicine, Monash University, Melbourne, VIC, Australia
| | - S N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - E P O'Sullivan
- Department of Anaesthesiology, St James's Hospital, Dublin, Ireland
| | - W H Rosenblatt
- Department of Anesthesia, Yale School of Medicine, New Haven, CT, USA
| | - C H Ross
- Department of Emergency Medicine, Mercy Health, Javon Bea Hospital, Rockton and Riverside Campuses, Rockford, IL, USA.,Department of Surgery, University of Illinois College of Medicine, Chicago, IL, USA
| | - J C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - M Sorbello
- Anesthesia and Intensive Care, AOU Policlinico San Marco University Hospital, Catania, Italy
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,School of Medicine, University of Bristol, Bristol, UK
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16
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Atherton P, Jungquist C, Spulecki C. An Educational Intervention to Improve Comfort with Applying and Interpreting Transcutaneous CO 2 and End-tidal CO 2 Monitoring in the PACU. J Perianesth Nurs 2022; 37:781-786. [PMID: 35691831 DOI: 10.1016/j.jopan.2022.03.001] [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] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/14/2022] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to assess the effectiveness of an educational program about measuring ventilation using devices that assess carbon dioxide levels in patients recovering from a surgical procedure. DESIGN A pre-post survey of knowledge attainment from an educational intervention about measuring ventilation using end-tidal carbon dioxide (EtCO2) and transcutaneous carbon dioxide (tcPCO2) devices in the postanesthesia care unit (PACU) was distributed to current members of the American Society of PeriAnesthesia Nurses. METHODS Participants received a 12-question pre-intervention (five were related to demographics) and a five-question post-intervention survey. Non-demographic survey questions used a one to five Likert scale to assess comfortability or confidence. The intervention created was a voice-over presentation designed to improve PACU RN's comfort and confidence with using and interpreting tcPCO2 or EtCO2 in the PACU. FINDINGS PACU RNs (N = 108) reported they 'never' or 'rarely' used EtCO2 (n = 57, 52.7%) monitoring or tcPCO2 (n = 93, 86.1%) monitoring in the PACU. A paired t test revealed statistically significant differences in the PACU RN's pre-survey and posttest comfortability of applying and interpreting EtCO2 or tcPCO2 monitors (P < .05). CONCLUSIONS Capnography monitoring should be considered a standard of care for PACU patients. Education of registered nurses working in the PACU is critical before implementing EtCO2 or tcPCO2 monitoring.
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Affiliation(s)
| | - Carla Jungquist
- University at Buffalo (SUNY), School of Nursing, Buffalo, NY
| | - Cheryl Spulecki
- University at Buffalo (SUNY), School of Nursing, Buffalo, NY
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17
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Baker PA, O'Sullivan EP, Aziz MF. Unrecognised oesophageal intubation: time for action. Br J Anaesth 2022; 129:836-840. [PMID: 36192220 DOI: 10.1016/j.bja.2022.08.027] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/02/2022] Open
Abstract
Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error. Unrecognised oesophageal intubation can occur in any patient of any age whenever intubation occurs regardless of the seniority or experience of the airway practitioner or others involved in the patient's airway management. The tragic fact is that it continues to happen despite improvements in monitoring, airway devices, and medical education. We review these improvements with strategies to eliminate this problem.
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Affiliation(s)
- Paul A Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand; Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.
| | - Ellen P O'Sullivan
- Department of Anaesthesia and Intensive Care Medicine, St James's Hospital, Dublin, Ireland
| | - Michael F Aziz
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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18
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Christensen L, Mansour K, Pleil JD, Troy R. Tunable laser spectroscopy for carbon dioxide capnography and water vapor sensing inside a breathing mask: application to pilot life support. J Breath Res 2022; 16. [PMID: 35623323 DOI: 10.1088/1752-7163/ac740e] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/27/2022] [Indexed: 11/11/2022]
Abstract
Tunable laser spectroscopy (TLS) near 2683 nm was used to measure carbon dioxide and water vapor inside a pilot mask during jet fighter flights. Measurement frequency was 100 Hz in order to capture breathing profiles and other gas flow dynamics. Analysis of the full inhalation and exhalation breathing cycle allowed precise monitoring of breathing performance and interaction of the pilot with the life-support system. Measurements revealed dynamic phenomena pertaining to mechanical gas flow and pilot respiration that may be used to understand gas delivery stresses imposed upon the pilot and pilot physiology during flight. Typically, such measurements are made with non-dispersive infrared (NDIR) instrumentation for only carbon dioxide with intrinsic challenges regarding time and optical resolution. The TLS approach is a major advance because the sensor is placed directly into the mask improving its time response and enabling use of water vapor measurements that are less impacted from memory effects. This article presents the implementation of TLS and shows highly time-resolved pilot breathing data for high-performance aircraft tests.
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Affiliation(s)
- Lance Christensen
- NASA Jet Propulsion Laboratory, 183-401, 4800 Oak Grove Dr., Pasadena, California, 91109-8001, UNITED STATES
| | - Kamjou Mansour
- NASA Jet Propulsion Laboratory, 4800 Oak Grove Dr., Pasadena, California, 91109-8001, UNITED STATES
| | - Joachim D Pleil
- University of North Carolina at Chapel Hill, Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, 27515, UNITED STATES
| | - Robert Troy
- Self, N/A, N/A, California, N/A, UNITED STATES
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19
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Conway A, Chang K, Goudarzi Rad M, Mafeld S, Parotto M. Integrated Pulmonary Index during nurse-administered procedural sedation: Study protocol for a cluster-randomized trial. J Adv Nurs 2022; 78:2245-2254. [PMID: 35485238 DOI: 10.1111/jan.15243] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
AIM To determine if smart alarm-guided treatment of respiratory depression using the Integrated Pulmonary Index is an effective way to implement capnography during nurse-administered sedation. DESIGN Parallel cluster-randomized trial. METHODS Nurses will be randomized to use capnography with or without the Integrated Pulmonary Index enabled. Capnography alarm performance will be compared between nurses using capnography alone or with the Integrated Pulmonary Index enabled. The target sample size is 400 adult patients scheduled for elective procedures with nurse-administered sedation. The primary outcome is the number of seconds in an alert condition state without an intervention being applied. Secondary outcomes are alarm burden, number of appropriate alarms, number of inappropriate alarms, total duration of alert conditions, choice of alarm settings and adverse sedation events. This study has been funded since April 2021. DISCUSSION Implementing capnography into practice for respiratory monitoring during nurse-administered sedation is considered a high priority. The Integrated Pulmonary Index shows promise as a strategy to optimize the implementation of capnography for respiratory monitoring during nurse-administered sedation. If it is found in this study that using the Integrated Pulmonary Index improves the nursing management of physiologically abnormal states during nurse-administered sedation, it would provide the high-level evidence needed to support broader use of this 'smart alarm' strategy for respiratory monitoring in practice. IMPACT With advances in medical technology continuing to expand the indications for minimally invasive surgical techniques, the use of nurse-administered sedation during medical procedures is likely to expand in the future. The findings may be applied to other populations receiving nurse-administered sedation during medical procedures. Results from this study will help translate the usage of smart alarm-guided treatment of respiratory depression during procedural sedation. TRIAL REGISTRATION NCT05068700.
