Capnography for all: A call to action
Myron Yaster MD and Lynne G. Maxwell MD
I’ve got to admit that I was a bit surprised that at the recent annual meeting of the Society for Pediatric Anesthesia, Sumit Das, MBBS, BSc, FRCA, the honorary secretary of the Association of Paediatric Anaesthetists of Great Britain and Ireland, presented a lecture on preventing undetected esophageal intubation. I naively thought that this was a problem solved a long time ago. I was wrong. The underlying premise of the lecture (and references) was that undetected esophageal intubations remain common particularly after multiple failed intubation attempts and a failure to have, use, and/or interpret capnography. Clinical signs of proper tube placement like presence of breath sounds or misting of the tube which are commonly used are simply unreliable. Three of his recommendations included: “exhaled carbon dioxide monitoring and pulse oximetry should be available and used for ALL episodes of airway management”, “the airway operator and assistant should each verbalize whether ‘sustained carbon dioxide’ and adequate oxygen saturation are present,” and “correct interpretation of waveform capnography is the primary tool of for detecting esophageal intubation: No trace=wrong place.”
These recommendations are valid not only for the operating room but wherever intubations occur including emergency departments and all ICUs (including the NICU). I’ve got to admit that I was always dumbfounded that capnography was not universal outside of the operating room. Is this still the case? A study published in 2018 by the NEAR4KIDS intubation registry (National Emergency Airway Registry for Children)1, a collaborative of peds ED and PICU examined trends in the use of ETCO2 by waveform capnography or colorimetry for emergency intubation in EDs (9) and PICUs (34) from January 2011 to December 2015. Over that time period, capnography use increased in ED's (20 - 70%) while increasing only slightly in PICU's (40-50%). The rate of delayed recognition of esophageal intubation was similar with both methods. I suspect that these numbers have not changed much and I think a great project for SPA’s Pediatric Intensive Care special interest group or our Society’s airway experts would be to study this (hint hint)!
The November issue of Anesthesia and Analgesia is focused on capnography and the attempts of several organizations including the World Health Organization, the Royal College of Anaesthetists and the Difficult Airway Society,2,3 the World Federation of Societies of Anaesthesiologists4,5 and others to make the availability and use of capnography and pulse oximetry a universal standard worldwide. Although capnography is a key element of monitoring deemed essential by the ASA, universally employed in operating rooms and other settings where anesthesia is administered in high income countries (HICs), the availability of, and familiarity with, capnography in low and middle income countries (LMICs) remains problematic. Enter Dr. Faye Evans and the Smile Train-Lifebox Capnography project.6
As I’ve previously pleaded, before reading today’s PAAD or upon completing your read, please, please, please consider making a donation to the non-profit LIFEBOX (www.lifebox.org) which is dedicated to making surgery and anesthesia safer through tools, training, and partnerships throughout the world. Several years ago, the Society for Pediatric Anesthesia and the Pediatric Anesthesia Program Directors Association raised thousands of dollars in this effort. Let’s do it again! A pulse oximeter (plus training) costs $250. The Smile Train-Lifebox capnograph (a dual parameter pulse oximeter capnography) costs (plus training) $1,000. I will start the ball rolling again and donate another $250 today. Myron Yaster MD
Editorial
O'Sullivan EP, Nabukenya MT, Newton M. Global Capnography to Improve Safety for All Patients: Time for Urgent Action. Anesth Analg. 2023 Nov 1;137(5):917-920. doi: 10.1213/ANE.0000000000006735. Epub 2023 Oct 20. PMID: 37862388
Original article
Evans, F. , Turc, R. , Echeto-Cerrato, M. , Gathuya, Z. & Enright, A. (2023). The Capnography Project. Anesthesia & Analgesia, 137 (5), 922-928. doi: 10.1213/ANE.0000000000006663.
