The use of capnography and the availability of airway equipment on Intensive Care Units in the UK and the Republic of Ireland*

Abstract

SummaryAt least 20% of reported major adverse airway events occur on the intensive care unit. This study surveyed 315 (96%) of all general, satellite, hepatobiliary, cardiac and neuro-intensive care units in the UK and the Republic of Ireland, finding that only 100 (32%) units always use capnography for tracheal intubation while only 80 (25%) always use capnography for continuous monitoring of patients requiring controlled ventilation. Three hundred and ten (98%) units utilise a checklist of airway equipment, 311 (99%) check its functionality on a daily basis and 296 (94%) units have access to a bronchoscope. Whilst 297 (94%) ICUs have an airway trolley, sufficient equipment for unanticipated difficult intubation was only seen on 33 (10%) of units. Guidelines addressing minimum standards for monitoring and airway safety on ICU are not being met and remain below the standard expected.

Capnography standards for outside the operating room

“…In 2009, the first AAGBI recommendation for the routine use of capnography in ICUs was published [6]. At the time, only 25% of UK ICUs used continuous capnography on ventilated patients and 40% never used it all [20].…”

Airway challenges in critical care

“…Although the use of capnography has long been mandatory during anaesthesia [23], and is also strongly recommended by the Intensive Care Society during tracheal intubation in the critically ill [24], a recent survey of all ICUs in the UK and the Republic of Ireland documented that capnography is always used for intubation in only one third of ICUs, and is always used continuously in patients receiving controlled ventilation in only 25% [25]. The NRLS data also echoed the rare use of capnography in the ICU, with documented use of capnography in just three of 1085 cases [8].…”

Time for capnography - everywhere

“…This appears an extremely high death rate, and the NAP4 investigators commented that it is likely that 74% of these ICU deaths could have been prevented had continuous capnography been used [48]. As only 25% of ICUs monitor patients routinely with capnography [9], this provides further evidence that capnography should become universal practice in the ICU as a matter of urgency. Indeed, NAP4 states as one of its recommendations that: “ continuous capnography should be used in all ITU patients with tracheal tubes (including tracheostomy) who are intubated and ventilator dependent ” [48].…”

“…Many of these incidents also involve human factors, training and other issues but for the team involved, never having the vital information from capnography available to them handicaps their response right from the start. Looking at the two groups of patients, one in theatre with 100% capnography and the other in ICU with only 25% capnography [9], NAP4 has virtually reported on the controlled trial of capnography that was never done in the 1980s and which would never get ethical approval today. In this way, the report now provides robust evidence – for anyone who was still in any doubt – that continuous capnography should be universal in ICU.…”