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Abramo TJ, Cowan MR, Scott SM, Primm PA, Wiebe RA, Signs M. Comparison of pediatric end-tidal CO₂ measured with nasal/oral cannula circuit and capillary PCO₂. American Journal of Emergency Medicine. January 1994;13:30-33.

The use of a duo-port nasal/oral cannula in this study demonstrates a reliable method for monitoring EtCO₂ in a nonintubated normal pediatric population.

EtCO₂ values obtained via oral/nasal cannula circuit with side-stream capnometry in a nonintubated normal pediatric population related significantly with capillary PCO₂.

Abramo TJ, Wiebe RA, Scott S, Goto CS, McIntyre DD. Noninvasive capnometry monitoring for respiratory status during pediatric seizures. Critical Care Medicine. July 1997; 25:1242-1246

"Dependable end-tidal CO₂ values can be obtained in pediatric seizure patients using an oral/nasal cannula capnometry circuit. Continuous end-tidal CO₂ monitoring provides the clinician with a reliable assessment of pulmonary status that can assist with decisions to provide ventilatory support."

Anesthesia Patient Safety Foundation Newsletter. Spring 2000;15:1-20.

This is a special issue on office-based anesthesia (OBA) safety. This edition includes the guidelines for OBA:

In any location in which anesthesia is administered, there should be appropriate anesthesia apparatus and equipment which allow monitoring consistent with ASA Standards for Basic Anesthetic Monitoring and documentation of regular preventive maintenance recommended by the manufacturer.

Anesthesia Patient Safety Foundation Newsletter. Summer 2000;15:1-32.

Includes a letter in response to the spring issue on office-based anesthesia.

Barton C. Correlation of End-Tidal CO₂ measurements to arterial PaCO₂ in nonintubated patients. Annals of Emergency Medicine. March 1994.

Measurements of end-tidal carbon dioxide concentrations correlate well with PaCO₂ values in nonintubated patients presenting with a variety of conditions to EDs. End-tidal carbon dioxide measurements may be sufficient measures of PaCO₂ in selected patients and obviate the need for repeat arterial blood gas determination.

Benumof JL. Interpretation of capnography. Journal of the American Association of Nurse Anesthetists. April 1998;66:169-176.

The capnogram is an extremely useful breath-by-breath monitor of CO₂ exhalation.

Furthermore, the diagnosis of significant physiology and pathophysiology is contained within the shape of the capnogram. The diagnosis of this pathophysiology is best made by a systematic analysis of the four phases of the capnogram.

Bhatia T, Mahlmeister M. Current applications of capnography. RT: The Journal for Respiratory Care Practitioners. June/July 1995.

Carbon dioxide gas monitoring has evolved over the past 20 years to reach the point at which it can serve as a safe, valuable tool for continuous non-invasive monitoring of gas exchange. Institutions demonstrating the greatest success with capnography have succeeded by incorporating carbon dioxide monitoring into established patient care protocols.

Bhende M. Capnography in the Pediatric Emergency Department. Pediatric Emergency Care. February 1999; 15:64-69

"EtCO₂ measurement has been found to be the most reliable method of confirming ETT position."

"EtCO₂ monitoring has emerged as a valuable non-invasive clinical tool in the setting of CPR, and some investigators have suggested using EtCO₂ as a guide to implementing more aggressive measures..."

"Capnography was found to be useful in detecting blocked airways and recognizing subclinical respiratory depression..."

"End-tidal carbon dioxide measurement is at present perhaps the most reliable means under all circumstances of determining proper tube position and should be employed routinely whenever possible."

Brodsky , JB, Lemmens HJM, Kumar KR, Brock-Utne JG. Evaluating Ventilation During Monitored anesthesia Care: A Comparison of Two Capnography Systems. Poster presented at ASA 2001.

Microstream® technology allows accurate measurement of ET-CO₂ in the absence of an endotracheal tube. Non-invasive CO₂ monitors are an important complement to pulse oximetry for spontaneously breathing patients in the operating room and at remote anesthetizing locations.

Carpenter R, Burns SM, Truwit JD. Development of a procedure using end-tidal CO₂ (EtCO₂) measurements to prevent placement of feeding tubes into the lungs. American Journal of Critical Care. May 2000;9:220. Abstract.

Inadvertent placement of feeding tubes into the lungs is relatively common. Since EtCO₂ monitors can rapidly detect CO₂, we hypothesized that a quality and cost-effective technique using the technology might be developed to accurately assess tube placement. The study hypothesis was supported.

Carroll P. Monitoring Patients During Infusion Therapy for Pain Control. RT, The Journal for Respiratory Care Practioners. August 2003

"..... a newer form of sidestream capnography has made it possible for any patient at risk for hypoventilation to benefit from continuous ETCO₂ monitoring." "RTs also should note that spot checks using pulse oximeters are not supported by research; hypoventilation can occur with no change in physicial assessment, even in the presence of normal SpO₂ readings; and the most effective way to monitor infusions that can put patients at risk for respiratory depression is to monitor oxygenation using pulse oximetry and to monitor ventilation using capnography."

Carroll P. Capnography. RN. May 1999

"But while ABGs have become a standard monitoring tool, capnography has been slower to catch on. That's partly because EtCO₂ is not strictly regulated by the patient's ventilatory status like arterial CO₂ levels are; values are affected by the matching of ventilation in the lungs with the perfusion of the pulmonary capillaries. Alterations of either can skew correlation with PaCO₂ values."

Carroll P, Farquharson G. Using Capnography Effectively in Critical Care. NTI News

With Microstream® capnography, the critical care nurse can monitor both intubated and non-intubated asthma patients to detect airway obstruction by analyzing waveform configuration. Waveform analysis can be used to assess progression of airway narrowing or efficacy of interventions.

Capnography monitoring detects apnea immediately, regardless of supplemental oxygen administration, and provides an earlier warning of apnea when compared with pulse oximetry during sedation 12.

Capnography, once a cumbersome device that was very difficult for bedside clinicians to use, has evolved into a simple device requiring infrequent calibration or that is self-calibrating. With advances in technology, capnography can now be used in spontaneously breathing adults and children as well as intubated patients.

Carroll P. Procedural sedation: Capnography heightened role. RN, Vol. 65, No. 10. October 2002.

Outside the OR, it has become increasingly common for nurses to administer procedural sedation. Now, with capnography, you can monitor patients respiratory status more closely and accurately.

