Prehospital Use of Waveform Capnography in Intubated Neonates

Introduction: Routine continuous monitoring of endotracheal tube placement with waveform capnography is considered standard of care in the prehospital setting. However, maintaining this standard in neonatal patients remains a challenge due to low tidal volumes that do not tolerate the additional dead space ETCO2 attachments add. Additionally, continuous ETCO2 can increase the risk of ETT dislodgement or kinking because of the weight and size of the capnography attachments relative to the patient and tube size. We hypothesize that there is a gap in care of intubated neonates when compared to adults in the prehospital setting in terms of continuous monitoring of ETT placement. Methods: Data were obtained from a single air medical agency. Through a retrospective chart review, records of intubated neonates (<28 days), children (≥28 days–12 years), adolescents (13–18 years), and adults (aged ≥18 years) were analyzed. Records were available from 11/21/13–1/21/22. The number of intubation attempts, whether an intubation was successful, and the use of capnography were recorded in RedCap. Statistical analysis was performed in Microsoft Excel via Chi Square Goodness of Fit Tests. Results: During the study period, 674 intubation attempts were identified, and 28 charts were excluded due to missing patient age. Continuous waveform ETCO2 monitoring was used on 62%, 94%, 95%, and 97% of successfully intubated neonates, children, adolescents, and adults, respectively. There was a statistically significant difference between use of continuous waveform capnography in adults and neonates (p-value = 0.013). There was also a statistically significant difference between use of continuous waveform capnography in intubated neonates, children, and adolescents (p-value = 0.049). Conclusion: Continuous ETCO2 monitoring is underutilized in intubated neonates compared to children, adolescents, and adults in the prehospital setting in this study population. This suggests a gap in the standard of care provided to neonates. Additional studies are needed to determine if these results are consistent around the industry and if there is a higher rate of undetected tube displacement in neonates who are transported without waveform capnography.