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Thread Title: Capnography Failure
Created On Mon Jan 15, 2007 6:37 AM
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medictool
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Mon Jan 15, 2007 6:37 AM

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This is a question about capnography.

I am taking a NREMT refresher and the first class was on Thursday. We got talking about capnography and some of the benefits. I believe that we are becoming too dependent on technology and not adaquetely assessing pt's ourselves. We and my partner who is also a paramedic had a call several months ago for a respiratory. A cop gets on scene and where we work these guys are nuts about medical calls so this is not a BS response by them; but anyway the cop states that the pt. is bad and then states that the pt. is in respiratory arrest. We are less than a minute away at this point. Find the cop ventilating the pt. with no CPR initiated at this time. CPR and all that stuff is done and pt. is intubated following standard ACLS protocols cause I know you guys are big on protocols. But anyway this is about as fresh of a code as you get without it happening in front of you. This lady had the whitest pearly gates you are going to find for an intubation. This lady weighed about 120-130kg. She had respiratory problems as far as a history and HPI according to the son. Capnography was put in place and it read nothing from the waveform and gave any numbers for measuring the C02. I knew I was in but I had my partner look and agreed with the fact I was in. We tried other devices but all failed. So I am thinking what the you know. We get to the hospital where the devices still don't work. Their capnography does not work and neither does any of their other devices. So the doc says I will take a look because everything looks ok. He takes a look and agrees without a doubt that I was in the right spot. So needless to say the tube was confirmed by an x-ray eventually but none of the devices worked for us of the ER. Now I have used capnography devices quite a bit and have done some research into them and have never read anything like this before. I forgot all about this until the other day and was thinking about what you guys have to say because to say the least everyone in the class was shocked. By the way the rhythm for anyone who cares thinking that might matter was PEA the whole time at a rate of 50-60. Any further questions I will answer but I just want to know if anyone else had the same problem or have heard of a similar problem.

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musicalmedic81
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Mon Jan 15, 2007 7:48 AM

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I actually had a similar problem. I had a very large obese pt who had coded. Probably in the ballpark of 180 kg. She had no neck and was an extremely difficult tube. I was working with an EMT-I who needed another intubation to get through our training program. So I let her give it a shot first. She nailed it, or she stated she did. She said she saw it pass through the chords and was 100% sure of it. however the pt was extremely hard to bag like her lungs may be closed up from COPD exacerbation. Anyway, I hooked up the capnography, nothing. Hooked up an End tidal Co2 detector, nothing, heard breathsounds and epigastric sounds present all over. And it appeared she was developing gastric distention. I asked her if she was positive she saw the tube pass through the chords, she said Im Positive. So I started considering equipment failure, maybe a busted cuff or tube. Well, the pts not getting any better and getting more cyanotic by the second. So I extubate and re-intubate with a larger (8.0) tube and I had the same view my parter had. I saw that puppy go right through them chords. And it was the same story, no capnography reading, no end tidal CO2 color change, lung sounds and epigastric sounds all over. And pt extremely difficult to ventilate.

So I dont know if maybe she had dropped a lung somewhere or maybe if it was related to the end stage COPD history, or possibly the fact that she was morbidly obese. But I have had the same problem as you. Maybe somebody can shine some light for both of us....

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Curt
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Mon Jan 15, 2007 9:45 AM

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Not related to a code but I have noticed how easy it is to block the actual capnography line that leads to the LP 12 with fluids, vomitus, ect. Could it be a case of this?