Until recently, capnography was a complicated technology that could be used only with adapters that attached to endotracheal or tracheotomy tubes. Today, a type of capnography called Microstream® allows you to monitor exhaled CO₂ levels on spontaneously breathing patients with a nasal cannula-like device.

Casati A, Gallioli G, Passaretta R, Scandroglio, Bignami E, Torri G. End tidal carbon dioxide monitoring in spontaneously breathing, non-intubated patients. A clinical comparision between conventional sidestream and Microstream® capnometers. Minerva Anestesiol 2001; 67:161-4

"The Microstream® capnometer provides a more accuarte end tidal CO₂ partial pressure measurement in nonintubated, spontaneously breathing patients than conventional sidestream capnometers, allowing for adequate monitoring of the respiratory function in nonintubated patients."

Casati A, Gallioli M, Passaretta R., Borghi, B, Torri G. Accuracy of end-tidal carbon dioxide monitoring using the NPB-75 Microstream® capnometer. A study in intubated ventilated and spontaneously breathing nonintubated patients. European Journal of Anaesthesiology 2000. 17, 622-626.

measuring the end-tidal carbon dioxide partial pressure through a nasal cannula using the NBP-75 Microstream® capnometer provides an estimation of arterial carbon dioxide partial pressure similar to that provided when the same patients are intubated and mechanically ventilated.

Colman Y, Krauss B. Microstream® capnography technology: a new approach to an old problem. Journal of Clinical Monitoring and Computing. August 1999; 15:403-409

"Microstream® features low flow rates, reduced dead space, lack of moisture-associated occlusion problems, and low power consumption. Furthermore, it can be used reliably in both intubated and non-intubated patients."

"The unique features of Microstream® core technology hold the potential to overcome the limitations associated with conventional capnography technologies."

Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. April 2000;105:805-814.

There has been a dramatic increase in the number and complexity of procedures conducted in children; for many, compassion and successful accomplishment dictate the use of sedation/analgesia.

Our study found that the most common issues judged to be associated with adverse sedation events were related to the effects of sedating medications on respiration.

Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. October 2000;106:633-644.

The observation that negative outcomes were associated with all classes of drugs and all routes of administration is clinically important because it points out that these negative outcomes occur not because of the drugs themselves but rather because of drug administration practices (drug combinations, errors, and monitoring standards).

Monitoring of patients who receive this medication should be no less rigorous than that used for patients sedated with other sedative medications.

Crawshaw J. [CRC Plus Editor] Capnography Now Available for Nonintubated Patients. Critical Care Alert. November, 2002

the greatest potential application for capnography is non-intubated patients, patients who have recently been extubated or have a severe respiratory problem such as asthma, and patients undergoing heavy sedation. "Technology is now available that allows non-intubated patients to have quite accurate end tidal CO₂ measurement," ."There are many more potential applications as well for non-intubated patients with conditions that could lead to hypoventilation. The next step is patient studies and peer-review."

Recommendations from the American Society of Anesthesiologists, he adds, suggest that monitoring for apnea using the detection of exhaled CO₂ is a useful adjunct to pulse oximetry in assessing ventilation of patients undergoing sedation and analgesia.

Crespo AS. Capnography. RT International. Fall 1997:71-73

"Capnography, in addition to evaluating alveolar ventilation, provides important data about airway permeability, cardiac and circulatory function, and ventilator performance. This non-invasive form of evaluation holds many potential advantages over ABG analysis..."

This article contains a thorough list of clinical applications as well as a chart comparing observations of mainstream and sidestream technology.

Croswell RJR, Dilley DC, Lucas WJ, Vann WF. A comparison of conventional versus electronic monitoring of sedated pediatric dental patients. Pediatric Dentistry. 1995; 17:352-339

"Ten confirmed episodes of respiratory compromise were identified by traditional monitoring. All of the ten confirmed respiratory compromise episodes were detected by capnography; none were detected by oximetry."

Dang K, Breen PH. Ambulatory capnography. RT Magazine. June/July 1998; 11

"Unrecognized respiratory difficulty with resultant hypoxemia is a major contributing factor to morbidity and mortality during conscious sedation in the ambulatory setting. In sedated patients, capnography appears to be the earliest, most effective monitoring aid to the detection of respiratory compromise, and it is recommended in conjunction with pulse oximetry."

Duarte AG, Lick S, Bidani A. Capnography in a double-lung transplant recipient with respiratory failure. Respiratory Care. October 1999;44:1207.

Identification of a biphasic capnogram in a double-lung transplant recipient should alert the clinician to the development of an airway complication at the anastomosis or elsewhere, because the capnogram should be of normal shape and contour after this type of surgery.

Editorial Staff. An objective measure of bronchospasm. Emergency Medicine. April 1997:50-56.

The slope of the alveolar plateau is changed by the asynchronous emptying caused by altered airway resistance. He believes that because it is at least as accurate as the PEFR and FEV1 and potentially easier to obtain, it will eventually replace other measurements.

Primary care physicians should learn to recognize the gross shapes of the normal and abnormal capnogram.

Egleston CV, Ben Aslam H, Lambert MA. Capnography for monitoring non-intubated spontaneously breathing patients in an emergency room setting. Journal of Accident and Emergency Medicine. July 1997;14:222-224.

An ideal form of respiratory monitoring would not rely heavily on patient compliance or require the interruption of oxygen or drug treatment, while giving a real time graphic display. Capnography has these qualities.

Capnography may be used as a means of continuous respiratory monitoring in non-intubated acutely ill patients. Capnogram analysis may be used to indicate airway obstruction in these patients.

Falk JL, Sayre MR. Confirmation of airway placement. Prehospital Emergency Care. October/December 1999; 3: 273-277

"All endotracheal intubations must be accompanied by an objective confirmation of endotracheal tube placement. The optimal method of measurement is quantitative capnography and its use on all intubated patients is strongly suggested. In patients without a pulse, use of quantitative capnography is especially important."

Falk JL. End-tidal CO₂ monitoring in the Emergency Department: how, when, and why. Clinical Courier. February 1994; 12

"The monitoring of end-tidal carbon dioxide pressure is becoming an increasingly important means of evaluating respiratory and circulatory function in both cardiopulmonary arrest and traumatic shock."

