Waveform Capnography Research Articles

Capnography Detection Using Nasal Cannula Is Superior to Modified Nasal Hood in an Open Airway System: A Randomized Controlled Trial

The nasal cannula and modified nasal hood are methods used by oral and maxillofacial surgeons to detect expired carbon dioxide during procedural sedation in an open airway system. The purpose of this study was to compare the accuracy of the detection of expired carbon dioxide between the nasal cannula and modified nasal hood. The authors designed a parallel-group randomized controlled trial to compare the nasal cannula and modified nasal hood. Patients presenting to the authors' institution for outpatient oral and maxillofacial surgery (OMS) using intravenous deep sedation or general anesthesia were randomized to have capnography detection by the modified nasal hood or the nasal cannula. The primary outcome variable was the percentage of accurately captured breaths, as determined by the average number of capnography waveforms per auscultated breath using a precordial stethoscope. The 2 groups were compared using t test. Fifty patients were screened for enrollment in the study. Twenty-five patients were randomized to the nasal cannula group and 25 patients were randomized to the modified nasal hood group. The proportion of accurate waveforms, recorded as a percentage of total breaths, was 95.7±4.7% for the nasal cannula and 75.8±14.1% for the modified nasal hood (P<.0001). When used for capnography for procedural sedation in an open airway system for routine OMS, the nasal cannula accurately recorded more breaths than the modified nasal hood.

Waveform capnography in a South African prehospital service: Knowledge assessment of paramedics.

BackgroundWaveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment.MethodsA cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants’ knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography.ResultsSeventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking.ConclusionParamedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent.

Mask ventilation.

Effective mask ventilation is an essential skill for any practitioner engaged in airway management. Recent methods to objectively describe mask ventilation using waveform capnography help practitioners to monitor and communicate the effectiveness of mask ventilation. Gentle mask ventilation is now considered acceptable during rapid sequence induction/intubation after loss of consciousness, hence reducing the incidence of hypoxia prior to tracheal intubation. Mask ventilation can be enhanced with muscle relaxation, a double C-E grip, and jaw thrust. This is particularly relevant for patients with reduced apnoea time. An awareness of the complications associated with mask ventilation may help reduce the morbidity associated with this technique. Effective ventilation technique and optimum device selection are important aspects for resuscitation of the newborn. Teaching correct establishment and maintenance of mask ventilation is essential for safe patient care. This review will examine some of the latest developments concerning mask ventilation for adult and paediatric patients.

Enhancement of capnogram waveform in the presence of chest compression artefact during cardiopulmonary resuscitation

BackgroundCurrent resuscitation guidelines emphasize the use of waveform capnography to help guide rescuers during cardiopulmonary resuscitation (CPR). However, chest compressions often cause oscillations in the capnogram, impeding its reliable interpretation, either visual or automated. The aim of the study was to design an algorithm to enhance waveform capnography by suppressing the chest compression artefact. MethodsMonitor-defibrillator recordings from 202 patients in out-of-hospital cardiac arrest were analysed. Capnograms were classified according to the morphology of the artefact. Ventilations were annotated using the transthoracic impedance signal acquired through defibrillation pads. The suppression algorithm is designed to operate in real-time, locating distorted intervals and restoring the envelope of the capnogram. We evaluated the improvement in automated ventilation detection, estimation of ventilation rate, and detection of excessive ventilation rates (over-ventilation) using the capnograms before and after artefact suppression. ResultsA total of 44 267 ventilations were annotated. After artefact suppression, sensitivity (Se) and positive predictive value (PPV) of the ventilation detector increased from 91.9/89.5% to 98.0/97.3% in the distorted episodes (83/202). Improvement was most noticeable for high-amplitude artefact, for which Se/PPV raised from 77.6/73.5% to 97.1/96.1%. Estimation of ventilation rate and detection of over-ventilation also upgraded. The suppression algorithm had minimal impact in non-distorted data. ConclusionVentilation detection based on waveform capnography improved after chest compression artefact suppression. Moreover, the algorithm enhances the capnogram tracing, potentially improving its clinical interpretation during CPR. Prospective research in clinical settings is needed to understand the feasibility and utility of the method.

Comparison of Upper Airway Ultrasonography with Standard Waveform Capnography and Auscultation to Verify Correct Placement of Endotracheal Tube after Intubation

Comparison of Upper Airway Ultrasonography with Standard Waveform Capnography and Auscultation to Verify Correct Placement of Endotracheal Tube after Intubation

Suppression of chest compression artefact to enhance reliability of capnography waveform analysis during cardiopulmonary resuscitation

Introduction: Real-time capnography is an important monitoring tool to guide ventilation rates during cardiopulmonary resuscitation (CPR). However, during CPR capnograms are commonly distorted by chest compressions (CC) [ [1] Leturiondo et al. Resuscitation. 2018; 124: 63-68 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar ]. The reliability of automated ventilation detection based on the capnogram decreases in the presence of CC artefact [ [1] Leturiondo et al. Resuscitation. 2018; 124: 63-68 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar ].

