With COVID-19 issuing disruptions to normalcy, the medical landscape is shifting dramatically. Emergency medical service (EMS) call volumes dropped by 26.1 percent as fears of going to the hospital during COVID-19 became more substantial.1 The time spent on each call, however, increased as personal protective equipment (PPE) requirements and COVID-19 screenings became new normal routines.1 The acuity of each patient also increased.1
As COVID-19 flooded hospitals with waves of infected patients, operating room (OR) elective surgical cases were cancelled with significance.2 Anesthesiologists and certified registered nurse anesthetists (CRNAs) were relocated to intensive care units (ICUs) in what has become known as COVID-19 units — a true reallocation of clinical resources. Experienced anesthesiologists and CRNAs brought capnography knowledge into these units and implemented the technology to help support improved patient outcomes.
Understanding the role of capnography on COVID-19 patients
Capnography monitoring is playing an important factor in managing COVID-19 patients. It is common practice to monitor EMS patients with capnography when pain medication, sedation or even oxygen is administered, and AHA society guidelines recommend it whenever an artificial airway is used.3 EMS patients are often monitored with capnography any time pain medication, sedation, or oxygen is given as well as if a patient is outfitted with an artificial airway. In acute care, capnography is important for assessing ventilation as well as detecting changes in perfusion and metabolism.4
Capnography serves as a unique tool with nothing else providing a snapshot of airway integrity, effective breathing and ventilation, perfusion, and metabolism in one clinical assessment tool.5 Connecting capnography monitors to a remote monitoring platform, such as Vital Sync™ remote monitoring technology, offer clinicians distancing opportunities in the hospital to help reduce COVID-19 exposure risks and supports PPE conservation.
Capnography expands beyond monitoring ventilation for COVID-19 patients
Anesthesiologists and CRNAs may use capnography through the original equipment manufacturer (OEM) or stand-alone monitor as their “makeshift” ventilator alarm because capnography is quick to pick up on airway loss or changes in patient ventilation while on the anesthesia machine.6
Clinicians continue to remain vigilant and agile in the face of COVID-19, applying capnography technology in the following ways to support improved patient outcomes:
- Airway patency and placement7
- Assisting in the identification of coagulation problems such as emboli, PE, DVT8
- Adequacy of ventilation and breathing9
- Objective measurement of respiratory rate10-13
- Assessment of intervention and treatment effectiveness14
- Changes in cardiac output, perfusion, and metabolism4
- Early identification of sepsis15
- Provides distance monitoring
- Ventilation/perfusion (V/Q) mismatch16
Limiting transmission in confined settings
Attention is focused on exposure and transmission of COVID-19 during hospital and medical transport risks. The size of a COVID-19 virus is 0.06 to 0.1 micron, but the virus uses patient aerosol to travel.6 Aerosol droplets are in the 0.3 to 10 micron size range and far exceed the size of the COVID-19 virus.6
Filtration of capnography sampling lines is important to help manage these risks. Recently, the Anesthesia Patient Safety Foundation (APSF) created COVID-19 specific resources on capnography filtration highlighting the 0.2-micron filtration capabilities of the Medtronic Microstream™ capnography sampling line.17
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2. Wu K., et al. Elective surgery during the covid-19 pandemic. The New England Journal of Medicine. October 2020.
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4. Cereceda-Sánchez, Francisco & Molina-Mula, Jesus. (2017). Capnography as a tool to detect metabolic changes in patients cared for in the emergency setting. Revista Latino-Americana de Enfermagem. 25. 10.1590/1518-8345.1756.2885.
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8. Sullivan, Bob. 4 Things EMS provides need to know about pulmonary embolism. June 2017. https://www.ems1.com/ems-products/capnography/articles/4-things-ems-providers-need-to-know-about-pulmonary-embolism-4I1Wv13PRksPyI0I/
9. Rieves A, Bleess B. (2017.) Be all end-tidal: The expanding role of capnography in prehospital care. National Association of EMS Physicians. Retrieved May 19, 2017, from www.naemsp-blog.com/emsmed/2017/3/22/be-all-end-tidal-the-expanding-role-of-capnography-in-prehospital-care.
10. Autet L, Frasca D, Pinsard M, Cancel A, Rousseau L, Debaene B and Mimoz O 2014 Evaluation of acoustic respiration rate monitoring after extubation in intensive care unit patients Br. J. Anaesth. 113 195–7
11. Frasca D, Geraud L, Charriere J M, Debaene B and Mimoz O 2015 Comparison of acoustic and impedance methods with mask capnometry to assess respiration rate in obese patients recovering from general anaesthesia Anaesthesia 70 26–31
12. Bergese S D, Mestek M L, Kelley S D, McIntyre R Jr, Uribe A A, Sethi R, Watson J N and Addison P S 2017 Multicenter study validating accuracy of a continuous respiratory rate measurement derived from pulse oximetry: a comparison with capnography Anesth. Analg. 124 1153–9
13. Ermer S, Brewer L, Kuck K and Orr J 2017 Detecting low respiratory rates using myriad, low-cost sensors SPACEGRANT (8th May 2017) (https://digitalcommons.usu.edu/spacegrant/2017/Session1/3/)
14. Spratt, Gregory, Farquharson, G. A Systematic Approach to Capnography Waveforms. Journal of Emergency Medical Services. August 2019. https://www.jems.com/2019/08/27/systematic-approach-to-capnography-waveforms/.
15. Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. American Journal of Emergency Medicine. 2013 Jan; 31(1):64-71.
16. Gravenstein JS, Jaffe MB, Gravenstein N, et al., editors. Capnography. Cambridge University Press: Cambridge, UK, 2011.
17. Feldman J., et al. FAQ on anesthesia machine use, protection, and decontamination during the COVID-19 pandemic. Anesthesia Patient Safety Foundation. May 2020. https://www.apsf.org/faq-on-anesthesia-machine-use-protection-and-decontamination-during-the-covid-19-pandemic.
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About the AuthorMore Content by Diane Larocque