"If you have the facility for end-tidal CO₂ monitoring, the days of having to stop pumping to feel for a pulse and check the patients heart rhythm are over. The end-tidal CO₂ will tell you whether you need to keep pumping or not."

Fay B. To Utilize Capnography Monitoring or not to Utilize Capnography Monitoring with Conscious Sedation During an Electrophysiology Procedure, that is the Question, a Two Year Review and Study. Abstract/Poster NASPE. 2002.

It is therefore postulated that with ETCO₂ monitoring, the non-anesthesiologist delivering conscious sedation is able to better to monitor the level of sedation to the patient.

Fearon DM, MD, Steelw DW, MD. End-tidal Carbon Dioxide Predicts the Presence and Severity of Acidosis in Children with Diabetes. Academic Emergency Medical Journal, December 2002; Vol 9, No. 12; 1373-378

End-tidal CO₂ is linearly related to HCO3 and is significantly lower in children with DKA [diabetic ketoacidosis].

We were able to demonstrate a linear relationship between ETCO₂ and HCO3. Additionally, we found that ETCO₂ measured by nasal capnography serves as a clinically useful predictor of acidosis.

Nasal capnography is easy to perform at the beside, provides continuous and almost instantaneous information, and is well tolerated by patients.

Flanagan JFK, Garrett JS, McDuffee A, Tobias JD. Noninvasive monitoring of end-tidal carbon dioxide tension via nasal cannulas in spontaneously breathing children with profound hypocarbia. Critical Care Medicine. June 1995;23:1140-1142.

End-tidal CO₂ measurement by infrared spectroscopy provides an accurate estimation of PaCO₂, even during episodes of severe hypocarbia. Its use may limit the need for invasive monitoring and/or repeated arterial blood gas analysis.

Frakes Michael A. Measuring End-tidal Carbon Dioxide: Clinical Applications and Usefulness. Critical Care Nurse. Vol 21 No. 5. October 2001

Capnometry and capnography provide useful clinical information. The use of PETCO₂ to estimate Paco₂ should be individualized, and the procedure should be implemented with caution, but use of PETCO₂ values and waveforms to confirm intubation, monitor mechanical ventilation, evaluate the progression of cardiac arrest, and aid in diagnosing pulmonary embolus is supported by the available research. Capnography provides valuable information beyond the partial pressure of exhaled carbon dioxide.

Gandhi SK, Munshi CA, Bardeen-Henschel A. Capnography for detection of endobronchial migration of an endotracheal tube. Journal of Clinical Monitoring. January 1991;7:35-38.

Unintended endobronchial intubation should be suspected when PetCO₂ drops acutely with increased peak airway pressure during a surgical procedure, especially when frequent manipulation of the head or neck or both is involved or the surgeon has manipulated the endotracheal tube.

Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA. February 2000;283:783-790.

Of 186 patients in both groups in whom intubation was believed successful and complications could be determined, 3 patients (2%) were esophageally intubated, 12 (6%) suffered unrecognized dislodgement of the endotracheal tube en route to the ED, 15 (8%) experienced recognized dislodgement of the endotracheal tube, 33 (18%) received main stem intubation, and 44 (24%) were intubated with a tube of the incorrect size.

The high dislodgement rate found in this study may be attributed to the short tracheal length of children and the constant movement that occurs in the out-of-hospital setting.

Genuit T, Napolitano LM. Capnography in the critically ill. International Journal of Intensive Care. Summer 2000;7:101-107.

Capnography has found application in a wide variety of clinical situations including acute respiratory and cardiovascular disturbances, monitoring during sedation and anesthesia, as well as monitoring of mechanical ventilation and ventilator weaning in critically ill patients. This review examines the different clinical applications of capnography and outlines its usefulness and limitations.

Glaeser P. Out-of-hospital intubation of children. JAMA. February 2000;283:797-798.

This is an editorial review of the Gausche article above.

Moreover, only 83% of the patients who received BVM and 82% of those who received ETI were reported to have good chest rise, suggesting inadequate ventilation for some patients in both groups.

In addition, end-tidal carbon dioxide monitors were used in only 77% of patients who were intubated and were not used continuously during transport.

Consensus from a prehospital care conference was that it is essential that emergency medical personnel not only use verification devices to check initial tube placement, but also use ongoing monitoring to be sure that the tube remains in place during transport.

Green SM, Krauss B. Pulmonary Aspiration Risk during Emergency Department Procedural Sedation - An Examination of the Role of Fasting and Sedation Depth. Academic Emergency Medicine. January 2002;9:35-42.

Emergency physicians should maximize the use of available monitoring technologies in order to reduce potential PSA risks. Although pulse oximetry is a reliable measure of oxygenation, it does not directly measure ventilation. Capnography provides a continuous, breath-by-breath measure of ventilatory function and the earliest detection of respiratory abnormalities with apnea resulting in an almost instantaneous loss of the carbon dioxide waveform"

Greensmith JE, Aker JG. Ventilatory management in the postanesthesia care unit. Journal of PeriAnesthesia Nursing. December 1998;13:370-381.

Respiratory complications are major contributors to morbidity and increased mortality in the immediate postoperative period.

Oxygenation is best monitored by the use of pulse oximetry, whereas ventilation is best monitored by the application of capnography.

It must be remembered that decreases in arterial oxygen saturation as determined by pulse oximetry may be a late indicator of a deterioration in ventilation.

By analyzing the capnograph trace instead of merely the numerical value, the bedside observer garners more accurate data.

Hagerty JJ, Kleinman ME, Lyons AC, Krauss B. Accuracy of a new low-flow sidestream capnography technology in newborns. Abstract presented at Pediatric Academic Societies and American Academy of Pediatrics Joint Meeting; 2000.

Low-flow capnography with Microstream® technology accurately measured alveolar PCO₂ in newborns without pulmonary disease, as demonstrated by normal Et-arterial CO₂ gradients.

Hagerty JJ, Krauss B, Insoft RM. Characterization of capnograms in healthy newborns. Abstract presented at Pediatric Academic Societies and American Academy of Pediatrics Joint Meeting; 2000.

Capnograms during spontaneous breathing in healthy, full-term newborns were characterized quantitatively using four waveform parameters. These parameters in healthy newborns can be used to compare characteristics of end-tidal CO₂ waveforms in spontaneously breathing infants with mild respiratory disease.

