Rationales and Applications for Capnography Monitoring During

Home , Capnography, Local anesthesia

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Advisory Board Rationales and Applications for Capnography

Richard Branson, MS, RRT, FAARC Monitoring During Sedation Professor of Surgery University of Cincinnati College of Medicine By Devin Carr, MSN, MS, RN, RRT, ACNS-BC, NEA-BC, CPPS and Anna Cartwright, BSN, RN Cincinnati, OH

Kathleen Deakins, MS, RRT, NPS Supervisor, Pediatric Respiratory Care In September 2011, the American Society of Anesthesiologists (ASA) approved Rainbow Babies & Children’s Hospital of University Hospitals the first substantive changes to its Standards for Basic Anesthetic Monitoring in Cleveland, OH

William Galvin, MSEd, RRT, CPFT, AE-C, FAARC almost a decade. Perhaps the most significant change is the recommendation for Program Director, Respiratory Care Program Gwynedd Mercy College, Gwynedd Valley, PA. use of capnography for monitoring the adequacy of ventilation during moderate

Carl Haas, MS, RRT, FAARC and deep sedation. The additional requirements borne by those guidelines have Educational & Research Coordinator University Hospitals and Health Centers Ann Arbor, MI generated much discussion as hospitals seek to manage risks associated with an-

Richard Kallet, MSc, RRT, FAARC Clinical Projects Manager esthesia and sedation. The purpose of this paper is to describe the drivers of this University of California Cardiovascular Research Institute change and to provide supporting evidence for use of capnography to improve San Francisco, CA

Neil MacIntyre, MD, FAARC quality outcomes by promoting patient safety in clinical practice. Medical Director of Respiratory Services Duke University Medical Center Durham, NC

Tim Myers, BS, RRT-NPS Pediatric Respiratory Care Panel Discussion: Capnography and Rainbow Babies and Children’s Hospital Cleveland, OH Conscious Sedation Tim Op’t Holt, EdD, RRT, AE-C, FAARC Moderator: Chad Epps, MD Professor, Department of Respiratory Care and Cardiopulmonary Sciences University of Southern Alabama Panelists: Bill Ehrman MD J. Brady Scott, MSc, RRT-ACCS, FAARC Mobile, AL

Helen Sorenson, MA, RRT, FAARC Brian Berry, MS, CRNA Assistant Professor, Dept. of Respiratory Care University of Texas Health Sciences Center San Antonio, TX In this panel discussion, 4 experts discuss the benefits of capnography to monitor various states of anesthesia during critical care. The panel addresses the consen- W ebinars sus guidelines and statements from multiple organizations regarding monitoring Clinical Foundations is dedi- of ventilation during procedural sedation and the application of those guidelines cated to providing healthcare in their practice; how capnography compares to pulse oximetry and respiratory professionals with clinically relevant, evidence-based rate measurement for detecting changes in respiratory status during procedural topics. Clinical Foundations sedation; the use of capnography in nonintubated patients; the primary barriers is pleased to announce a we- to implementing ventilatory monitoring during procedural sedation; capnography binar series featuring leading healthcare professionals. waveform interpretation (and the difficulty doing so among many clinicians); and To find out more about the finally, the use of capnography in neonatal and pediatric populations. current webinar and to register, go to www.clinicalfoundations.org. Each webinar is accredited for CRCEs and CEs.

MC-001200 This program is sponsored by Teleflex Incorporated Clinical Foundations

nography along with pulse oximetry. As familiar as both are in that milieu, Rationales and it is still relatively foreign to think about capnography in outpatient and alternative settings such as endoscopy Applications for centers and dental clinics, as well as emergency departments and other Capnography Monitoring procedural settings beyond traditional ORs. During Sedation Lack of familiarity and the greater variability of human and capital re- By Devin Carr, MSN, MS, RN, RRT, ACNS-BC, NEA-BC, CPPS and Anna Cartwright, BSN, RN sources in non-OR settings translate to barriers to implementing ASA’s n September 2011, the Ameri- latest standards. Inconsistencies in can Society of Anesthesiologists The standard of care for staffing levels, education levels, lack (ASA) approved the first substan- of capital funds and available train- tive changes to its Standards for ing, looser oversight from hospitals IBasic Anesthetic Monitoring in almost patients who undergo or other bodies, and the relatively few a decade. Perhaps the most significant studies published regarding outcomes change is the recommendation for use secondary to capnography in non-OR/ of capnography for monitoring the ad- general anesthesia in non-general anesthesia settings all can equacy of ventilation during moderate slow the impetus for change. Besides the cost of basic EtCO and deep sedation. The additional re- hospital ORs has long 2 quirements borne by those guidelines monitoring equipment (est. $3,000– have generated much discussion as $5,000 or more per device, plus dis- hospitals seek to manage risks associ- included capnography posable supplies), additional clinical ated with anesthesia and sedation. The staff and additional training may be purpose of this paper is to describe along with pulse required. In an era of increasing costs the drivers of this change and to pro- and declining reimbursements, the vide supporting evidence for use of up-front costs could be a rate-limiting capnography to improve quality out- oximetry. step. However, to understand the re- comes by promoting patient safety in turn on investment, clinicians and ad- clinical practice. ministrators need to fully understand must carefully interpret standards in the implications of not implementing Drivers of Change prioritizing which practice changes to the guidelines: an increased rate of ad- ASA’s standards are the backbone implement. verse events (AEs) and the cost of their of basic anesthesia monitoring in hos- While the benefits of capnography sequelae (extra lab tests and interven- pitals and clinics. Those standards for confirmation of airway status and tions), as well as potential litigation represent expert consensus, based on early detection of hypoventilation in costs if severe harm occurs. research findings and best evidence the OR setting are clearly documented Evidence for increased AEs and available. The most recent iteration in the literature, much debate remains their cost is abundant in the litera- of the standards includes the addition regarding its necessity during moni- ture for OR scenarios. A systematic of capnography (end-tidal carbon di- tored anesthesia care and procedural review of previously published stud- sedation when other means of assess- ies2 revealed that an estimated 41% of oxide [EtCO2]) monitoring for deep and moderate sedation1(July 2011). By ment are employed. Consequently, all hospital-related AEs occurred in definition, standards are rules or re- debate has arisen over the breadth of the OR with fewer events (3.1%) oc-

quirements that reflect accepted prac- practice for EtCO2 monitoring. curring in the intensive care environ- tices for safe patient care. Standards ment. Thus, despite ASA saying that set by professional organizations serve Impediments to Change capnography is now required during as care guidelines but not necessar- The standard of care for patients moderate and deep sedation, it re- ily regulatory requirements. As such, who undergo general anesthesia in mains a question mark in many peo- healthcare practitioners and providers hospital ORs has long included cap- ple’s minds. This creates a gap between

