logging in or signing up Detecting Methods of ET tube positions drvenugopalpp Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 940 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: November 18, 2008 This Presentation is Public Favorites: 0 Presentation Description The lecture presented at First Eurasian International Congress on Emergency Medicine at Antalya, Turkey on 05.11.08 to 09.11.08. Comments Posting comment... By: drvenugopalpp (13 month(s) ago) Thanks a lot. I shall send it to your email. Dr.Venu Saving..... Post Reply Close Saving..... Edit Comment Close By: prof_mibi (13 month(s) ago) nice ppt. could you pls send it to hesty_l@yahoo.com. thanks Saving..... Post Reply Close Saving..... Edit Comment Close By: hariomshillong (24 month(s) ago) it is a very nice n helpful presentation.... Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript DETECTING METHODS OF ENDOTRACHEAL TUBE POSITION : DETECTING METHODS OF ENDOTRACHEAL TUBE POSITION Venugopalan P.P. MB;BS, DA, DNB, MNAMS. Chief of Emergency Medicine Deputy Director, MIMS Academy Malabar Institute of Medical Sciences Ltd., Kozhikode , India Slide 2: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Objectives : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Objectives Review of conventional methods Good and Gold Standards for ETT positioning International recommendations An algorithm to confirm tube position Slide 4: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Endotracheal intubation is a potential minefield for disaster. Errors in its performance can be associated with high morbidity and mortality for the patient and legal liability for the practitioner. Verification methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Verification methods Observational verification Measured verification Anatomical verification Observational verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observational verification Direct visualization Observation of chest movement Five point auscultation Presence of exhaled tidal volume Observational verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observational verification Reservoir bag compliance Tube condensation with exhalation Absence of gastric contents within the ETT Measured verifications : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Measured verifications End-tidal Carbon dioxide (ETCO2) Pulse Oximeter Anatomical verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Anatomical verification Esophageal Detector Device (EDD) Chest Radiograph Lighted Stylet Anatomical verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Anatomical verification Sonography (USG) Fiberoptic Bronchoscope / Laryngoscope Video Assisted Laryngoscope Direct visualization : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Direct visualization Non visualization of cords Dislodged tube (before / after securing) Inadvertent esophageal tube position after direct vision intubation * * White SJ, Slovis CM. Inadvertent esophageal intubation in the field: Reliance on a fool’s “gold standard”. Acad Emerg Med 1997; 4: 89-91 Chest Movement : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Chest Movement Obesity - decreased or absent chest excursion Lung diseases - decreased or absent chest excursion Esophageal intubation does produce some degree of chest movement * * Cundy J. Accidental Intubation of Esophagus (letter) Anesth Intensive Care 1981; 9:76 Ogden PN. Endotracheal Tube misplacement (letter) Anesth Intensive Care 1983; 11: 273-4 Auscultation – Axilla : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Auscultation – Axilla Breath sounds may be heard in both axillae but may result in misdiagnosis in up to 15 % of all esophageal intubations* * Linko K. Capnography for detection of accidental esophageal intubation. Acta Anesthsiol Scand 1983; 27: 199-202 Auscultation - Epigastrium : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Auscultation - Epigastrium Not 100% reliable Gastric distention is gradual due to previous bag mask ventilation End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection CO2 in exhaled air confirms tracheal tube position in patients with spontaneous circulation * * Takeda T. The assessment of three different methods to verify tracheal tube placement in the emergency setting. Resuscitation 56; 153, 2003. End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Cardiac arrest CO2 level > 2 % - confirms tracheal tube position Absence of CO2 will not rule out esophageal intubation. * Ron M W. Airway, Rosen’s Emergency Medicine Concepts and Clinical Practice, Vol 1, Sixth Edition 2006, MOSBY ELSEVIER ETCO2 useful as an adjunct to confirm ET tube placement : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey ETCO2 useful as an adjunct to confirm ET tube placement End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Positive predictive value (Endotracheal placement if CO2 is detected) 100 % Negative predictive value (Esophageal placement if CO2 is not detected) 20-100% End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Threshold to detect - 15 mmHg for the colorimetric capnometer Waveform may be detected at much lower levels with capnography Nellcor.Easy Cap ET CO2 detector product information Hayward, CA: Nellcor, Inc 1992 End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Most reliable method Independent of user’s experience Sylvia K. Assessment of for deferent methods to verify tracheal tube placement in critical care setting Anesth. Analg 1999; 88: 766-70 False negative reading (Failure to detect CO2 when tube is in the trachea) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey False negative reading (Failure to