Capnography Monitoring Research Articles

Intramucosal pH as a criterion for the organism emergency from hepatospanchnic ischemia, or centralization of blood flow

In critical conditions, despite the restoration of systemic hemodynamics and overall oxygen delivery, tissue hypoxia and reduced oxygen extraction remain. One of the important tasks of intensive care for critical conditions is the early diagnosis of tissue perfusion disorders. In clinical circumstances, signs of hypoperfusion are arterial hypotension, tachycardia, oliguria, encephalopathy, low body temperature, the disappearance of skin capillary pattern, metabolic lactate acidosis. However, blood pressure is an insensitive indicator of tissue hypoperfusion itself. Experimental clinical trials have repeatedly documented that local perfusion pressure in critical conditions does not directly depend on systemic blood pressure. Lactate is not a specific marker of anaerobic metabolism, but rather impaired microcirculation seems to be one of the possible mechanisms of hyperlactatemia. Reliable markers of tissue perfusion and the effectiveness of early targeted therapy are regional capnometry (gastric intramucosal pH, sublingual pCO2), a saturation of mixed venous blood, etc. Intramucosal pH is of particular practical importance as a marker of regional capnometry. The aim of the study is the analysis of literature sources devoted to the effectiveness and diagnostic significance of intramucosal pH as a marker of regional perfusion. The value of intramucosal pH was evaluated: 1) during abdominal operations and the development of postoperative complications in comparison against IL-6 and IL-8; 2) during and after surgical interventions in conditions of prolonged cardiopulmonary bypass to assess the adequacy of blood supply to the abdominal organs; 3) in experimental septic shock compared to the values of lactate and hypoxanthine concentration in the liver and arterial blood; 4) the correlation between intramucosal pH va-lues, indices of the pediatric mortality risk scale, forming of great (cardiac arrest, shock) and minor (hypotension, hypovolemia, arrhythmia) hemodynamic complications and duration of staying in intensive care unit and intensive therapy; 5) during laparoscopic cholecystectomy in apparently healthy patients with the simultaneous calculation of the difference between arterial and intramucosal pH. Intramuscular pH-controlled intensive therapy is a separate fragment: an intramucosal pH of less than 7.3 reflects splanchnic hypoperfusion and is an indicator of the unfavorable outcomes; intramucousal pH of more than 7.3 is a criterion for the emergency of the organism from hepatosplanchic ischemia, i.e. centralization of blood circulation. Therefore, the intramucosal pH is valuable in the clinical picture of critical conditions as a marker of regional perfusion measured by capnometry, which allows monitoring that reflects the perfusion of the intestinal wall. The lower threshold is 7.35 (the sensitivity of the method is 67 %, specificity is 74 %). An intramucosal pH of < 7.3 reflects splanchnic hypoperfusion and is an indicator of an adverse outcome. An alternative measurement of intramucosal pCO2, pCO2 in arterial blood and the difference [P (1-a) CO2] is a more reliable index of intestinal oxygenation than single intramucosal pH, but rather pH (1-a) makes it possible to adequately assess the acid-base state of arterial blood. The improvement and widespread use of capnometry and capnography for monitoring during general anaesthesia and intensive care, on the one hand, and modern knowledge of the pathophysiology of gas exchange, on the other hand, stimulate the wider use of less invasive and more affordable methods of regional capnometry and aerial tonometry.

Máscara laríngea I-Gel® versus bolsa-válvula-mascarilla en la reanimación cardiopulmonar instrumental bajo monitorización capnográfica: ensayo clínico piloto aleatorizado por grupos

ObjectiveTo compare the basic airway and the advanced airway with the supraglottic device I-Gel®, by means of capnography during intermediate CPR. DesignRandomized experimental pilot study by groups. SettingOut-hospital care basic life support units on the Island of Mallorca. ParticipantsAdults attended after cardiorespiratory arrest of non-traumatic origin. InterventionsAdvanced airway management during instrumental CPR with I-Gel® or basic CPR with bag-valve-mask, under capnographic monitoring. Main measurementsCapnometric levels obtained according to the device used, number of insertions of the I-Gel®, cases without achieving correct insertion/ventilation by branches, achievement of ROSC in CPR and number of hospital live admissions. ResultsTwenty-three cases were recruited for analysis. The insertion success rate of the I-Gel® was 92.9% at the first attempt, the mean capnometric values were 16.3mmHg in the control group and 27.4% in the intervention group. 34.8% (n=8) of the patients achieved spontaneous circulation recovery at some point and 26.1% (n=6) were admitted to hospital alive. The survival analysis, taking into account the arrival of the unit and the first minute of ventilations recorded together with the variable hospital admission, suggests a certain trend of greater survival in the intervention branch (P=.066). ConclusionsThe use of I-Gel® raises an improvement in the ventilation of the patients in PCR, evidenced by the mean capnometric values in the intervention group, finding no correlation with CPR outcome variables.