2 www.clinicalfoundations.org Clinical Foundations evidence and practice. dead space present must be taken into To address that question, two Pulse oximetry consideration if doing a side-by-side buckets of information need to be eval- comparison. But, because EtCO2 may uated: (1) what capnography contrib- seem to not measure up to an ABG utes to the clinical picture compared measures value, some clinicians question the ac- to the contributions of pulse oximetry, curacy of capnography data and there- and (2) what the literature says about fore discount the value of this ventila- capnography in these broader settings. oxyhemoglobin tory parameter.8 Understanding both will shed light on what led ASA to these recommended saturation, but it Physical assessment practice changes. While clinical observation is always a part of patient care, it does not Oxygenation vs. Ventilation: cannot determine yield information regarding respira- Oximetry, Capnometry, Arterial tory sufficiency beyond what pulse Blood Gases, and Observation oxygen consumption or oximetry and capnography can pro- Even though oxygenation and vide. For example, assessing depth of ventilation are related, they are sepa- breathing as a surrogate for oxygen- rate physiologic processes.3 Simply metabolism. ation is subjective. Similarly, skin col- put, ventilation is inhaling and exhal- or is a subjective evaluation inherently ing, while oxygenation is the process fraught with problems including skin of putting oxygen into the body. Ven- (range of 15-120 seconds) following pigmentation. It is also an unreliable tilation adequacy is a precondition capnographic detection of respiratory predictor of cyanosis, as the skin may for oxygenation and refers to the ex- depression.4 Continuous monitoring not show evidence of that until satura- 9 change of air between the alveoli and of exhaled CO2 provides evidence of tion levels are well below 80%. the atmosphere. Ventilation cannot be respiratory depression much sooner As with oxygenation, observa- adequately assessed simply by moni- and allows the clinician to take faster tional assessments have been used toring oxygenation. corrective action.5 historically to determine respiratory rate, depth, and effort. Qualitative Pulse oximetry Capnography assessments of chest excursion and Pulse oximetry measures oxyhe- Capnography is the direct mea- breath sounds are appropriate (though moglobin saturation, but it cannot de- surement of exhaled carbon dioxide. subjective) for assessing breathing ef- termine oxygen consumption or me- Alterations in expired CO2 serve as an fectiveness in patients undergoing re- tabolism; as such, it is an incomplete early indicator of respiratory compro- gional or local anesthesia with no se- measure of respiratory function. Even mise, providing medical professionals dation—but not for patients receiving when combined with clinical observa- with information about ventilation as general anesthesia or sedation. Such tion, oximetry lacks the sensitivity to well as oxygenation.6,7 assessments are not early detectors of provide early detection of hypoventi- depressed ventilatory function. lation. Hypercarbic changes may go Arterial blood gases (ABGs) Respiratory rate (RR) alone may undetected by oximetry, at least ini- ABGs measure arterial pH, oxygen be one of the earlier indicators of tially, until hypoxemia—a late sign— and carbon dioxide tension, bicarbon- complications, including respiratory manifests. In short, pulse oximetry ate, and oxygen saturation. Because acidosis, and may signal the onset of provides excellent information about capnography determines the exhaled a crisis. However, research shows that oxygenation, yet it fails to provide partial pressure of CO2, one might observational RR is measured im- information about ventilation—and think it should always correlate with properly. Clinicians often assess RR changes in O2 saturation tend to be the partial pressure of CO2 obtained for only 15 or 30 seconds, then extrap- late signs of patient compromise. As from an ABG. However, multiple fac- olate a full minute. Also, studies have noted by Vargo and colleagues (2002), tors can affect capnography values so demonstrated that manual RR may be pulse oximetry only identified 50% that they do not appear to align with a best guess rather than a precise mea- 10 of events related to apnea or respira- PaCO2 values from an ABG. The cap- surement. Capnography includes au- tory depression, and for those events nography measurement technique tomated RR readouts. detected by pulse oximetry, there was (mainstream vs. sidestream) and the In a final comparative note, pa- a delay of approximately 45.6 seconds amount of physiologic or mechanical tients receiving continuous capnogra-

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phy monitoring demonstrate a signifi- populations. However, the studies that cantly higher rate of hypoventilation Benefits of capnography do exist show the benefits of capnog- compared to patients who receive tra- raphy—and the dangers of not using ditional monitoring with pulse oxim- it—in those settings. etry combined with routine vital sign in the OR include Fanning’s 2008 “snapshot audit” monitoring and patient assessment. underscored the dangers. This survey This further suggests a high rate of un- of non-anesthetic doctors showed that recognized respiratory depression.8 confirmation of minimal monitoring requirements were not always in place. Procedures What the Literature Says about endotracheal tube performed included endoscopies, in- Capnography in Traditional ORs terventional cardiology and radiol- and Beyond. Where it started: in ogy. Notably, (1) capnography was the OR placement, guidance of never used, and (2) incidences of hy- Over the past two decades, end- poxia and respiratory depression far tidal carbon dioxide monitoring has ventilation parameters, outstripped all other adverse events. emerged as a standard for intra-op- Twenty-two percent of the doctors re- erative monitoring for patients un- ported that they had treated a patient dergoing general anesthesia.11 Studies and early detection with an adverse event.14 have documented the contribution of On the flip side, a 2006 study on capnography in the operating room. and diagnosis of the use of capnography during endos- Specifically, Brown (1992) studied the copies on pediatric patients showed utility of capnography in detecting that fewer respiratory events occurred anesthesia-related events using a ret- hypoventilation. when capnography prompted early rospective cohort design.12 Findings intervention, even in the absence of 15 suggested that EtCO2 was instrumen- other clinical indicators. Similarly, a tal in confirming suspected events in iar with monitoring standards that are 2010 randomized controlled study in 58% of documented complications mandated in the OR. an emergency department exhibited a and was the initial detector of 27% of A meta-analysis conducted by the 17% decrease in hypoxic events by uti- all documented anesthesia-related ad- University of Alabama demonstrated lizing capnography during procedural verse events. Benefits of capnography that capnography was a valuable ad- sedation.16 The ColoCap study (2012) in the OR include confirmation of en- dition to standard pulse oximetry in conducted in German endoscopy cen- dotracheal tube placement, guidance identifying respiratory depression ters showed that ventilation changes of ventilation parameters, and early during procedural sedation. Review- (apnea, hypoxemia) were detected far detection and diagnosis of hypoventi- ing studies published between 1995 more often in colonoscopy patients lation. and 2009, researchers analyzed ad- by using capnography compared to verse respiratory events reported dur- standard monitoring (pulse oximetry Beyond the OR ing procedural sedation and analgesia + blood pressure + EKG).17 As Beitz Today, many procedures which when clearly defined end-tidal carbon noted in the 2012 study, these findings were once performed in the operat- dioxide thresholds were present. Five have broad applicability because colo- ing room using rigorous standards studies were included in the analy- noscopy is one of the most common for physiological monitoring are per- sis; results indicated that respiratory invasive GI procedures performed. formed outside of the OR. Unfortu- events were 17.6 times more likely to There is widespread agreement nately, as noted by Galvagno and Ko- be detected correctly with capnogra- that improved monitoring and aware- dali (2009), the monitoring standards phy.13 ness of cardiorespiratory status yields for these remote locations have not Studies of capnography use in better outcomes. Additionally, an conformed to the standards in place venues such as gastroenterology, emerging body of evidence indicates in the OR setting.11 Several reasons for emergency medicine, and pediat- that broader use of capnography is this discrepancy in practice are noted rics remain limited. The paucity of warranted. Agencies such as The Joint and include lack of anesthesiolo- research to date on capnography in Commission, the American Society gist participation in planning for out those arenas has led some to question of Anesthesiologists, the Institute for of OR procedures as well as medical the broad applicability of capnogra- Safe Medication Practices, the Anes- proceduralists who may be unfamil- phy across diverse patient settings and thesia Patient Safety Foundation, and

