Detection of Hypoventilation by Capnography and Its Association With Hypoxia in Children Undergoing Sedation With Ketamine Capnography improves detection of apnea during procedural sedation for percutaneous transhepatic cholangiodrainage. Detection of hypoventilation during deep sedation in patients undergoing ambulatory gynaecological hysteroscopy: a comparison between transcutaneous and nasal end-tidal carbon dioxide measurements. The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: a randomized study A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Capnographic monitoring of propofol-based sedation during colonoscopy. A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Sidestream Capnographic Monitoring Reduces the Incidence of Arterial Oxygen Desaturation During Propofol Ambulatory Anesthesia for Surgical Abortion Capnographic Monitoring Reduces the Incidence of Arterial Oxygen Desaturation and Hypoxemia During Propofol Sedation for Colonoscopy: A Randomized, Controlled Study (ColoCap Study) Capnographic monitoring for carbon dioxide insufflation during endoscopic mucosal dissection: comparison of transcutaneous and end-tidal capnometers Detection of respiratory compromise by acoustic monitoring, capnography, and brain function monitoring during monitored anesthesia care Capnography Accurately Detects Apnea During Monitored Anesthesia Care Capnographic Monitoring in Routine EGD and Colonoscopy With Moderate Sedation: A Prospective, Randomized, Controlled Trial Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? The utility of supplemental oxygen during emergency department procedural sedation with propofol: a randomized, controlled trial. Complications associated with anesthesia administered for dental treatment. Carbon dioxide accumulation during analgosedated colonoscopy: comparison of propofol and midazolam. End-tidal carbon dioxide monitoring during procedural sedation. Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography. [Usefulness of capnography for monitoring sedoanalgesia: influence of oxygen on the parameters monitored].
Objectives : Hypopneic hypoventilation , a decrease in tidal volume without a change in respiratory rate , is not easily detected by st and ard monitoring practice s during sedation but can be detected by capnography . Our goal was to determine the frequency of hypopneic hypoventilation and its association with hypoxia in children undergoing sedation with ketamine .  Methods : Children who received intravenous ketamine with or without midazolam for sedation in a pediatric emergency department were prospect ively enrolled . Heart rate , respiratory rate , pulse oximetry , and end-tidal carbon dioxide ( ETCO2 ) levels were recorded every 30 seconds . Results : Fifty-eight subjects were included in this study . Fifty percent of subjects had recorded ETCO2 values less than 30 mm Hg without a rise in respiratory rate . Twenty-eight percent of subjects experienced a decrease in pulse oximetry less than 95 % . Patients who experienced a persistent decrease in ETCO2 at least 30 seconds in length were much more likely to have a persistent decrease in pulse oximetry than those with normal or transient decreases in ETCO2 ( relative risk , 6.6 ; 95 % confidence interval , 1.4 - 30.5 ) . Decreases in ETcO2 occurred on an average of 3.7 minutes before decreases in pulse oximetry . Conclusions : Hypopneic hypoventilation as detected by capnography is common in children undergoing sedation with ketamine with or without midazolam .  Hypoxia is frequently preceded by low ETCO2 levels . Further studies are needed to determine if the addition of routine monitoring with capnography can reduce the frequency of hypoxia in children undergoing sedation BACKGROUND Capnography provides noninvasive monitoring of ventilation and can enable early recognition of altered respiration patterns and apnea . OBJECTIVE To compare the detection of apnea and the prediction of oxygen desaturation and hypoxemia using capnography versus clinical surveillance during procedural sedation for percutaneous transhepatic cholangiodrainage ( PTCD ) .  