New applications of
versus bronchoscope during percutaneous tracheostomy
randomized controlled trial of capnography vs. bronchoscopy for
Blue Rhino percutaneous tracheostomy.
Mallick A, Venkatanath D, Elliot SC, Hollins T, Nanda Kumar CG.
A prospective randomized controlled trial of capnography vs. bronchoscopy for
Blue Rhino percutaneous tracheostomy. Anaesthesia. 2003 Sep; 58(9): 864-8.
A crucial step for successful percutaneous tracheostomy is the introduction of
the needle and guide wire into the trachea. Capnography has recently been
proposed as one way to confirm tracheal needle placement. In this randomized
controlled study, the authors used capnography in 26 patients and bronchoscopy in 29
patients to confirm needle placement for percutaneous tracheostomy using Blue
Rhino kit. The operating times and the incidence of peri-operative complications
were similar for both groups. Capnography proved to be as effective as
bronchoscopy in confirming correct needle placement.
Capnography for feeding
of feeding tubes: a new technique of insertion and monitoring
D'Souza CR, Kilam SA, D'Souza U, Janzen EP, Sipos RA. Can J Surg.
1994 Oct; 37(5): 404-8.
The study consisted of thirteen anesthetized adult patients and 7
awake subjects scheduled to undergo elective surgery. Airway sampling for
carbon dioxide with capnography was performed in 13 anesthetized adults with the tip of the
feeding tube in the pharynx, in the esophagus and in the trachea, and airway
sampling for carbon dioxide from the pharynx and esophagus in 7 awake subjects
during introduction of the feeding tube. Fluoroscopic monitoring of the position
of the tip of the feeding tube was performed during introduction in two patients and two
volunteers. In all patients, with the tube either
in the trachea or pharynx, a normal capnogram was displayed. When the tube was
introduced into the esophagus no capnogram curve was seen, indicating the
absence of carbon dioxide. With the subject lying down during introduction, the
weighted tube followed the posterior pharyngeal wall to the upper esophageal
CONCLUSION: Positioning of the patient lying down with the head
flexed and capnographic measurement of carbon dioxide levels from the tip of the
feeding tube during insertion is a safe, accurate and cost-effective method for
the introduction of feeding tubes.
Capnography confirms correct feeding tube placement in intensive care unit
Kindopp AS, Drover JW, Heyland DK.
Can J Anaesth. 2001
The authors tested the accuracy and potential time savings of capnography as
compared with a two-step radiographic method in placing feeding tubes in
critically ill patients. One hundred feeding tube placements were
studied in a tertiary care intensive care unit. All placements utilized a
two-step radiographic method, but capnography was added to the procedure. The
procedure was then completed or abandoned depending on radiographic
interpretation. Radiography showed 11 feeding tubes projecting within
the tracheobronchial tree. In all 11 of these placements, the capnography unit
displayed a normal capnogram. Radiography revealed 86 tube placements in the
midesophageal region. In all 86 of these placements, capnography displayed a
"purging warning". In three placements, radiography indicated that the tube was
coiled in the oropharynx. In these cases, the capnograph displayed one "no
purging/no capnogram" result, and two "purging" warnings. If using capnography
alone, an average of 72.5 min would be required to complete a feeding tube
placement (which includes time for requisite "pre-feed radiograph"). The
two-step radiological approach took an average of 169.4 min, a difference of
96.9 min (P <0.0001) between the two methods.
accurately identified all intratracheal feeding tube placements in this study.
This study also shows that the use of capnography would significantly shorten
the time needed for tube placement compared with a two-step radiologic method.
The authors conclude that capnography should be considered for routine use when placing feeding tubes
since it adds little time to the procedure and may improve patient safety.
Report on the development of a procedure to prevent placement of feeding tubes
into the lungs using end-tidal CO2 measurements.
Burns SM, Carpenter R, Truwit JD. Crit Care Med. 2001 May; 29(5): 936-9.
: To determine the accuracy of a technique using capnography to prevent
inadvertent placement of small-bore feeding tubes and Salem sump tubes into the
lungs. : A total of 25 ventilated adult MICU patients were
studied-5 in phase 1 and 20 in phase 2. Phase 1 tested the ability of
the end-tidal CO2 (ETCO2) monitor to detect flow (and thus accurately detect
CO2) through small-bore feeding tubes. A small-bore feeding tube, with stylet in
place, was placed 5 cm through the top of the tracheostomy tube ventilator
adapter in five consecutive patients. The distal end of the feeding tube was
attached to the ETCO2 monitor. The ETCO2 level and waveform were assessed and
recorded. Because CO2 waveforms were successfully detected, a convenience sample
of 20 adult MICU patients who were having feeding tubes placed (13 Salem sump
tubes, 7 small-bore feeding tubes) was then studied. The technique consisted of
attaching the ETCO2 monitor to the tubes and observing the ETCO2 waveform
throughout placement. Of the seven
small-bore feeding tubes tested, all were successfully placed on initial
insertion. Placement was confirmed by absence of an ETCO2 waveform and by
radiograph. Of the 13 Salem sump tubes, 9 were placed successfully on first
attempt and confirmed by absence of CO2 and by air bolus and aspiration of
stomach contents. ETCO2 waveforms were detected with insertion of four of the
Salem sump tubes; the tubes were immediately withdrawn, and placement was
reattempted until successful.
CONCLUSIONS: The technique described is a simple,
cost-effective method of assuring accurate gastric tube placement in critically