UNASSIGNED: Different sedo-analgesia and monitoring methods are used during endoscopic procedures. And yet, there is no consensus on optimal sedating agents. In this study, the main aim is to compare ketamine-propofol and remifentanil propofol sedo-analgesia protocols by monitoring integrated pulmonary index (IPI).
UNASSIGNED: The study population is divided into two groups: Group ketamine received 0.25 mg/kg ketamine and 0.75 mg/kg propofol at the beginning of anesthesia. 1 mcg/kg of remifentanil and 0.75 mg/kg propofol were administered to group remifentanil patients at the induction of anesthesia. Anesthesia maintenance was provided by titration of drug doses according to the Ramsey sedation scale. Measurements were taken at four different points in time: just before anesthesia was induced, five minutes after sedation was induced, ten minutes later, and five minutes after the treatment was finished.
UNASSIGNED: There was no significant difference in respiratory parameters such as respiratory rate, SPO2, and EtCO2 measured in the T1 time period between the groups. In the T2 time period, a significant difference was found between the groups in the integrated pulmonary index (IPI), sPO2, respiratory rate, and systolic pressure parameters were found to be significantly higher in group ketamine. T3 time period results were higher in these three parameters: IPI, sPO2, and respiration rate. In the T2, T3, T4 time periods, there was a difference between the groups in the respiration count parameter and it was found to be higher in group ketamine.
UNASSIGNED: Although it causes slight prolongation in recovery, ketamine is a safe and effective drug that can be used during endoscopic procedures.

Head and neck trauma can result in difficult airway management. A 25-year-old male required emergency tracheal intubation on arrival to the emergency department following a motorbike accident. Despite the presence of a normal capnography a computed tomography scan demonstrated a tracheal opening, an extra-tracheal position of the distal end of the tracheal tube, and extensive subcutaneous emphysema. The tube was re-directed into the trachea and the tracheal injury was surgically repaired. This case highlights that the presence of a normal capnograph does not necessarily mean that the distal end of the tracheal tube resides within the airway.

UNASSIGNED: While widely measured, the time-varying association between exhaled end-tidal carbon dioxide (EtCO2) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear.
UNASSIGNED: To evaluate temporal associations between EtCO2 and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART).
UNASSIGNED: This study was a secondary analysis of a cluster randomized trial performed at multicenter emergency medical services agencies from the Resuscitation Outcomes Consortium. PART enrolled 3004 adults (aged ≥18 years) with nontraumatic OHCA from December 1, 2015, to November 4, 2017. EtCO2 was available in 1172 cases for this analysis performed in June 2023.
UNASSIGNED: PART evaluated the effect of laryngeal tube vs endotracheal intubation on 72-hour survival. Emergency medical services agencies collected continuous EtCO2 recordings using standard monitors, and this secondary analysis identified maximal EtCO2 values per ventilation and determined mean EtCO2 in 1-minute epochs using previously validated automated signal processing. All advanced airway cases with greater than 50% interpretable EtCO2 signal were included, and the slope of EtCO2 change over resuscitation was calculated.
UNASSIGNED: The primary outcome was ROSC determined by prehospital or emergency department palpable pulses. EtCO2 values were compared at discrete time points using Mann-Whitney test, and temporal trends in EtCO2 were compared using Cochran-Armitage test of trend. Multivariable logistic regression was performed, adjusting for Utstein criteria and EtCO2 slope.
UNASSIGNED: Among 1113 patients included in the study, 694 (62.4%) were male; 285 (25.6%) were Black or African American, 592 (53.2%) were White, and 236 (21.2%) were another race; and the median (IQR) age was 64 (52-75) years. Cardiac arrest was most commonly unwitnessed (n = 579 [52.0%]), nonshockable (n = 941 [84.6%]), and nonpublic (n = 999 [89.8%]). There were 198 patients (17.8%) with ROSC and 915 (82.2%) without ROSC. Median EtCO2 values between ROSC and non-ROSC cases were significantly different at 10 minutes (39.8 [IQR, 27.1-56.4] mm Hg vs 26.1 [IQR, 14.9-39.0] mm Hg; P < .001) and 5 minutes (43.0 [IQR, 28.1-55.8] mm Hg vs 25.0 [IQR, 13.3-37.4] mm Hg; P < .001) prior to end of resuscitation. In ROSC cases, median EtCO2 increased from 30.5 (IQR, 22.4-54.2) mm HG to 43.0 (IQR, 28.1-55.8) mm Hg (P for trend < .001). In non-ROSC cases, EtCO2 declined from 30.8 (IQR, 18.2-43.8) mm Hg to 22.5 (IQR, 12.8-35.4) mm Hg (P for trend < .001). Using adjusted multivariable logistic regression with slope of EtCO2, the temporal change in EtCO2 was associated with ROSC (odds ratio, 1.45 [95% CI, 1.31-1.61]).
UNASSIGNED: In this secondary analysis of the PART trial, temporal increases in EtCO2 were associated with increased odds of ROSC. These results suggest value in leveraging continuous waveform capnography during OHCA resuscitation.
UNASSIGNED: ClinicalTrials.gov Identifier: NCT02419573.

