Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Comment on Capnography Use Saves Lives AND Money – Part III

On Capnography Use Saves Lives AND Money – Part III, there is a comment by Christopher of My Variables Only Have 6 Letters.

I’m of the mindset that if you don’t have access to Continuous Waveform Capnography you have no business intubating patients…even dead ones. Some folks may say that they need to intubate to protect some class of patients even if they don’t have capnography. This is weak.

It isn’t just weak, intubating without waveform capnography is completely wrong.

In Cardiac arrest patients? They’re dead. Drop a King and forget about it. Research shows you shouldn’t waste any time with a tube. Wake County NC has amazing numbers: King first.

On the other hand, there is no research to show any benefit from the early use of any kind of airway.

Unfortunately, the AHA (American Heart Association) biases the outcome of its guideline reviews by applying the assumption that withholding an unproven traditional treatment is an intervention. Therefore this new intervention must have clear evidence that it is better than the unproven traditional standard of care.

This Orwellian redefinition only encourages more errors of judgment.

More treatment, in spite of a lack of evidence of any benefit, is considered better than less treatment.

In the absence of evidence of benefit, we should only be treating patients in controlled trials.

Epinephrine is the standard of care/gold standard.

After over 3 decades, there is still no evidence of improved survival to discharge.

Amiodarone is the standard of care/gold standard.

After a decade, there is still no evidence of improved survival to discharge.

Lidocaine is the standard of care/gold standard (when amiodarone is not available).

After 3 decades, there is still no evidence of improved survival to discharge.

Ventilation is the standard of care/gold standard for professional rescuers.

After over a century, there is still no evidence of improved survival to discharge.

Why let reality get in the way of pushing this alternative medicine nonsense?

What class of patient is left? Probably those you’d need RSI for anyway. This is the patient where it is borderline negligent to NOT obtain waveform capnography on. These patients aren’t dead yet, they need to have a patent airway. If you can’t prove you placed the tube, you shouldn’t place it.

Not using waveform capnography is not borderline negligence.

Not using waveform capnography is clear evidence of negligence.

The AHA is too timid with their criticism of the refusal to use waveform capnography.

In retrospective studies, endotracheal intubation has been associated with a 6% to 25% incidence of unrecognized tube misplacement or displacement.68–72 This may reflect inadequate initial training or lack of experience on the part of the provider who performed intubation, or it may have resulted from displacement of a correctly positioned tube when the patient was moved. The risk of tube misplacement, displacement, or obstruction is high,67,70 especially when the patient is moved.73 Thus, even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventilation, providers should obtain additional confirmation of placement using waveform capnography or an exhaled CO2 or esophageal detector device (EDD).74[1]

The risk of tube misplacement, displacement, or obstruction is high,67,70 especially when the patient is moved.73

Why should that be a reason to demand that we treat patients appropriately?

Better to focus on requiring treatments that do not appear to work – epinephrine, lidocaine, amiodarone, ventilation in the initial part of cardiac arrest.

even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventilation, providers should obtain additional confirmation of placement using waveform capnography or an exhaled CO2 or esophageal detector device (EDD).74

Should?

That’s it?

There are still plenty of incompetents out there stating that chest rise is the gold standard for tube confirmation.

There are still plenty of incompetents out there stating that seeing the tube go through the cords is the gold standard for tube confirmation.

The risk of tube misplacement, displacement, or obstruction is high,67,70 especially when the patient is moved.73

Seeing the tube go through the cords is a bad form of initial confirmation of tube placement, but it is completely useless at all times after the laryngoscope is removed from the patient’s mouth.

Relying on seeing the tube go through the cords is something that needs to be aggressively condemned.

The provider should use both clinical assessment and confirmation devices to verify tube placement immediately after insertion and again when the patient is moved. However, no single confirmation technique is completely reliable.75,76 Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A).[1]

Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A).

We could use the most reliable method of confirming and monitoring correct placement of an endotracheal tube, but we don’t.

Too many of us do not. We use the extremely unreliable method of seeing the tube go through the cords.

What do paramedic schools teach medic students to say when intubating?

I see the tube go through the cords.

If a student does not say this, but place the tube properly, the student fails.

If a student does say this, but places the tube in the esophagus, it is not any worse than if they did not say this and placed the tube in the esophagus.

We are training paramedic students to say, I see the tube go through the cords, when they place the tube in the esophagus.

Should we be surprised at 6% to 25% incidence of unrecognized tube misplacement or displacement?

Of course not.

This is what we are training paramedic students to do.

We are just too stupid to understand what we are doing.

Exhaled CO2 Detectors. Detection of exhaled CO2 is one of several independent methods of confirming endotracheal tube position. Studies of waveform capnography to verify endotracheal tube position in victims of cardiac arrest have shown 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement.72,77,81–88 Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A).[1]

Still waveform capnography is only recommended.

Given the simplicity of colorimetric and nonwaveform exhaled CO2 detectors, these methods can be used in addition to clinical assessment as the initial method for confirming correct tube placement in a patient in cardiac arrest when waveform capnography is not available (Class IIa, LOE B). However, studies of colorimetric exhaled CO2 detectors89–94 and nonwaveform PETCO2 capnometers77,89,90,95 indicate that the accuracy of these devices does not exceed that of auscultation and direct visualization for confirming the tracheal position of an endotracheal tube in victims of cardiac arrest.[1]

The color change devices and the handheld CO2 detectors are not any better than auscultation and direct visualization, but they a definitely not as good as waveform capnography.

Should we take the endotracheal tubes away from everyone who does not use waveform capnography?

Yes.

Should we take the endotracheal tubes away from paramedics who do not use waveform capnography?

Yes.

Should we take the endotracheal tubes away from doctors who do not use waveform capnography?

Yes.

Footnotes:

[1] Endotracheal Intubation
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.1: Adjuncts for Airway Control and Ventilation
Advanced Airways
Free Full Text Article with links to Free Full Text PDF download

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Comments

  1. On the other hand, there is no research to show any benefit from the early use of any kind of airway.

    My recommendation was more, “if you are going to manage the airway, use a King.” Takes about as long as an OPA to place, and everybody on the truck can place it.

    Could the AHA be waffling on their recommendations for ETCO2 because, like many hospital based providers, they don’t completely understand ETCO2? I was fairly dumbfounded when I learned nobody in the hospital has their ETCO2 monitored when on ventilators…they puncture an artery at fixed intervals. Yeeesh.

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