Harrison TH, Ahmed W, Thomas SH, Wedel SK. Effect of fentanyl on end-tidal carbon dioxide in air-transported patients. Annals of Emergency Medicine. October 2000;36:4. Abstract.

This study demonstrates the feasibility of out-of-hospital EtCO₂ monitoring with the implication for increased safety margin for out-of-hospital analgesia provision.

Hart LS, Berns SD, Houck CS, Boenning DA. The value of end-tidal CO₂ monitoring when comparing three methods of conscious sedation for children undergoing painful procedures in the emergency department. Pediatric Emergency Care. June 1997;13:189-193.

The ability to adequately monitor for respiratory depression is essential when these potent sedatives are used. A recent study demonstrated that inadequate monitoring is the second leading cause of death and major adverse sequelae in children undergoing conscious sedation.

In this study we found that the incidence of respiratory depression in patients who received either fentanyl or fentanyl-midazolam was twice that reported in previous studies, a finding that may be attributed to the fact that this study was the first to use etCO₂ monitoring.

End-tidal CO₂ monitoring provided an earlier indication of respiratory depression than pulse oximetry and respiratory rate alone.

Heard L. Early Warning. Capnography may help nurses detect hypoventilation in sedated patients. Advance for Nurses August 19, 2003.

"Capnography has been shown to rapidly detect hypoventilation and early signs of respiratory distress before visual assessment of pulse oximetry. This advance in technology may reduce the incidence of respiratory emergencies."

"Capnography is a technical advance that appears to allow for a more accurate indication of patient ventilation during procedures. Ultimately, capnography may prevent over sedation and allow for prompt stimulation of sedated patients, ensuring they are responsive and spontaneously breathing."

Heard LA, Donovan KM, Lightdale JF, Sethna NF, Fox VL. Integrating capnograpy into the monitoring of children undergoing gastrointestinal procedures requiring sedation. Poster presentation. ASNA 2002.

We found that Microstream® capnography was easily integrated into the routine monitoring of children undergoing endoscopy with conscious sedation. The dual cannulae were easy to apply for nursing staff and well tolerated by patients. ..Finally, capnography may have indicated ventilatory compromise in some patients that was not detected by routine electronic monitoring and clinical assessment.

Hill J. Policy in the making. Advance for Managers of Respiratory Care. June 1998;7:40-43.

The project successfully decreased ABG collection and decreased overall SICU time.

It also continues to cut half of the previous ABG draws. In the first 100 cases of the protocol trial, the facility saved more than $7,200.

Once we demonstrated the validity of pulse oximetry and capnography, the staff and department heads became more willing to study, experiment with and accept new advances, techniques and ideas.

Hospodar GJ. Conscious sedation are we asleep at the wheelRT: The Journal for Respiratory Care Practitioners. February/March 2001.

One must always remember that it is not the medication itself that denotes sedation in the patient, but the patient's individualized response to the administered medication.

Pulse oximetry (SpO₂), end-tidal carbon dioxide (EtCO₂), and supplemental oxygen may be used as appropriate to procedure protocol or to the patient's condition. Recent improvements in EtCO₂ sidestream technology make this a viable, non-invasive option for assessment purposes that rapidly notes respiratory response to administered medications. In addition, capnography has been clearly shown to provide the earliest warning of respiratory depression and apnea long before changes in pulse oximetry occur.

Hunt GE. Essentials of capnography in neonatal and pediatric patients. RT: The Journal for Respiratory Care Practitioners. June/July 1994;36-38.

The appropriate, effective use of capnography in neonatal and pediatric patients requires that the RCP become thoroughly acquainted with how the application and interpretation of capnography in pediatric patients differ from those in adult patients.

Ireland D. Pediatric legalities. Journal of PeriAnesthesia Nursing. December 2000;15: 423-429.

The American Academy of Pediatrics (AAP) developed guidelines for suggested monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures (Table 2).

The AAP states that airway monitoring might be the most important factor in assuring the safety of the pediatric patient.

Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine. January 2001;37:32-37.

The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency medical services (EMS) community in which ETCO₂ monitoring was not consistently used.

With one exception, all patients found to have esophageal tube placement exhibited the absence of ETCO₂ on patient survival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.

"Ironically, in the out-of-hospital setting, where reliable techniques to verify proper tube placement are needed most, use of ETCO₂ monitoring has been limited. There are, however, examples of EMS systems throughout the country in which routine use of ETCO₂ monitors for verification of tube placement has contributed to the virtual elimination of the problem of unrecognized, misplaced tubes."

Kline JA, Arunachlam M. Preliminary study of the capnogram waveform area to screen for pulmonary embolism. Annals of Emergency Medicine. September 1998;32:289-296.

"This study provides preliminary evidence that the capnogram waveform area may have value in the clinical evaluation for PE. The mean capnogram area among subjects with PE was approximately one half the area of capnograms from patients without PE."

Knapp S, Kofler J, Stoiser B, et al. The assessment of four different methods to verify tracheal tube placement in the critical care setting. Anesthesia and Analgesia. 1999; 88:770-776

"...capnography is the most reliable method for detecting tube position, independent of the examiner's experience."

Krauss , B. Capnography in EMS. JEMS . January 2003.

"Capnography can provide important objective information in conditions where EMS professionals have previously had to rely on subjective assessment."

"You can now use capnography in nonintubated patients with acute bronchospastic disease or in hypoventilation states to objectively confirm your clinical judgment and guide patient management...The potential for improving patient care and outcomes is significantly enhanced with this [capnography] additional objective assessment data."

"Capnography, using continuous waveform monitoring, can immediately alert an EMS professional to a misplaced or dislodged endotracheal tube. This is particularly critical during transports or when caring for children with small, uncuffed enddtracheal tubes that can easily move out of position."

Krauss B, Carroll P. Procedural sedation and analgesia: an evolving role for RCPs. RT Magazine. June/July 2000; 13:31-35

"Improvements in capnography technology means that this monitoring is easy to use and reliable. Historical problems with accuracy during sidestream sampling via nasal cannula in children have recently been solved by new low-flow technology. A sidestream capnograph with nasal cannula can be placed on the patient prior to medication administration to establish a baseline. Readings from the capnograph can be displayed in both digital and waveform configurations, and a knowledgeable clinician watching the capnogram can immediately identify changes in waveform that could indicate hypoventilation due to oversedation, or loss of the waveform indicating apnea. Capnography has been clearly shown to provide the earliest warning of respiratory depression and apnea, long before changes in pulse oximetry occur."