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the American Heart Association all “the most important technological the OR has increased. However, an recommend capnography as an early advance ever made in monitoring the increasing number of people needing detection strategy to improve patient well-being and safety of patients dur- those procedures are patients with safety and yield quality outcomes.18 ing anesthesia, recovery, and critical multiple comorbidities and complex Despite all that, some professional or- c a r e”. 9 While that pronouncement care needs. We can expect that to in- ganizations affected by the latest ASA could be challenged, Severinghaus crease as America ages. Today one in guidelines do not subscribe to the (2011) further noted that pulse oxim- seven Americans is age 65 or older. By need for capnography during mod- etry monitoring has been associated 2030, it will be one in five—and most erate and deep sedation and have with a ten-fold reduction in deaths of them will have multiple chronic reflected that sentiment in an official attributed to anesthesia. Interestingly, conditions.20 An aging America plus statement.19 multiple double-blind studies (total n increasingly more care being pushed = 23,000) have failed to demonstrate a out from acute care settings to other Old Habits Die Hard direct relationship between pulse ox- venues increases the need for ade- Since the 1990s, the gold stan- imetry and adverse outcomes when quate respiratory monitoring during

dard for respiratory monitoring, par- clinicians were unaware of SpO2 val- procedures. ticularly during anesthesia, has been ues during anesthesia. ASA’s latest guidelines propel pulse oximetry. Pulse oximetry mea- capnography into broader usage sures oxygenation but fails to provide Optimal Patient Monitoring with more diverse patient popula- information about ventilation—and Non-anesthesia providers in di- tions. Even so, the proposed benefits changes in oxygen saturation tend to verse procedural settings may be less of capnography extend far beyond be late signs of patient compromise likely to adhere to the new guidelines operating rooms and procedural ar- with oximetric changes manifest- or facility protocols than those who eas. Because measuring exhaled CO2 ing approximately 45 seconds after work in the more highly scrutinized provides the earliest possible detec- changes in ventilation occur.4 De- inpatient OR settings. This is evi- tion of respiratory depression, this spite its inability to assess ventilation denced by studies showing a higher mode of patient monitoring has even status, oximetry’s popularity, ease of incidence of respiratory depression wider applicability. Capnography has use, and broad applicability earned and desaturation events as the num- been demonstrated to detect sudden- it a nod from at least one author as ber of procedures performed outside onset respiratory failure, respiratory depression for patients receiving opioid analgesics, and even undiagnosed obstructive sleep apnea. Due to its perceived benefits in those patients, and, in the interest of patient safety, many institutions have incorporated capnography into routine monitoring for patients at high risk for respiratory complications.18

Implementing the 2011 ASA Guidelines Prior to the 2011 guidelines, capnography was optional during moderate and deep sedation as long as other methods of assessing ventilation were utilized. The new guidelines, which include specifics regarding both, create resource challenges as many procedural areas attempt to

implement EtCO2 monitoring. But guidelines form the basis of facil- The ASA recommends patient monitoring of CO during moderate or deep sedation. The use of a proprietary 2 ity protocols, and guidelines often Sampling Cannula allows delivery of supplemental oxygen while simultaneously sampling expired CO2 (Courtesy of Teleflex Incorporated). evolve into regulations; so it is pru-