Modeling the Cost Savings of Continuous Pulse Oximetry and Capnography Monitoring of United States General Care Floor Patients Receiving Opioids Based on the PRODIGY Trial.

IntroductionDespite the high incidence of respiratory depression on the general care floor and evidence that continuous monitoring improves patient outcomes, the cost–benefit of continuous pulse oximetry and capnography monitoring of general care floor patients remains unknown. This study modeled the cost and length of stay savings, investment break-even point, and likelihood of cost savings for continuous pulse oximetry and capnography monitoring of general care floor patients at risk for respiratory depression.MethodsA decision tree model was created to compare intermittent pulse oximetry versus continuous pulse oximetry and capnography monitoring. The model utilized costs and outcomes from the PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial, and was applied to a modeled cohort of 2447 patients receiving opioids per median-sized United States general care floor annually.ResultsContinuous pulse oximetry and capnography monitoring of high-risk patients is projected to reduce annual hospital cost by $535,531 and cumulative patient length of stay by 103 days. A 1.5% reduction in respiratory depression would achieve a break-even investment point and justify the investment cost. The probability of cost saving is ≥ 80% if respiratory depression is decreased by ≥ 17%. Expansion of continuous monitoring to high- and intermediate-risk patients, or to all patients, is projected to reach a break-even point when respiratory depression is reduced by 2.5% and 3.5%, respectively, with a ≥ 80% probability of cost savings when respiratory depression decreases by ≥ 27% and ≥ 31%, respectively.ConclusionCompared to intermittent pulse oximetry, continuous pulse oximetry and capnography monitoring of general care floor patients receiving opioids has a high chance of being cost-effective.Trial Registrationwww.clinicaltrials.gov, Registration ID: NCT02811302.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01779-7.

Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department.

Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring. Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training. Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66). Addition of capnography to current care significantly decreased procedure-related safety events.

Tilt Test: A Review.

This review recapitulates the head-up tilt test, which is commonly used for evaluation of orthostatic syndromes and dysautonomia. Tilt test evaluates autonomic system responses to orthostatic stress. Established tilt testing includes monitoring of heart rate and blood pressure; adding capnography and cerebral blood flow monitoring expands its diagnostic yield and allows assessing cerebral blood flow regulation. Common syndromes detectable by the tilt test are neurally mediated syncope (vasodepressor, cardiovagal, or mixed), orthostatic hypotension, postural orthostatic tachycardia syndrome, hypocapnic cerebral hypoperfusion, and orthostatic cerebral hypoperfusion syndrome. This review describes relevant physiology, tilt test protocols, diagnostic criteria for orthostatic syndromes, grading test results, diagnostic accuracy, limitations of the tilt test, and safety considerations.

Opioid-induced respiratory depression increases hospital costs and length of stay in patients recovering on the general care floor

BackgroundOpioid-induced respiratory depression is common on the general care floor. However, the clinical and economic burden of respiratory depression is not well-described. The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial created a prediction tool to identify patients at risk of respiratory depression. The purpose of this retrospective sub-analysis was to examine healthcare utilization and hospital cost associated with respiratory depression.MethodsOne thousand three hundred thirty-five patients (N = 769 United States patients) enrolled in the PRODIGY trial received parenteral opioids and underwent continuous capnography and pulse oximetry monitoring. Cost data was retrospectively collected for 420 United States patients. Differences in healthcare utilization and costs between patients with and without ≥1 respiratory depression episode were determined. The impact of respiratory depression on hospital cost per patient was evaluated using a propensity weighted generalized linear model.ResultsPatients with ≥1 respiratory depression episode had a longer length of stay (6.4 ± 7.8 days vs 5.0 ± 4.3 days, p = 0.009) and higher hospital cost ($21,892 ± $11,540 vs $18,206 ± $10,864, p = 0.002) compared to patients without respiratory depression. Patients at high risk for respiratory depression, determined using the PRODIGY risk prediction tool, who had ≥1 respiratory depression episode had higher hospital costs compared to high risk patients without respiratory depression ($21,948 ± $9128 vs $18,474 ± $9767, p = 0.0495). Propensity weighted analysis identified 17% higher costs for patients with ≥1 respiratory depression episode (p = 0.007). Length of stay significantly increased total cost, with cost increasing exponentially for patients with ≥1 respiratory depression episode as length of stay increased.ConclusionsRespiratory depression on the general care floor is associated with a significantly longer length of stay and increased hospital costs. Early identification of patients at risk for respiratory depression, along with early proactive intervention, may reduce the incidence of respiratory depression and its associated clinical and economic burden.Trial registrationClinicalTrials.gov, NCT02811302.