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Affiliation(s)
- Aaron Conway
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kristina Chang
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Mohammad Goudarzi Rad
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Interventional Radiology, Joint Department of Medical Imaging, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Management, Toronto General Hospital, UHN, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Henricson J, Glasin J, Rindebratt S, Wilhelms D. Respiratory rate monitoring in healthy volunteers by central photoplethysmography compared to capnography. J Biophotonics 2022; 15:e202100270. [PMID: 34874126 DOI: 10.1002/jbio.202100270] [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] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 06/13/2023]
Abstract
Monitoring of respiration is a central task in clinical medicine, crucial to patient safety. Despite the uncontroversial role of altered respiratory frequency as an important sign of impending or manifest deterioration, reliable measurement methods are mostly lacking outside of intensive care units and operating theaters. Photoplethysmography targeting the central blood circulation in the sternum could offer accurate and inexpensive monitoring of respiration. Changes in blood flow related to the different parts of the respiratory cycle are used to identify the respiratory pattern. The aim of this observational study was to compare photoplethysmography at the sternum to standard capnography in healthy volunteers. Bland Altman analysis showed good agreement (bias -0.21, SD 1.6, 95% limits of agreement -3.4 to 2.9) in respiratory rate values. Photoplethysmography provided high-quality measurements of respiratory rate comparable to capnographic measurements. This suggests that photoplethysmography may become a precise, cost-effective alternative for respiratory monitoring.
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Affiliation(s)
- Joakim Henricson
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden
| | - Joakim Glasin
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden
| | - Sandra Rindebratt
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden
| | - Daniel Wilhelms
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden
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Agudelo-Uribe JF, Ramirez-Barrera JD, Espinal-Montoya JA, Miranda-Arboleda AF, Saenz-Jaramillo G, Tobon-Upegui MP, Castellanos-Martinez E. Accuracy of Delta Capnography for the Prediction of Pulmonary Vein Occlusion During Cryoablation for Atrial Fibrillation. J Innov Card Rhythm Manag 2022. [PMID: 35317207 PMCID: PMC8930007 DOI: 10.19102/icrm.2022.130302] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The purpose of this study was to quantify the relationship between a drop in end-tidal carbon dioxide (etCO2) and occlusion of pulmonary veins (PVs) to find a delta etCO2 (ΔetCO2) able to predict occlusion during PV isolation (PVI) by cryoballoon. We designed a prospective registry. Paroxysmal atrial fibrillation patients who underwent cryoballoon PVI were included. Capnography was performed. Occlusion was tested by injection. A comparison between ΔetCO2 and occlusion was performed. Eighteen subjects (138 injections) were included. A drop of >3.5 mmHg predicted occlusion of the PV (sensitivity, 80%; specificity, 86.7%). A ΔetCO2 of ≥3.5 mmHg during inflation of the cryoballoon in each PV directly correlates with PV balloon occlusion.
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Affiliation(s)
- Juan Fernando Agudelo-Uribe
- Interventional Cardiology Department, CardioVID Clinic, Medellin, Colombia,Address correspondence to: Juan Fernando Agudelo-Uribe, MD, MSC, Interventional Cardiology Department, Second Floor, CardioVID Clinic, Calle 78B # 75—21, 050034 Medellin, Colombia.
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22
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Dost B, Kömürcü Ö, Bilgin S, Dökmeci H, Terzi Ö, Barış S. Investigating the Effects of Protective Face Masks on the Respiratory Parameters of Children in the Postanesthesia Care Unit During the COVID-19 Pandemic. J Perianesth Nurs 2022; 37:94-99. [PMID: 34824000 PMCID: PMC7877201 DOI: 10.1016/j.jopan.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to investigate the effect of protective face mask usage during the postoperative period on carbon dioxide retention in children during the COVID-19 pandemic. DESIGN This study was designed as a prospective, randomized trial including 40 ASA I-II patients aged 3 to 10 years who were scheduled for elective surgery. METHODS Patients were randomly allocated to two groups. The first group (group 1) received O2 treatment over the protective face mask. In the second group (group 2), the protective face mask was worn over the O2 delivery system. Heart rate, oxygen saturation (SPO2) level, end-tidal carbon dioxide (EtCO2) level, and respiratory rate were measured using a patient monitor at 0, 5, 10, 15, 30, and 45 minutes and recorded. The primary outcome of the study was the determination of the EtCO2 levels, which were used to assess the safety of the mask in terms of potential carbon dioxide retention. FINDINGS None of the participants' SPO2 levels fell below 92% while wearing masks. There was no statistically significant difference between the groups in terms of EtCO2, heart rate, SPO2, and respiratory rate (P > .05). CONCLUSIONS During the COVID-19 pandemic, protective surgical face masks can be used safely in the postoperative period for pediatric patients aged 3 to 10 years.
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Affiliation(s)
- Burhan Dost
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey.
| | - Özgür Kömürcü
- Division of Intensive Care, Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sezgin Bilgin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
| | - Hilal Dökmeci
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
| | - Özlem Terzi
- Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sibel Barış
- Department of Anesthesiology and Reanimation, Faculty of Medicine, OndokuzMayis University, Samsun, Turkey
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23
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Neumann RP, Gerull R, Zannin E, Fouzas S, Schulzke SM. Volumetric Capnography at 36 Weeks Postmenstrual Age and Bronchopulmonary Dysplasia in Very Preterm Infants. J Pediatr 2022; 241:97-102.e2. [PMID: 34687691 DOI: 10.1016/j.jpeds.2021.10.019] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/15/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the feasibility of volumetric capnography in spontaneously breathing very preterm infants at 36 weeks postmenstrual age (PMA) and its association with clinical markers of lung disease including the duration of respiratory support and bronchopulmonary dysplasia (BPD). STUDY DESIGN We obtained mainstream volumetric capnography measurements in 143 very preterm infants at 36 weeks PMA. BPD was categorized into no, mild, moderate, and severe according to the 2001 National Heart, Lung and Blood Institute workshop report. Normalized capnographic slopes of phase II (SnII) and phase III (SnIII) were calculated. We assessed the effect of BPD, duration of respiratory support, and duration of supplemental oxygen on capnographic slopes. RESULTS SnIII was steeper in infants with moderate to severe BPD (76 ± 25/L) compared with mild (31 ± 20/L) or no BPD (26 ± 18/L) (P < .001). The association of SnIII with moderate to severe BPD persisted after adjusting for birth weight z-score, respiratory rate, and airway dead space to tidal volume ratio. The diagnostic usefulness of SnIII to discriminate between infants with and without moderate to severe BPD was high (area under the curve, 0.94; 95% CI, 0.89-0.99). CONCLUSIONS Volumetric capnography is feasible in spontaneously breathing preterm infants at 36 weeks PMA and reflects the degree of lung disease. This promising bedside lung function technique may offer an objective, continuous physiological outcome measure for assessment of BPD severity. TRIAL REGISTRATION ClinicalTrials.gov: NCT02083562.