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medic1488
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Mon Jan 15, 2007 10:00 AM

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I was the FTO for a new medic at the company that I worked for at the time. I had an experienced medic from another service that had to go through our process with us. Had a code, COPD/renal failure/IDDM etc.., that he went to intubate. Was positive he saw the chords, lung and epigastric sounds all over, no waveform. I reintubated, saw what appeared to be very white pearly vocal cords. I intubated with the same result. Took another look after bagging the patient and looked more anterior, and there were the vocal chords. The patient had some something on the top of her epiglottitis that made them look white and shiny like vocal chords. (Being familar with this patient it was a surprise to see anything that white in her airway with as much as she smoked). Long story short, direct visualization is not the gold standard of intubation confirmation. I am one that absolutely agrees that we should not get over reliant on technology and know how to assess our patients, but we also must know when to trust technology. 99.9% of the time, if you dont have a waveform, you dont have the tube. I've found in texts were its been said that waveform capnography is the gold standard (even above a chest xray) for ETT verification. I also remember reading a study that among other things looked at medic tube placement, of all the misplaced tubes brought into the ED by this service the medics had either not used capnography or disregarded the negative waveform as equipment problem. Did you possibly get one of those very few instances in which capnography wasn't effective, from what your describing, maybe. Personally I would have pulled it and went in with an LMA/combitube instead of taking the risk of a ventilating through a misplaced tube.

Questions:
At the ED did they also have waveform, or one of those EZCAP devices?
Did they do just a frontal chest xray, or did they also do a cross table chest?

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arctickat
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Mon Jan 15, 2007 2:34 PM

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I'm sure that everyone knows that EtCO2 requires more than just having the tube in the right plcae to be able to confirm placement. Consider all of the variables associated with the respiratory process during a code. CPR effective enough to provide adequate pulmonary pressures. Alveoli capable of air exchange, ventilatory support pressures adequate to provide air exchange, hemoglobin levels adequate enough to provide CO2 exchange, and more. EtCOS doesn't just confirm tube placement, it confirms adequate air exchange. Any compromise of any of these can result in poor or no EtCO2 reading.

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medic1488
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Mon Jan 15, 2007 5:04 PM

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Even in code situations though, except for some very specfic circumstances there should be some return of etCO2. Not enough to change one of the those colormetric devices, but should have enough to get a very low reading or waveform.

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arctickat
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Mon Jan 15, 2007 6:31 PM

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Agreed, even doing a code on an exsangunated patient I was getting 3 or 4 but it just proves that a perfect tube doesn't always mean great CO2

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medictool
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Mon Jan 15, 2007 6:35 PM

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Alright I thought of a couple of other things to after reading some of your comments. One is that adaquate CPR was being done. How the guy did not get tired from this was beyond my belief but anyway. The other thing is that there was no fluids in the tube or that would have interfered with the capnography unit. There were no medications given via the tube. I thought about a connection problem with the LP12 initially. However the hospital has a different adapter and there was another model which also failed. I agree that there should have been some levels generated for a reading at the very least even if there was not a waveform. Breath sounds were equal bilaterally with none over the epigastrum. Pt. even though she was rather large never had any gastric distention. Pt. actually returned a somewhat decent coloration after being intubated. One comment that did bother me a little was from the person who said he would have pulled the tube. If you have visible signs of a positive tube and I mean multiple signs why would you pull a tube. I remember the research initially on the color matrix devices when they first came out that they were error proof. However it was not until several years later that it was proven not to be the case. I agree that technology is beneficial. I would not place my egotistical self over the life of a patient. However with that being said when I have visible signs telling me the tube is in and the pt. shows positive changes after the intubation I would not remove it. There are so many things that you can use to tell if a tube is in other than technology. But don't get me wrong technology is good in most cases. I watched a medic a long time ago when I was an EMT not pull a tube that everyone told him to and that pt. died as a result. I will not go into the specifics because people involved with that situation read these forums. I promised myself that I would never ever under any circumstance allow for that. I have only missed one tube in my entire life and I owe that to an anestesiologist who took his personal time to show me techniques. The difference that he taught me was preparation and not to rush the situation because if you have to intubate x2 you wasted more time anyway. So in my career tubes have not been an issue. I believe IV's are harder then tubes because everyone has an airway but not everyone has a vein well except for an IJ I have never seen anyone without them. I did not really want this debate to be about technology and its overuse of making us trust ourselves less but when I read my initial thread it came across that way. Sorry about that. What I really want to know is if anyone ever had this happen or know of someone who had this happen. By the way for the person who wanted to yank the tube I understand why you would of. But the same tube that I did not yank in this situation was the same one that she died with x1 week later. The hospital because of the doctors wanted to know why this failure had happened pushed an investigation. They obviously intubate more than us and never had that problem. I have intubated with the use of capnography over a 100 times and never had any problems. This was the first so I am using this as an isolated situation and not the norm.