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dent to implement today what may be further supports the wider use of 13. Waugh J, Epps C, Khodneva Y. Capnography enhances surveillance of respiratory events dur- mandated tomorrow. capnography. Capnography provides ing procedural sedation: A meta-analysis. J Clin However, even the best protocols real-time, quantitative assessment of Anesth. 2011;23:189-196. are subject to individual practice de- oxygenation and ventilation and can 14. Fanning RM. Monitoring during sedation given by non-anaesthetic doctors. Anaesthesia. cisions and inconsistent compliance. alert clinicians to early changes before 2008;63(4):370-374. Beyond capnography itself, adequate hypoventilation or hypoxia occurs. 15. Lightdale J, Goldmann D, Feldman H, et al. Mi- knowledge and training in the prac- There is demonstrated value to en- crostream capnography improves patient monitoring during moderate sedation: A randomized, tices of sedation and anesthesia have hanced monitoring, which combines controlled trial. Pediatrics. 2006;117(6):e1170- been found to vary widely, as noted oximetry and capnography; that value e1178. 14 16. Deitch K, Miner J, Chudnofsky C, Dominici P, in Fanning’s 2008 study. That poses is reflected in the 2011 ASA guide- Latta D. Does end title CO2 monitoring during significant patient risk. For example, lines. The ASA guidelines provide a emergency department procedural sedation and delivering standard bolus volumes safety net of safer patient monitoring analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled instead of weight-based dosing regi- practices during administration of an- trial. Ann Emerg Med. 2010:55(3):258-264. mens is both a protocol issue as well as esthetic and sedative agents. 17. Beitz, A, Riphaus A, Meining A, et al. Capno- graphic monitoring reduces the incidence of an individual preference. The Fanning References arterial oxygen desaturation and hypoxemia study highlighted such variations in 1. American Society of Anesthesiologists. Stan- during propofol sedation for colonoscopy: A practice despite the presence of guide- dards for basic anesthetic monitoring. October randomized, controlled study (ColoCap study). 2010. www.asahq.org/.../Basic%20Anesthet- Am J Gastroenterol. 2012:107;1205-1212. lines and protocols. ic%20Monitoring%202011.ashx. Accessed Sep- 18. Moore P. The case for capnography: It saves To ensure optimal compliance tember 3, 2014. lives. RT for Decision Makers in Respiratory with protocols for monitoring pa- 2. de Vries EN, Ramrattan MA, Smorenburg SM, Care. May, 10, 2013. http://www.rtmagazine. Gouma DJ, & Boermeester MA . The incidence com/2013/05/the-case-for-capnography-it- tients during anesthesia and sedation, and nature of in-hospital adverse events: a sys- saves-lives/ Accessed September 4, 2014. healthcare facilities can benefit from tematic review. Quality and Safety in Health 19. American Society for Gastrointestinal Endos- Care. 2008;17:216-233. policies that guide the safe administra- copy, American College of Gastroenterology, 3. Becker DE, Casabianca AB. Respiratory moni- & the American Gastroenterological Associa- tion of anesthesia and sedation. Such toring: Physiological and technical consider- tion. 2012 joint statement. http://www.asge.org/ ations. Anesth Prog. 2009;56:14-22. assets/0/71542/71544/90dc9b63-593d-48a9- policies should include roles and re- bec1-9f0ab3ce946a.pdf. Accessed September 3, 4. Vargo, JJ, Zuccaro G, Dumot JA, Cornwell DL, 2014. sponsibilities for providers, processes Morrow JB, Shay SS (2002). Automated graphic by which providers are credentialed to assessment of respiratory activity is superior to 20. Administration on Aging. U.S. Department of provide care, a list of suggested medi- pulse oximetry and visual assessment for the Health & Human Resources. A Profile of Older detection of early respiratory depression during Americans: 2013. cations with suggested doses, and ap- therapeutic upper endoscopy. Gastrointestinal 21. Caperelli-White L, Urman RD. Developing a propriate methods of patient monitor- Endoscopy. 2002;55(7), 826-831. moderate sedation policy: Essential elements 21 5. Spratt G. Preventing unnecessary deaths with and evidence-based considerations. AORN J. ing. capnography. AARC Times. 2010;34(2):28-32. 2014:99(3):416-430. 6. Ortega R, Connor C, Kim S, Djang R, Patel K. 22. Hanlon P. Tech Insider: Capnography use dur- Summary Monitoring ventilation with capnography. N ing endoscopy and colonoscopy. RT for Deci- Engl J Med. 2012;367(19):e27. sion Makers in Respiratory Care. June 2, 2014. Clinicians and researchers con- http://www.rtmagazine.com/2014/06/tech-in- 7. Burton J, Harrah J, Germann C, Dillon D. sider-capnography-use-endoscopy-colonosco- sistently agree that capnography pro- Does end-tidal carbon dioxide monitoring vides useful clinical information while detect respiratory events prior to current seda- reducing the incidence of hypoxemic tion monitoring practices? Acad Emerg Med. Devin S. Carr, MSN, RN, RRT, ACNS-BC, NEA- 2006;13(5):500-504. BC is Administrative Director, Surgery and Trau- and/or hypercarbic events during an- 8. Provencher MT, Nuccio PF. Capnography mon- ma Patient Care Centers at Vanderbilt University esthesia and sedation.22 It is essential itoring. The Journal for Respiratory Care Prac- Medical Center, Nashville, TN. His job is to devel- titioners. 2010;23(8);8-10. http://www.rtmaga- that patients receive optimal monitor- op and maintain high performance work teams zine.com/2010/08/capnography-monitoring/ to support the mission, vision, and credo of the ing to detect early signs of impaired 9. Severinghaus JW. Monitoring oxygenation. J clinical enterprise. He is a peer reviewer on 3 ma- ventilation and/or oxygenation. This Clin Monit Comput. 2011;25:155-161. http:// jor medical journals in critical care and lead au- dx.doi.org10.1007/s10877-011-9284-2 is universally true, but the paradigms thor on 7 publications in his areas of interest. He 10. Elliott M, Coventry A. Critical care: the eight vi- has presented frequently on topics in respiratory applying to monitoring during anes- tal signs of patient monitoring. Br J Nurs. 2012 medicine. thesia versus moderate/deep sedation May 24-Jun 13;21(10):621-5. 11. Galvagno SM, Kodali BS. Critical monitoring Anna Cartwright, BSN, RN is a staff nurses on differed in the past. Now that they are issues outside the operating room. Anesthesiol the Cardiac/Telemetry Unit at Vanderbilt Uni- on equal footing, it is important to Clin. 2009 Mar;27(1):141-56. versity Medical Center, Nashville, TN. Ms. Cart- wright is committed to community service and know why. Anesthesia and sedation 12. Brown ML. End-tidal carbon dioxide monitoring in the detection of anesthesia-related critical has been actively involved with the Tennessee are associated with known risks, par- incidents. Journal of the American Association Action Coalition to identify primary care service ticularly in elderly patients and those of Nurse Anesthetists. 1992:60:33-40. and clinician shortages. Ms. Cartwright will be completing her MSN this year. with multiple comorbidities—which

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Clinical Foundations Panel Discussion