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey.

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.

Enhancing ventilation detection during cardiopulmonary resuscitation by filtering chest compression artifact from the capnography waveform.

BackgroundDuring cardiopulmonary resuscitation (CPR), there is a high incidence of capnograms distorted by chest compression artifact. This phenomenon adversely affects the reliability of automated ventilation detection based on the analysis of the capnography waveform. This study explored the feasibility of several filtering techniques for suppressing the artifact to improve the accuracy of ventilation detection.Materials and methodsWe gathered a database of 232 out-of-hospital cardiac arrest defibrillator recordings containing concurrent capnograms, compression depth and transthoracic impedance signals. Capnograms were classified as non-distorted or distorted by chest compression artifact. All chest compression and ventilation instances were also annotated. Three filtering techniques were explored: a fixed-coefficient (FC) filter, an open-loop (OL) adaptive filter, and a closed-loop (CL) adaptive filter. The improvement in ventilation detection was assessed by comparing the performance of a capnogram-based ventilation detection algorithm with original and filtered capnograms.ResultsSensitivity and positive predictive value of the ventilation algorithm improved from 91.9%/89.5% to 97.7%/96.5% (FC filter), 97.6%/96.7% (OL), and 97.0%/97.1% (CL) for the distorted capnograms (42% of the whole set). The highest improvement was obtained for the artifact named type III, for which performance improved from 77.8%/74.5% to values above 95.5%/94.5%. In addition, errors in the measurement of ventilation rate decreased and accuracy in the detection of over-ventilation increased with filtered capnograms.ConclusionsCapnogram-based ventilation detection during CPR was enhanced after suppressing the artifact caused by chest compressions. All filtering approaches performed similarly, so the simplicity of fixed-coefficient filters would take advantage for a practical implementation.

Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound.

Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation. A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience. During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location. Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed. LemaPC, O'BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB. Avoid the goose! Paramedic identification of esophageal intubation by ultrasound. Prehosp Disaster Med. 2018;33(4):406-410.

Abstract 239: The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

Purpose: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals regularly track these metrics. Other studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. Therefore, we developed a unique curriculum for a Code Team Training (CTT) course, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes at our institution. Methods: CPR quality data was prospectively collected for quality improvement purposes once our institution had that capability, with 12-months pre-CTT and 21 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. A total of 456 multi-professional code team members were trained in 22 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed, except the ED. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Target metrics for CPR quality were based on 2015 AHA guidelines. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. Results: CPR quality was obtained from 140 of 230 (61%) in- and out-of-hospital pulseless adult cardiac arrest events over 33 months (50 [36%] before CTT and 90 [64%] following the first course). There was no significant difference between groups in terms of event location within the hospital nor initial event rhythm. A total of 116,908 chest compressions were evaluated. Median compressions in target rate improved from 32% before CTT to 49% after CTT (p&lt;0.05). When accounting for target rate and depth, the median compressions rate improved to 38% post-CTT compared to 31% pre-CTT (p&lt;0.05). While compression depth had a non-statistically significant decline (90.8% pre-CTT and 83.4% post-CTT), mean rate and median rate-in-target improved from 119.99 +/- 15.6 cpm and 32.4% pre-CTT to 113.7 +/- 16.1 cpm and 48.6% post-CTT (p&lt;0.05). The rate of ROSC improved from 60% (30 of 50) to 78% (70 of 90) after implementation of CTT (p=0.003), excluding IHCA in the ED. Index IHCA survival rate for our institution improved from 26% to 33% before and after CTT [p-value NS], which far surpasses the national average (23.8%). Conclusions: After the initiation of a CTT course that targets key code team member personnel, CPR quality significantly improved, which was associated with an increase in ROSC and a trend towards increased survival for in-hospital cardiac arrest patients.

