Inappropriate Ventilation in Intubated
Prehospital Patients on Arrival at the ED
In a study at a single emergency department, end-tidal CO2 values revealed inappropriate
ventilation in nearly half the patients.
Previous studies have raised concerns about excessive ventilation during resuscitation with a bag
and mask, but does this also occur during intubation? In a prospective observational study,
researchers in California assessed end-tidal carbon dioxide (ETCO2) levels on arrival to the
emergency department in 100 patients without cardiac arrest who received prehospital
endotracheal intubation. Four patients with esophageal intubation were excluded.
Among the 96 patients (age range, 2 months to 92 years), presenting conditions were trauma (74
patients), medical (12), and burns (10). Overall, 61% of patients were transported by air. Median
ETCO2 was 32 mm Hg (range, 18–80 mm Hg). Nearly half the patients (48%) had abnormal
ETCO2 values, including 39% with ETCO2 <30 mm Hg (hyperventilated) and 9% with ETCO2
>45 mm Hg (hypoventilated). Use of continuous ETCO2 monitoring during transport did not
affect rates of abnormal values.
Comment: Most concerning is that use of ETCO2 monitoring did not improve performance of
prehospital providers in this study. Both overventilation and underventilation have adverse
consequences, and providers should ensure use and proper interpretation of ETCO2 monitoring
for all intubated patients. Training should emphasize appropriate ventilation, not just intubation.
— Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine January 20, 2012
Citation(s):
Holmes J et al. Abnormal end-tidal carbon dioxide levels on emergency department arrival in
adult and pediatric intubated patients. Prehosp Emerg Care 2012 Jan 4; [e-pub ahead of print].
(http://informahealthcare.com/doi/abs/10.3109/10903127.2011.640416)
Copyright © 2012. Massachusetts Medical Society. All rights reserved.