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People Are Not Using EtCO2 for ETT Confirmation?

March 22, 2018

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This study showed 7% of doctors intubating children were not using any form of EtCO2 detection to confirm placement: waveform capnography or colorimetric.  This is appalling.  The point of the article was to encourage use of capnography, but a more important message is you must use some form of EtCO2 detection.

Why does this matter?
Detection of end-tidal CO2 after intubation is the best method to determine if the ETT is in place.  Especially in children, auscultation, mist in the tube, and “seeing it go through the cords” can all be deceiving.  EtCO2 colorimetry is good, but EtCO2 capnography (waveform) is even better.  The AHA recommends waveform if available. This study looks at capnography trends.

People are not using waveform or colorimetric EtCO2 after intubation?
This was a large registry of 34 ICUs and EDs in the US.  Only 5% of the 9639 patients were from the ED.  Use of capnographic EtCO2 increased during the study period, and colorimetric EtCO2 decreased.  Use of capnography did not seem to statistically aid in detection of delayed esophageal intubation any better than colorimetry.  That said, all three cases of delayed recognition of esophageal intubation leading to cardiac arrest used colorimetry (gastric CO2 and gastric acid can cause false reassurance with colorimetry).  The most surprising statistic is that 7% (677/9639) still don’t use either one.  How can this be?  Have these docs been living under a rock?  Anyway, the point of the study is that using waveform capnography is increasing, is a best practice, and should be used in preference over colorimetry.  Personally, I use both.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry.  Pediatr Crit Care Med. 2018 Feb;19(2):98-105. doi: 10.1097/PCC.0000000000001372.

Peer reviewed by Thomas Davis, MD.

What are your thoughts?