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Affiliation(s)
- Roland P Neumann
- Department of Neonatology, University Children's Hospital Basel UKBB, University of Basel, Switzerland.
| | - Roland Gerull
- Department of Neonatology, University Children's Hospital Basel UKBB, University of Basel, Switzerland; Department of Neonatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Emanuela Zannin
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milano, Italy
| | - Sotirios Fouzas
- Pediatric Respiratory Unit, University Hospital of Patras, Greece
| | - Sven M Schulzke
- Department of Neonatology, University Children's Hospital Basel UKBB, University of Basel, Switzerland
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Hibberd O, Hazlerigg A, Cocker PJ, Wilson AW, Berry N, Harris T. The PaCO 2-ETCO 2 gradient in pre-hospital intubations of all aetiologies from a single UK helicopter emergency medicine service 2015-2018. J Intensive Care Soc 2022; 23:11-19. [PMID: 37593537 PMCID: PMC10427849 DOI: 10.1177/1751143720970356] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background Control of the arterial partial pressure of carbon dioxide (PaCO2) is important in the ventilated patient. End-tidal carbon dioxide (ETCO2) levels are often used as a proxy, but are clinically limited. The difference between the PaCO2 and ETCO2 has been suggested to be 0.5-1.0 kPa. However, this has not been consistently reflected in the physiologically unstable pre-hospital patient. This study aims to elucidate the PaCO2-ETCO2 gradient for pre-hospital intubated patients. Methods This was a retrospective, cohort study using data identified from the HEMSbase 2 database (Feb 2015-Nov 2018). Patients were included if they had documented ETCO2 and arterial PaCO2 measurements. Arterial PaCO2 data that could not be linked to within 5 minutes of ETCO2 were excluded. Bland-Altman plots were calculated to describe agreement. Results A total of 73 patients were identified. Aetiology was arranged into three categories: 13 (17.8%) medical, 22 (30.1%) traumatic and 38 (52.1%) out-of-hospital cardiac arrest (OHCA). The median PaCO2-ETCO2 gradient was 2.0 [1.3-3.1] kPa. A PaCO2-ETCO2 gradient of 0-1 kPa was seen for only 11 (15.1%) of total patients. The Bland-Altman agreement for all aetiologies was more than the accepted gradient of 0-1 kPa with the largest bias and widest limits of agreement seen for OHCA (-3.2 [0.3 - -6.8]). Conclusion The magnitude of the differences between the ETCO2 and PaCO2, levels of variation and inability to predict this suggest that ETCO2 is not a suitable surrogate upon which to base ventilatory settings in conditions where pH or PaCO2 require precise control.
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Affiliation(s)
| | | | | | | | - Neil Berry
- East Anglian Air Ambulance, Cambridge, UK
| | - Tim Harris
- Blizard Institute, Queen Mary University of London, London, UK
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Vithalani V, Sondheim S, Cornelius A, Gonzales J, Mercer MP, Burton B, Redlener M. Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:14-22. [PMID: 35001828 DOI: 10.1080/10903127.2021.1989530] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.
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26
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Kovács BN, Südy R, Peták F, Balogh ÁL, Fodor HG, Tolnai J, Korsós A, Schranc Á, Lengyel C, Babik B. Respiratory consequences of obesity and diabetes. Orv Hetil 2022; 163:63-73. [PMID: 34999572 DOI: 10.1556/650.2022.32335] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/26/2021] [Indexed: 11/19/2022]
Abstract
Összefoglaló. Bevezetés: A cukorbetegségben nő a simaizmok tónusa, és megváltozik az elasztin és a kollagén szerkezete. Mivel a tüdőszövetben ezek a strukturális elemek meghatározóak, a cukorbetegség várhatóan módosítja a légutak és a tüdőszövet mechanikai és funkcionális viselkedését. Célkitűzés: Vizsgálatunk során diabetesben szenvedő, elhízott és nem elhízott betegeink körében tanulmányoztuk a légzésmechanikai elváltozásokat és a gázcserefunkciót. Módszer: Elektív szívsebészeti beavatkozásra kerülő, normál testalkatú betegeket diabetesben nem szenvedő (n = 80), illetve cukorbeteg (n = 35) csoportokra osztottuk. További két betegcsoportba elhízott és nem cukorbeteg (n = 47), valamint elhízott és diabetesben szenvedő (n = 33) betegek kerültek. A légzőrendszer mechanikai tulajdonságait kényszerített oszcillációs technikával határoztuk meg, mellyel a légúti ellenállás (Raw), valamint a szöveti csillapítás (G) és rugalmasság (H) tényezői jellemezhetők. Volumetriás kapnográfia segítségével a kapnogram 3. fázisának meredekségét és a légzési térfogat különböző ventilációs/perfúziós illeszkedési zavaraiból adódó holttérfrakciókat határoztuk meg. Az intrapulmonalis shuntfrakciót és az oxigenizációs indexet (PaO2/FiO2) artériás és centrális vénás vérgázmintákból határoztuk meg. Eredmények: A megfelelő kontrollcsoportokhoz hasonlítva a cukorbetegség önmagában is növelte az Raw (7,4 ± 5 vs. 3,0 ± 1,7 H2Ocm.s/l), a G (11,3 ± 4,9 vs. 6,2 ± 2,4 H2Ocm/l) és a H (32,3 ± 12,0 vs. 25,1± 6,9 H2Ocm/l) értékét (p<0,001 mindegyik betegcsoportnál), de ez nem járt együtt a gázcserefunckció romlásával. Hasonló patológiás elváltozásokat észleltünk elhízás során a légzésmechanikában és az alveolaris heterogenitásban, amelyek azonban a gázcsere hatékonyságát is rontották. Következtetés: Cukorbetegségben a légzésmechanika romlását a fokozott hypoxiás pulmonalis vasoconstrictio ellensúlyozni képes, ezzel kivédve az intrapulmonalis shunt növekedését és az oxigenizációs képesség romlását. Orv Hetil. 2022; 163(2): 63-73. SUMMARY INTRODUCTION While sustained hyperglicemia affects the smooth muscle tone and the elastin-collagen network, the effect of diabetes mellitus on the function and structure of the airways and the lung parenchyma has not been characterized, and the confounding influence of obesity has not been elucidated. OBJECTIVE To reveal the separate and additive roles of diabetes mellitus and obesity on the respiratory function. METHOD Non-obese mechanically ventilated patients were categorized as control non-diabetic (n = 80) and diabetic (n = 35) groups. Obese patients with (n = 33) or without (n = 47) associated diabetes were also enrolled. Forced oscillation technique was applied to measure airway resistance (Raw), tissue damping (G), and tissue elastance (H). Capnography was utilized to determine phase 3 slopes and ventilation dead space parameters. Arterial and central venous blood samples were analyzed to assess intrapulmonary shunt fraction (Qs/Qt) and the lung oxygenation index (PaO2/FiO2). RESULTS Diabetes without obesity increased the Raw (7.4 ± 5 cmH2O.s/l vs. 3.0 ± 1.7 cmH2O.s/l), G (11.3 ± 4.9 cmH2O/l vs. 6.2 ± 2.4 cmH2O/l), and H (32.3 ± 12.0 cmH2O/l vs. 25.1 ± 6.9 cmH2O/l, (p<0.001 for all), compared with the corresponding control groups. Capnographic phase 3 slope was increased in diabetes without significant changes in PaO2/FiO2 or Qs/Qt. While similar detrimental changes in respiratory mechanics and alveolar heterogeneity were observed in obese patients without diabetes, these alterations also compromised gas exchange. CONCLUSION The intrinsic mechanical abnormalities in the airways and lung tissue induced by diabetes are counterbalanced by hypoxic pulmonary vasoconstriction, thereby maintaining intrapulmonary shunt fraction and oxygenation ability of the lungs. Orv Hetil. 2022; 163(2): 63-73.