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medic1488
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Mon Jan 15, 2007 8:38 PM

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First off, I was a medic with quite a number of tubes before etCO2 in the field was a reality. I am very confident in my assesmment of a patient.

1. You stated however that no devices were working to confirm the placement, I'd rather walk in with an airway I was 100% about rather than one than in the event that I'm wrong, I'll have to explain to a family or a court that all the technology was wrong and I was right. An LMA is a good airway and there are plenty of people at a hospital that could have reintubated the patient.

2. EtCO2 is a tried and proven method. It has been around for a long time, just like many things, its introduction to the field is the recent change.

I too have only had one missed intubation in my career, very much due to my constant vilagence to learning and praticing all I can concerning airway control. Part of that has taught me though that anyday of the week I would rather pull a tube I am not 100% sure about and ventilate thru an LMA. With all the means of confirming a tube that are available telling me its not in, and no means of explaining why, that would definetly put some doubt in my mind.

It sounds like you might have had one of those rare instances in which the stars were aligned to have absolutely no CO2 return. Never seen it before, have heard about it in a case of two badly burned pedi arrests but I have no idea of the rest of their physical findings or if the tubes were good when they got to the hospital.

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kohlerrf
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Mon Jan 15, 2007 10:30 PM

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I have also clogged my etco2s with vomit or fluid from the lung, I am not a fan of the colormetric caps, and on aside if you think you tubed the wrong hole dont extubate just tube over the old tube into what ever hole is left.! You have to have real tallent to shove 2 tubes down the esophagus. Then choose which tube is right for you and stick an NG tube down the other otherwise it will get messy very fast.

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medic1488
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Originally posted by: kohlerrf
I have also clogged my etco2s with vomit or fluid from the lung, I am not a fan of the colormetric caps, and on aside if you think you tubed the wrong hole dont extubate just tube over the old tube into what ever hole is left.! You have to have real tallent to shove 2 tubes down the esophagus. Then choose which tube is right for you and stick an NG tube down the other otherwise it will get messy very fast.


Definetly a good option. If you cant get a return from either, you know somethings definetly wrong with your machine.

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EMT-Pstudent
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Mon Jan 15, 2007 11:25 PM

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I recently had problems with a clogged line on our LP12, not sure why, I took it right from the presealed bag and attatched it to the monitor a feww feet away with no fluids on or near it, thought it might be dust, tried blowing it out with no success...kinda odd I dunno what the deal was.
In reference to the questions: as others have stated, there are many factors that contribute to the capnography. Problems with gas exchange certainly is top on the list. Also, despite good CPR, if the cellular metabolism has stopped and cells have died, no amount of CPR will reinitiate the this proccess. This in effect will give you a very low (generally below 10) reading and poor waveform (if one is present at all) in our service, this can serve as a reason to terminate efforts if this persists despite rhythm.

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grambograham
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Tue Jan 16, 2007 4:53 AM

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We deal with many intubated patients in the ICU. We use the colormetric device to confirm placement of the ETT. As for using capnography beyond that, I've seen it once in 9 months and that was for the benefit of the paramedic students. We will bring it out if we suspect PE but that is about it.

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Curt
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Tue Jan 16, 2007 11:37 AM

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The Med Director in my county (Orange County, FL) has in the protocols that if there is no ETCO2 reading on the LP 12 we are req to pull the tube no matter what other signs of a successful intubation exist. We are only allowed to use a colormetric device in the event of LP 12 failure.

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medic1488
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Tue Jan 16, 2007 12:09 PM

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Being only several counties away in Florida, I have heard that the state is requiring all services to have etCO2 as mandatory equipment.

