Waveform capnography

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iridesingltrack

iridesingltrack

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Are any of you using continuous waveform capnography on a regular basis?

Are you using it on every intubated patient?

Codes only?

TBI only?

Another specific population?

I am interested because at my shop it is very provider specific. Some really like it, some don't care about it.

What do you think?

iride
 
every intubated patient
we also have capability to use it in conjuction with nasal cannulas. We use it in those cases on mixed drug overdose patients who are lethargic or worse. much earlier detection of poor ventilation than SpO2 monitoring.

On coding patients it's very cool though to see an initial ETCO2 of 15 jump to 30 within moments of ROSC. don't even have to wait for the pulse check to realize they're perfusing again.
 
The way I look at it, you intubate generally for two purposes, oxygenation and ventilation. We don't do serial ABG's anymore, we do pulse oximetry. that measures oxygenation and you make adjustments to vent settings based on that. If you want to adjust ventilation, why do serial VBG's, when you can just look up at the monitor and check the continuous capnography. None of this "get an ABG/VBG and readjust".
 
Drug OD (esp narcotics / long acting narcs), intubated patients, resp distress patients (those not yet bad enough for BiPAP but don't know which direction they are going to go, and procedural sedations. I will ask for it in other pts that I just worry about for one reason or another. I probably use it more than some, but when I do, my attendings seem to like that it's on them.

Anyone know the cost of monitoring?
 
I imagine the cost over time would be significantly less than using ABG/VBGs as Rendar mentioned although that's not a direct comparison, apples to oranges so to speak. Since the capnogaphy doesn't replace the blood gasses that would blunt the savings a bit.

EMS loves it because it's a good way to verify tubes and bad tubes is a prominent problem in EMS. In the ED we don't have that problem. That sounds arrogant but I haven't heard about an unrecognized esophageal tube in my shops in years.

That said I think we should have the capability. We can't do capnography, invasive monitoring like swans or even CVP all for political reasons.
 
EVERY intubated patient. EVERY one.

And every procedural sedation (nasal cannula).

And many lethargic patients/ODs/intox who are likely to be hypoventilating or many soon hypoventilate.

-----------

Cost? Not sure, but it is likely to be a miniscule amount compared to the overall costs of an intubated patient (vent, VAP, ICU stay, etc)...not to mention the costs of an unnoticed misplaced tube or dislocated tube.


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Given that anesthesia is required to use ETCO2 for every intubated patient and procedural sedation -- and they're daily job is to monitor ventilation -- don't you think we should be doing it also?

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Regarding the use of ETCO2 for not getting ABGs: Yes, I think it helps to get fewer ABGs, but at least one needs to be obtained after intubation and the patient has had time to setttle out on the vent. Just because the ETCO2 says 30, doesn't mean the paCO2 is 30...it just means that it is at least 30. This is especially true for BiPAP and procedural sedation monitoring.

HH




HH
 
Hamhock said:
EVERY intubated patient. EVERY one.

And every procedural sedation (nasal cannula).

And many lethargic patients/ODs/intox who are likely to be hypoventilating or many soon hypoventilate.

-----------

Cost? Not sure, but it is likely to be a miniscule amount compared to the overall costs of an intubated patient (vent, VAP, ICU stay, etc)...not to mention the costs of an unnoticed misplaced tube or dislocated tube.


----------


Given that anesthesia is required to use ETCO2 for every intubated patient and procedural sedation -- and they're daily job is to monitor ventilation -- don't you think we should be doing it also?

----------

Regarding the use of ETCO2 for not getting ABGs: Yes, I think it helps to get fewer ABGs, but at least one needs to be obtained after intubation and the patient has had time to setttle out on the vent. Just because the ETCO2 says 30, doesn't mean the paCO2 is 30...it just means that it is at least 30. This is especially true for BiPAP and procedural sedation monitoring.

HH




HH
Click to expand...

This is definitely in line with my way of the thinking.

I have no idea what the costs associated are. I am sure there is the set up cost (having a compatible monitor, the lens, and cable) but it sure can be nice to have.

As for the number matching the pCO2...it depends on the patients lungs and cardiac output, as I understand it. If they have pulmonary disease it seems all bets are off, low cardiac output is lower than expected, but if they are normal lungs without pathology, and normal CO then it should be pretty close (example, isolated head injury).

Given the somewhat (predictable?) unreliability of the number I have not used it to replace my ABG/VBG. Do any of you that use it, get an ABG/VBG then correlate it to the number and assume a consistent difference?

I am plus/minus for use for immediate tube verification (presumably in place of colormetric CO2 detector) but with continuous monitoring it is nice to know breath-by-breath if your tube is dislodged when moving the pt from the stretcher to the CT scanner.

Overall, I feel it is a useful tool.

iride
 
If only we could do it here.
Although from my perusing the literature, it is useful in code situations/intubations, but the data for sedation just isn't there. Yes, you may recognize hypoventilation faster, but there were no adverse outcomes for the pulse ox group either. If it were quick, and convenient, I might use it for that purpose, but in residency there was only one portable etCO2 machine, and waiting to give that dose of propofol on the machine being used in another room was a pain.
 
We have recently started using it for procedural sedations...otherwise never.
 
We have compatible monitors in every room in the ED, so it is simple.

In reference to lung disease: I use it as a trend. If they are 45-50 to start before I do anything (prior to sedation / intubation / observation), I try to keep them in that range. Heavier smokers tend to run in that range, so I watch their breathing with the monitor for a few minutes while I examine them. If the numbers are consistent with good wave form, that is the goal I discuss with nurses so they can notify me if the pt drops or increases from there.
 
We do waveform capnography on every patient that gets conscious sedation (Nasal cannula) and continuous monitoring on ALL intubated patients in the hospital. I am at a community/academic hospital on the south side of Chicago, we are not rich so i doubt its horribly expensive, but don't know off the top of my head. We did just upgrade ALL ED monitors 2 years ago.

You mention not using it immediately for tube confirmation, and I somewhat disagree. In your cardiac arrest patients sometimes the CO will be so poor that there will be no color change on your colorimetric device, but a WAVEFORM capnography WILL ALWAYS have a waveform if it is not in the esophagus even if the CO is minimal (it may have a reading of like 3-4, but a waveform will be there.) in the goose it will be flatline.

As for use for continuous monitoring ETCO2 SHOULD IN THEORY correlate with your CO2 on an ABG or VBG. This is not always the case, (i.e.; dead space ventilation). You should therefore get a gas on all intubated patients (doesn't have to be arterial) if your VBG says the CO2 is 75, and your ETCO2 is reading 45, this is information you should know.

There are two advantages of non-invasive ETCO2 monitoring you are missing when you say it lets you identify desaturation faster, but no one has bad outcomes. First off if you plan on supplementing O2 you will identify the desaturation MUCH faster. This has little clinical significance in you or I or most procedural sedations for that matter (hypercarbia is tolerated extremely well), but in your ASA 3-4s, inadequate ventilation for a short period of time with increasing acidosis is not tolerated well and can be irritating to the myocardium resulting in dysrhythmia. I have been called to codes in the GI lab multiple times for VIFB/VTACH from over sedation with fentanyl/versed and resultant apnea.

Just my opinion
 
every intubated patient

every procedural sedation - yes - I'd like to know if apnea is occurring. We use nasal cannula capnograph.

intermittently with cardiac arrest - in conjunction with cardiac US, pulse checks, and telemetry wave.
 
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