Krauss B, Green S, Sedation and analgesia for procedures in children. New England Journal of Medicine. March 2000; 342:938-945

Excellent coverage of procedures, pharmaceuticals, definitions and proper preparation of staff. A new primer for anyone who sedates pediatric patients.

Letterer , A, Respiratory Monitoring During Procedural Sedation. Medtronic Physio-Control, 2000

"Monitoring a patient's ventilatory status can be best done through end-tidal carbon dioxide (EtCO₂) monitoring. End-tidal carbon dioxide (EtCO₂) monitoring is the most effective way to clinically evaluate ventilation in an alert but sedated patient."

"Sidestream Capnography units are configured for use in nonintubated spontaneously breathing patients using a nasal cannula for sampling. EtCO₂ and respiratory rate can be monitored on a breath-to-breath basis and may provide the earliest warning sign of breathing difficulty. The ability to detect increased EtCO₂ levels will alert the clinician to the presence of respiratory problems, allowing for intervention before hypoxia develops."

"This new ASA standard in conjunction with JCAHO and AAP guidelines clearly mandate the use of CO₂ monitoring for patients who are deeply sedated or rendered unconscious by anesthetic agents."

Levine R. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. New England Journal of Medicine. July 1997; 337:301-306

"An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patients."

"The difference between survivors and nonsurvivors in 20-minute end-tidal carbon dioxide levels is dramatic and obvious, and extensive analyses are not necessary to demonstrate it."

Lightdale JR, Sethna NF, Heard LA, Donovan KM, Fox VL. A pilot study of end-tidal carbon dioxide monitoring using Microstream® capnography in children undergoing endoscopy with conscious sedation. Abstract, DDW 2002.

"We found Microstream® capnography to be well tolerated by children undergoing endoscopy. Furthermore, capnography may have indicated ventilatory compromise in some patients that was not detected by routine electronic monitoring and clinical assessment. Recent technical advances in this technology may allow the accurate monitoring of ETCO₂ in the endoscopy suite, which may provide a better indicator of patient ventilation during procedures.

Malviya S, Voepel-Lewis T, Tait AR, Merkel S. Sedation/analgesia for diagnostic and therapeutic procedures in children. Journal of PeriAnesthesia Nursing. December 2000;15:415-422.

"Children, however, frequently require deeper levels of sedation to tolerate or cooperate with procedures."

"The implementation of stringent monitoring standards for all sedated patients is necessary to avoid potentially disastrous events. In one study, 7 of 11 major intraoperative anesthesia-related adverse events occurred because of unrecognized hypoventilation, and at least 8 of these incidents could have been avoided by appropriate monitoring."

"capnography via a nasal cannula may provide a valuable monitor for presence of air exchange and early detection of airway obstruction."

Maslow A, Stearns G, Bert A, et al. Monitoring end-tidal carbon dioxide weaning from cardiopulmonary bypass in patients without significant lung disease. Anesthesia and Analgesia. February 2001;92:306-313.

"Over a wide range of pulmonary blood flow observed in normothermic patients without significant pulmonary disease, there was a close correlation between PetCO₂ and PAQt, suggesting that PetCO₂ could be used to assess hemodynamics during weaning from CPB."

"it would be a cost-effective monitor of blood flow that does not require additional cost, technology, personnel, or training."

Mason K, Connor L, Burrows P, Zurakowski, Krauss B. Accuracy of capnography with a 30 foot nasal cannula for monitoring respiratory rate and end-tidal CO₂ in sedated children undergoing MRI. Abstract Presentation, Society for Pediatric Anesthesia. 1999 .

"We conclude that the NPB-75 with a specially designed 30' NC is accurate in the measurement of RR and EtCO₂. The NPB-75 with the 30' NC may be adapted for use on the non-intubated, sedated pediatric patient undergoing MRI."

Matera P. The truth about ET tube movement. JEMS. June 1998 23:37-42

"The ET tube tip can be displaced out of the trachea without any movement of the proximal endotracheal tube. Therefore, unobserved extubation may occur."

"We must revisit prior studies that have alleged improper ET tube placement by prehospital providers to correct for this phenomenon."

"If the proximal end of the ET tube is pulled away from the patient's trachea at the same time the patient's head is extended, the ET tube tip movement is accentuated. Additionally, the lung root, which is not a rigid structure, can move up and down during a patient's cough and accentuate ET tube displacement."

Morris M, Kinkade S. Does capnometry enhance patient care in the prehospital setting" Journal of Emergency Nursing, 1999

"Capnography can be useful in the prehospital setting to help maintain appropriate manual and mechanical ventilation. Capnography may be helpful in preventing hypo- and hypercapnia in the critically ill and injured patient if the prehospital staff use the feedback to make appropriate adjustment in manual ventilation techniques or ventilator settings."

Nguyen J. End tidal carbon dioxide monitoring during CPR: a predictor of outcome. Emergency Nursing World. http://ENW.org (online publication, 2001)

"Approximately $1 billion is spent on emergency department and in-hospital care for cardiac arrest nonsurvivors. A reliable method of assessing the efficacy and usefulness of ongoing cardiopulmonary resuscitation (CPR) would conserve scarce health care resources, avoid futile care, pain and suffering."

O'Connor R, Sworr R. NAEMSP Position Paper: Verification of endotracheal tube placement following intubation. Prehospital Emergency Care. July/September 1999; 3:248-250

"Given the efficacy of devices such as the electronic EtCO₂ detector in the operating suite, the American Society of Anesthesiology has included EtCO₂ detection in their "Standards for Basic Intra-operative Monitoring." This action, combined with the ready availability of inexpensive devices, has established EtCO₂ detection as the standard of care for endotracheal intubation in the hospital."

Ornato J, Peberdy MA. Prehospital end-tidal carbon dioxide monitoring: it's not all hot air. JEMS. March 1993;18:140-146.

"Being able to monitor the PetCO₂ concentrations gives prehospital providers useful information about both ventilation and perfusion."

Phillips S. Critical care transport in Summit County. Emergency Medical Services. June 1999; 28:94-96

"We did exhaustive research and had to base our protocol on information gathered from anesthesia papers and anecdotal information from local flight programs. We finally settled on ranges of 28-32 mmHg EtCO₂ for head-injured patients and 32-36 mmHg for non-head-injured patients. When we first started monitoring this parameter, we were able to set the ventilator rate as low as 8 breaths per minute and still achieve relative hyperventilation."