METHODS Twenty consecutive patients scheduled for PTCD were included in the study . All patients were se date d during the procedure using midazolam and propofol . Aside from st and ard monitoring , additional capnographic monitoring was used and analyzed by an independent observer . RESULTS The mean ( ± SD ) cumulative duration of apnea demonstrated by capnography was significantly longer than the mean cumulative duration of clinical ly detected apnea ( 207.5 ± 348.8 s versus 8.2 ± 17.9 s ; P=0.015 ) . The overall number of detected episodes of apnea was also significantly different ( 113 versus seven ; P=0.012 ) . There were 15 events of oxygen desaturation ( decrease in oxygen saturation [ SaO2 ] ≥ 5 % ) , which were predicted in eight of 15 cases by capnography and in one of 15 cases by clinical observation . There were three events of hypoxemia ( SaO2 < 90 % ) that were predicted in three of three cases by capnography and in one of three cases by clinical observation . CONCLUSION Capnographic monitoring was superior to clinical surveillance in the detection of apnea and in the prediction of oxygen desaturation during procedural sedation for PTCD BACKGROUND Transcutaneous measurement of carbon dioxide ( Tc(co(2 ) ) ) provides a non-invasive estimation of arterial carbon dioxide ( Pa(co(2 ) ) ) . Nasal capnography ( Pe'(co(2 ) ) ) is used to assess ventilation during monitored anaesthesia care ( MAC ) with sedation since it can readily detect apnoea . We compared the agreement between Tc(co(2 ) ) and Pe'(co(2 ) ) with Pa(co(2 ) ) and the ability to detect hypercarbia in patients under deep sedation . METHODS Forty healthy female subjects receiving deep sedation for hysteroscopy were studied . A Tc(co(2 ) ) ( TOSCA 500 , Radiometer , Inc. , Westlake , OH , USA ) electrode was applied to the earlobe and Pe'(co(2 ) ) capnography was monitored using nasal side-stream sampling . All subjects received oxygen ( 3 litre min(-1 ) ) . Subjects were evaluated at intervals using a modified Ramsay sedation score until they reached a score > or=5 . Arterial blood gas values were compared with Tc(co(2 ) ) and Pe'(co(2 ) ) values . Bl and -Altman , linear regression , and receiver operator characteristics analysis were performed . RESULTS The mean ( sd ) absolute difference between the Tc(co(2 ) ) , Pe'(co(2 ) ) , and the Pa(co(2 ) ) were 0.43 ( 0.35 ) and 1.06 ( 0.8 ) kPa , respectively ( P=0.002 ) . Tc(co(2 ) ) demonstrated a mean bias ( 2 sd ) of 0.23 ( 0.07 - 0.4 ) kPa with Pa(co(2 ) ) compared with -0.93 ( -1.24 to -0.63 ) kPa for Pe'(co(2 ) ) . One minute before blood sampling , the sensitivity of the Tc(co(2 ) ) monitor for detecting Pa(co(2 ) ) > 6.65 kPa was greater than for Pe'(co(2 ) ) ( 66.7 % vs 33.3 % , P<0.01 ) . CONCLUSIONS Tc(co(2 ) ) demonstrated better agreement with Pa(co(2 ) ) than Pe'(co(2 ) ) for patients under MAC with deep sedation . Tc(co(2 ) ) monitoring was more sensitive for detection of Pa(co(2 ) ) > 6.65 kPa than Pe'(co(2 ) ) Abstract Objective . St and ard benzodiazepine/opioid cocktail has proven inferior to propofol sedation during complicated endoscopic procedures and in low-tolerance patients . Propofol is a short-acting hypnotic with a potential risk of respiratory depression at levels of moderate to deep sedation . The existing literature on capnography for endoscopy patients se date d with nurse-administered propofol sedation ( NAPS ) is limited . Can the addition of capnography to st and ard monitoring during endoscopy with NAPS reduce the number , duration , and level of hypoxia . Material s and methods . This study was a r and omized controlled trial with an intervention group ( capnography ) and a control group ( without capnography ) . Eligible subjects were consecutive patients for endoscopy at Gentofte Hospital compliant with the criteria of NAPS . Results . Five hundred and forty patients , 263 with capnography and 277 without capnography , were included in the analysis . The number and total duration of hypoxia was reduced by 39.3 % and 21.1 % in the intervention group compared to the control group ( p > 0.05 ) . No differences in actions taken against insufficient respiration were found . Changes in end-tidal carbon dioxide ( R = 0.177 , p-value < 0.001 ) and respiratory rate ( R = 0.092 , p-value < 0.001 ) were correlated to oxygen saturation ( SpO2 ) up to 36 s prior to changes in SpO2 . Conclusions . Capnography seems to reduce the number and duration of hypoxia in NAPS patients ( p > 0.05 ) . Capnography is able to detect insufficient respiration that may lead to hypoxia prior to changes in pulse