tory distress. Panel Discussion: Capnography SCOTT: In addition to those organiza- and Conscious Sedation tions, the American Society of Anes- thesiologists and the American Col- lege of Emergency Physicians both Moderator: Chad Epps, MD recommend the use of capnography Panelists: Bill Ehrman, MD during procedural sedation to moni- 5,6 Jonathan Scott, RRT tor ventilation adequacy. Both organizations clearly acknowledge the Brian Berry, MS, CRNA benefits of capnography as an adjunct Multiple organizations have released to standard clinical assessment and consensus guidelines and state- We utilize end- other tools such as pulse oximetry. ments regarding monitoring of ventilation during procedural sedation. For anyone providing procedural What standards of practice do you tidal carbon dioxide sedation, it is imperative to detect use for capnography in that arena? changes in respiratory status as EHRMAN: Our practice is guided by the early as possible. How does capnog- current ASA recommendations.1 We monitoring during any raphy compare to pulse oximetry utilize end-tidal carbon dioxide moni- and respiratory rate measurement toring during any procedure in which procedure in which for detecting changes in respiratory moderate or deep sedation is indicat- status during procedural sedation? ed; for example, to avoid significant EHRMAN: First off, capnography as- patient discomfort during colonosco- moderate or deep sesses ventilation; pulse oximetry and pies and endoscopies. While deeper respiratory rate (RR) do not. Beyond sedation improves patient satisfaction sedation is indicated. that basic difference, the changes in a and the gastroenterologist’s ability to patient’s respiratory status can be de- perform the procedure,2 the short-act- tected much earlier with continuous ing agent propofol is being used more - Ehrman - capnography than with pulse oxim- widely for procedural sedation. That etry and RR measurements. Burton et introduces increased risk of hypoven- al. showed that minutes can pass in a tilation, apnea, aspiration, airway ob- BERRY: According to the Institute for patient who is apneic or hypoventilat- struction and cardiovascular instabili- Safe Medication Practices3 and the ing prior to development of hypoxia ty. Capnography detects those changes Anesthesia Patient Safety Foundation,4 that can be detected by means other earlier, which improves patient moni- all healthcare professionals should than capnography.7 In fact, Burton’s toring and safety. We also utilize cap- use technology equipped to estimate study was stopped sooner than an- nography during procedures requir- carbon dioxide in the blood. Imple- ticipated when an independent review ing mild sedation, such as cataract menting those guidelines ensures showed that capnography detected surgery. Even then, patients with co- safe, effective procedural sedation for 20 acute respiratory events in 60 pa- morbidities such as obstructive sleep patients. During procedural sedation, tient sedation encounters—most of apnea have the potential to obstruct. which had EtCO abnormalities that SpO2 monitoring lags behind capnog- 2 Therefore, with consistent use of cap- raphy cessation alarms. Capnography occurred before hypoxia could be de- nography, patient safety is improved. is a more sensitive indicator of respira- tected clinically or by pulse oximetry.

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Continuous pulse oximetry has its measureable changes in heart rate and place. It assesses a patient’s oxygen- pulse oximetry. ation, but there can be a significant So I recommend that all delay in detecting desaturation dur- Accurate breath sampling is critical in ing apnea, obstruction, or hypoventi- healthcare professionals assessing ventilation for patients un- lation. When looking at the oxygen- dergoing procedural sedation. Breath hemoglobin dissociation curve, once a sampling is historically less accurate patient’s partial pressure of blood oxy- use capnography during for the non-intubated patient. What gen decreases to a certain point, the is your experience using capnography amount of oxygenated hemoglobin procedural sedation in non-intubated patients, and has re- declines even more rapidly—giving cent technology enhanced your ability the anesthesiologist less time to pro- to do this accurately? vide sufficient oxygenation and ven- for the most up-to- EHRMAN: Accuracy is a relative term tilation. With the use of capnography, when discussing breath sampling. ventilatory changes are detected ear- Quantitatively speaking, the ETCO date, safe, and sensitive 2 lier, giving the anesthesiologist more measured with capnography is more time to manage the patient’s airway. accurate when the patient is intubated

Similar concerns exist with RR monitoring because there is less dilution of CO2 monitors, such as impedance pneu- with non-pulmonary gases [room air, mographs and pressure-sensitive - Berry - dead-space gases]. However, the ex- pads. They can fail to alarm in the act end-tidal CO2 concentration is not presence of apnea and obstruc- the purpose of capnography during tion because of interference from tion begins, leading to hypoxia and procedural sedation—the qualitative paradoxical chest wall movements, ultimately cardiopulmonary arrest. graphic visualization of ventilation artifacts from patient movement So I recommend that all healthcare and respiratory rate to detect early ap- and even the patient’s heartbeat. professionals use capnography during nea and obstruction is the impetus for procedural sedation for the most up- capnography during procedural seda- BERRY: A recent study in Anesthesia & to-date, safe, and sensitive monitoring. tion. Analgesia also graphically described the sensitivity of capnography com- SCOTT: The greater sensitivity of cap- SCOTT: Most of my experience using pared to pulse oximetry.8 Patients nography has been widely published capnography in non-intubated pa- monitored by capnography demon- and is easy to illustrate in the labo- tients is in the emergency department. strated respiratory depression 58% ratory and classroom settings. For While there are some occasions when of the time. Based on pulse oximetry example, Miner et al. reported that, the waveform or numeric display is readings alone, only 12% of the pa- during procedural sedation and an- less than stellar, overall I find it works tients would have been detected as algesia in the emergency department, nicely. A while back, providing supple- having respiratory depression. Fur- capnography could detect respiratory mental oxygen posed some challenges, thermore, when using supplemental depression, independent of pulse ox- as the flow seemed to distort the read- oxygen, studies suggest that pulse imetry.10-12 Anderson’s study of cap- out. That issue was alleviated by newer oximetry does not provide clinically nography during pediatric orthopedic cannulas that allow for simultaneous effective data. The Joint Commission procedures showed that it detected oxygen delivery and carbon dioxide Sentinel Event #49 clearly states that apnea in all cases before pulse oxim- sampling. Another problem occurred healthcare providers should not rely etry did.13 In the classroom, I teach when patients directed airflow from

solely on SpO2 when using supple- the limitations of pulse oximetry and the nose to the mouth. Again, im- mental oxygen, but instead employ the real-time feedback of capnography proved cannulas reduced that issue by continuous capnography.9 I’ve per- by putting myself on the devices and sampling both from the nose and over sonally seen pulse oximetry remain holding my breath to mimic apnea. the mouth. at 100% while the patient’s capnogra- The students gain an appreciation for phy waveform was absent for several the breath-to-breath analysis of respi- BERRY: Agreed. The latest capnogra- seconds. Unfortunately, those seconds ratory status. They can see that some- phy technology can indicate the pa- can become dangerous as obstruc- one can be apneic for a time with no tient’s quality of breath, respiratory