Price D, Burns B. Brain injuries. Emergency Medical Services. June 1999;28:65-67.

This article discusses the latest national evidence-based recommendations for treatment of TBI (traumatic brain injury) as they relate to prehospital care.

"only patients with signs of herniation should be hyperventilated, and then only to a level of 30 mmHg, not 25 mmHg as recommended in the past."

"We strongly urge all EMS agencies to invest in EtCO₂ monitoring by purchasing new units, or when replacing your monitors."

Recker D, Cost containment: weaning of the cardiac surgical patient. Journal of Nursing Quality Assurance. 1991; 5(4):50-55

"The most significant difference was in the number of ABGs done. There was a 44% decrease in the number of ABGs obtained with the use of the weaning protocol."

"The average savings to the patient following weaning protocol use was $156.71. This amounts to an annual cost savings of $62,684."

Renaghan D. Capnometric analysis of carbon dioxide rebreathing during non-invasive positive pressure ventilation with BiPAP. Critical Care Medicine. December 2000;28: A177. Abstract.

"Preliminary data in normal subjects demonstrates the utility of side-stream capnometry during nasal BiPAP ventilation. Nasal measurements accurately reveal impaired ventilation with reproducible elevations in FiCO₂ and EtCO₂."

Roberts W, Maniscaico W, Cohen AR, Litman R, Chhibber A. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatric Pulmonology. 1995; 19:262-268

"Of greater importance is the fact that no group of clinicians was free of risk for esophageal intubation."

"The results demonstrate that

1. in neonates, capnography is a more sensitive and specific indicator of esophageal intubation than is clinical examination;
2. capnography accelerates recognition of misintubation;
3. even experienced intubators misplace endotracheal tubes in neonates, and capnography can help recognize these esophageal intubations;
4. capnography may prevent the unnecessary removal of correctly placed tubes, especially when the clinical examination is ambiguous;
5. many unintentional extubations occur during the taping of the tube."

Roskowski D. Is EtCO₂ analysis indicated during conscious sedation... Anesthesiology News. April 1999.

"Monitoring respiration can be broken down into two components: oxygenation and ventilation. Pulse oximetry has become the standard for measuring oxygenation in a conscious patient. Ventilation, the other half of respiratory monitoring, is best accomplished by capnography."

"In patients receiving oxygen, the increased FiO₂ may provide a benign readout on the pulse oximeter while dangerous hypercapnia is emerging undetected in a hypoventilated patient."

Santos LJ, Varon J, Pic-Aluas L, Combs AH. Practical uses of end-tidal carbon dioxide monitoring in the Emergency Department. The Journal of Emergency Medicine. May 1994;12:633-644.

"Clinicians felt that the most beneficial features of the PetCO₂ monitor were the ability to immediately detect changes in the respiratory pattern with a glance at the capnographic waveform and the apnea alarm. The alarm may be especially helpful after completion of emergency procedures when personnel are less likely to be at the bedside and patient stimulation is minimized. Thus capnography appears to be useful and practical enhancement of ED monitoring during conscious sedation of spontaneously breathing patients."

Saura P, Blanch L, Lucangelo U, Fernandez R, Mestre J, Artigas A. Use of capnography to detect hypercapnic episodes during weaning from mechanical ventilation. Intensive Care Medicine. 1996;22:374-381.

"The construction of a ROC curve...an analysis that is independent of the threshold value-resulted in a large area under the curve, indicating that PetCO₂ monitoring could be a reliable tool for detecting hypercapnic episodes during weaning periods in intensive care patients. Capnography therefore appears useful for identifying clinically relevant hypercapnic episodes."

Schallom L, Ahrens T. Hemodynamic applications of capnography. Journal of Cardiovascular Nursing. January 2001;15:56-70.

"This article reviews the hemodynamic assessment applications of capnography, which include identification of end-expiration during hemodynamic pressure waveform measurements, alveolar deadspace assessment, evaluation of cardiopulmonary resuscitation efficacy, and possible prognosis of a patient's chance of survival from cardiopulmonary arrest."

"Critical care nurses can utilize capnography information to supplement their hemodynamic assessment parameters of mixed venous oxygen saturation, cardiac output, cardiac index, stroke volume, and stroke index to evaluate the effect of interventions aimed at increasing perfusion."

Semen F, Bordes M, Cros A. Detection of Episodes of Hypoventilation in the Paediatric PACU: The Contribution of Nasal or Oral Capnography. Presentation at SFAR Meeting in France, September 2003

"Clinical evaluation is rather poor at detecting all postoperative hypoventilation episodes in the paediatric PACU. Monitoring oral and nasal capnography using FilterLine® is a simple and reliable method and should contribute to improving the safety of patients, all the more so as it allows oxygen to be administered at the same time."

Silvestri S, Ralls, G, Carter E, Senn, A, Rothrock, S G, Giordano, P A, Brandt P, Falk, J L. Improvement in Misplaced Endotracheal Tube Recognition within a Regional Emergency Medical Services System. Abstract, American Emergency Medicine Volume 10, Number 5 445.

"Implementation of a pre-hospital airway management protocol requiring continuous ETCO₂ confirmation substantially decreased the number of unrecognized, misplaced endotracheal tubes. This problem was eliminated among patients in whom the protocol requirements for continuous ETCO₂ was adhered to."

Sinclair S. Dispelling myths of capnography. Dimensions of Critical Care Nursing. January-February 1998;17:48-55.

This article lists the five most commonly held myths regarding the use of capnography and provides current information on technology and application. The information provided is a basis for advanced practice nurses, educators, and clinical nurse specialists to educate and provide peers a means to incorporate capnography into critical care patient management.

Singh A, Megargel R E, Schnyder M R, O'Connor R E. Comparing the Ability of Colorimetric and Digital Waveform End Tidal Capnography to Verify Endotracheal Tube Placement in the Prehospital Setting. Abstract, American Emergency Medicine Volume 10, Number 5 466-467

"Due to an ability to detect low levels of exhaled CO₂, digital capnography is superior to colorimetric methods in confirming correct endotracheal tube placement, especially in cardiac arrest."