oximetry . However , due to a limited clinical benefit and additional costs associated with capnography , we do not find capnography necessary during the use of NAPS OBJECTIVE Data suggest that capnography is a more sensitive measure of ventilation than st and ard modalities and detects respiratory depression before hypoxemia occurs . We sought to determine if adding capnography to st and ard monitoring during sedation of children increased the frequency of interventions for hypoventilation , and whether these interventions would decrease the frequency of oxygen desaturations . METHODS We enrolled 154 children receiving procedural sedation in a pediatric emergency department . All subjects received st and ard monitoring and capnography , but were r and omized to whether staff could view the capnography monitor ( intervention ) or were blinded to it ( controls ) . Primary outcome were the rate of interventions provided by staff for hypoventilation and the rate of oxygen desaturation less than 95 % . RESULTS Seventy-seven children were r and omized to each group . Forty-five percent had at least 1 episode of hypoventilation . The rate of hypoventilation per minute was significantly higher among controls ( 7.1 % vs 1.0 % , P = .008 ) . There were significantly fewer interventions in the intervention group than in the control group ( odds ratio , 0.25 ; 95 % confidence interval [ CI ] , 0.13 - 0.50 ) . Interventions were more likely to occur contemporaneously with hypoventilation in the intervention group ( 2.26 ; 95 % CI , 1.34 - 3.81 ) . Interventions not in time with hypoventilation were associated with higher odds of oxygen desaturation less than 95 % ( odds ratio , 5.31 ; 95 % CI , 2.76 - 10.22 ) . CONCLUSION Hypoventilation is common during sedation of pediatric emergency department patients . This can be difficult to detect by current monitoring methods other than capnography . Providers with access to capnography provided fewer but more timely interventions for hypoventilation . This led to fewer episodes of hypoventilation and of oxygen desaturation BACKGROUND AND STUDY AIMS Capnography enables the measurement of end-tidal CO2 and thereby the early detection of apnea , prompting immediate intervention to restore ventilation . Studies have shown that capnographic monitoring is associated with a reduction of hypoxemia during sedation for endoscopy and early detection of apnea during sedation for colonoscopy . The primary aim of this prospect i ve r and omized study was to evaluate whether capnographic monitoring without tracheal intubation reduces hypoxemia during propofol-based sedation in patients undergoing colonoscopy . PATIENTS AND METHODS A total of 533 patients presenting for colonoscopy at two study sites were r and omized to either st and ard monitoring ( n = 266 ) or to st and ard monitoring with capnography ( n = 267 ) . The incidence of hypoxemia ( SO2 < 90 % ) and severe hypoxemia ( SO2 < 85 % ) were compared between the groups . Furthermore , risk factors for hypoxemia were evaluated , and sedation performed by anesthesiologists was compared with nurse-administered propofol sedation ( NAPS ) or endoscopist-directed sedation ( EDS ) . RESULTS The incidence of hypoxemia was significantly lower in patients with capnography monitoring compared with those receiving st and ard monitoring ( 18 % vs. 32 % ; P = 0.00091 ) . Independent risk factors for hypoxemia were age ( P = 0.00015 ) , high body mass index ( P = 0.0044 ) , history of sleep apnea ( P = 0.025 ) , st and ard monitoring group ( P = 0.000069 ) , total dose of propofol ( P = 0.031 ) , and dose of ketamine ( P < 0.000001 ) . Patients receiving anesthesiologist-administered sedation developed hypoxemic events more often than those receiving NAPS or EDS . In patients with anesthesiologist-administered sedation , sedation was deeper , a combination of sedative medication ( propofol , midazolam and /or ketamine ) was administered significantly more often , and sedative doses were significantly higher compared with patients receiving NAPS or EDS . CONCLUSIONS In patients undergoing colonoscopy during propofol-based sedation capnography monitoring with a simple and inexpensive device reduced the incidence of hypoxemia OBJECTIVE Important questions remain regarding how best to monitor patients during procedural sedation and analgesia ( PSA ) .  