End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit

ObjectiveTo assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants.Study designA case–control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36).ResultThe infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases.ConclusionContinuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.

Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial

Study objectiveOpioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression. DesignProspective observational trial. Setting16 general care medical and surgical wards in Asia, Europe, and the United States. Patients1335 patients receiving parenteral opioids. InterventionsBlinded, alarm-silenced continuous capnography and pulse oximetry monitoring. MeasurementsOpioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO2 ≤ 85%, or ETCO2 ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event. ResultsAcross all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5–76.7) MME, 31.0 (6.2–99.0) MME, and 7.2 (1.7–18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424–0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322–0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression. ConclusionsDespite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. Registration numberwww.clinicaltrials.gov, ID: NCT02811302

Characteristics and selection of the sedative agents and clinical strategies of intravenous moderate sedation during dental treatment

As reported in the previous review, midazolam, propofol and their combination are common choices for intravenous moderate sedation of dental outpatients in Japan. In the “Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018”, midazolam and dexmedetomidine are recommended for “sedative/analgesic medications not intended for general anesthesia”, that is moderate sedation. The aim of this review is to introduce modern view of the sedative agents’ characteristics and to present the clinical strategies of intravenous moderate sedation during dental treatment. Practitioners should select the sedative agent or its combination depending on the patient’s condition and coexisting diseases. Suppression of hemodynamic fluctuation is important in the dental treatment of medically compromised patients such as patients with cardiovascular diseases including hypertension and/or ischemic heart disease. Intravenous moderate sedation has stronger sedative effects than inhalation sedation with nitrous oxide (Minimal sedation: Anxiolysis). Both midazolam and propofol are commonly used in phobic and medically compromised patients. In contrast, propofol is a good candidate for patients with gag reflex and receiving prolonged treatment. Patients with acute closed angle glaucoma and myasthenia gravis, and taking HIV protease inhibitor are contraindications of benzodiazepines including midazolam. Systemic condition of the patient should be evaluated before sedation. Practitioners should consult the family doctor and obtain medical information including laboratory data and regular medications. During sedation basic monitoring items include consciousness, oxygenation, ventilation and circulation such as heart rate and blood pressure. In addition, electrocardiography, capnography and bispectra index monitoring may be appended in some patients with coexisting cardiorespiratory diseases or during deep sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Conclusion. Intravenous moderate sedation has wide range of indications and practitioners can propose safe and comfortable dentistry to the patients.

Initial capnography values and resuscitation outcomes of patients assisted by basic life support units in first instance; descriptive prospective study

Introduction: Understanding the key factors which affect out hospital cardiac arrest (OHCA) outcomes is essential in order to promote patient treatment. The main objective of this research was to describe the correlations between the capnographic values obtained during the first minute of monitoring on cardiopulmonary resuscitation, assisted by basic life-support units, with the results as return of spontaneous circulation (ROSC) and alive hospital admission. The secondary objectives were to describe the sociodemographic characteristics of the patients assisted, and to analyze any correlations between receiving basic life-support units and/or defibrillation prior to the arrival of basic life-support units, and the results of the cardiopulmonary resuscitation maneuvers. Methods: A prospective, descriptive, observational study of adult non-traumatic out hospital cardiac arrest patients was conducted. The patients were initially assisted by basic life-support units on the island of Mallorca, with one minute of initial capnography monitoring. Results: From July 2018 to March 2020, fifty-nine patients meeting the inclusion criteria were assisted, 76% were men and their mean age was 64.45 (±15.07) years old. The number of emergency lifesaving technicians who participated in the study was 58, they had a mean work experience of 14.05 (±6.7) years. Thirty-seven (63.7%) patients underwent basic life-support by bystanders and in 91.5% of cases the semi-automatic external defibrillator was used. Capnometry values during the first minute were obtained in 34 (58.6%) patients, their mean values were 22 (±19.07) mmHg, 35.5% of patients had values &lt;10 mmHg. In 25.4% of the patients, spontaneous circulation returned during cardiopulmonary resuscitation, and 18.6% were admitted to hospital alive. Conclusion: No correlations were found between initial capnography values scoring above or below 10 mmHg and survival, however, basic life-support maneuvers, and defibrillation by bystanders and first responders, did correlate with survival rates. The average patient assisted in out of hospital cardiac arrest by the basic life-support units sampled was an adult male aged over 65 years.

