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This is reproduced from the Association of Anaesthetists of Great Britain and Ireland
AAGBI SAFETY STATEMENT
The use of capnography outside the operating theatre
Updated statement from the Association of Anaesthetists of Great Britain & Ireland
(AAGBI) May 2011
The AAGBI publications ‘Recommendations for standards of monitoring during
anaesthesia and recovery’ (4 th edition) 2007 (1) and ‘Capnography outside the operating
room’ 2009 (2) recommend continuous capnography in all patients who are
anaesthetised or intubated, regardless of their location in the hospital, or the type of
airway device used. In addition, continuous capnography is recommended for all
patients undergoing deep sedation or any sedation where the airway cannot be directly
observed, and should be immediately available during the treatment of cardiac arrest.
Whilst the use of capnography is routine in the operating theatre, this is not so in other
areas of hospital practice, and the AAGBI recognises that the practice of moderate
sedation using agents such as propofol is increasing. The AAGBI would also like to alert
the membership to two important recent publications and to strengthen our
recommendations on the routine use of capnography. This has the potential to have a
major impact on deaths due to airway complications outside the operating theatre (5).
1. The 2010 International Consensus Guidelines on Cardiopulmonary
Resuscitation (3) and the Resuscitation Council UK Resuscitation Guidelines
2010 (4) emphasise the importance of capnography during cardiopulmonary
resuscitation to continually monitor tracheal tube placement and quality of CPR
and to provide an early indication of return of spontaneous circulation.
2. The fourth National Audit Project ‘Major complications of airway management’
(NAP4) was published in March 2011 (5) and raised particular concerns about
complications of airway management in ICU and the emergency department. At
least one in four major airway complications reported to NAP4 was from the
ICU or the emergency department and more than 60% of events in the ICU led 2
to death or brain damage. Common factors in both the ICU and emergency
department included unrecognised oesophageal intubation or unrecognised
displacement of tracheal tubes or tracheostomy tubes after patient movement,
intervention, or during transport. Capnography was frequently absent or a flat
capnography trace due to airway displacement was misinterpreted during
cardiopulmonary resuscitation. The absence of capnography, or the failure to
use it properly, contributed to 80% of deaths from airway complications in the
ICU and 50% of deaths from airway complications in the emergency
department.
The AAGBI recommends that:
• Continuous capnography should be used in all anaesthetised patients,
regardless of the airway device used or the location of the patient.
• Continuous capnography should be used for all patients whose trachea is
intubated, regardless of the location of the patient (see note 1).
• Continuous capnography should be used for all patients undergoing moderate
or deep sedation, and should be available wherever any patients undergoing
anaesthesia or moderate or deep sedation are recovered (see note 2).
• Continuous capnography should be used for all patients undergoing advanced
life support (see note 3).
Notes
1. Patients with tracheostomy tubes and who are also breathing spontaneously
without ventilator support or continuous positive airway pressure (CPAP) do not
normally require continuous capnography.
2. Sedation is a continuum and it is not always possible to predict how an
individual patient will respond. Moderate Sedation/ Analgesia (“Conscious
Sedation”) is a drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or accompanied by
light tactile stimulation. No interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate…Deep Sedation/ Analgesia is a
drug-induced depression of consciousness during which patients cannot be
easily aroused but respond purposefully following repeated or painful
stimulation. The ability to independently maintain ventilatory function may be
impaired. Patients may require assistance in maintaining a patent airway, and
spontaneous ventilation may be inadequate (6).3
3. The AAGBI recognises that capnography is not yet standard on resuscitation
trolleys, but notes that a number of companies produce defibrillators with
integrated capnography. The AAGBI recommends that capnography should be
available and delivered promptly to any patient undergoing advanced life
support.
References
1. AAGBI Recommendations for standards of monitoring during anaesthesia and
recovery’ 2007 (4th edition)
http://www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf (accessed
24th May 2011)
2. AAGBI Capnography outside the operating room’ 2009
http://www.aagbi.org/sites/default/files/AAGBI%20SAFETY%20STATEMENT_0.p
df (accessed 24 th May 2011)
3.Deakin CD, Morrison LJ, Morley PT. 2010 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
with Treatment Recommendations Part 8: Advanced life support. Resuscitation
2010; 81s: 93–174.
4.Resuscitation Council (UK) Resuscitation Guidelines 2010
http://www.resus.org.uk/pages/guide.htm (accessed 24th May 2011)
5.4th National Audit of the Royal College of Anaesthetists and the Difficult Airway
Society: Major complications of airway management 2011 Ed Cook T, Woodall
N, Frerk C http://rcoa.ac.uk/index.asp?PageID=1089 (accessed 24th May 2011)
6.ASA Committee on Quality Management and Departmental Administration:
Continuum of depth of sedation, definition of general anesthesia and levels of
sedation/analgesia (approved by ASA House of Delegates on October 27th
2004 and amended on October 21st 2009)
http://www.asahq.org/publicationsAndServices/sgstoc.htm (accessed 17th June
2011