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rate, amount of CO2, and if the pa- given must adhere to the guideline. tient stops breathing.14 When using Hopefully additional studies will the best products available, health- ...newer cannulas are clearly demonstrate the economics care professionals can expect to see of patient safety as being much more accurate morphology of the capnog- available that allow for important than the minimal cost of raphy waveform in sedated patients. the technology. Many hospitals will Conversely, using older technology need time to implement this endeav- can generate skewed results or poor simultaneous oxygen or due to the many layers of approv- morphology of capnogram wave- als. forms.15 delivery and carbon SCOTT: Even though pulse oximetry EHRMAN: Yes, technology is definitely is used widely as an exclusive moni- catching up with expanding needs. dioxide sampling. tor for oxygen and ventilation,17 al- And today’s technology is much though its is an off-label use in respect more accessible. Less bulky, more - Scott - to ventilation. Still, the reality is that readily transportable capnography pulse oximetry is easy to use, readily machines make monitoring in off- available and usually simple to inter- site procedure areas more reasonable. sampling nasal cannulas can be a sig- pret. With new technology like cap- nificant financial burden, especially nography comes additional training SCOTT: Ultimately, the clinician must in small, independent institutions. needs, including initial training and be savvy in interpreting capnography Another reason for not routinely us- ongoing annual competencies. All of results. Like any device, the monitor’s ing capnography is a lack of educa- that, coupled with the overall lack of information must be taken into con- tion about the new ASA guidelines evidence regarding outcomes, may text of the clinical situation. A slight- for moderate and deep sedation. Fi- pose barriers in many institutions. ly distorted waveform that reveals a nally, anesthesia providers have been normal breathing rate/ pattern, cou- performing sedation procedures for The literature suggests substantial pled with normal pulse oximetry and decades without using end-tidal car- limitations in healthcare provid- other physiologic measures, may still bon dioxide monitoring, so a certain ers’ abilities to accurately interpret add the clinical confidence needed to comfort level has developed amongst capnography waveforms. Even with continue with the procedure. Cap- that generation of providers to use substantial training, this sometimes nography is not without limitations, sedation without this technology. remains an issue for non-anesthe- but advancements in the technology siologists providing procedural se- have certainly improved it over time. BERRY: Simply put, the barriers are dation. Why do you think this is, the institution and logistics. Hos- and what are possible solutions? In 2011, The American Society of pitals fear that the cost of providing EHRMAN: Again, interpreting cap- Anesthesiology revised its Stan- capnography will drastically increase nography waveform shape is not the dards for Basic Anesthetic Moni- expenditures. However, studies dis- purpose of EtCO2 monitoring dur- toring to include monitoring of prove that. In fact, the benefits sig- ing procedural sedation. Under gen- ventilation by capnography during nificantly outweigh the risks. If, for eral anesthesia, with an endotracheal procedural sedation. Even so, many example, a patient does have a respi- tube in place, waveform interpreta- institutions and providers are not ratory complication, the cost to treat tion can be important in diagnosing routinely doing this. What do you that patient will be substantially high- bronchospasm, pulmonary embo- think are the primary barriers to er than providing the basic monitor.16 lism and hypermetabolic states such implementing ventilatory monitor- Conversely, many health care organi- as malignant hyperthermia and thy- ing during procedural sedation? zations understand that capnography rotoxicosis. During procedural seda- EHRMAN: I believe the most com- monitoring is warranted but cannot tion, the goal is to monitor whether mon barrier is the additional cost, ensure that all facility locations are or not the patient has sufficient gas especially for offsite procedure lo- equipped to actually utilize capnog- exchange—and to detect apnea and cations [ERs; MRI/CT, GI and cath raphy. Once a hospital declares it will obstruction quicker than pulse ox- labs; outpatient centers]. The cost monitor capnography during seda- imetry, RR monitors or visual clinical for the machine, sample tubing and tion, all locations where sedation is changes [chest-wall movement and

www.clinicalfoundations.org 9 Clinical Foundations

facemask humidification] can. Teach- utilizing staff (like respiratory thera- est method to detect such changes. ing non-anesthesiologists to detect pists) that use capnography regularly. Better monitoring of pediatric pa- the presence or absence of a waveform Uses range from cardiac arrest situa- tients improves their standard of care. on a screen should not be an issue. tions, such as evaluating adequacy of Interpreting capnography waveforms chest compressions/return of spon- SCOTT: Currently, pediatric masks and in great detail is not necessary. The taneous circulation, to trending of cannulas can simultaneously provide goal of capnography during proce- mechanically ventilated patients over supplemental oxygen and sample car- dural sedation is to monitor whether time. It is respiratory therapist’s duty bon dioxide. If the patient is some- or not a waveform is present, the to analyze and interpret the results what compliant and the equipment is frequency of the waveform and pos- to make timely interventions. Unfor- properly applied, I find capnography sibly any change in waveform ampli- tunately, staffing demands may pre- to be reliable in pediatric patients. tude, which would alert the provider vent respiratory therapists from being to any signs of respiratory depression. available in all clinical areas. However, BERRY: As healthcare professionals, we if they are available, their skill set may are expected to deliver the safest care BERRY: I believe that many non-anes- meet this need.19 possible. As already noted, pediatric thesia providers have not been edu- patients can deteriorate rapidly due cated properly in capnography. This is Neonatal and pediatric populations to their higher oxygen consumption.22 probably due to inadequate exposure present unique challenges for utiliz- I believe that pediatric societies will to the latest advances in monitoring ing capnography in procedural seda- follow other organizations that have standards. Departments should pro- tion. Can capnography be utilized already issued position statements vide in-services that explain the pa- reliably in all patient populations? about capnography monitoring. More tient safety benefits of capnography. research will help expedite that. Specifically, hospitals are responsible EHRMAN: Lightdale’s study of non- for instruction on how to interpret the intubated children receiving mod- References 1 American Society of Anesthesiologists. Standards capnography waveform in terms of erate sedation for nonsurgical for Basic Anesthetic Monitoring, Standards and morphology, quality of breathing, re- procedures demonstrated that cap- Practice Parameters. https://www.asahq.org/For- nography does alert the provider Members/Standards-Guidelines-and-Statements. spiratory rate, EtCO2 values, obstruc- aspx. Accessed June 19, 2014. tion, and apnea. Finally, staff should earlier of alveolar hypoventilation 2 McQuaid KR, Laine L. A systematic review and be able to demonstrate the ability to and does reduce arterial hypoxemia meta-analysis of randomized, controlled trials of understand capnography by written or in pediatric patients during proce- moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008;67:910-23. dures requiring moderate sedation.20 oral examination. I’m optimistic that 3 Institute For Safe Medication Practices: Ongoing, institutions will begin to implement preventable fatal events with fentanyl transder- capnography lectures so healthcare SCOTT: Even before Lightdale, mal patches are alarming! Medication Safety Alert, June 28, 2007, professionals are up to date on the lat- more than 14 years ago, cap- 4 Anesthesia Patient Safety Foundation Newsletter est trends of procedural sedation as nography was shown to be use- [all articles]. Winter 2006-2007;21(4):61-68. 21 well as current monitoring guidelines. ful in the pediatric population. 5 American Society for Anesthesiology. Standards for Basic Anesthetic Monitoring, Standards and Practice Parameters. https://www.asahq.org/For- SCOTT: Proficiency often follows train- EHRMAN: Even though neonatal and Members/Standards-Guidelines-and-Statements. ing and repetition. In medical educa- pediatric patients desaturate much aspx. Accessed June 19, 2014. tion using high-fidelity simulations, more quickly than adult patients, 6 Godwin SA, Burton JH, Gerardo CJ, et al. Clini- cal policy: procedural sedation and analgesia in repetitive practice enhances skill capnography still detects apnea and the emergency department. Ann Emerg Med. achievement and maintenance.18 Dit- obstruction earlier than pulse oxim- 2014;63(2):247-58.e18. to for clinical skills being enhanced by etry. Because neonates and infants 7 Burton JH, Harrah JD, Germann CA, et al. Does have a lower functional residual ca- end-tidal carbon dioxide monitoring detect respi- repetitive clinical practice. Unfortu- ratory events prior to current sedation monitor- nately, non-anesthesia providers may pacity, fewer functional alveoli and ing practices? Acad Emerg Med. 2006;13:500-4. be tasked with conscious sedation pro- increased oxygen consumption, the 8 Overdyk FJ, Carter R, Maddox RR, et al. Continu- cedures only on a limited basis, which time from apnea or obstruction to de- ous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient could result in an inadequate under- saturation is much shorter. Therefore, controlled analgesia. Anesth Analg. 2007;105:412- standing of the technology. Solutions earlier detection of the pediatric pa- 8. to this issue could include increasing tient’s ventilatory status is even more 9 The Joint Commission. Sentinel Event Alert. 2012;49:1-5. http://www.jointcommission.org/as- training frequency for current staff or critical—and capnography is the fast- sets/1/18/SEA_49_opioids_8_2_12_final.pdf. Ac-

