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Prehospital capnography or capnometry: are we going in the right direction?

04 November 2011
Features
02 November 2011
Volume 3 · Issue 11

Abstract

End tidal carbon dioxide (etCO2) measurements enable accurate monitoring of airway patency, ventilation (self or assisted) and metabolism. It is mandatory in current in-hospital anaesthetic practice and now recommended in the prehospital setting. Traditional methods of capnography have used either mainstream or sidestream devices, but both are not without their disadvantages, which may be potentiated in the prehospital environment. Portable devices either display a waveform (capnography) or a numerical reading alone (capnometry). Waveform capnography is often the preferred mode of CO2 detection in prehospital practice (mirroring experiences from in-hospital), however, there is no published evidence comparing the superiority of either method. The most recent advancement in prehospital capnometry is the introduction of a compact, light-weight, battery powered, self-contained mainstream capnometer. This device has been shown to be accurate when compared with anaesthetic equipment and appears to meet all the qualities required for inclusion as a tool for the improved care of the prehospital patient. It displays only a numerical reading as opposed to some new defibrillators used by certain ambulance services which include waveform capnography. The authors feel this difference would have very little detrimental effect on patient management out-of-hospital. This, coupled with the advantages gained by greater access to etCO2 monitoring, related to both cost and training, considerations have enabled the conclusion that this type of mainstream capnometer should be considered more often for prehospital care.

In 2008, the Joint Royal Collages Ambulance Liaison Committee (JRCALC) airway working group concluded that:

‘Tracheal intubation without the use of drugs has little value in prehospital practice’

This has led to much discussion both for and against paramedic intubation. Contributing factors informing their decision included: inadequate training and skill fade of paramedics with endotracheal tubes (ETTs); insufficient evidence supporting intubation; improving patient outcome; and increasing development, availability and ease of use of supraglottic airway devices (SADs).

Intubation should not be forgotten in prehospital practice as SADs become increasingly favoured. Medical personnel, other than paramedics and paramedics with extended roles, are increasingly attending incidents out-of-hospital to provide their expertise in airway management and resuscitation techniques. This complies with the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) trauma report that recommended:

‘The prehospital response for these patients should include someone with the skill to secure the airway (including the use of rapid sequence intubation), and maintain adequate ventilation’

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Capnography
End tidal
Prehospital
Portable