detect CO2 when tube is in the trachea) Low Blood flow and CO2 delivery to lung (CPR) Pulmonary embolism – decreased pulmonary blood flow Contaminated detector – gastric content and acidic drugs like epinephrine when administered through trachea. False negative reading (Failure to detect CO2 when tube is in the trachea) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey False negative reading (Failure to detect CO2 when tube is in the trachea) IV Epinephrine will reduce elimination and detection of CO2 * Severe airway obstruction Status Asthmatics Pulmonary Edema * Cantineau JP; Effect of epinephrine on end-tidal carbon dioxide pressure during pre hospital cardio pulmonary resuscitation. AmJ Emerg Med 1998; 5: 637-646 Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) The EDD consists of a bulb that is compressed and attached to ET tube or a syringe that is attached to ETT. Collapsible Esophagus & Non collapsible Trachea : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Collapsible Esophagus & Non collapsible Trachea Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) The suction created by the EDD will collapse lumen of the esophagus and the bulb will not re expand EDD sensitivity for esophageal tube position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD sensitivity for esophageal tube position EDD –Less specific for tracheal tube position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD –Less specific for tracheal tube position Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) Highly sensitive for detection of esophageal intubation * Poor specificity for tracheal tube placement EDD is not accurate for continuous monitoring * Takeda T. The assessment of three methods to verify tracheal tube placement in emergency setting. Resuscitation 2003; 56:153-157 Pelucio M. Out-of-hospital experience with the syringe esophageal detector device Acad Emerg Med 1997; 4: 563-68 Tanigwa K. Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patient Anesthesiology 2000; 93: 1432-1446 EDD will be misleading : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD will be misleading Morbid obesity Late pregnancy Status Asthmaticus Copious ET Secretions Tracheal collapse Pulse Oximetry : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Pulse Oximetry Useful? Pulse Oximetry : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Pulse Oximetry Useful But, Delayed !! * Benumof J. Critical Hemoglobin desaturation will occurs before return to un paralyzed state following 1mg/kg intravenous succinyl choline. Anesthesiology 87, 979, 1997 Chest Radiography : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Chest Radiography Primary purpose is to ensure its position below the cords and above the carina * * Ron M W. Airway, Rosen’s Emergency Medicine Concepts and Clinical Practice, Vol 1, Sixth Edition 2006, MOSBY ELSEVIER Other methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Other methods Sonography Lighted Stylet Other methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Other methods Fiberoptic scope Video Assisted Laryngoscope International Recommendations : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey International Recommendations Emergency Medicine Journal March 2001 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Emergency Medicine Journal March 2001 “Independent confirmation of correct tube placement by the use of devices that detect end-tidal CO2 is mandatory for every endotracheal intubation performed in the emergency department and as part of the assessment of all patients who arrive at the emergency department already intubated” * Position statement number 1.Confirmation of endotracheal tube placement with end tidal CO2 detection. Emerg Med J 2001:18 :329, review March, 2003 American College of Emergency Physicians (ACEP) October 2001 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey American College of Emergency Physicians (ACEP) October 2001 End-tidal CO2 detection, either qualitative, quantitative, or continuous, is the most accurate and easily available method to monitor correct endotracheal tube position in patients who have adequate tissue perfusion * * Verification of endotracheal tube placement; policy statement. American College of Emergency Physicians. www.acep.org /1,4923,0.html National Association of EMS Physicians (NAEMPS) – Position statement 1999 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey National Association of EMS Physicians (NAEMPS) – Position statement 1999 In the patient with a perfusing rhythm, end-tidal CO2 detection is the best method for verification * O’Connor RE. Verification of endotracheal tube placement following intubation. National Association of EMS Physicians Standards and Clinical Practice committee, Pre hosp Emerg Care 1999; 3:248-50 American Heart Association (AHA) Protocol for Advanced Cardiac Life Support [ACLS] 2002 and 2005 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey American Heart Association (AHA) Protocol for Advanced Cardiac Life Support [ACLS] 2002 and 2005 Expired CO2 detectors are very reliable in patients with perfusing rhythm and are recommended to confirm tube position in these patients (Class IIa) * * American Heart Association Resuscitation guidelines 2005, Circulation 2005; 112: IV-51-IV 57) Association of Anesthetists of Great Britain & Ireland and American Society for Anesthesiologists (ASA) * : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Association of Anesthetists of Great Britain & Ireland and American Society for Anesthesiologists (ASA) * Capnography is essential to the safe conduct of anesthesia Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment * Recommendation for standard of monitoring during Anesthesia and recovery. 