10 www.clinicalfoundations.org Clinical Foundations

cessed August 31, 2014. Clinical Foundations is a serial education pro- 10 Miner JR, Biros M, Krieg S, Johnson C, Heegaard Chad Epps, MD is currently Associate Profes- gram distributed free of charge to health profes- W, Plummer D. Randomized clinical trial of pro- sor and Director of Simulation at the University sionals. Clinical Foundations is published by Saxe pofol versus methohexital for procedural seda- of Alabama in Birmingham, AL. Dr. Epps has ex- Healthcare Communications and is sponsored by tion during fracture and dislocation reduction tensive experience working in human simulation Teleflex Incorporated. The goal of Clinical Foun- in the emergency department. Acad Emerg Med. and the development of simulation curricula for dations: A Patient-Focused Education Program for 2003;10(9):931-937. education and assessment of a variety of healthcare professionals. He holds many professional Healthcare Professionals is to present clinically- 11 Miner JR, Biros MH, Heegaard W, Plummer memberships including the American Society and evidence-based practices to assist the clini- D. Bispectral electroencephalographic analysis of Anesthesiologists and Society for Simulation cian in making an informed decision on what is of patients undergoing procedural sedation in in Healthcare. Dr. Epps received his M.D. from best for his/her patient. The opinions expressed the emergency department. Acad Emerg Med. the Medical College of Georgia. He completed in Clinical Foundations are those of the authors 2003;10(6):638-643. an internship in Internal Medicine at the Univer- only. Neither Saxe Healthcare Communications 12 Miner JR, Heegaard W, Plummer D. End-tidal car- sity of Florida before moving to New York City to nor Teleflex Incorporated make any warranty or bon dioxide monitoring during procedural seda- continue his training in Anesthesiology at The representations about the accuracy or reliabil- tion. Acad Emerg Med. 2002;9(4):275-280. Mount Sinai Medical Center. ity of those opinions or their applicability to a 13 Anderson JL, Junkins E, Pribble C, et al. Capnog- particular clinical situation. Review of these ma- raphy and depth of sedation during propofol seda- Brady Scott, MSc, RRT-ACCS, FAARC is Direc- terials is not a substitute for a practitioner’s in- tion in children. Ann Emerg Med. 2007;49:9-13. tor of Clinical Education at Rush University, Chi- dependent research and medical opinion. Saxe cago, Illinois. He is active on 11 professional com- Healthcare Communications and Teleflex dis- 14 Covidien website. Capnography monitoring. mittees and holds 5 specialty and subspecialty claim any responsibility or liability for such mate- http://www.covidien.com/rms/products/capnog- certifications, including the National Board for rial. They shall not be liable for any direct, special, raphy. Accessed August 31, 2014. Respiratory Care, Certified Respiratory Thera- indirect, incidental, or consequential damages of 15 Buncombe County EMS website. Capnography: pist, Registered Respiratory Therapist, and Adult any kind arising from the use of this publication Part II. http://emsstaff.buncombecounty.org/in- Critical Care Specialist. Mr. Scott is a member of or the materials contained therein. housetraining/capnography/part-2/ Accessed Au- the American College of Chest Physicians, the Please direct your correspondence to: gust 31, 2014. Coalition for Baccalaureate and Graduate Respi- 16 Maddox RR, Williams CK. Clinical Experience ratory Therapy Education, the Illinois Society for Saxe Healthcare Communications with Capnography Monitoring for PCA Patients. Respiratory Care, the American Association for [email protected] Anesthesia Patient Safety Foundation Newsletter. Respiratory Care, the North Carolina Society for © Saxe Communications 2015 2012;26(3):47-50. Respiratory Care, and the Lambda Beta Society; National Honors Society for the Profession of 17 Waugh JB, Epps CA, Khodneva YA. Capnography Respiratory Care. He has a very active teaching enhances surveillance of respiratory events during career and has contributed to 27 papers and ab- procedural sedation: a meta-analysis. J Clin Anes- stracts in the field of respiratory medicine. th. 2011;23(3):189-196. Scan this QR code to be 18 Issenberg SB, McGaghie WC, Petrusa ER, Lee Brian D. Berry Jr., CRNA, MS is currently the placed on our mailing list Gordon D, Scalese RJ. Features and uses of high- CRNA Chief at Anesthesia Management Solu- fidelity medical simulations that lead to effective tions (AmSol) in West Virginia and Ohio (affiliat- and receive information learning: a BEME systematic review. Med Teach. ed with the Ohio State University). Mr. Berry pro- on Clinical Foundations 2005;27(1):10-28. vides the directional leadership for all the CRNAs publications and webinars. 19 Scott JB, Cappiello JL, Davies JD, MacIntyre NR. associated with AmSol. In addition to his clinical Utility of a respiratory care practitioner during work, Mr. Berry is Adjunct Faculty member at the procedural sedation. [abstract]. Respiratory Care. University of Pennsylvania and lecturer at the Ex- 2005;50 (11):1502. cela Health School of Anesthesia/St. Vincent Col- 20 Lightdale JR, Goldmann DA, Feldman HA, et al. lege. He has published several articles in peer-re- Mainstream capnography improves patient moni- viewed journals and has presented frequently at toring during moderate sedation: a randomized local and national anesthesia conferences. controlled trial. Pediatrics. 2006;117(6):e1170-78. William B. Ehrman, D.O. is Assistant Professor 21 McQuillen KK, Steele DW. Capnography during of Anesthesiology and Acute Pain at the Univer- sedation/analgesia in the pediatric emergency sity of Pittsburgh Medical Center (UPMC East and department. Pediatr Emerg Care. 2000;16(6):401- UPMC South Side) and the University of Pitts- 404. burgh Physicians. Among his current certifica- 22 Brett, Claire. Chapter 33 in “Basics of Anesthesia.” tions and licenses are Board Certification in An- 5th ed. Philadelphia, PA: Elsevier; 2007:pg 508-509. esthesiology, Controlled Substance Registration Certificate, Pennsylvania State Medical License, Basic Life Support, and Advanced Cardiac Life Support. Dr. Ehrman holds several academic and professional honors for his educational work, including the 2008 Orris B. Hirtzel and Beatrice Dewey Hirtzel Memorial Foundation Merit and Scholarship Award, presented to the student of the graduating class with the highest academic standing at the end of 4 years of medical school. (Class Rank #1 out of 218 students.) He currently serves on 4 committees (American Society of Anesthesiologists, Pennsylvania Society of An- esthesiologists, American Osteopathic Associa- tion, and the Pennsylvania Osteopathic Medical Association.