A focused ethnography of how endoscopy practitioners utilize capnography in sedated patients

The literature shows that respiratory complications are common with sedation. Given the inherent risk, capnography monitoring is recommended whenever sedation is administered. We aimed to explore sedation practitioners’ behavior patterns and perceptions regarding capnography monitoring during endoscopy sedation and examine how capnography influenced clinical decision making when assessing respiration. We conducted a focused ethnography with triangulated observations and semi-structured interviews, and we purposively sampled and recruited five sedation practitioners as participants at a hospital in Saudi Arabia. Through data analysis, we identified representative themes and found cultural differences between anesthesia practitioners and nurses when using capnography during sedation. Anesthesia practitioners linked safety and the use of capnography to maintain adequate respiration, while nurses believed capnography was a secondary supportive monitor to patient observation and assessment. Findings also captured the unique cultures and values of each professional group to be associated with the varying perceptions. We also identified several factors facilitating and barring adequate utilization of capnography. In conclusion, professional culture, hospital policy, knowledge and previous experience with capnography guided the monitoring practice of endoscopy practitioners when assessing respiration during sedation.

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor.

Capnography is commonly used to monitor patient's ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

REGISTRIES, CARE, QUALITY OF LIFE, MANAGEMENT OF NMD: P.336 Novel and more sensitive criteria for identifying chronic respiratory failure in progressive neuromuscular disease

In conditions with progressive respiratory muscle weakness the end stage is chronic respiratory failure. This is defined as the point at which the respiratory system is no longer able to both inhale the oxygen that the metabolic demands of the body requires and also to remove the carbon dioxide that the metabolic processes of the body produces. This is evaluated on nocturnal polysomnogram (sleep) study with monitoring of respiratory effort, oxygenation and capnography. The standard interpretation is based on American Society of Sleep Medicine (ASSM) guidelines using criteria for hypercarbia defined in patients with normal respiratory muscle strength (CO2 > 50 mmHg for > 20% sleep).

Evaluation of the Integrated Pulmonary Index\xae during non-anesthesiologist sedation for percutaneous endoscopic gastrostomy

Standard monitoring of heart rate, blood pressure and arterial oxygen saturation during endoscopy is recommended by current guidelines on procedural sedation. A number of studies indicated a reduction of hypoxic (art. oxygenation < 90% for > 15 s) and severe hypoxic events (art. oxygenation < 85%) by additional use of capnography. Therefore, U.S. and the European guidelines comment that additional capnography monitoring can be considered in long or deep sedation. Integrated Pulmonary Index® (IPI) is an algorithm-based monitoring parameter that combines oxygenation measured by pulse oximetry (art. oxygenation, heart rate) and ventilation measured by capnography (respiratory rate, apnea > 10 s, partial pressure of end-tidal carbon dioxide [PetCO2]). The aim of this paper was to analyze the value of IPI as parameter to monitor the respiratory status in patients receiving propofol sedation during PEG-procedure. Patients reporting for PEG-placement under sedation were randomized 1:1 in either standard monitoring group (SM) or capnography monitoring group including IPI (IM). Heart rate, blood pressure and arterial oxygen saturation were monitored in SM. In IM additional monitoring was performed measuring PetCO2, respiratory rate and IPI. Capnography and IPI values were recorded for all patients but were only visible to the endoscopic team for the IM-group. IPI values range between 1 and 10 (10 = normal; 8–9 = within normal range; 7 = close to normal range, requires attention; 5–6 = requires attention and may require intervention; 3–4 = requires intervention; 1–2 requires immediate intervention). Results on capnography versus standard monitoring of the same study population was published previously. A total of 147 patients (74 in SM and 73 in IM) were included in the present study. Hypoxic events occurred in 62 patients (42%) and severe hypoxic events in 44 patients (29%), respectively. Baseline characteristics were equally distributed in both groups. IPI = 1, IPI < 7 as well as the parameters PetCO2 = 0 mmHg and apnea > 10 s had a high sensitivity for hypoxic and severe hypoxic events, respectively (IPI = 1: 81%/81% [hypoxic/severe hypoxic event], IPI < 7: 82%/88%, PetCO2: 69%/68%, apnea > 10 s: 84%/84%). All four parameters had a low specificity for both hypoxic and severe hypoxic events (IPI = 1: 13%/12%, IPI < 7: 7%/7%, PetCO2: 29%/27%, apnea > 10 s: 7%/7%). In multivariate analysis, only SM and PetCO2 = 0 mmHg were independent risk factors for hypoxia. IPI (IPI = 1 and IPI < 7) as well as the individual parameters PetCO2 = 0 mmHg and apnea > 10 s allow a fast and convenient conclusion on patients’ respiratory status in a morbid patient population. Sensitivity is good for most parameters, but specificity is poor. In conclusion, IPI can be a useful metric to assess respiratory status during propofol-sedation in PEG-placement. However, IPI was not superior to PetCO2 and apnea > 10 s.