“Evans et al.6 described the detailed process undertaken to source a robust, context-appropriate, combined capnography and oximetry unit by ZUG Medical Systems (www. https://www.zugmed.com/). In addition to sourcing an appropriate technical solution, the importance of an effective and appropriate educational package is emphasized. This educational package was developed by an experienced global team, trialed in a low-resource setting, and subsequently revised. In the same issue, McDougall et al.7 focused on the barriers, strategies, and proposed solutions to an implementation plan to scale distribution of these combined devices where they are most needed, the thousands of low and middle income (LMIC) operating rooms. They suggested a Coalition for Capnography (CFC) consisting of partners who have acquired expertise from the Global Oximetry (GO) project. These partners need to have expertise in procurement, education, and advocacy if global capnography access and implementation is to be a reality. This paper suggests the likely lead partners as Lifebox, WFSA, and Smile Train, alongside additional collaborating partners including governments, academic institutions, and industry.”8
“Lifebox (www.lifebox.org) is a nonprofit organization, cofounded by Atul Gawande and leaders in global anesthesia in 2011, that works to improve the safety of surgery and anesthesia globally. Smile Train, with its network of over 1100 partner hospitals around the world, empowers local medical professionals with training, funding, and resources to provide free cleft surgery and comprehensive cleft care to children. Both organizations have a commitment to programmatic and technical innovation to improve safety in anesthesia and surgery. The Smile Train-Lifebox Safe Surgery and Anesthesia Initiative was launched in 2020 as a multiyear program aimed at elevating the quality and safety of cleft and pediatric surgery.”6
Unlike pulse oximetry, widespread availability of capnography has been limited by “size, cost (device, maintenance, and supply of consumables), fragility of the devices, and lack of mobility.”7 Now that many of these issues are resolved, widespread adoption will require “fundraising, procurement, distribution, advocacy, and education.”7 We believe that this is where you, our readers come in. The PAAD has almost 4,200 daily readers in 92 countries. This vast network can make a very real difference! We implore all of you to talk to your colleagues, partners, department and divisional leaders, students and surgeons to step up and contribute to Lifebox. As the sage said “If not us, who, if not now, when?”
If you’ve been successful in raising money for this project, let us know how you did it so that our readers can learn from your experience. Additionally, please send your thoughts about the capnography project, esophageal intubations, or Lifebox to Myron who will post in a Friday reader response.
References
1. Langhan ML, Emerson BL, Nett S, Pinto M, Harwayne-Gidansky I, Rehder KJ, Krawiec C, Meyer K, Giuliano JS, Jr., Owen EB, Tarquinio KM, Sanders RC, Jr., Shepherd M, Bysani GK, Shenoi AN, Napolitano N, Gangadharan S, Parsons SJ, Simon DW, Nadkarni VM, Nishisaki A: End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry. Pediatr Crit Care Med 2018; 19: 98-105
2. Cook TM, Woodall N, Frerk C: Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011; 106: 617-31
3. Cook TM, Woodall N, Harper J, Benger J: Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106: 632-42
4. Gelb AW, Morriss WW, Johnson W, Merry AF, Abayadeera A, Belîi N, Brull SJ, Chibana A, Evans F, Goddia C, Haylock-Loor C, Khan F, Leal S, Lin N, Merchant R, Newton MW, Rowles JS, Sanusi A, Wilson I, Velazquez Berumen A: World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg 2018; 126: 2047-2055
5. Gelb AW, McDougall RJ, Gore-Booth J, Mainland PA: The World Federation of Societies of Anaesthesiologists Minimum Capnometer Specifications 2021-A Guide for Health Care Decision Makers. Anesth Analg 2021; 133: 1132-1137
6. Evans FM, Turc R, Echeto-Cerrato MA, Gathuya ZN, Enright A: The Capnography Project. Anesth Analg 2023; 137: 922-928
7. McDougall RJ, Morriss WW, Desai PK, Batgombo N: Getting Capnography to the Front Lines. Anesth Analg 2023; 137: 929-933
8. O'Sullivan EP, Nabukenya MT, Newton M: Global Capnography to Improve Safety for All Patients: Time for Urgent Action. Anesth Analg 2023; 137: 917-920