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Bhavani Shankar Kodali MD


This is reproduced from the Association of Anaesthetists of Great Britain and Ireland
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 
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).
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 
1. AAGBI Recommendations for standards of monitoring during anaesthesia and 
recovery’ 2007 (4th  edition) (accessed 
24th May 2011)
2. AAGBI Capnography outside the operating room’ 2009
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 (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 (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) (accessed 17th June 

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