3 ways to teach capnography with active learning

Add electronic response devices and video to lectures and train with simulation to keep learners engaged, stimulate discussion and apply content

This feature is part of our Paramedic Chief Digital Edition, a regular supplement to EMS1.com that brings a sharpened focus to some of the most challenging topics facing paramedic chiefs and EMS leaders everywhere. To read all of the articles included in the Spring 2016 issue, click here.

By Bob Sullivan

EMS tends to attract action-oriented people with short attention spans, which is a challenge when designing education programs. Whether for initial or continuing education, students are more likely to remember material if they are involved in lessons, and directed to analyze and apply what they learn. Active learning uses activities to engage learners in higher-order thinking tasks rather than passively receiving knowledge conferred by an instructor [1].


Capnography is a valuable assessment tool that many EMS providers do not utilize to its full potential. Here are three strategies that use active learning principles to teach about capnography use for respiratory compromise, sepsis and resuscitation:

1. Embrace mobile devices and media during lectures
Everyone has sat through torturous lectures driven by PowerPoint slides, and knowledge retention even from good lectures is notoriously poor. Students are more likely to remember material if they are involved in lessons and directed to analyze and apply what they learn, and lectures are more effective when students are given the opportunity to participate. Frequent recall of material, such as answering questions throughout chapters in a textbook, greatly improves knowledge retention [1].

Mobile devices allow review questions to be answered during a lecture, which keeps students thinking about the material and shows the instructor how well they are grasping it. Free polling programs such as Poll Everywhere and Kahoot allow you to insert multiple-choice questions into PowerPoint slides, and participants can see the poll results immediately. Polling can gamify a lecture.

Videos can also be embedded into slides that demonstrate content in action. Thousands of videos of real patient care on YouTube and Vimeo show abstract concepts being applied in practice. For example, in a lesson about respiratory compromise, present students with a case study about an 84-year-old female short of breath, with a history of CHF and COPD, speaking in two- or three-word phrases and with diminished breath sounds. Use an online polling program to give participants the choice to:

A.   Apply supplemental oxygen

B.   Administer albuterol


After the class sees their preferred treatment, follow up by asking why participants chose their answers. Both can be justified, and the real value is in the discussion about why they thought one choice was better.

Then show this video where paramedics apply capnography to a patient with that same presentation. After seeing the nearly-rectangular capnography waveform indicating no bronchospasm, ask the poll question again to see if the results are different. Show the rest of the video, which includes a lesson from well-known EMS educator Dave Page, about assessing respiratory patients and end with a discussion about how applying capnography early can affect critical treatment decisions.

Using mobile devices to answer questions and showing videos that demonstrate the concepts during a lecture will help students remember information and make the experience more meaningful.

2. Assign class work at home and homework in class
An alternative to a lecture is the flipped classroom model, in which learners watch a video, listen to a recorded lecture or podcast or complete a reading assignment before class. Students then do activities that apply material from those assignments in class. This allows class time to be used for higher-level thinking and problem solving.

For example, a service wants to use capnography to improve sepsis patient care. Instead of lecturing from slides in a classroom about how EMS recognition of severe sepsis, IV fluid administration and hospital notification can save lives, participants could watch a free online presentation from Mike McEvoy about capnography and sepsis before their face-to-face training meeting. After watching the video, ask participants to write an email or post on a discussion board completing the following sentences:

  • Now I understand _____ about sepsis.
  • I still don’t get _____ about sepsis.
  • EMS sepsis recognition is or is not important because _____.

This pre-class activity allows the instructor to plan the lesson and focus on the less-understood areas of sepsis and capnography in class, as well as learn if there will be any resistance to the idea. It also encourages learners to reflect on and process what they watched in their own words, which improves knowledge retention [1].

After a review of the webinar in class, participants could work on cases in small groups that apply capnography for suspected sepsis. Some example cases:

  • 80-year-old male with altered mental status and decreased urine output.
  • 70-year-old female with difficulty breathing and isolated wheezing.
  • 40-year old male with pain and redness around his knee three days after surgery.
  • 12-year old with pain and red streaks up his arm three days after being bitten by a dog.

Assign vital signs for each patient, including ETCO2 and temperature, and have the groups of students report to their classmates' answers to these questions:

  1. Is the patient in systemic inflammatory response syndrome, sepsis, severe sepsis or septic shock? How do you know?
  2. How would monitoring ETCO2 help determine which patients need IV fluid? (ETCO2 below 25 mm HG with signs of infection is correlated with severe sepsis) [2].
  3. How could reporting the patient’s ETCO2 and temperature affect the patient’s hospital course?

By recalling, analyzing and applying content while working out problems in class, learners have more tools to use that information in their practice.

3. Practice like you plan to play with simulation
Simulation allows learners to practice psychomotor skills, build pattern recognition and improve team dynamics in a safe environment. Simulators range from task trainers, such as an airway head or IV arm, to human actors and high-fidelity patient simulators that talk, generate cardiac rhythms and lung sounds and physiologically respond to medications.

Regardless of the tools used, applying a few active learning principles can make simulation a successful learning experience. Write learning objectives before the simulation. Make participants actually perform the steps of as many assessment and treatment tasks as possible. Finally, participants should reflect on the experience in a debriefing after the simulation.

For example, use a pit-crew resuscitation simulation focused on the use of capnography. An instructor with a CPR torso, airway head, IV arm and rhythm generator available will read vital signs and ETCO2 levels to the pit crew. The participants need to use ETCO2 levels to guide compression quality, change compressors, identify a spike and sustained ETCO2 after ROSC and recognize re-arrest after a loss of ETCO2.

Participants should carry gear the same way they would into someone’s home. Teams should practice performing chest compressions around other interventions (including placing an advanced airway, starting an IV, administering simulated medications, applying the capnography circuit and checking blood pressure before having one read to them by the facilitator) and rotating compressors every two minutes. The facilitator could read trends in the patient’s ETCO2 as feedback on the quality of compressions. Have participants work through problems together, even if mistakes are made, and discuss them during a debriefing.

The debriefing should likely last at least half as long as the scenario [3]. The facilitator should guide the discussion in a way that allows students to learn from each other. Instead of giving an American Idol-style critique of the simulation, the facilitator should ask what the participants thought went well and what could have gone better, and then ask how they feel about the learning points. For this scenario, the facilitator could ask what could cause a sudden drop in ETCO2 (hint: misplaced airway, secretions in the tube or a pneumothorax). Practice followed by reflection helps participants apply that experience later.

When developing an education program, think about ways to engage learners. Using mobile devices in lectures, flipping the classroom and simulation exercises are three ways to get students to analyze, apply and practice using capnography.


1. Brown PC, Roediger HL, McDaniel MA. Making it stick: the science of successful learning. Belknap Press of Harvard University Press, Cambridge, MA: 2014.

2. Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. American Journal of Emergency Medicine. 2013 Jan; 31(1):64-71.

3. Kamerer J. Teaching healthcare professionals using simulation. Net CE; 2015.


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