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Curt
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What county or town?

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medic1488
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Live in Sarasota County, work in Lee County at one of the transport FD.

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grambograham
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That's just dumb.

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greshmedic
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Indeed it is dumb!

What was the reasoning to pulling a tube out if it is confirmed?





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PARAMEDICMIKE
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Tue Jan 16, 2007 6:17 PM

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Very dumb indeed. Another case of treating the monitor not the patient. In a sense, I'm happy to see that it's coming from a doc. At least that way I know that it can happen all across the board.

-be safe

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ALTAZANSW
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Tue Jan 16, 2007 11:13 PM

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We have the Zoll M series here, we have to slip an adapter between the Tube and BVM that the sensor clips onto-no real problem with clogs. Our protocols say we have to check with visualization and auscultation. ETCO2 and Tube check bulbs if we have time or need addtional confirmation. I've had them go either way. Sometimes we get a waveform, sometimes we don't. The Zoll's seem to be especially sensitive to calibration.

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BENDAVIS
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The patient's in arrest? I wouldn't worry about it. ETCO2 isn't a good tool for tube confirmation in arrested pt.s. Even with good CPR and no exsanguination, pulmonary perfusion pressures are significantly significantly reduced. You can be extremely acidotic, and if there's no (or minimal) perfusion to the pulmonary vasculature, your CO2 may be negative. A far superior device for this situation is the esophageal detector device (EDD).

[Don't get me wrong, I like using ETCO2 as a prognostic tool; if I'm getting good waveform and good CO2, I'm thinking about possible ROSC, and I've read the study on survival approaching zero with ETCO2 of < 10 mmHg @ 20 mins. It's just not a good tool for initial confirmation in arrested pt.s].

If this is a perfusing pt. with an ETCO2 of zero, it's time to worry. Then you've got to start looking at other options. Are there lung sounds, epigastric sounds, =chest rise, tube condensation. Can the tube be visualised passing through the cords on direct laryngoscopy? is there a tube obstruction? (i.e. can you pass a suction catheter down it), is there a pneumothorax, mucus plug?, etc. Secondary confirmation is just part of the overall clinical picture, and equipment failure is an ever-present part of EMS.

I respect everyone's awareness of tube displacement -- I, also, don't, want to be that guy who brings in the unrecognised esophageal. But there's far more to tube confirmation than ETCO2 or CXR -- direct visualisation of the tube passing the cords and stopping at the marker remains an excellent primary tool.

Ben.

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medictool
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Bendavis,

I did not want a debate on what is good and bad but factual accounts of good or bad experiences with capnography. However reading your opinion reminds of myself so much and greatly appreciate hearing other people say the same thing that I have been saying for a long time. Thank You.

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medic1488
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Quote
Originally posted by: BENDAVIS
The patient's in arrest? I wouldn't worry about it. ETCO2 isn't a good tool for tube confirmation in arrested pt.s. Even with good CPR and no exsanguination, pulmonary perfusion pressures are significantly significantly reduced. You can be extremely acidotic, and if there's no (or minimal) perfusion to the pulmonary vasculature, your CO2 may be negative. A far superior device for this situation is the esophageal detector device (EDD).

[Don't get me wrong, I like using ETCO2 as a prognostic tool; if I'm getting good waveform and good CO2, I'm thinking about possible ROSC, and I've read the study on survival approaching zero with ETCO2 of < 10 mmHg @ 20 mins. It's just not a good tool for initial confirmation in arrested pt.s].

If this is a perfusing pt. with an ETCO2 of zero, it's time to worry. Then you've got to start looking at other options. Are there lung sounds, epigastric sounds, =chest rise, tube condensation. Can the tube be visualised passing through the cords on direct laryngoscopy? is there a tube obstruction? (i.e. can you pass a suction catheter down it), is there a pneumothorax, mucus plug?, etc. Secondary confirmation is just part of the overall clinical picture, and equipment failure is an ever-present part of EMS.

