5 FTO tips for teaching capnography

The field training officer is responsible for ensuring new paramedics achieve competency with capnography use and interpretation

By Chris Cebollero

Capnography is an essential tool for all paramedics. The Field Training Officer (FTO) plays a critical role in helping paramedics learn about capnography, meet basic competencies, and eventually achieve mastery.

As an FTO you are the most important person in the transition of new employees joining your EMS system. In addition to being the "gatekeeper" ensuring people hired are a good fit you need to ensure that also have the necessary skills to deliver the highest quality of patient care possible.

The duty of an FTO includes being a teacher. Let's take a look at five tips for teaching capnography to new paramedics.

1. Capnography competency and learning resources
Teaching the pathophysiology of capnography can be a challenge. As an FTO you need to have a full working knowledge of the science or capnography. Develop a resource manual with capnography articles, videos and slide decks. This resource guide will help you teach to personnel with different levels of knowledge and with a multitude of resources. You can also assign personnel to complete independent study — research and reading — to prepare for group and one-on-one training discussions.

As a FTO you should develop relationships with as many different allied health professionals as possible. Use this network of peers when a question comes up that you are unable to answer. Use other experts as resources to increase your knowledge and to train your new recruits. A number of times the respiratory therapists in my network were helpful in strengthening capnography lessons I was creating. You are also reinforcing or role modeling to your trainee the usefulness of developing professional networks and continuous professional learning.

2. Practical experience with capnography
Use capnography on every patient, even nonintubated patients. You may be thinking this is overkill, but appreciating a normal appearance is half the battle for new paramedics. Once your trainee knows what normal ventilation looks like, through repeated waveform interpretation, any variation raises an eyebrow, demanding further investigation.

In between calls have your trainee put on nasal prongs and employ different breathing patterns. Review with them the various waveform changes as their breathing pattern changes. Have them write a short report of their observations and have an in-depth discussion on their findings. Or ask them to present their findings to a group of EMTs or emergency medical responders. The process of observation, documentation and discussion will reinforce the knowledge they are creating for themselves.

Have the trainee explain to their patients the purpose of using capnography. This forces them to explain capnography in terms suitable for a layperson. This allows the patients to understand the process and gives you the opportunity to gauge the trainee’s knowledge.

3. Non-stop Questioning Technique
As an FTO for many years, I have learned that questions are a more powerful tool for training than giving answers. I use the Non-stop Questioning Technique (NQT) with my trainees to ask them as many questions as possible in a short amount of time. Their answers have to come quick and be well thought out. This practices critical thinking in determining question response. This is an example NQT dialogue:

FTO: What’s the relationship between capnography and cardiac output?
Trainee: A decrease in cardiac output results in a decrease of pulmonary blood flow, resulting in decreased perfusion to the alveoli.

FTO: Once pulmonary end tidal CO2 (PETCO2) is decreased to the alveoli, what happens to the PACO2?
Trainee: That would result in a decrease of PACO2.

FTO: During continual decrease in cardiac output, resulting in an increasing CO2 accumulation in the tissues and blood occurs after how long?
Trainee: I’m not sure.

Once we get to a question that the trainee cannot answer, the question is researched, and the drill resumes.

FTO: Look it up and get back to me.

Most often the trainee’s research leads to another block of questions. As an FTO it challenges you to be the ultimate authority, in turn, helping the trainee become an authority as well.

4. Understanding the capnography waveform
Every part of the capnography waveform represents a part of the respiratory cycle. Once you have an understanding of each component you can determine what treatment is needed, and if the treatment is working.

A great learning activity for the trainee is to have them label and carry around a normal waveform, just like they might carry a 12-lead ECG reference sheet. When they are discussing how capnography works have them refer to the example waveform as they discuss their answer.

5. Manual delivery of ventilations
When transporting an intubated patient some systems may have automatic transport ventilators. If you are one of these systems, forgo the use of the ventilator and direct the trainee to ventilate the patient using a BVM.

The trainee needs to keep the patient’s ETCO2 between 35 to 45 mm Hg. Make sure the trainee keeps a close eye on the capnogram; taking note of how their ventilations changes the numbers. Manual ventilation reinforces:

  • Control and deliberate bagging a patient
  • The paradigm shift from 12-20 ventilations per minute to capnogram guided ventilations
  • Less frequent ventilations, perhaps just 8 to 10 per minute to stay with 35 to 45 mm Hg
  • How ventilation affects perfusion and CO2 elimination

Remember, as an FTO, your role is essential in the organization and to the delivery of excellent patient care. Develop rapport, become a role model and teach the skills and knowledge needed to ensure patients in your system receive the best care possible. 

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