The Theatre Recovery and Anaesthetic Nurse Capnography Education (TRACE) project is a multidisciplinary quality improvement project. The overall aim is to educate anaesthetic and recovery nurses on the correct use of capnography and educate non-consultant hospital doctors on the guidelines on Preventing Unrecognised Oesophageal Intubation from the Project for Universal Management of Airways group. This project addresses technical aspects of task performance such as correct waveform identification and interpretation, troubleshooting abnormal waveforms and establishing routine checks of capnography both pre-induction and post-intubation. The pre-induction verification of the correct function of capnography is an essential component of this project. In addition, the project focuses on team aspects of task performance with an emphasis on team psychological safety, empowering nurses to speak up using graded assertiveness and flattening hierarchies. As a result of the project, our nurses\' knowledge about capnography and waveform identification improved to over 80% correct answers six months after completion of the project. In addition, over 90% of participants reported feeling confident in speaking up to both consultants and non-consultant hospital doctors when a waveform was not present before induction of anaesthesia or after attempted tracheal intubation.

UNASSIGNED: This study aimed to compare the different respiratory rate (RR) monitoring methods used in the emergency department (ED): manual documentation, telemetry, and capnography.
UNASSIGNED: This is a retrospective study using recorded patient monitoring data. The study population includes patients who presented to a tertiary care ED between January 2020 and December 2022. Inclusion and exclusion criteria were patients with simultaneous recorded RR data from all three methods and less than 10 min of recording, respectively. Linear regression and Bland-Altman analysis were performed between different methods.
UNASSIGNED: A total of 351 patient encounters met study criteria. Linear regression yielded an R-value of 0.06 (95% confidence interval [CI] 0.00-0.12) between manual documentation and telemetry, 0.07 (95% CI 0.01-0.13) between manual documentation and capnography, and 0.82 (95% CI 0.79-0.85) between telemetry and capnography. The Bland-Altman analysis yielded a bias of -0.8 (95% limits of agreement [LOA] -12.2 to 10.6) between manual documentation and telemetry, bias of -0.6 (95% LOA -13.5 to 12.3) between manual documentation and capnography, and bias of 0.2 (95% LOA -6.2 to 6.6) between telemetry and capnography.
UNASSIGNED: There is a poor correlation between manual documentation and both automated methods, while there is relatively good agreement between the automated methods. This finding highlights the need to further investigate the methodology used by the ED staff in monitoring and documenting RR and ways to improve its reliability given that many important clinical decisions are made based on these assessments.

