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Editor,—We were disturbed to note from the survey of Florance et al that fewer than 50% of “major” accident and emergency departments in East Anglia report having any facilities for end tidal carbon dioxide (ETCO2) monitoring available for trauma patients.1
All emergency departments in North America that manage trauma patients routinely keep in their trauma rooms at least a calorimetric device for ETCO2 detection—not to do so would be considered indefensible in the event of an adverse airway event (R N Walls, personal communication).
Relying on having seen the endotracheal tube “pass through the cords” and depending on clinical signs is hazardous in the multiply injured patient. Capnography should be considered mandatory in any patient requiring intubation, especially as an emergency. The endotracheal tube must be replaced immediately in any patient not in cardiac arrest in whom ETCO2 is not detected.2
Endotracheal intubation continues to remain the “gold standard” for airway management for patients in cardiac arrest. The standard clinical signs widely used to confirm endotracheal intubation are again potentially unreliable and capnography is unhelpful. The use of a lit tracheal stylet (for example Trachlight Stylet and Tracheal Lightwand, Rusch Inc, Duluth, GA, USA), inserted through the endotracheal tube after intubation, can very simply provide indirect and rapid confirmation of correct tracheal placement by transillumination of the soft tissues of the neck. This simple technique may help to reduce the tragedy of failure to recognise oesophageal intubation in critically ill patients.
The authors reply
We would like to thank Black and Skinner for their interest in our survey. Since then, one more department has acquired a capnograph, with more contemplating purchase. We hope this trend will continue.
We agree that capnography is essential in patients who require endotracheal intubation and is a minimal monitor for anaesthesia in the UK and the USA. We have no experience of the “lit tracheal stylet” and so cannot comment on its usefulness.
However we question whether capnography is unhelpful in cardiac arrest. The level of carbon dioxide has been correlated with survival in cardiac arrest and the ability to resuscitate.1 After cardiac arrest in patients already intubated, for example during surgery, ETCO2 levels are invaluable in guiding resuscitation (personal experience RG).
In summary, capnography provides useful information about the correct placement of an endotracheal tube (“A”), the adequacy of ventilation (“B”), and the perfusion of the lungs (“C”).