Singh S, Allen, WD, Venkataraman ST, Bhende, MS. Utility of a Novel Quantitative Handheld Microstream® Capnometer during Transport of Critically Ill Children. Presented at the Society for Pediatric Research meetings. May 2001.

"This capnometer [NPB-75] functioned well in the prehospital setting to continuously monitor ETCO₂ and thereby monitor endotracheal tube position and ventilation during transport of intubated patients...It provided both quantitative and graphic real-time detection of ETCO₂ in intubated patients, which was of critical importance for the optimal management of patients during transport."

Stein T. Capnography in EMS. The Journal of Emergency Care, Rescue, & Transportation. August 2000;29:51-57.

"The measure of tidal carbon dioxide (CO₂) is useful in caring for critically ill and injured patients. The numerical and graphical display of CO₂ concentration, or partial pressure, is called capnography and may be used for ventilation assessment, endotracheal tube placement confirmation, and as an early warning system for serious patient events."

"Capnography is not a new methodology; however, technological advances and decreasing costs are making capnographs more attractive for critical care ground transport teams now, and modular design of new monitor-defibrillators will add the capability to ALS units in the near future."

Sury MRJ, Hatch DJ, Deeley T, Dicks-Mireaux C, Chong WK. Development of a nurse-led sedation service for paediatric magnetic resonance imaging. The Lancet. May 1999; 353:1667-1671.

"Magnetic resonance imaging (MRI) requires the patient to be immobile in a noisy and enclosed space for at least 20 min."

"..most children will lie still for the required time only if they are made to sleep by sedation or anaesthesia."

"..anaesthesia resources are limited and demand for sedation is increasing with use of the MRI."

"The sedationist monitored patients throughout the period of the MRI scan, using continuous clinical observation assisted by pulse oximetry. Capnography, electrocardiography, non-invasive blood-pressure measurement, and full resuscitation equipment were available for use if necessary."

Swedlow D. Capnometry and capnography: The anesthesia disaster early warning system. Seminars in Anesthesia. September 1986; 5:194-205

This seminal article discusses using capnography as an early warning system by recognizing changes in the shape of the waveform. It presents strong arguments for using continuous capnography on all intubated patients and on all patients with respiratory compromise. The article serves as a primer in waveform analysis and a-ADCO₂.

"Since the essence of pulmonary ventilation is the elimination of CO₂ from the lung, the capnogram is probably the single most reliable and effective monitor for the presence of pulmonary ventilation and gas exchange."

Szaflarski NL, Cohen NH. Use of capnography in critically ill adults. Heart and Lung: The Journal of Acute and Critical Care. July 1991;20:363-372.

"Capnography offers the potential to improve our ability to safely care for critically ill adults. It provides a useful, non-invasive, and continuous monitor of ventilation that is associated with minimal risks. The clinical applications of capnography in critically ill adults have grown in recent years, and its use is expected to increase."

Tobias J, Flanagan JFK, Wheeler TJ, Garrett JS, Burney C. Noninvasive monitoring of end-tidal CO₂ via nasal cannulas in spontaneously breathing children during the perioperative period. Critical Care Medicine. November 1994; 22:1805-1808.

"We demonstrated that end-tidal CO₂ measured via nasal cannulas correlates with PaCO₂ during spontaneous ventilation in children."

"...end-tidal CO₂ measurement may prove to be a useful adjunct to the monitoring of certain patient groups in the pediatric ICU."

Tobias J, Lynch A, Garrett J. Alterations of end-tidal carbon dioxide during the intrahospital transport of children. Pediatric Emergency Care. August 1996; 12:249-251

"...a high incidence of unintentional hyperventilation occurs during patient transport. While matching the respiratory rate with that provided by the ventilator may be easily accomplished during patient transport, maintaining the same tidal volume may be more difficult and probably accounts for the variations noted in our study. Overventilation with EtCO₂ values less than 25 torr are most likely to occur (62% of the time). As these alterations may affect cerebral blood flow, monitoring EtCO₂ is recommended, even during brief transports."

"Additional applications of EtCO₂ monitoring outside of the operating room include patient monitoring during conscious sedation, documentation of endotracheal tube placement during intubation, and as a means to judge the effectiveness of cardiopulmonary resuscitation."

Tobias JD. End-tidal carbon dioxide monitoring during sedation with a combination of midazolam and ketamine for children undergoing painful, invasive procedures. Pediatric Emergency Care. June 1999; 15:173-175

"The addition of EtCO₂ monitoring provides an additional monitor to allow for early detection of airway obstruction or subclinical degrees of respiratory depression."

"Hypoxemia is a late finding in respiratory depression."

"The value of adding EtCO₂ was most evident in the patient who developed upper airway obstruction. The loss of EtCO₂ waveform alerted the practitioner immediately that airflow had ceased, allowing for immediate intervention."

"The use of EtCO₂ monitoring to allow early identification of the problem may be particularly useful when the opportunity to directly observe the patient is limited. The latter may be the case during radiologic procedures such as computed tomography scanning or magnetic resonance imaging."

Twersky R. Anesthesiologists should move to regulate the office setting. Anesthesiology News. October 2000.

"Just because Big Brother is not looking over your shoulder does not mean you don't need a pulse oximeter or capnographer or an anesthesia record."

"The basic premise is that the standards of care in an office surgical suite should be no less than those of a general acute care hospital or an ambulatory surgical facility."

Vardi A, Levin I, Paret G, Barzilay Z. The Sixth Vital Sign: end-tidal CO₂ in Pediatric Trauma Patients during Transport. Harefuah. 2000.

"We find EtCO₂ an important adjunct in monitoring pediatric trauma patients during transport. In addition to conventional monitoring of heart rate, blood pressure, respiratory rate, body temperature and blood oxygen saturation, we suggest EtCO₂ as the sixth vital sign that should be monitored."

Vargo JJ, Zuccaro G, Dumot JA, Dumot JA, Shermock KM, Morrow B, Conwell DL, Trolli PA, Maurer, WG. Gastroenterologist-administered propofol Versus Meperidine and Midazolam for Advanced Upper Endoscopy: A Prospective, Randomized Trial. Gastrointestinal Endoscopy. 2002; 123:8-16.

"In summary, our study has shown that the administration of propofol for ERCP and EUS by a properly trained Gastroenterologist using extended monitoring with capnography is safe and provides similar levels of patient and endoscopist satisfaction when compared with meperidine and midazolam."