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Affiliation(s)
- Barbara Nóra Kovács
- 1 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Intézet Szeged, Semmelweis u. 6., 6720.,2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - Roberta Südy
- 1 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Intézet Szeged, Semmelweis u. 6., 6720.,2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - Ferenc Peták
- 2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - Ádám László Balogh
- 1 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Intézet Szeged, Semmelweis u. 6., 6720.,2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - H Gergely Fodor
- 2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - József Tolnai
- 2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - Anita Korsós
- 1 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Intézet Szeged, Semmelweis u. 6., 6720
| | - Álmos Schranc
- 2 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Orvosi Fizikai és Orvosi Informatikai Intézet Szeged
| | - Csaba Lengyel
- 3 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Belgyógyászati Klinika Szeged
| | - Barna Babik
- 1 Szegedi Tudományegyetem, Általános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Intézet Szeged, Semmelweis u. 6., 6720
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Acuti Martellucci C, Flacco ME, Martellucci M, Violante FS, Manzoli L. Inhaled CO 2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography. Environ Health Insights 2022. [PMID: 36133777 DOI: 10.1101/2022.05.10.22274813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO2) concentration, when wearing masks. METHODS We measured end-tidal CO2 using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO2 concentration was computed as: ([mask volume × end-tidal CO2] + [tidal volume - mask volume] × ambient air CO2)/tidal volume. RESULTS With surgical masks, the mean CO2 concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO2 concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO2 concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors. CONCLUSION If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.
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Affiliation(s)
| | - Maria Elena Flacco
- Department of Environmental and Prevention Sciences, University of Ferrara, Ferrara, Italy
| | - Mosè Martellucci
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Francesco Saverio Violante
- Occupational Health Unit, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Abstract
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.
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Affiliation(s)
- Rahul Shah
- From the Department of Pediatrics, Yale University School of Medicine
| | | | - Marc Auerbach
- Section of Pediatric Emergency Medicine, Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Melissa L. Langhan
- Section of Pediatric Emergency Medicine, Department of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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Karaali R, Çakir A, Bora ES, Akyol PY, Kavalci C, Acar H. The Evaluation of End Tidal Carbon Dioxide Values in Intubated Patients with COVID-19. Acta Biomed 2022; 93:e2022032. [PMID: 35315404 PMCID: PMC8972851 DOI: 10.23750/abm.v93i1.11989] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/01/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study is to establish the value of PETCO2 in COVID-19 patients intubated in emergency department, and its effects on mortality. Objectives: Between May 15, 2020 and January 15, 2021, The patients aged ≥18 years and diagnosed COVID-19, scheduled for urgent intubation in the emergency department were included. METHOD Single-center, prospective and observational study. Age, gender, vital signs, laboratory findings are recorded. Immediately after intubation as measured by the capnography, the initial PETCO2_1 and at post-ventilation 15 min, PETCO2_2 and first, second arterial blood gas analysis are recorded. RESULTS The mean age of the 48 patients was 74 years. The PETCO2_1 and PETCO2_2 measurements were statistically significantly different between the patients who survived and those who died (p=0.014, p=0.015). The patients with a high first PETCO2_1 value and a decrease to the normal level survived, but those with a low PETCO2_1 value that could not increase to a normal value died (p=0.038, p=0.031). Increased levels of SpO2, PETCO2_1, PETCO2_2 and PaCO2_2 decreased the risk of mortality, while an increased level of PaO2_2 increased the risk of mortality. CONCLUSION Capnography is non-invasive and provides continuous measurement. Assessment of changes in PETCO2 value would contribute to patient survival.
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Affiliation(s)
- Rezan Karaali
- Department of Emergency Medicine, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Turkey
| | - Adem Çakir
- Department of Emergency Medicine, Republic of Turkey, Ministry of Health Başakşehir Çam ve Sakura City Hospital, Istanbul, Turkey
| | - Ejder Saylav Bora
- Department of Emergency Medicine, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Turkey
| | - Pınar Yeşim Akyol
- Department of Emergency Medicine, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Turkey
| | - Cemil Kavalci
- Department of Emergency Medicine Republic of Turkey, Ministry of Health Antalya Research and Training Hospital, Turkey
| | - Hüseyin Acar
- Department of Emergency Medicine, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Turkey
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Acuti Martellucci C, Flacco ME, Martellucci M, Violante FS, Manzoli L. Inhaled CO 2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography. Environ Health Insights 2022; 16:11786302221123573. [PMID: 36133777 PMCID: PMC9483963 DOI: 10.1177/11786302221123573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 05/21/2023]
Abstract
BACKGROUND Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO2) concentration, when wearing masks. METHODS We measured end-tidal CO2 using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO2 concentration was computed as: ([mask volume × end-tidal CO2] + [tidal volume - mask volume] × ambient air CO2)/tidal volume. RESULTS With surgical masks, the mean CO2 concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO2 concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO2 concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors. CONCLUSION If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.
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Affiliation(s)
- Cecilia Acuti Martellucci
- Department of Environmental and
Prevention Sciences, University of Ferrara, Ferrara, Italy
- Cecilia Acuti Martellucci, Department of
Environmental and Prevention Sciences, University of Ferrara, Via Fossato di
Mortara 64/B, Ferrara 44121, Italy.