3rd Edition, December 2000. The Association of Anesthetists of Great Britain and Ireland. www.aagbi.org/guidelines.html The American Society of Anesthesiologists. Standard for Basic Anesthetic Monitoring. Approved by House of Delegates, October 1986, amended 1998. http://www.asahq.org/publicationsAndServices/standards/02.pdf#2 NRP (Neonatal Resuscitation Protocol) Guidelines 2006. Consensuses on sciences; : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey NRP (Neonatal Resuscitation Protocol) Guidelines 2006. Consensuses on sciences; Exhaled CO2 detection is reliable indicator of ETT placement in infants and it identifies esophageal intubation faster than clinical assessment. NRP recommends using exhaled CO2 detection to confirm tracheal tube placement * (Aziz J perinatol 1999, Bhende, Pediatrics 1995, Repetto, J Perinatol 2001, Roberts, Pediatric Pulmonl 1995) Slide 44: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey “Despite the recommendations issued by various National organizations that endorse continues monitoring of ET CO2 for confirming ET tube placement, it is neither widely available nor consistently applied” * Delorio NM, Continuous and-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement is neither widely available nor consistently applied by emergency physicians, Emerg Med J 2005; 22:490-493 Suggesting : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Suggesting A Practical Approach !! Slide 46: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Attach ETCO2 Detector, Start Ventilation Slide 47: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observe ETCO2 color change / Wave form / Digital display Algorithm to confirm Tube Position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Algorithm to confirm Tube Position Conclusion : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Conclusion Confirmation of proper tracheal tube placement is as important as successful intubation. Exhaled CO2 detection is reliable and should be considered the standard for confirmation of tracheal placement of an ETT and for early detection of accidental esophageal intubation. Conclusion : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Conclusion The Emergency Physician should make sure the availability of ET CO2 detection devices in ER and with EMS team when they are in the field. They should also ensure usage of confirmation devices by the concerned persons Slide 51: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Slide 52: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Slide 53: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey venugopal@mimsindia.com Thank You You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Detecting Methods of ET tube positions drvenugopalpp Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 940 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: November 18, 2008 This Presentation is Public Favorites: 0 Presentation Description The lecture presented at First Eurasian International Congress on Emergency Medicine at Antalya, Turkey on 05.11.08 to 09.11.08. Comments Posting comment... By: drvenugopalpp (13 month(s) ago) Thanks a lot. I shall send it to your email. Dr.Venu Saving..... Post Reply Close Saving..... Edit Comment Close By: prof_mibi (13 month(s) ago) nice ppt. could you pls send it to hesty_l@yahoo.com. thanks Saving..... Post Reply Close Saving..... Edit Comment Close By: hariomshillong (24 month(s) ago) it is a very nice n helpful presentation.... Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript DETECTING METHODS OF ENDOTRACHEAL TUBE POSITION : DETECTING METHODS OF ENDOTRACHEAL TUBE POSITION Venugopalan P.P. MB;BS, DA, DNB, MNAMS. Chief of Emergency Medicine Deputy Director, MIMS Academy Malabar Institute of Medical Sciences Ltd., Kozhikode , India Slide 2: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Objectives : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Objectives Review of conventional methods Good and Gold Standards for ETT positioning International recommendations An algorithm to confirm tube position Slide 4: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Endotracheal intubation is a potential minefield for disaster. Errors in its performance can be associated with high morbidity and mortality for the patient and legal liability for the practitioner. Verification methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Verification methods Observational verification Measured verification Anatomical verification Observational verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observational verification Direct visualization Observation of chest movement Five point auscultation Presence of exhaled tidal volume Observational verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observational verification Reservoir bag compliance Tube condensation with exhalation Absence of gastric contents within the ETT Measured verifications : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Measured verifications End-tidal Carbon dioxide (ETCO2) Pulse Oximeter Anatomical verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Anatomical verification Esophageal Detector Device (EDD) Chest Radiograph Lighted Stylet Anatomical verification : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Anatomical verification Sonography (USG) Fiberoptic Bronchoscope / Laryngoscope Video Assisted Laryngoscope Direct visualization : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Direct visualization Non visualization of cords Dislodged tube (before / after securing) Inadvertent esophageal tube