End-expiratory lung volume (EELV) is reduced in mechanically ventilated patients, especially in pathologic conditions. The resulting heterogeneous distribution of ventilation increases the risk for ventilation induced lung injury. Clinical measurement of EELV however, remains difficult.
Validation of a novel continuous capnodynamic method based on expired carbon dioxide (CO2) kinetics for measuring EELV in mechanically ventilated critically-ill patients.
Prospective study of mechanically ventilated patients scheduled for a diagnostic computed tomography exploration. Comparisons were made between absolute and corrected EELVCO2 values, the latter accounting for the amount of CO2 dissolved in lung tissue, with the reference EELV measured by computed tomography (EELVCT). Uncorrected and corrected EELVCO2 was compared with total CT volume (density compartments between - 1000 and 0 Hounsfield units (HU) and functional CT volume, including density compartments of - 1000 to - 200HU eliminating regions of increased shunt. We used comparative statistics including correlations and measurement of accuracy and precision by the Bland Altman method.
Of the 46 patients included in the final analysis, 25 had a diagnosis of ARDS (24 of which COVID-19). Both EELVCT and EELVCO2 were significantly reduced (39 and 40% respectively) when compared with theoretical values of functional residual capacity (p < 0.0001). Uncorrected EELVCO2 tended to overestimate EELVCT with a correlation r2 0.58; Bias - 285 and limits of agreement (LoA) (+ 513 to - 1083; 95% CI) ml. Agreement improved for the corrected EELVCO2 to a Bias of - 23 and LoA of (+ 763 to - 716; 95% CI) ml. The best agreement of the method was obtained by comparison of corrected EELVCO2 with functional EELVCT with a r2 of 0.59; Bias - 2.75 (+ 755 to - 761; 95% CI) ml. We did not observe major differences in the performance of the method between ARDS (most of them COVID related) and non-ARDS patients.
In this first validation in critically ill patients, the capnodynamic method provided good estimates of both total and functional EELV. Bias improved after correcting EELVCO2 for extra-alveolar CO2 content when compared with CT estimated volume. If confirmed in further validations EELVCO2 may become an attractive monitoring option for continuously monitor EELV in critically ill mechanically ventilated patients.
clinicaltrials.gov (NCT04045262).

UNASSIGNED: There is continued research to find new faster, highly accurate, easily accessible, and portable methods of confirming endotracheal tube position during intubation. A newer modality for visualizing endotracheal tube location is transtracheal or transcricothyroid ultrasonography. The aim of this study was to see if ultrasound machine can also be routinely used for the confirmation of endotracheal tube position in operating theaters along with capnograph.
UNASSIGNED: The study was observational and prospective, conducted from January 2017 to July 2017. Study locations were at the Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center operating rooms. Sample size taken was 95.
UNASSIGNED: In the study, 11 patients had esophageal intubation out of the 95. The accuracy of both ultrasonography and capnography was found to be 96.84%. For ultrasonography, the sensitivity, specificity, along with positive predictive value and negative predictive value were 97.62%, 90.91%, 98.80%, and 83.33%, respectively, while that for capnography were found to be 96.43%, 100%, 100%, and 78.57%, respectively. The kappa value was calculated to be 0.749, which suggested the degree of agreement of result between the methods to be good. Compared to capnography, ultrasonography was found to be significantly faster for the confirmation of endotracheal tube location by 16.36 s (15.70-17.02) (P = 0.011).
UNASSIGNED: Both waveform capnography and ultrasonography were found to be accurate and reliable in confirming endotracheal tube location. The use of ultrasound during intubation can help confirm endotracheal tube location faster and also aid in precision when used along with capnography. Manual bag ventilations are not necessary when confirming endotracheal tube position by ultrasonography and thus may help in preventing aspiration of gastric contents into the lungs of the patient.