| | - Maria Elena Flacco
- Department of Environmental and
Prevention Sciences, University of Ferrara, Ferrara, Italy
| | - Mosè Martellucci
- Department of Medicine and Surgery,
University of Perugia, Perugia, Italy
| | - Francesco Saverio Violante
- Occupational Health Unit, Sant’Orsola
Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Lamberto Manzoli
- Department of Medical and Surgical
Sciences, University of Bologna, Bologna, Italy
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McNeill MM, Tabet CH. The Effectiveness of Capnography Versus Pulse Oximetry in Detecting Respiratory Adverse Events in the Postanesthesia Care Unit (PACU): A Narrative Review and Synthesis. J Perianesth Nurs 2021; 37:264-269.e1. [PMID: 34974968 DOI: 10.1016/j.jopan.2021.03.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this review was to evaluate the effectiveness of capnography monitoring versus standard monitoring of pulse oximetry in detecting respiratory adverse events in nonintubated pediatric and adult postanesthesia care unit (PACU) patients. DESIGN Experimental, quasi-experimental, and observational studies examining pulse oximetry and capnography in adult and pediatric patients in the PACU were included in this systematic review. METHODS An initial search of MEDLINE and CINAHL, PubMed, Web of Science, Prospero, Google Scholar, and Cochrane was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy in July 2019. Reference lists of studies included at critical appraisal stage were hand-searched. Studies published in English from 1978 onward were included. FINDINGS Meta-analysis was not possible due to variation in outcome measurements; therefore, results are presented in narrative form. Four studies were included in the review: 1 randomized controlled trial (RCT) and 3 observational cross-sectional studies. The RCT was considered of moderate to high quality, and the observational cross-sectional studies were of high quality. The main findings of this review suggest that there is limited high-quality evidence that capnography improves detection of respiratory adverse events in the PACU versus pulse oximetry. CONCLUSIONS The lack of RCTs and varied outcomes measures in the 4 studies reviewed meant that meta-analysis was not possible. Early detection of respiratory adverse events afforded by the addition of PETCO2 to SpO2 in the PACU was seen in these studies. More research is needed to determine if widespread implementation of capnography in addition to pulse oximetry would reduce severity of respiratory related adverse events in the PACU through more timely identification.
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Affiliation(s)
- Margaret M McNeill
- Nursing Professional Development, Frederick Health Hospital, Frederick, MD.
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Wood J, Tabacof L, Tosto-Mancuso J, McCarthy D, Kontorovich A, Putrino D. Levels of end-tidal carbon dioxide are low despite normal respiratory rate in individuals with long COVID. J Breath Res 2021; 16. [PMID: 34808607 DOI: 10.1088/1752-7163/ac3c18] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/22/2021] [Indexed: 02/01/2023]
Affiliation(s)
- Jamie Wood
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Laura Tabacof
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jenna Tosto-Mancuso
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Dayna McCarthy
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Amy Kontorovich
- Zena and Michael A Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.,The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - David Putrino
- Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Vijayam B, Supriyanto E, Malarvili MB. Digitization and Analysis of Capnography Using Image Processing Technique. Front Digit Health 2021; 3:723204. [PMID: 34778867 PMCID: PMC8585923 DOI: 10.3389/fdgth.2021.723204] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
The study of carbon dioxide expiration is called capnometry. The graphical representation of capnometry is called capnography. There is a growing interest in the usage of capnography as the usage has expanded toward the study of metabolism, circulation, lung perfusion and diffusion, quality of spontaneous respiration, and patency of airways outside of its typical usage in the anesthetic and emergency medicine field. The parameters of the capnograph could be classified as carbon dioxide (CO2) concentration and time points and coordinates, slopes angle, volumetric studies, and functional transformation of wave data. Up to date, there is no gold standard device for the calculation of the capnographic parameters. Capnography digitization using the image processing technique could serve as an option. From the algorithm we developed, eight identical breath waves were tested by four investigators. The values of the parameters chosen showed no significant difference between investigators. Although there were no significant differences between any of the parameters tested, there were a few related parameters that were not calculable. Further testing after refinement of the algorithm could be done. As more capnographic parameters are being derived and rediscovered by clinicians and researchers alike for both lung and non-lung-related diseases, there is a dire need for data analysis and interpretation. Although the proposed algorithm still needs minor refinements and further large-scale testing, we proposed that the digitization of the capnograph via image processing technique could serve as an intellectual option as it is fast, convenient, easy to use, and efficient.
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Affiliation(s)
- Bhuwaneswaran Vijayam
- School of Biomedical Engineering and Health Sciences, Universiti Teknologi Malaysia (UTM), Skudai, Malaysia
| | - Eko Supriyanto
- School of Biomedical Engineering and Health Sciences, Universiti Teknologi Malaysia (UTM), Skudai, Malaysia.,Institut Jantung Negara - Universiti Teknologi Malaysia (IJN-UTM) Cardiovascular Engineering Center, Universiti Teknologi Malaysia (UTM), Skudai, Malaysia
| | - M B Malarvili
- School of Biomedical Engineering and Health Sciences, Universiti Teknologi Malaysia (UTM), Skudai, Malaysia
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Conway A, Jungquist CR, Chang K, Kamboj N, Sutherland J, Mafeld S, Parotto M. Predicting Prolonged Apnea During Nurse-Administered Procedural Sedation: Machine Learning Study. JMIR Perioper Med 2021; 4:e29200. [PMID: 34609322 PMCID: PMC8527383 DOI: 10.2196/29200] [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] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Capnography is commonly used for nurse-administered procedural sedation. Distinguishing between capnography waveform abnormalities that signal the need for clinical intervention for an event and those that do not indicate the need for intervention is essential for the successful implementation of this technology into practice. It is possible that capnography alarm management may be improved by using machine learning to create a "smart alarm" that can alert clinicians to apneic events that are predicted to be prolonged. OBJECTIVE To determine the accuracy of machine learning models for predicting at the 15-second time point if apnea will be prolonged (ie, apnea that persists for >30 seconds). METHODS A secondary analysis of an observational study was conducted. We selected several candidate models to evaluate, including a random forest model, generalized linear model (logistic regression), least absolute shrinkage and selection operator regression, ridge regression, and the XGBoost model. Out-of-sample accuracy of the models was calculated using 10-fold cross-validation. The net benefit decision analytic measure was used to assist with deciding whether using the models in practice would lead to better outcomes on average than using the current default capnography alarm management strategies. The default strategies are the aggressive approach, in which an alarm is triggered after brief periods of apnea (typically 15 seconds) and the conservative approach, in which an alarm is triggered for only prolonged periods of apnea (typically >30 seconds). RESULTS A total of 384 apneic events longer than 15 seconds were observed in 61 of the 102 patients (59.8%) who participated in the observational study. Nearly half of the apneic events (180/384, 46.9%) were prolonged. The random forest model performed the best in terms of discrimination (area under the receiver operating characteristic curve 0.66) and calibration. The net benefit associated with the random forest model exceeded that associated with the aggressive strategy but was lower than that associated with the conservative strategy. CONCLUSIONS Decision curve analysis indicated that using a random forest model would lead to a better outcome for capnography alarm management than using an aggressive strategy in which alarms are triggered after 15 seconds of apnea. The model would not be superior to the conservative strategy in which alarms are only triggered after 30 seconds.
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Affiliation(s)
- Aaron Conway
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada.,School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Carla R Jungquist
- School of Nursing, The University at Buffalo, Buffalo, NY, United States
| | - Kristina Chang
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Navpreet Kamboj
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Joanna Sutherland
- Rural Clinical School, University of New South Wales, Coffs Harbour, Australia
| | - Sebastian Mafeld
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, ON, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Williams E, Dassios T, Greenough A. Carbon dioxide monitoring in the newborn infant. Pediatr Pulmonol 2021; 56:3148-3156. [PMID: 34365738 DOI: 10.1002/ppul.25605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
Carbon dioxide (CO2 ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO2 levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO2 (EtCO2 ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO2 measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO2 can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.
