Capnography in Sub-Saharan Africa

A recent study, ‘Global Capnography Project (GCAP): implementation of capnography in Malawi – an international anaesthesia quality improvement project’ published in the journal Anaesthesia (https://www.onlinelibrary.wiley.com/doi/10.1111/anae.14426) estimated that 11,000 potentially fatal anaesthetic accidents could be prevented every year by access to a simple breathing monitor, the Capnograph.

The authors R. Jooste, F. Roberts, S. Mindolo, D. Mabedi, S. Chikumbanje, D.K. Whitaker, and E.P. O’Sullivan must be congratulated for having conducted this study.  The findings of such studies are critical for future processes in order to decrease mortality and morbidity during surgery and in intensive care units.

The aim of this study was twofold: to measure the prevalence of capnography in the operating rooms and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low‐income or low-resource country. This is the first project to do this. Forty Capnographs were donated to eight hospitals in Malawi. Thirty‐two anaesthesia providers received a 1‐day capnography training course with pre‐ and post‐course knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow‐up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating room had a Capnograph. Overall, 97% and 100% ‘capnography gaps’ were identified in the operating rooms and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anesthesia providers reported recognizing 44 esophageal intubations and 28 (90%) believed that capnography had saved lives. This study shows it is feasible to introduce capnography in a low‐income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low‐income countries in 2007, we believe this is one of the most important projects in anesthesia safety in the last decade.

One noteworthy point is that during the 6‐month study period, 44 esophageal intubations were reported in Southern Malawi, which has a population of 7.5 million 16, giving a rate of 11.7 esophageal intubations per million population per year. Assuming intubation rates and capnography use in Malawi to be representative of sub-Saharan Africa, with a population of 1022 million 16, we estimate that over 11,000 esophageal intubations could occur per year. These pose a very significant patient safety risk that would most effectively be mitigated by the implementation of capnography. Esophageal intubation, undetected because capnography is not used, is now labelled a ‘Never Event’ in the National Health Service in United Kingdom.

The introduction of capnography and pulse oximetry has certainly enhanced safety of anesthesia in countries where they are the standards of monitoring during anesthesia.  The findings of this study are not surprising given that the introduction of capnography to low-resource countries enhances patient safety during anesthesia and decreases overall mortality. It is encouraging to note from this study that it is indeed feasible to train clinical care providers and introduce capnography into clinical practice.

It is hoped that in the future, LIFEBOX will include capnography along with pulse oximetry, and that this combination will enhance patient safety and decrease morbidity and mortality around the world.