Research analysis: Capnography to assess effectiveness of pediatric ventilation

Anesthesiologists compare mask ventilation adequacy with endotracheal intubation and laryngeal mask airway for pediatric patients

By Greg Friese, EMS1 Editor-in-Chief

Capnographs from pediatric patients undergoing elective surgery were analyzed to assess the effectiveness of ventilation. The objective of the research, reported in the American Journal of Emergency Medicine, was to compare capnographs from three airway management techniques [1]. Data, which was a 10- to 14-second capnography, was collected on 29 patients who received ventilation with two types of masks and then ventilation with either an laryngeal mask airway or endotracheal tube.

Two board certified pediatric anesthesiologists, blinded to the patients and procedures, reviewed four capnographs from each patient (116 total capnographs). The reviewers were unable to differentiate the type of airway management from the capnographs. They also rated bag-valve mask ventilation inadequate more frequently than LMA and ETT ventilation.

The researchers recommend capnography for all types of pediatric ventilation and airway management. They also recommended capnography training for EMS providers and the use of monitors large enough to display capnographs from several ventilations, as well as the numerical ETCO2 data.

Memorable quotes on pediatric airway management and ventilation
These three quotes from Freeman et al. stood out.

"Regardless of which advanced airway modality is used, confirmation of proper placement, adequate ventilation, and prompt recognition of device displacement are central to improving outcomes in prehospital pediatric advanced airway management."

"Infrequency of ventilation and prolonged expiratory phase were the most common concerns identified."

"Continuous capnography appears to be a useful tool for assessing ventilation via ETT, LMA, and mask ventilation and may help facilitate high-quality ventilation of any type."

Key takeaways: Capnography to monitor pediatric patient ventilation
Here are four takeaways for prehospital providers from this research on the use of capnography to monitor pediatric patient ventilation.

1. Always use capnography
Paramedics absolutely need to use capnography to continuously confirm airway placement in the trachea and the effectiveness of ventilations, regardless of the patient's age or the device used.

2. Capnography for mask-only ventilation works
This study showed that capnographs can be generated for pediatric patients receiving mask only ventilation. The difference in capnography between mask ventilation and ETT or LMA ventilation was "indiscernible" to the reviewers.

3. Practice and improve mask ventilation
Mask ventilations were most frequently rated as "inadequate" which may point to need for more effective mask ventilation technique, as well as being prepared to switch from mask to LMA or ETT ventilation quickly.

4. Review capnographs during paramedic training
The research methods asked reviewers to select the type of airway (BVM, LMA, ETT) and subjectively rate the adequacy of ventilations based on the capnography is a replicable exercise EMS instructors could use for pediatric airway management continuing education.

Finally, the researchers used a convenience sample of children undergoing elective surgery. They excluded patients undergoing airway, cardiothoracic or abdominal surgeries. They also excluded neonates and children with preexisting cardiac or pulmonary disease. The findings, while interesting and relevant, excluded study subjects — sick kids — who are potentially most likely to need prehospital airway management and ventilator support. Airway management and effective ventilation on sick and injured children is inherently more difficult than the controlled conditions of the operating room.

After reading the study, share your key takeaways and questions in the comments.


1. Use of capnographs to assess quality of pediatric ventilation with 3 different airway modalities. Freeman, Julia Fuzak et al. The American Journal of Emergency Medicine, Volume 34, Issue 1, 69 - 74

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