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Affiliation(s)
- Emma Williams
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Pleil JD, Christensen LE. Rationale for developing tunable laser spectroscopy (TLS) technology for high resolution real-time carbon dioxide monitoring ( capnography) in human breath. J Breath Res 2021; 15. [PMID: 34525465 DOI: 10.1088/1752-7163/ac2723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/11/2021] [Accepted: 09/15/2021] [Indexed: 12/18/2022]
Abstract
Real-time monitoring of exhaled carbon dioxide (CO2), also known as capnography, is a valuable hospital tool for assessing patient health during anesthesia and in both the emergency department and critical care units. The fundamental measurement is referred to as end-tidal carbon dioxide concentration that reflects pulmonary gas exchange of CO2representing systemic metabolism. The shape of the exhaled CO2concentration for individual inhalation/exhalation breath cycles can offer additional information regarding lung function, airway obstruction, alveolar ventilation, and worsening disease. The most frequent use is to indicate appropriate placement of an endotracheal tube but and it is also employed in the assessment of disease severity and response to treatment (e.g. asthma). Other applications include outpatient monitoring with oxygen supplementation (nasal cannula) and continuous positive airway pressure control for sleep apnea. As technology has evolved, CO2measurements have become more mobile; capnography systems are now used by emergency medical services personnel for verifying proper placement of airway devices in 'pre-hospital' environments. The use of CO2diagnostics has evolved to identify breathing system disruptions in 'on-demand' regulator/masks equipment, both in medical and occupational settings. Most recently, miniaturized tunable laser spectroscopy sensors have been implemented for assessing pilot breathing in high-performance military aircraft. This editorial describes the use of CO2breath sensors and proposes some new applications based on miniaturized sensors that can be directly inserted into breathing masks.
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Affiliation(s)
- Joachim D Pleil
- Gillings School of Public Health, University of North Carolina, Chapel Hill, NC 27599, United States of America
| | - Lance E Christensen
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA 91109, United States of America
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Russotto V, Cook TM. Capnography use in the critical care setting: why do clinicians fail to implement this safety measure? Br J Anaesth 2021; 127:661-664. [PMID: 34503831 DOI: 10.1016/j.bja.2021.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 12/20/2022] Open
Abstract
Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Project (NAP4) was identification of waveform capnography as the single intervention with the highest potential for reducing morbidity and mortality during tracheal intubation and maintenance of an artificial airway. In the INTUBE study, penetration of capnography into ICUs was low, and was not in use in 70% of the episodes of oesophageal intubation. To reduce harm and avoidable death, there is a need for a global initiative to increase access to and use of capnography in ICUs.
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Affiliation(s)
- Vincenzo Russotto
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.
| | - Tim M Cook
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK; School of Medicine, University of Bristol, Bristol, UK
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de Almeida GC, Pereira MC, Moreira MM, Souza JRM, Paschoal IA. Lung function and stress echocardiography in pulmonary arterial hypertension: a cross-sectional study. SAO PAULO MED J 2021; 139:505-510. [PMID: 34378739 PMCID: PMC9632527 DOI: 10.1590/1516-3180.2021.0045.r1.0604221] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/06/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The mechanism of exercise limitation in idiopathic pulmonary arterial hypertension (IPAH) is not fully understood. The role of hemodynamic alterations is well recognized, but mechanical, ventilatory and gasometric factors may also contribute to reduction of exercise capacity in these individuals. OBJECTIVE To investigate whether there is an association between ventilatory pattern and stress Doppler echocardiography (SDE) variables in IPAH patients. DESIGN AND SETTING Single-center prospective study conducted in a Brazilian university hospital. METHODS We included 14 stable IPAH patients and 14 age and sex-matched controls. Volumetric capnography (VCap), spirometry, six-minute walk test and SDE were performed on both the patients and the control subjects. Arterial blood gases were collected only from the patients. The IPAH patients and control subjects were compared with regard to the abovementioned variables. RESULTS The mean age of the patients was 38.4 years, and 78.6% were women. The patients showed hypocapnia, and in spirometry 42.9% presented forced vital capacity (FVC) below the lower limit of normality. In VCap, IPAH patients had higher respiratory rates (RR) and lower elimination of CO2 in each breath. There was a significant correlation between reduced FVC and the magnitude of increases in tricuspid regurgitation velocity (TRV). In IPAH patients, VCap showed similar tidal volumes and a higher RR, which at least partially explained the hypocapnia. CONCLUSIONS The patients with IPAH showed hypocapnia, probably related to their higher respiratory rate with preserved tidal volumes; FVC was reduced and this reduction was positively correlated with cardiac output.
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Affiliation(s)
| | - Mônica Corso Pereira
- MD, PhD. Professor, Discipline of Pulmonology, Department of Internal Medicine, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Marcos Mello Moreira
- PT, PhD. Physiotherapist, Discipline of Pulmonology, Department of Internal Medicine, and Professor of Postgraduate Program on Surgical Sciences, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas (SP), Brazil.
| | - José Roberto Matos Souza
- MD, PhD. Professor, Discipline of Cardiology, Department of Internal Medicine, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Ilma Aparecida Paschoal
- MD, PhD. Full Professor, Discipline of Pulmonology, Department of Internal Medicine, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas (SP), Brazil.
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Peták F, Balogh ÁL, Hankovszky P, Fodor GH, Tolnai J, Südy R, Kovács BN, Molnár A, Babik B. Dopamine Reverses Lung Function Deterioration After Cardiopulmonary Bypass Without Affecting Gas Exchange. J Cardiothorac Vasc Anesth 2021; 36:1047-1055. [PMID: 34404593 DOI: 10.1053/j.jvca.2021.07.033] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the effects of dopamine on the adverse pulmonary changes after cardiopulmonary bypass. DESIGN A prospective, nonrandomized clinical investigation. SETTING A university hospital. PARTICIPANTS One hundred fifty-seven patients who underwent elective cardiac surgery that required cardiopulmonary bypass. INTERVENTIONS Fifty-two patients were administered intravenous infusion of dopamine (3 µg/kg/min) for five minutes after weaning from cardiopulmonary bypass; no intervention was applied in the other 105 patients. MEASUREMENTS AND MAIN RESULTS Measurements were performed under general anesthesia and mechanical ventilation before cardiopulmonary bypass, after cardiopulmonary bypass, and after the intervention. In each protocol stage, forced oscillatory lung impedance was measured to assess airway and tissue mechanical changes. Mainstream capnography was performed to assess ventilation- and/or perfusion-matching by calculating the normalized phase-3 slopes of the time and volumetric capnograms and the physiologic deadspace. Arterial and central venous blood samples were analyzed to characterize lung oxygenation and intrapulmonary shunt. After cardiopulmonary bypass, dopamineinduced marked improvements in airway resistance and tissue damping, with relatively small decreases in lung tissue elastance. These changes were associated with decreases in the normalized phase-3 slopes of the time and volumetric capnograms. The inotrope had no effect on physiologic deadspace, intrapulmonary shunt, or lung oxygenation. CONCLUSION Dopamine reversed the complex detrimental lung mechanical changes induced by cardiopulmonary bypass and alleviated ventilation heterogeneities without affecting the physiologic deadspace or intrapulmonary shunt. Therefore, dopamine has a potential benefit on the gas exchange abnormalities after weaning from cardiopulmonary bypass.