BACKGROUND: Capnography is a quantitative and reliable method of determining the ventilatory status of patients. We describe the test characteristics of capnography obtained during Emergency Department triage for screening acidemia.
RESULTS: We performed an observational, pilot study of adult patients presenting to Emergency Department (ED) triage. The primary outcome was acidemia, as determined by the basic metabolic panel and/or blood gas during the ED visit. Secondary outcomes include comparison of estimated and measured respiratory rates (RR), relationships between end-tidal CO2 (EtCO2) and venous partial pressure of CO2, admission disposition, in-hospital mortality during admission, and capnogram waveform analysis. A total of 100 adult ED encounters were included in the study and acidemia ([Formula: see text] or [Formula: see text]) was identified in 28 patients. The measured respiratory rate (20.3 ± 6.4 breaths/min) was significantly different from the estimated rate (18.4 ± 1.6 breaths/min), and its area under the receiver operating curve (c-statistic) to predict acidemia was only 0.60 (95% CI 0.51-0.75, p = 0.03). A low end-tidal CO2 (EtCO2 < 32 mmHg) had positive (LR+) and negative (LR-) likelihood ratios of 4.68 (95% CI 2.59-8.45) and 0.34 (95% CI 0.19-0.61) for acidemia, respectively-corresponding to sensitivity 71.4% (95% CI 51.3-86.8) and specificity 84.7% (95% CI 74.3-92.1). The c-statistic for EtCO2 was 0.849 (95% CI 0.76-0.94, p = 0.00). Waveform analysis further revealed characteristically abnormal capnograms that were associated with underlying pathophysiology.
CONCLUSIONS: Capnography is a quantitative method of screening acidemia in patients and can be implemented feasibly in Emergency Department triage as an adjunct to vital signs. While it was shown to have only modest ability to predict acidemia, triage capnography has wide generalizability to screen other life-threatening disease processes such as sepsis or can serve as an early indicator of clinical deterioration.

End-tidal capnography can provide useful clinical information displayed on the ventilator screen or bedside monitor. It is important that clinicians can assess and utilise this information to assist in identifying underlying complications and pulmonary pathology. Sudden change or loss of the CO2 waveform can act as a safety measure in alerting clinicians of a dislodged or blocked endotracheal tube, considering the concurrent flow and volume waveforms. Visual pattern recognition by the clinicians of commonly seen waveform traces may act as an adjunct to other modes of ventilatory monitoring techniques. Waveforms traces can aid clinical management, help identify cases of ventilation asynchrony between the infant and the ventilator. We present some common clinical scenarios where tidal capnography can be useful in the timely identification of pulmonary complication and for practical troubleshooting at the cot-side.

UNASSIGNED: While critically ill patients experience a life-threatening illness, they commonly develop ventilator-associated pneumonia (VAP) which can increase morbidity, mortality, and healthcare costs. The present study aimed to compare the effect of respiratory physiotherapy and increased positive endexpiratory pressure (PEEP) on capnography results.
UNASSIGNED: This randomized control clinical trial was performed on 80 adult patients with VAP in the intensive care unit (ICU). The patients were randomized to receive either PEEP at 5 cm H2O, followed by a moderate increase in PEEP to 10 cm H2O, or PEEP at 5 cm H2O with respiratory physiotherapy for 15 min. The numerical values were recorded on the capnograph at minutes 1, 5, 10, 15, and 30 in both methods. Data collection instruments included a checklist and MASIMO capnograph.
UNASSIGNED: As evidenced by the obtained results, the two methods significantly differed in the excreted pCO2 (partial pressure of carbon dioxide) (P<0.0001). However, the average amount of excreted pCO2 was higher in the respiratory physiotherapy and PEEP intervention (38.151mmHg) in comparison with increasing PEEP alone method (36.184mmHg). Also, PEEP elevation method prolonged the time of the first phase (inhalation time) and the second phase while shortening the third phase (exhalation time) in capnography waves.
UNASSIGNED: CO2 excretion in patients with VAP increased after respiratory physiotherapy. Further, physiotherapy demonstrated more acceptable results in CO2 excretion compared with PEEP changes in mechanically ventilated patients.