Vargo , JJ, Zuccaro G, Dumot JA, Conwell DL, Morrow JB, Shay SS. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointestinal Endoscopy. Volume 55, No. 7, 2002.

"Apnea/disordered respiration occurs commonly during therapeutic upper endoscopy and frequently precedes the development of hypoxemia. Potentially important abnormalities in respiratory activity are undetected with pulse oximetry and visual assessment."

"The technology is inexpensive, the information provided is easy to interpret...This technology has allowed us to safely use Gastroenterologist-administered propofol for therapeutic endoscopy."

Vargo JJ, Zuccaro G, Dumot JA, Shay SS, Conwell DL, Morrow B. Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series. Gastrointestinal Endoscopy. February 2000;52:250-255.

"The graphic display of respiratory activity led to early identification of respiratory depression not detected by conventional pulse oximetry, with timely adjustment of the propofol infusion."

"We strongly emphasize that monitoring respiratory activity is essential, because it allowed for a downward titration or temporary discontinuation of the propofol infusion before development of more significant respiratory depression, necessitating discontinuation of the procedure and resusciation."

"Capnography allowed for a timely adjustment in the propofol infusion before the development of significant cardiopulmonary depression."

Walker DH, Stumpf S, Penrose KA, Merzel D. Patient monitoring during mechanical ventilation specific to the open lung concept and multi-organ function. International Journal of Intensive Care. Winter 2000;7:221-226.

"Simultaneous monitoring of expired CO₂ values integrated with lung mechanics measurements will alert the clinician to the exact level of ventilator positive pressure that creates right-to-left shunting."

Ward KR, Menegazzi JJ, Zelenak RR, Sullivan RJ, McSwain NE. A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal PCO₂ during human cardiac arrest. Annals of Emergency Medicine. April 1993;22:669-674.

"The purpose of this study was to compare cardiac output, as indirectly measured by PetCO₂, between manually and mechanically performed chest compressions during the resuscitation of human beings in cardiac arrest."

"Monitoring PetCO₂ during cardiac arrest may be valuable to help optimize chest compressions during resuscitation, regardless of the CPR technique used."

Wayne MA, Slovis CM, Pirrallo RG. Management of difficult airways in the field. Prehospital Emergency Care. October/December 1999; 2:290-296

"Consensus was reached that EtCO₂ evaluation was currently the best method for confirming correct endotracheal tube placement. The group agreed that quantitative capnography was currently the best method for determining endotracheal tube position and strongly recommends its use."

West G, Gumm T, West M, Kusumoto F. Capnography monitoring guides level of sedation and administration of narcotic and analgesic agents in the electrophysiology laboratory. Abstract: North American Society Pacing and Electrophysiology, May 2000

"Capnography provides an objective measurement for assessing level of sedation and is particularly useful for guiding narcotic and analgesic use in patients undergoing ICD implant or ABL."

White S, Slovis C. Inadvertent esophageal intubation in the field: reliance on a fool's "gold standard." Academic Emergency Medicine. February 1997; 4:89-90

"In our practice of emergency medicine in an academic center, we confirm all of our own intubations with a qualitative EtCO₂ detector even when we're certain that we've seen the ETT go through the cords. Our anesthesia colleagues require adherence to a similar standard in all ORs throughout the nation. We should teach and require out-of-hospital care providers to conform to the same standards."

Wiegand UKH, Kurowski V, Giannitsis E, Katus HA, Djonlagic H. Effectiveness of end-tidal carbon dioxide tension for monitoring of thrombolytic therapy in acute pulmonary embolism. Critical Care Medicine. November 2000;28:3588-3592.

"In respiratory-dependent patients with massive, pulmonary embolism, monitoring of ETCO₂ reliably indicates improvement of pulmonary perfusion and may reflect recurrent embolism. Therefore, ETCO₂ measurements may be used for non-invasive monitoring of the efficacy of thrombolytic therapy in massive pulmonary embolism."

Wilson S. Review of monitors and monitoring during sedation with emphasis on clinical applications. Pediatric Dentistry. July 1995; 17:413-418

"Capnography is the only monitor on the market that can give an indication of the airway patency when used properly."

"I believe that in the future this monitor will become the most important monitor in the hierarchy of monitors used in sedating children for dentistry."

Wong EK, Filbin M, Gurr DE, Walls RM. Confirmation of endotracheal tube placement: analysis of 6294 Emergency Department intubations. Annals of Emergency Medicine. October 2000;36:4. Abstract.

"Direct auscultation as a method of confirmation of tube placement immediately after intubation is complemented by end-tidal CO₂ detection in a significant percentage of intubations. The increasingly ubiquitous presence of end-tidal CO₂ detectors along with data indicating successful integration of this device into clinical practice suggest that it may be part of the standard of care to detect esophageal intubations in the ED."

Yaron M, Padyk P, Hutsinpiller M, Cairns C. Utility of the expiratory capnogram in the assessment of bronchospasm. Annals of Emergency Medicine. October 1996; 28:403-408

"The dCO₂/dt is an effort-independent, rapid, non-invasive measure that indicates significant bronchospasm in ED adult patients with asthma. The dCO₂/dt value is correlated with PEFR, an effort-dependent measure of airway obstruction. The change in dtCO₂/dt with inhaled beta-agonists may be useful in monitoring the therapy of acute asthma."

You B, Peslin R, Duvivier C, Dang V, Grilliat JP. Expiratory capnography in asthma: evaluation of various shape indices. European Respiratory Journal. 1994; 7:318-323

"Capnography can be used in awake and sleeping subjects and could allow various new applications to be envisaged: monitoring of status asthmaticus, detection of nocturnal attacks, evaluation of the duration of action of bronchodilator drugs, intra- and post-operative monitoring of asthmatic patients, and dynamic bronchial provocation tests, especially in children."

Zahodnic R. Intrahospital transport of the mechanically ventilated patient. AARC Times. March 2000: 26-29

"The use of capnography in conjunction with an MRD or mechanical ventilator may facilitate a more optimal level of ventilation when direct assessment of spirometry is not available. Capnography can be used not only to guide appropriate ventilation but also to provide reassurance at all times that the airway remains secured. In the event of a cardiopulmonary event, capnography can give non-invasive information about the effectiveness of resuscitation efforts and may signal the return of spontaneous circulation."