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Affiliation(s)
- Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Ádám L Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Péter Hankovszky
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - József Tolnai
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Südy
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barbara N Kovács
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Andrea Molnár
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Hotta M, Hirata K, Nozaki M, Mochizuki N, Hirano S, Wada K. Availability of portable capnometers in children with tracheostomy. Pediatr Int 2021; 63:833-837. [PMID: 33078497 DOI: 10.1111/ped.14516] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/01/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND A capnometer is a noninvasive monitor that is used to assess patients' respiratory status. This study was performed to evaluate the availability of a portable capnometer in children with tracheostomy. METHODS This retrospective study included children with tracheostomy who were treated at the Osaka Women's and Children's Hospital Osaka, Japan, from 1 September 2018 to 31 October 2019. We assessed the correlation between the partial pressure of venous carbon dioxide (PvCO2 ) and end-tidal carbon dioxide tension (EtCO2 ) using a portable capnometer (EMMA; Masimo, Irvine, CA, USA). RESULTS Nine infants and 43 simultaneous PvCO2 -EtCO2 pairs were analyzed. The correlation coefficient of these pairs was 0.87 (95% confidence interval, 0.77-0.93; P < 0.001). The Bland-Altman plot showed that EtCO2 was on average 10.0 mmHg lower than its paired PvCO2 value (95% limits of agreement, 1.0-19.1). The difference between PvCO2 and EtCO2 was significantly greater in patients on ventilators. CONCLUSIONS The portable capnometer evaluated in this study (EMMA) was readily available and useful for assessment of the respiratory condition in children with tracheostomy.
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Affiliation(s)
- Masashi Hotta
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Masatoshi Nozaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Pandit JJ. 'No trace, wrong place' does not mean 'positive trace, right place'. Identifying and managing misplaced or displaced tracheal tubes in cardiopulmonary resuscitation. Anaesthesia 2021; 77:16-21. [PMID: 34121176 DOI: 10.1111/anae.15526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 01/19/2023]
Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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Martins IPM, Nakato AM, Hembecker PK, Ioshii SO, Nohama P. Correlation of End-Tidal Carbon Dioxide with Arterial Carbon Dioxide in Mechanically Ventilated Neonates: A Scoping Review. Glob Pediatr Health 2021; 8:2333794X211016790. [PMID: 34036124 PMCID: PMC8132087 DOI: 10.1177/2333794x211016790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/21/2021] [Indexed: 12/03/2022] Open
Abstract
Monitoring CO2 levels in intubated neonates is highly relevant in the face of complications associated with altered CO2 levels. Thus, this review aims to present the scientific evidence in the literature regarding the correlation between arterial carbon dioxide measured by non-invasive methods in newborns submitted to invasive mechanical ventilation. The search was carried out from January 2020 to January 2021, in the Scopus, Medline, The Cochrane Library, Web of Science, CINAHL and Embase databases. Also, a manual search of the references of included studies was performed. The main descriptors used were: "capnography," "premature infant," "blood gas analysis," and "mechanical ventilation." As a result, 221 articles were identified, and 18 were included in this review. A total of 789 newborns were evaluated, with gestational age between 22.8 and 42.2 weeks and birth weight between 332 and 4790 g. Capnometry was the most widely used non-invasive method. In general, the correlation and agreement between the methods evaluated in the studies were strong/high. The birth weight did not influence the results. The gestational age of fewer than 37 weeks implied, in its majority, a moderate correlation and agreement. Therefore, we can conclude that there was a predominance of a strong correlation between arterial blood gases and non-invasive methods, although there are variations found in the literature. Even so, the results were promising and may provide valuable data for future studies, which are necessary to consolidate non-invasive methods as a reliable and viable alternative to arterial blood gasometry.
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Affiliation(s)
| | - Adriane Muller Nakato
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Paula Karina Hembecker
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Sérgio Ossamu Ioshii
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Percy Nohama
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Curitiba, Paraná, Brazil
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Sneyd JR, Cook TM. Waking the dragon: national audit in China and the benefits of having a NAP. Br J Anaesth 2021; 127:2-5. [PMID: 33985790 DOI: 10.1016/j.bja.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- J Robert Sneyd
- Faculty of Medicine and Dentistry, University of Plymouth, Plymouth Science Park, Plymouth, UK.
| | - Tim M Cook
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK; School of Medicine, University of Bristol, Bristol, UK
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Blonder Y, Mazor E, Jew K. Advanced Capnography Sampling Lines May Improve Patient Comfort and Compliance. Med Devices (Auckl) 2021; 14:37-42. [PMID: 33633472 PMCID: PMC7901562 DOI: 10.2147/mder.s292526] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/01/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Capnography monitoring in non-intubated patients requires the use of an end-tidal carbon dioxide (EtCO2) sampling line composed of a nasal or oral/nasal cannula connected to tubing that goes behind the ears to secure it in place. Some patients find wearing sampling lines to be uncomfortable, which can lead to compliance issues with monitoring. To address this important issue, we developed advanced sampling lines, designed to ameliorate the primary factors impacting patient tolerance. Patients and Methods A clinical evaluation was conducted to assess patient comfort level and wearing experience with the advanced sampling lines compared to the original sampling lines. Subjects were asked to wear the predicate line and the advanced line for 72 hours each, with individual testing periods separated by at least 48hrs. Subjects were asked to complete questionnaires assessing comfort and smell of the sampling lines at designated intervals throughout the trial process. In addition, a clinician assessed subjects’ skin during and after wearing each sampling line to determine if any skin irritation and disruption was evident. Results Repeated measures analysis demonstrated improved patient comfort with the advanced sampling line compared to the original line over the course of the wearing period (p<0.05). Additionally, scores indicate that the smell of the advanced lines was perceived as less noticeable than the original line over time. No incidents of skin redness or irritation were reported for either sampling line. Conclusion The enhancements to the newly designed sampling lines improve the user experience, related to both line comfort and smell, which may increase patient compliance with monitoring. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/xAug_BpU6oM
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Affiliation(s)
| | - Eytan Mazor
- Research & Development, Medtronic, Inc., Jerusalem, Israel
| | - Korinne Jew
- Clinical Research and Medical Science, Medtronic, Boulder, CO, USA
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Abstract
Mechanical ventilation is an indispensable form of life support for patients undergoing general anesthesia or experiencing respiratory failure in the setting of critical illness. These patients are at risk for a number of complications related to both their underlying disease states and the mechanical ventilation itself. Intensive monitoring is required to identify early signs of clinical worsening and to minimize the risk of iatrogenic harm. Pulse oximetry and capnography are used to ensure that appropriate oxygenation and ventilation are achieved and maintained. Assessments of driving pressure, transpulmonary pressure, and the pressure-volume loop are performed to ensure that adequate PEEP is applied and excess distending pressure is minimized. Finally, monitoring and frequent adjustment of airway cuff pressures is performed to minimize the risk of airway injury and ventilator-associated pneumonia. We will discuss monitoring during mechanical ventilation with a focus on the accuracy, ease of use, and effectiveness in preventing harm for each of these monitoring modalities.