I respect everyone's awareness of tube displacement -- I, also, don't, want to be that guy who brings in the unrecognised esophageal. But there's far more to tube confirmation than ETCO2 or CXR -- direct visualisation of the tube passing the cords and stopping at the marker remains an excellent primary tool.

Ben.


I'm going to have to disagree on this one Ben. Except for some very rare circumstances you should have a waveform, even if a very small one, in your arrested patient. If you dont either you need to start some CPR or think about how long tha patient has really been down. Unless your talking about colormetric then I will have to disagree that it is not an effective confirmation.

Also:
A 2005 study comparing field intubations that used continuous capnography to confirm intubations versus non-use showed zero unrecognized misplaced intubations in the monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir, Annals of Emergency Medicine, May 2005

“When exhaled CO2 is detected (positive reading for CO2) in cardiac arrest, it is usually a reliable indicator of tube position in the trachea.” - The American Heart Association 2005 CPR and ECG Guidelines

I agree nothing is ever full proof, but I personally have found etCO2 waveform much better than an EDD for confirmation. I also know of another study that found similar results of esophegeal intubation, I just cant find it off hand right now. Everybody wants to practice evidence based medicine, until the evidence disagrees with you.

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ncmedic309
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Thu Jan 18, 2007 12:17 AM

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Originally posted by: Curt
The Med Director in my county (Orange County, FL) has in the protocols that if there is no ETCO2 reading on the LP 12 we are req to pull the tube no matter what other signs of a successful intubation exist. We are only allowed to use a colormetric device in the event of LP 12 failure.


What's his logic behind this? There are numerous reasons that you may not get an EtCO2 reading and still have a great tube. It sounds like your medical director is a little insecure with allowing your medics to do field intubations. It's important to remember that EtCO2 is a great tool when it comes to assessing for confirmation of ET intubation and adequate ventilation, but it's just a tool. The most efficient method for confirming placement is you watching the tube pass through the glottic opening. Next in line is adequate chest rise and fall with bilateral breath sounds. It's nice having the tools, but we should keep in mind that they are not a save all, just a nice addition to your arsenal...

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medic1488
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One of the studies that found no misplaced tubes with etCO2 and 23% without was conducted in 11 counties in Florida. Maybe Orange County was one of these counties so the medical director is very convinced of the need. Although I dont agree with it, we also must remeber protocols are often written to the lowest skilled medics we have, not the best. Where I personally run into the problem with that protocol is the term "all". Although I am an absolute believer in waveform cap, its got to be recignized that there are those rare circumstances in which you wont get a return.

Edited: Thu Jan 18, 2007 at 7:07 AM by medic1488

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p3medic
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i remember a few years back the study published in Annals of Emergency Medicine about unrecognized esophageal intubation in a large percentage of pts in the Metro Orlando area, however I don't know which services were the culprits.....If I were the medical director of a group of medics who have a 23% unrecognized esophageal intubation rate, I'd probably remove the skill, or come up with a protocol like the one you stated, no etco2 = bad tube, no questions asked....and come up with some serious training in airway management too.....IMHO

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Curt
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The study you mentioned does not take into account tubes dislodging during movement either on scene, in rescue/ambulance or in the ER. All of these were considered improperly placed tubes. Once the Med Director got involved and required ER Doc to verify proper placement immediately on arrival at the ER the success rate miracuously shot up (Imagine that)! As a medic in the study area I probably would try to get all the facts before labeling an entire EMS system as incompetant.

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medic1488
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Thu Jan 18, 2007 4:57 PM

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So when was it getting dislodged? Ambulance stretcher to hospital? or was the doc waiting awhile to verify after the patient had been being worked in the ED?

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Curt
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It appeared that the major problem was with cardiac arrest pt's that were taken to radiology after unsuccessful resuscitation efforts in the ER. I'm not saying that there has not been bad tubes, but those individuals are retrained as directed by Med Dir. The EMS system here is very sensitive to airway issues. Many medics here felt like the study was misleading to make a bigger impact.

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