position after direct vision intubation * * White SJ, Slovis CM. Inadvertent esophageal intubation in the field: Reliance on a fool’s “gold standard”. Acad Emerg Med 1997; 4: 89-91 Chest Movement : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Chest Movement Obesity - decreased or absent chest excursion Lung diseases - decreased or absent chest excursion Esophageal intubation does produce some degree of chest movement * * Cundy J. Accidental Intubation of Esophagus (letter) Anesth Intensive Care 1981; 9:76 Ogden PN. Endotracheal Tube misplacement (letter) Anesth Intensive Care 1983; 11: 273-4 Auscultation – Axilla : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Auscultation – Axilla Breath sounds may be heard in both axillae but may result in misdiagnosis in up to 15 % of all esophageal intubations* * Linko K. Capnography for detection of accidental esophageal intubation. Acta Anesthsiol Scand 1983; 27: 199-202 Auscultation - Epigastrium : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Auscultation - Epigastrium Not 100% reliable Gastric distention is gradual due to previous bag mask ventilation End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection CO2 in exhaled air confirms tracheal tube position in patients with spontaneous circulation * * Takeda T. The assessment of three different methods to verify tracheal tube placement in the emergency setting. Resuscitation 56; 153, 2003. End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Cardiac arrest CO2 level > 2 % - confirms tracheal tube position Absence of CO2 will not rule out esophageal intubation. * Ron M W. Airway, Rosen’s Emergency Medicine Concepts and Clinical Practice, Vol 1, Sixth Edition 2006, MOSBY ELSEVIER ETCO2 useful as an adjunct to confirm ET tube placement : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey ETCO2 useful as an adjunct to confirm ET tube placement End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Positive predictive value (Endotracheal placement if CO2 is detected) 100 % Negative predictive value (Esophageal placement if CO2 is not detected) 20-100% End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Threshold to detect - 15 mmHg for the colorimetric capnometer Waveform may be detected at much lower levels with capnography Nellcor.Easy Cap ET CO2 detector product information Hayward, CA: Nellcor, Inc 1992 End tidal CO2 detection : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey End tidal CO2 detection Most reliable method Independent of user’s experience Sylvia K. Assessment of for deferent methods to verify tracheal tube placement in critical care setting Anesth. Analg 1999; 88: 766-70 False negative reading (Failure to detect CO2 when tube is in the trachea) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey False negative reading (Failure to detect CO2 when tube is in the trachea) Low Blood flow and CO2 delivery to lung (CPR) Pulmonary embolism – decreased pulmonary blood flow Contaminated detector – gastric content and acidic drugs like epinephrine when administered through trachea. False negative reading (Failure to detect CO2 when tube is in the trachea) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey False negative reading (Failure to detect CO2 when tube is in the trachea) IV Epinephrine will reduce elimination and detection of CO2 * Severe airway obstruction Status Asthmatics Pulmonary Edema * Cantineau JP; Effect of epinephrine on end-tidal carbon dioxide pressure during pre hospital cardio pulmonary resuscitation. AmJ Emerg Med 1998; 5: 637-646 Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) The EDD consists of a bulb that is compressed and attached to ET tube or a syringe that is attached to ETT. Collapsible Esophagus & Non collapsible Trachea : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Collapsible Esophagus & Non collapsible Trachea Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) The suction created by the EDD will collapse lumen of the esophagus and the bulb will not re expand EDD sensitivity for esophageal tube position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD sensitivity for esophageal tube position EDD –Less specific for tracheal tube position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD –Less specific for tracheal tube position Esophageal Detector Devices (EDD) : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Esophageal Detector Devices (EDD) Highly sensitive for detection of esophageal intubation * Poor specificity for tracheal tube placement EDD is not accurate for continuous monitoring * Takeda T. The assessment of three methods to verify tracheal tube placement in emergency setting. Resuscitation 2003; 56:153-157 Pelucio M. Out-of-hospital experience with the syringe esophageal detector device Acad Emerg Med 1997; 4: 563-68 Tanigwa K. Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patient Anesthesiology 2000; 93: 1432-1446 EDD will be misleading : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey EDD will be misleading Morbid obesity Late pregnancy Status Asthmaticus Copious ET Secretions Tracheal collapse Pulse Oximetry : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Pulse Oximetry Useful? Pulse Oximetry : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Pulse Oximetry Useful But, Delayed !! * Benumof J. Critical Hemoglobin desaturation will occurs before return to un paralyzed state following 1mg/kg intravenous succinyl choline. Anesthesiology 87, 979, 1997 Chest Radiography : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Chest Radiography Primary purpose is to ensure its position below the cords and above the carina * * Ron M W. Airway, Rosen’s