Follow-Up and Monitoring of Children Needing Long Term Home Ventilation.

Once continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) is started in a child, and the child is discharged home, follow-up needs to be organized with regular visits in order to check the tolerance and efficacy of the treatment. But there is a lack of validated clinical guidelines, mainly because of the heterogeneity of the ventilator servicing, the costs and health care systems among countries. Therefore, visits timing and strategies to monitor CPAP/NIV are not clearly defined. Moreover, depending on various factors such as the underlying disorder, the medical stability, the age of the child, and socio-economic factors, follow-up usually ranges between 1 month and 3–6 months, or even 1 year following treatment initiation, with an overnight hospital stay, an out-patient visit, a home visit, via telemonitoring or telemedicine, alone or in combination. Apart from clinical evaluation, nocturnal oximetry and capnography monitoring and/or poly(somno)graphy (P(S)G) are usually carried out during the follow-up visits to monitor the delivered pressure, leaks, residual respiratory events and synchrony between the patient and the ventilator. Built-in software data of CPAP/NIV devices can be used to assess the adherence of treatment, to monitor pressure efficiency, leaks, asynchronies, and to estimate the presence of residual respiratory events under CPAP/NIV if P(S)G is not available or in alternance with P(S)G. The possibility of CPAP/NIV weaning should be assessed on a regular basis, but no criteria for the timing and procedures have been validated. Weaning timing depends on the clinical condition that justified CPAP/NIV initiation, spontaneous improvement with growth, and the possibility and efficacy of various upper airway, maxillofacial and/or neurosurgical procedures. Weaning may be allowed in case of the disappearance of nocturnal and daytime symptoms of sleep-disordered breathing (SDB) after several nights without CPAP/NIV and the objective correction of SDB on a P(S)G. But no parameters are defined. In any case, a long term follow-up is necessary to ascertain the weaning success. Large prospective studies, together with international and national guidelines, are required in order to build evidence for standardizing practice for the follow-up and weaning of CPAP/NIV in children.

Capnography monitoring in procedural intravenous sedation: a systematic review and meta-analysis.

Currently, procedural sedation in the clinical setting relies heavily on the use of pulse oximetry to monitor hypoxemia. Different studies suggest that incidence of hypoxemia and incidence of arterial oxygen desaturation are reduced by early intervention via capnography monitoring. The aim of this article was to discuss the importance of implementing capnography monitoring during procedural sedations performed in a dental setting and determine whether additional capnographic monitoring reduces the incidence of arterial oxygen desaturation and the overall complications rate. Two independent reviewers conducted electronic (PubMed and EMBASE) and manual searches up to February 2020. Randomized clinical trials (RCTs), including both patients under procedural sedation monitored by capnography and oximetry, and reporting the incidence of hypoxemia or episodes of oxygen desaturation were included. Risk ratio was used to compare the outcomes (i.e., the incidence of hypoxemia, the episodes of oxygen desaturation, the detection of apnea, the reduction of events of bradycardia, and hypotension) between patients monitored by capnography and standard approach. Fourteen randomized clinical trials fulfilling the inclusion criteria were selected. The analysis revealed that capnography monitoring group showed the lower incidence of hypoxemia (RR 0.76, 95%CI 0.70 to 0.83, p < 0.001) and the episodes of oxygen desaturation (RR 0.79, 95%CI 0.71 to 0.87, p < 0.001) compared with the oximetry monitoring group. Apnea was detected in capnography monitoring earlier than standard monitoring (RR 2.60, 95%CI 2.30 to 2.93, p < 0.001). No significant difference was found between capnography and standard monitoring groups in terms of reduction of events of bradycardia (RR 1.17, 95%CI 0.91 to 1.50, p = 0.225) and hypotension (RR 0.96, 95%CI 0.76 to 1.21, p = 0.746). Capnography monitoring reduced incidence of hypoxemia during procedural sedations. Within the limitations of this review, we suggest that the application of capnography during procedural sedation would decrease the frequency of oxygen desaturation events and incidence of hypoxemia. Training and instructing dental providers on using capnography monitoring would help in reducing adverse events during intravenous sedation.