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Affiliation(s)
- Craig R Rackley
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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Abstract
Transport of critically ill patients within and between hospitals is a common undertaking in an effort to improve patient outcomes. Intrahospital transports are frequently conducted to aid in diagnosis through advanced imaging techniques or to allow image-guided procedures. Interhospital transport is most frequently conducted to bring patients to specialized care, including centers of excellence for cardiac, trauma, transplant, and respiratory failure. Transport outside the hospital can be accomplished by ground or air, the latter including fixed-wing and rotor-wing aircraft. Often overlooked, transport of patients from the scene of an accident or illness to the hospital by emergency medical services is less sophisticated but more common than the other methods combined. Patients are also routinely transported to and from the operating room, a form of transport not commonly studied. Risks are inherent to transport, and an analysis of risks and benefits must be part of any risk-mitigation strategy. Monitoring the patient during transport by attendants and equipment is a key component of risk mitigation. Quicker transport times and specialized transport teams are associated with improved outcomes, whereas severity of illness is a harbinger of untoward complications. The type of monitoring during transport varies widely with the environment, the skill of the attendants, and the severity of patient illness. Standards for patient monitoring during transport are available, but they are predominantly based on expert opinion. This paper reviews guidelines and the risks of transport as a template for required monitoring, and it discusses common mishaps associated with transport and how these can be avoided with appropriate monitoring.
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Affiliation(s)
- Richard D Branson
- Division of Trauma/Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Dario Rodriquez
- Warfighter Medical Optimization Division, Airman Systems Directorate, 711th Human Performance Wing, Wright-Patterson Air Force Base, Ohio
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Abstract
Critical illness can threaten the adequacy of O2 delivery or CO2 excretion. Monitoring seeks to identify the adequacy of oxygenation and ventilation and to detect deterioration early. Advances in oximetry, capnography, and transcutaneous CO2 monitoring offer new opportunities for more accurate estimation of gas exchange, noninvasive monitoring of parameters previously not amenable (eg, total hemoglobin measurement), detection of disease, and prediction of fluid responsiveness.
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Affiliation(s)
- Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, Iowa.
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Südy R, Peták F, Kiss L, Balogh ÁL, Fodor GH, Korsós A, Schranc Á, Babik B. Obesity and diabetes: similar respiratory mechanical but different gas exchange defects. Am J Physiol Lung Cell Mol Physiol 2020; 320:L368-L376. [PMID: 33264577 DOI: 10.1152/ajplung.00439.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Diabetes mellitus increases smooth muscle tone and causes tissue remodeling, affecting elastin and collagen. Although the lung is dominated by these elements, diabetes is expected to modify the airway function and respiratory tissue mechanics. Therefore, we characterized the respiratory function in patients with diabetes with and without associated obesity. Mechanically ventilated patients with normal body shapes were divided into the control nondiabetic (n = 73) and diabetic (n = 31) groups. The other two groups included obese patients without diabetes (n = 43) or with diabetes (n = 30). The mechanical properties of the respiratory system were determined by forced oscillation technique. Airway resistance (Raw), tissue damping (G), and tissue elastance (H) were assessed by forced oscillation. Capnography was applied to determine phase 3 slopes and dead space indices. The intrapulmonary shunt fraction (Qs/Qt) and the lung oxygenation index (PaO2/FIO2) were estimated from arterial and central venous blood samples. Compared with the corresponding control groups, diabetes alone increased the Raw (7.6 ± 6 cmH2O.s/l vs. 3.1 ± 1.9 cmH2O.s/l), G (11.7 ± 5.5 cmH2O/l vs. 6.5 ± 2.8 cmH2O/l), and H (31.5 ± 11.8 cmH2O/l vs. 24.2 ± 7.2 cmH2O/l (P < 0.001 for all). Diabetes increased the capnographic phase 3 slope, whereas PaO2/FIO2 or Qs/Qt was not affected. Obesity alone caused similar detrimental changes in respiratory mechanics and alveolar heterogeneity, but these alterations also compromised gas exchange. We conclude that diabetes-induced intrinsic mechanical abnormalities are counterbalanced by hypoxic pulmonary vasoconstriction, which maintained intrapulmonary shunt fraction and oxygenation ability of the lungs.
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Affiliation(s)
- Roberta Südy
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary.,Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Liliána Kiss
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary.,Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ádám L Balogh
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary.,Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Anita Korsós
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Álmos Schranc
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Overdevest E, van den Heuvel E, van Hoeven M. A retrospective analysis of CO 2 derived goal-directed perfusion variables under normothermic conditions: do we need to re-evaluate threshold values? Perfusion 2020; 36:853-860. [PMID: 33203311 DOI: 10.1177/0267659120972994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study investigated if current predictive values for increased lactate formation: VCO2i > 60 ml min-1 m-2, respiratory quotient (RQ) > 0.90, and DO2/VCO2 < 5.0, are valid under normothermic conditions. CO2 derived parameters were analyzed in 91 patients undergoing normothermic CABG and related to increase of blood lactate concentrations during bypass. In this study population, 85 patients (93%) had a median VCO2i above 60 ml min-1 m-2 and 53 patients (58%) had a DO2/VCO2 ⩽ 5.0. Eighteen patients (20%) had a median RQ ⩾ 0.90, but RQ remained with a maximum value of 0.94 below the biological threshold of 1.0. Increase of lactate concentrations remained without clinical significance and showed weak correlations with VCO2i (rs = 0.277, p = 0.008) and RQ (rs = 0.346, p = 0.001).The cohort was separated for the different CO2 variables by their median value to compare increase in lactate concentration. Patients with a high VCO2i (⩾70 ml min-1 m-2) and a high RQ (⩾0.82) showed significant higher increase in lactate concentration compared to patients with VCO2i < 70 ml min-1 m-2 (p = 0.004), and a RQ < 0.82 (p = 0.012). Groups separated by a median DO2/VCO2 of 4.8 did not show a difference in increase of lactate concentration in blood. In summary, specific CO2 derived threshold values for the prediction of lactate formation, which have been reported in other studies, cannot be confirmed with our findings. However, a CO2 production ⩾70 ml min-1 m-2 and a RQ ⩾ 0.82 in this study population were correlated with increased lactate formation. Because CO2 production during bypass depends on patient temperature, a different cutoff value, that may take into account the influence of demographic variables, should be determined during normothermic CPB.
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Affiliation(s)
- Eddy Overdevest
- Department of Extracorporeal Circulation, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Marloes van Hoeven
- Department of Extracorporeal Circulation, Catharina Hospital, Eindhoven, The Netherlands
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