Capnography prevents avoidable deathsBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l439 (Published 05 February 2019) Cite this as: BMJ 2019;364:l439
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We read with interest the editorial on the use of capnography in adults, children and the newborn and would like to highlight the British Association of Perinatal Medicine (BAPM) position statement on waveform capnography in the newborn published in response to Professor Cook’s article in Anaesthesia. We agree that the detection of exhaled carbon dioxide is a useful adjunct to confirm correct placement of an endotracheal tube, but urge caution in applying results from adult studies to paediatric populations, especially newborn infants. As Professor Cook notes, waveform capnography has improved tube placement in adults but does not completely prevent death due to oesophageal intubation, and may have a false negative rate of around 1 in 40 in neonatal intubation.
The majority of neonatal units and neonatal transport teams nationally now use colorimetric capnometry as standard for all intubations both in delivery suite and on NICU. Practitioners are taught that physiological differences in the newly born infant during fetal-to-neonatal transition at birth require careful interpretation of capnometry in this population. We are not aware of any work in the newborn comparing interpretation of waveform capnography with colorimetric capnometry. Ventilators used for babies receiving mechanical ventilation on NICU are highly sensitive to changes in flow produced by extubation, and provide both visual and auditory alarms in these circumstances. As a result, spontaneous extubations are almost invariably immediately recognised. An additional value of continuous waveform capnography to detect tube dislodgement in the neonatal population has yet to be proven.
Carbon dioxide detection of any sort also provides no information about endotracheal tip position: compared to adults, the difference between optimal tracheal position and bronchial intubation may only be a matter of millimetres in a preterm baby. We note with interest that videolaryngoscopy (VL) has recently been reported to have produced a rate of success in trainee-performed intubation of 100% (improved over a number of months from baseline of 30%) in a single Scottish quaternary Neonatal Intensive Care Unit (O’Shea J: personal communication). VL combined with use of ventilator graphics once the baby has been intubated provides a reproducible approach to reliable and correct tube placement with ongoing monitoring of endotracheal location in the neonatal population. There is additional benefit in this approach due to the educational value inherent in use of VL.
We reiterate that practices with proven benefits for older patients may not apply in the NICU and that any new technology should be shown to provide greater benefit than risk in the relevant setting. We highlight that BAPM is currently developing a Framework for Practice to inform management of the difficult airway in neonatal practice.
1. Cook TM, Harrop-Griffiths W. Capnography prevents avoidable deaths, BMJ 2019; 364:l439
2. Mactier H et al. Correspondence: Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2018; 74:116-7
3. Foy KE, Mew E, Cook TM, et al.Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia2018;73:1337-44
4. Roberts WA, Maniscalco WM, Cohen AR, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr. Pulmonol. 1995;19:262-8
5. Advanced Airway Management (2014), in Fawke J, Cusack J (Eds), Advanced Resuscitation of the Newborn Infant (1st Edition). London, Resuscitation Council (UK) p33-43.
Competing interests: No competing interests