A new reliable acoustic respiratory monitoring technology during upper gastrointestinal tract therapeutic endoscopy with CO2 insufflation.

Previous studies documented the effectiveness and benefits of capnography monitoring during propofol-based sedation for colonoscopy to reduce the incidence of hypoxemia. However, the performance of capnography during longer duration endoscopic therapy of upper gastrointestinal tract cancers under CO2 insufflation it is not well known. In this study, we compare a new device with acoustic monitoring technology to standard capnography monitoring. We retrospectively analyzed 49 patients who underwent endoscopic resection of early upper gastrointestinal tract cancer between December 2013 and October 2014. All 49 patients were monitored using both acoustic monitoring technology and standard capnography. We investigated the duration of the periods with unmeasurable respiratory rate during the overall procedure. When comparing standard capnography monitoring to the new acoustic monitoring technology, the ratio of the unmeasurable time was significantly lower in RRa (36.9% vs. 21.6%, p < 0.01). The ratio of unmeasurable respiratory rate by capnography was strongly correlated to the ratio of unmeasurable PETCO2 level by capnography (R2 = 0.847). There were no severe events or adverse events (grade 2 or more) during all 49 procedures. The acoustic monitoring technology provides a more reliable respiratory monitoring when compared to standard capnography during endoscopic resection of upper gastrointestinal tract cancers under CO2 insufflation, even if the procedures were prolonged and complex.

Volumetric Capnography Monitoring and Effects of Epinephrine on Volume of Carbon Dioxide Elimination during Resuscitation after Cardiac Arrest in a Swine Pediatric Ventricular Fibrillatory Arrest.

The aim of this study was to examine the use of volumetric capnography monitoring to assess cardiopulmonary resuscitation (CPR) effectiveness by correlating it with cardiac output (CO), and to evaluate the effect of epinephrine boluses on both end-tidal carbon dioxide (EtCO 2 ) and the volume of CO 2 elimination (VCO 2 ) in a swine ventricular fibrillation cardiac arrest model. Planned secondary analysis of data collected to investigate the use of noninvasive monitors in a pediatric swine ventricular fibrillation cardiac arrest model was performed. Twenty-eight ventricular fibrillatory arrests with open cardiac massage were conducted. During CPR, EtCO 2 and VCO 2 had strong correlation with CO, measured as a percentage of baseline pulmonary blood flow, with correlation coefficients of 0.83 ( p < 0.001) and 0.53 ( p = 0.018), respectively. However, both EtCO 2 and VCO 2 had weak and nonsignificant correlation with diastolic blood pressure during CPR 0.30 ( p = 0.484) (95% confidence interval [CI], -0.51-0.83) and 0.25 ( p = 0.566) (95% CI, -0.55-0.81), respectively. EtCO 2 and VCO 2 increased significantly after the first epinephrine bolus without significant change in CO. The correlations between EtCO 2 and VCO 2 and CO were weak 0.20 ( p = 0.646) (95% CI, -0.59-0.79), and 0.27 ( p = 0.543) (95% CI, -0.54-0.82) following epinephrine boluses. Continuous EtCO 2 and VCO 2 monitoring are potentially useful metrics to ensure effective CPR. However, transient epinephrine administration by boluses might confound the use of EtCO 2 and VCO 2 to guide chest compression.

Respiratory Monitoring in General Care Units.

Respiratory compromise is a common and potentially dangerous complication of patients admitted to general care units of hospitals. There are several distinct and disparate pathophysiologic trajectories of respiratory deterioration that hospitalized patients may suffer. Obstructive sleep apnea and preexisting cardiopulmonary disease increase the risk of respiratory failure after major surgery. Patients in general care units of hospitals currently receive only intermittent monitoring of vital signs. Early warning systems that utilize analysis of intermittently collected vital signs may result in earlier recognition of clinical deterioration. Continuous monitoring of oximetry and capnography may allow the detection of pathophysiologic abnormalities earlier in patients in general care units, but the evidence for improved clinical outcomes remains weak. Increased monitoring may lead to increased monitor alarms that can have negative effects on patient care.