Ultrasonography for Endotracheal Tube Placement Confirmation in an Emergency Setting - A Prospective Study in a Teritiary Hospital

Background: Ultrasonography, clinical methods and capnography are used to confirm the proper placement of endotracheal tube. Ultrasonography was thought to have high sensitivity and specificity and took less when compared with other two methods.&#x0D; Aims: To compare ultrasonography with the traditional clinical methods and the gold standard quantitative waveform capnography in confirming the proper placement of endotracheal tube.&#x0D; Materials and Methods: We carried out a prospective cohort study on 120 patients who were indicated for intubation in an emergency department of a tertiary care hospital, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana State, India. The study was carried out from June 2017 to December 2017. The confirmation of endotracheal tube placement was identified by three methods, ultrasonography, quantitative waveform capnography (end-tidal carbon dioxide) and traditional clinical method. The parameters recorded by three methods were confirmation of tube placement and time taken for tube placement.&#x0D; Results: Out of the 120 intubation attempts, six (5 %) had esophageal intubations. Ultrasonography produced a sensitivity and specificity of diagnosis of 98.63% and 100%, respectively, which was statistically comparable with the other two methods. When the time taken to confirm tube placement was compared, it was found that ultrasonography took significantly less time. The time taken by ultrasonography, waveform capnography and clinical methods was 8.13 ± 1.27, 17.86 ± 2.34 and 20.13 ± 2.72 seconds respectively.&#x0D; Conclusion: The endotracheal tube placement was confirmed by ultrasonography with comparable sensitivity and specificity to other two methods i.e. quantitative waveform capnography and clinical methods and it took less time.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry.

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events. A multicenter retrospective cohort study. Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative. Primary tracheal intubation in children younger than 18 years. None. Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics. Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Anaesthetic management of robotic-assisted gynaecology surgery in the morbidly obese - A case series of 46 patients in a UK university teaching hospital.

Background and Aims:The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position.Methods:We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis.Results:The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days.Conclusion:Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.

The Use of Waveform Capnography During Neonatal and Pediatric Transport

The Use of Waveform Capnography During Neonatal and Pediatric Transport

Using Benchmarks to Develop a Quality Improvement Project: Continuous Monitoring of Waveform Capnography in the Intubated Neonatal Patient

Using Benchmarks to Develop a Quality Improvement Project: Continuous Monitoring of Waveform Capnography in the Intubated Neonatal Patient

Accuracy of Real-time Intratracheal Bedside Ultrasonography and Waveform Capnography for Confirmation of Intubation in Multiple Trauma Patients

Background:A secure airway and effective ventilation are key components of advanced life support, and misplacement of endotracheal tube (ETT) can lead to morbidity in multiple trauma patients. The purpose of this study was to investigate the accuracy of ultrasound in diagnosis of direction for tracheal intubation.Materials and Methods:This descriptive-analytical study was conducted on 100 traumatic patients requiring intubation in 2016 in the Emergency Department of Al-Zahra and Kashani Medical Education Centers in Isfahan. Surface probe was placed transversally in the front of the neck at the top of the suprasternal notch, and the position of trachea was specified by front of comet-tail artifact which is the contour between hyperechoic air–mucosa (A–M) and a posterior reverberation artifact. Intubation accuracy by capnography was investigated, and the results were recorded in each patient's profile. Tracheal sonography was done during placement, or as soon as, the ETT has been embedded. The scanning time was minimized and it was carried out in total time of 10 s.Results:The diagnosis of intubation accuracy indicated that it was successful in 94 individuals (94%) and unsuccessful in 6 ones (6%). Intubation accuracy in 93 people (93%) was confirmed, and inaccuracy of intubation in 7 people (7%) was diagnosed. Ultrasound sensitivity in diagnosis of intubation accuracy was 97.9% (92.94) with 83.3% (5.6%) specificity. The positive and negative predictive values were 98.9% (92.93) and 71.4% (5.7%) respectively.Conclusion:Ultrasound method has high sensitivity and specificity to determine the correct placement of the tracheal tube, and it can be implemented as a reliable method given the acceptable positive and negative predictive values.

Use of Capnography to Optimize Procedural Sedation in the Emergency Department Pediatric Population

•Waveform capnography is a continuous measurement and graphical display of the carbon dioxide (CO2) levels throughout inspiration and expiration. It varies in accordance with a patient’s respiratory rate and tidal volume. During pediatric procedural sedation and analgesia (PSA), waveform capnography can indicate abnormal ventilation before it can be detected through physical assessment of ventilation or by pulse oximetry. •The weight of a few small, single-center, randomized controlled trials and observational studies suggest a benefit to the use of this technology. However, additional and larger studies are needed to elucidate a more substantial basis to inform best nursing practice. •Emergency nurses should be engaged in assessing all appropriate sources of data to determine whether use of capnography during PSA improves patient outcomes. •Waveform capnography is a continuous measurement and graphical display of the carbon dioxide (CO2) levels throughout inspiration and expiration. It varies in accordance with a patient’s respiratory rate and tidal volume. During pediatric procedural sedation and analgesia (PSA), waveform capnography can indicate abnormal ventilation before it can be detected through physical assessment of ventilation or by pulse oximetry. •The weight of a few small, single-center, randomized controlled trials and observational studies suggest a benefit to the use of this technology. However, additional and larger studies are needed to elucidate a more substantial basis to inform best nursing practice. •Emergency nurses should be engaged in assessing all appropriate sources of data to determine whether use of capnography during PSA improves patient outcomes. Leonie Rose Bovino, Member, ENA Connecticut State Council, is Assistant Professor, Quinnipiac University School of Nursing, Hamden, CT. Christina Brainard is Nursing Student at Quinnipiac University School of Nursing, Hamden, CT. Kristen Beaumier is Nurse at Quinnipiac University School of Nursing, Hamden, CT. Victoria Concetti is Nurse at Quinnipiac University School of Nursing, Hamden, CT. Nicole Lefurge is Nurse at Quinnipiac University School of Nursing, Hamden, CT. Emily Mittelstadt is Nurse at Quinnipiac University School of Nursing, Hamden, CT. Tabea Wilson is Nurse at Yale New Haven Hospital, New Haven, CT. Melissa L. Langhan is Physician at Yale New Haven Hospital, New Haven, CT, and Associate Professor, Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT.

Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents

PurposeWe sought to evaluate the utility of waveform capnography (WC) in detecting paralysis, by using apnoea as a surrogate determinant, as compared with clinical gestalt during rapid sequence intubation. Additionally,...

The Effect of an Interdisciplinary Simulation Training Program on Translational Outcomes for In-Hospital Cardiopulmonary Arrests

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: High-quality cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) is the primary component influencing return of circulation (ROSC) and survival to hospital discharge, but few hospitals track these metrics. Small studies have demonstrated significant improvements in survival after IHCA events following implementation of a dedicated code team training program. We developed a Code Team Training (CTT) course for our institution, and evaluated its post-implementation effect on CPR quality and post-IHCA patient outcomes. METHODS: CPR quality data was prospectively collected from actual IHCA events for quality improvement purposes, with 12-months pre-CTT and 11 months post-CTT. Pre-CTT data shaped the elements of the four-hour CTT course that included didactics, small group sessions, and high-fidelity simulation exercises. 111 multi-professional code team members were trained in 10 courses. Data collection included CPR quality and translational outcomes for events where CPR was performed. CodeNet® software was used for CPR quality measures, cardiac rhythm, defibrillation metrics, use of continuous waveform capnography, and pauses in compressions. Key translational outcomes measures included event location, ROSC, and survival to hospital discharge. RESULTS: CPR quality was obtained from 150 of 303 (49.5%) in- and out-of-hospital pulseless adult cardiac arrest events over 23 months (63 [44.4%] before CTT and 87 [54.0%] following the first course). Total CPR time captured was 24 hours, 5 minutes, 32 seconds (146,449 chest compressions). There was no difference between groups in terms of event location within the hospital, initial event rhythm, or the proportion of events transmitted to CodeNet™ via WiFi. Of note, there were significantly more out-of-hospital arrests in the post-CTT group. Median compressions in target depth and rate was 31.9% [IQR 10.2-64.4] before CTT and 75.0% [IQR 53.0-83.4] after CTT (p=0.005). While compression depth remained similar (88.2% pre-CTT and 94.3% post-CTT), mean rate and median rate-in-target improved from 117.49 +/- 16 cpm and 29% pre-CTT to 109.5 +/- 13.8 cpm and 61% post-CTT (p=0.0006). Index in-hospital pulseless cardiac arrest survival rate for our institution improved from 28% to 36% before and after CTT [p-value NS], which far surpasses the national average (23.8%). ROSC also trended towards an improvement from 49% to 58% (p-value NS). Survival for out-of-hospital arrests also improved from 0% to 8% (p-value NS). CONCLUSIONS: After the initiation of a CTT program targeting key code team member personnel, CPR quality significantly improved, which translated into a nonstatistically significant trend towards increased survival for IHCA patients. CLINICAL IMPLICATIONS: IHCA is a relatively infrequent high-stakes event with a low national average for survival to discharge that has not significantly improved over the years even with increased knowledge and technical advances. Preliminary results from our pilot study demonstrate that implementation of a formal CTT program resulted in 10 additional lives saved over a 6-month span compared to pre-intervention standard-of-care. Ongoing research is currently evaluating the long term sustainability and exportability of our CTT program. DISCLOSURE: The following authors have nothing to disclose: John Hunninghake, Heather Delaney, Justin Reis, Matthew Borgman, Raquel Trevino, Renee Matos No Product/Research Disclosure Information

Unrecognized failed airway management using a supraglottic airway device

Background911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. MethodsRetrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider’s assessment of success were then calculated. ResultsA total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider’s assessment was 98.5%; specificity was 28.7%. ConclusionThe use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.