Capnography and Infants

[18G]

I was in PEPP class today and one of the instructors told us that we are not able to use in-line capnography for monitoring tube placement due to the dead space that is created with the EtCO2 filter line adapter. It was told that we can apply it to initially verify but then we have to remove it and manually replace from time to time to confirm continued placement.

I have never heard of this and does not make any sense to me. If we're ventilating an infant with a BVM and are maintaining a proper EtCO2 and SpO2 what is the issue? It doesn't take much to dislodge an ETT in an infant and I do not feel comfortable not having continuous, real-time monitoring of the tube placement.

Thoughts?

 

[CANMAN]

Meh the end tidal adapter isn't going to cause a dead space issue as it's not enough to make a difference. That's more of an issue with small infants or neonates and the correct sized ventilator tubing if they are vented.

You will find most patients 5.0kgs and under are NICU criteria and most NICU teams don't use end tidal because there is little/no research of it's use in the neo world. As stupid as that sounds.

For our intubated peds transports all of them over 5kgs have continuous waveform end tidal monitoring from arrival at bedside til drop off in PICU.

In the field I would say peds patient use it, if you have a true neonate, like new born delivery, I wouldn't bother. Most providers will likely rarely/never intubate something that small and it comes with it's own struggles. A 10 second intubation attempt can put you bradycardia and hypoxic in that population. Your also gonna struggle to keep them warm enough so I would worry about good BVM techniques and keeping them warm/rapid transport over intubation in the field.

There is also the concern when your dealing with a 2.0 or 2.5 ETT that any additional appliance/weight on the tube is added position stress, even if adequately taped. When you dealing with a neo sometimes a half a cm is the difference between right mainstemmed and proper position above the carina.

 

[Flight-LP]

Meh the end tidal adapter isn't going to cause a dead space issue as it's not enough to make a difference. That's more of an issue with small infants or neonates and the correct sized ventilator tubing if they are vented.

You will find most patients 5.0kgs and under are NICU criteria and most NICU teams don't use end tidal because there is little/no research of it's use in the neo world. As stupid as that sounds.

For our intubated peds transports all of them over 5kgs have continuous waveform end tidal monitoring from arrival at bedside til drop off in PICU.

In the field I would say peds patient use it, if you have a true neonate, like new born delivery, I wouldn't bother.

There is also the concern when your dealing with a 2.0 or 2.5 ETT that any additional appliance/weight on the tube is added position stress, even if adequately taped. When you dealing with a neo sometimes a half a cm is the difference between right mainstemmed and proper position above the carina.

I concur.

Accuracy in the neonate is still inconclusive and as CANMAN mentioned, the appliance itself can cause some complications when it comes to ventilating these fragile newborns. As Neo and preemie tubes are uncuffed, it literally is less than a cm between "in place" and "somewhere else you don't want it to be". For these tiny little angels we will usually get an ABG and adjust ventilators needs off of it vs. trying to chase an EtCO2.

Around here it's not a weight based criteria for NICU vs. PICU. If they are out of the isolette (dirty), they're going to the PICU, be it 2 kg or 5 kg.