Emergency Medicine Concepts and Clinical Practice, Vol 1, Sixth Edition 2006, MOSBY ELSEVIER Other methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Other methods Sonography Lighted Stylet Other methods : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Other methods Fiberoptic scope Video Assisted Laryngoscope International Recommendations : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey International Recommendations Emergency Medicine Journal March 2001 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Emergency Medicine Journal March 2001 “Independent confirmation of correct tube placement by the use of devices that detect end-tidal CO2 is mandatory for every endotracheal intubation performed in the emergency department and as part of the assessment of all patients who arrive at the emergency department already intubated” * Position statement number 1.Confirmation of endotracheal tube placement with end tidal CO2 detection. Emerg Med J 2001:18 :329, review March, 2003 American College of Emergency Physicians (ACEP) October 2001 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey American College of Emergency Physicians (ACEP) October 2001 End-tidal CO2 detection, either qualitative, quantitative, or continuous, is the most accurate and easily available method to monitor correct endotracheal tube position in patients who have adequate tissue perfusion * * Verification of endotracheal tube placement; policy statement. American College of Emergency Physicians. www.acep.org /1,4923,0.html National Association of EMS Physicians (NAEMPS) – Position statement 1999 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey National Association of EMS Physicians (NAEMPS) – Position statement 1999 In the patient with a perfusing rhythm, end-tidal CO2 detection is the best method for verification * O’Connor RE. Verification of endotracheal tube placement following intubation. National Association of EMS Physicians Standards and Clinical Practice committee, Pre hosp Emerg Care 1999; 3:248-50 American Heart Association (AHA) Protocol for Advanced Cardiac Life Support [ACLS] 2002 and 2005 : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey American Heart Association (AHA) Protocol for Advanced Cardiac Life Support [ACLS] 2002 and 2005 Expired CO2 detectors are very reliable in patients with perfusing rhythm and are recommended to confirm tube position in these patients (Class IIa) * * American Heart Association Resuscitation guidelines 2005, Circulation 2005; 112: IV-51-IV 57) Association of Anesthetists of Great Britain & Ireland and American Society for Anesthesiologists (ASA) * : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Association of Anesthetists of Great Britain & Ireland and American Society for Anesthesiologists (ASA) * Capnography is essential to the safe conduct of anesthesia Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment * Recommendation for standard of monitoring during Anesthesia and recovery. 3rd Edition, December 2000. The Association of Anesthetists of Great Britain and Ireland. www.aagbi.org/guidelines.html The American Society of Anesthesiologists. Standard for Basic Anesthetic Monitoring. Approved by House of Delegates, October 1986, amended 1998. http://www.asahq.org/publicationsAndServices/standards/02.pdf#2 NRP (Neonatal Resuscitation Protocol) Guidelines 2006. Consensuses on sciences; : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey NRP (Neonatal Resuscitation Protocol) Guidelines 2006. Consensuses on sciences; Exhaled CO2 detection is reliable indicator of ETT placement in infants and it identifies esophageal intubation faster than clinical assessment. NRP recommends using exhaled CO2 detection to confirm tracheal tube placement * (Aziz J perinatol 1999, Bhende, Pediatrics 1995, Repetto, J Perinatol 2001, Roberts, Pediatric Pulmonl 1995) Slide 44: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey “Despite the recommendations issued by various National organizations that endorse continues monitoring of ET CO2 for confirming ET tube placement, it is neither widely available nor consistently applied” * Delorio NM, Continuous and-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement is neither widely available nor consistently applied by emergency physicians, Emerg Med J 2005; 22:490-493 Suggesting : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Suggesting A Practical Approach !! Slide 46: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Attach ETCO2 Detector, Start Ventilation Slide 47: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Observe ETCO2 color change / Wave form / Digital display Algorithm to confirm Tube Position : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Algorithm to confirm Tube Position Conclusion : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Conclusion Confirmation of proper tracheal tube placement is as important as successful intubation. Exhaled CO2 detection is reliable and should be considered the standard for confirmation of tracheal placement of an ETT and for early detection of accidental esophageal intubation. Conclusion : 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Conclusion The Emergency Physician should make sure the availability of ET CO2 detection devices in ER and with EMS team when they are in the field. They should also ensure usage of confirmation devices by the concerned persons Slide 51: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Slide 52: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey Slide 53: 1st Eurasian International Congress on Emergency Medicine 5th – 9th Nov 2008 at Antalya Turkey venugopal@mimsindia.com Thank You