www.clinicalfoundations.org 11 Questions

1. Capnography provides earlier detection of hy- 5. All of the following have impeded capnog- 9. Which of the following is a primary benefit of poventilation than pulse oximetry? raphy from broad use outside the operating using capnography for procedural sedation? A True room EXCEPT A shorter recovery period for the patient B False A cost of equipment B early detection of complications leading to early intervention 2. The 2011 changes to ASA Standards for Basic B limited research on outcomes in procedural areas C lack of familiarity in outpatient and alternative C lower sedation dose required Anesthetic Monitoring suggested the addition settings D decreased risk of procedural complications of which of the following during moderate D increasingly complex health status of Americans and deep sedation? 10. To ensure patient safety and compliance with 6. Detection of respiratory depression using best practices, health care facilities should A continuous pulse oximetry monitoring B frequent assessment of rate and depth of pulse oximetry alone may be delayed by an have which of the following measures in place respirations average time of ______following capno- for patients undergoing anesthesia and seda- C capnography graphic detection. tion? D continuous ECG monitoring A 5 seconds A policies to guide the safe administration of 3. All of the following represents additional ben- B 45 seconds anesthesia/sedation C 3 minutes B clearly defined roles and responsibilities for efits of capnographic monitoring in the OR D 5 minutes providers setting EXCEPT? C appropriate methods for patient monitoring A precise measurement of oxygenation status 7. Capnography provides clinicians with a better D all of the above B detection of more hypoventilation than pulse picture of both ventilation and oxygenation. oximetry alone A True C earlier detection of hypoventilation B False D confirmation of airway status 8. Which of the following are true regarding cli- 4. Newer uses of capnography include the detec- nician assessment of respiratory rate? tion of respiratory depression in patients A observational RR is often measured improperly receiving opioid analgesics as inpatients. B clinicians only assess for 15-30 seconds then A True extrapolate rate per minute B False C studies have demonstrated that measurement of RR is often a best guess D all of the above

Answers This program has been approved for 2.0 contact Participant’s Evaluation hours of continuing education (CRCE) by the American Association for Respiratory Care (AARC). 1. What is the highest degree you have earned? AARC is accredited as an approver of continuing Circle one. 1. Diploma 2. Associate 3. Bachelor A B C D A B C D education in respiratory care. 4. Masters 5. Doctorate 1 Saxe Communications is accredited as a provider 2. Indicate to what degree the program met the of continuing education by the American objectives: Nurses Credentialing Center’s Commission on Accreditation. A B C D A B C D Objectives This education activity is approved for 2.0 contact Upon completion of the course, the reader was 2 hours. Provider approved by California Board of Nursing, Provider #14477 able to: Provider approved by the Florida Board of Nursing. 1. Explore drivers of change for basic anes- A B C D A B C D Provider # CE 50-17032 for 2.0 contact hours. thetic monitoring. To earn credit, do the following: Strongly Agree Strongly Disagree 1 2 3 4 5 6 1. Read all the articles. 2. Discuss capnography as a strategy for A B C D A B C D 2. Complete the entire post-test. promotion of patient safety. 3. Mark your answers clearly with an “X” in Strongly Agree Strongly Disagree the box next to the correct answer. You 1 2 3 4 5 6 can make copies. A B C D A B C D 4. Complete the participant evaluation. 3. Evaluate barriers to implementation of capnographic monitoring 5 10 5. Go to www.saxetesting.com to take the test online. Strongly Agree Strongly Disagree 1 2 3 4 5 6 6. To earn 2.0 CRCEs or CEs, you must achieve 1This test is available only online. a score of 75% or more. If you do not pass 4. Please indicate your agreement with the the test you may take it over one more following statement. “The content of this Mark your answers in the box time. course was presented without bias toward above, and then please go to 7. Test must be taken by: Aug. 12, 2016 (RTs) / any product or drug.” Aug. 1, 2017 (Nurses). Strongly Agree Strongly Disagree www.saxetesting.com/cf and Strongly 1 Agree 2 3 Strongly 4 Disagree 5 6 8. This test must be taken online. Go to 1 2 3 4 5 6 register to take your test. Enter www.saxetesting.com/cf and log in. Upon successful completion, your certificate can your answers in the appropriate be printed out immediately. AARC members’ results are automatically forwarded to Please consult www.clinicalfoundations.org box. Once successfully completed, the AARC for accreditation. for current annual renewal dates. your certificate of completion 9. Faculty Disclosures. Nurse Planner: Lisa Caf- fery, MS, RN, CIC disclosed no conflicts of can be printed out immediately. interest. Content Experts: Devin Carr, MSN, RT; Anna Cartwright, BSN, RN; Chad Epps, (AARC members results are posted MD; Bill Ehrman, MD; Brady Scott, RRT; Brian automatically) Berry, CRNA disclosed no conflicts associated with this activity