Capnometry can detect hypoventilation and apnea , yet it is rarely used in emergency patients . Even the routine practice of performing preoxygenation in low-risk patients is controversial , as supplementary oxygen can delay the detection of respiratory depression by pulse oximetry . The purpose of this study was to determine whether the capnometer or the pulse oximeter would first detect respiratory events in adults breathing room air . METHODS During a r and omized clinical trial comparing fentanyl with low-dose ketamine for PSA with titrated propofol , patients were monitored using pulse oximetry and continuous oral-nasal sample d capnography . Supplemental oxygen was administered only for oxygen desaturation . Sedating physicians identified prespecified respiratory events , including hypoventilation ( end-tidal carbon dioxide > 50 mm Hg , rise of 10 mm Hg from baseline or loss of waveform ) and oxygen desaturation ( pulse oximetry < 92 % ) . These events and their timing were corroborated by memory data retrieved from the monitors . RESULTS Of 63 patients enrolled , 57 % ( 36 ) developed brief oxygen desaturation at some point during the sedation . All responded to oxygen , stimulation or interruption of propofol . Measurements of end-tidal carbon dioxide varied substantially between and within patients before study intervention . Hypoventilation ( 19 patients , 30 % ) was only weakly associated with oxygen desaturation ( crude odds ratio 1.4 [ 95 % confidence interval 0.47 to 4.3 ] ) , and preceded oxygen desaturation in none of the 12 patients in whom both events occurred ( median lag 1:50 m : ss [ interquartile range 0:01 to 3:24 m : ss ] ) . CONCLUSION During  PSA in adults breathing room air , desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified BACKGROUND Recommendations from the American Society of Anesthesiologists suggest that monitoring for apnea using the detection of exhaled carbon dioxide ( capnography ) is a useful adjunct in the assessment of ventilatory status of patients undergoing sedation and analgesia . There are no data on the utility of capnography in GI endoscopy , nor is the frequency of abnormal ventilatory activity during endoscopy known . The aims of this study were to determine the following : ( 1 ) the frequency of abnormal ventilatory activity during therapeutic upper endoscopy , ( 2 ) the sensitivity of observation and pulse oximetry in the detection of apnea or disordered respiration , and ( 3 ) whether capnography provides an improvement over accepted monitoring techniques . METHODS Forty-nine patients undergoing therapeutic upper endoscopy  were monitored with st and ard methods including pulse oximetry , automated blood pressure measurement , and visual assessment . In addition , graphic assessment of respiratory activity with sidestream capnography was performed in all patients . Endoscopy personnel were blinded to capnography data . Episodes of apnea or disordered respiration detected by capnography were documented and compared with the occurrence of hypoxemia , hypercapnea , hypotension , and the recognition of abnormal respiratory activity by endoscopy personnel . RESULTS Comparison of simultaneous respiratory rate measurements obtained by capnography and by auscultation with a pretracheal stethoscope verified that capnography was an excellent indicator of respiratory rate when compared with the reference st and ard ( auscultation ) ( r = 0.967 , p < 0.001 ) . Fifty-four episodes of apnea or disordered respiration occurred in 28 patients ( mean duration 70.8 seconds ) . Only 50 % of apnea or disordered respiration episodes were eventually detected by pulse oximetry . None were detected by visual assessment ( p < 0.0010 ) . CONCLUSIONS Apnea/disordered respiration occurs commonly during therapeutic upper endoscopy and frequently precedes the development of hypoxemia . Potentially important abnormalities in respiratory activity are undetected with pulse oximetry and visual assessment STUDY OBJECTIVE We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than st and ard monitoring alone during emergency department ( ED ) sedation with propofol . METHODS Adults underwent ED propofol sedation with st and ard monitoring ( pulse oximetry , cardiac and blood pressure ) and capnography  and were r and omized into a group in which treating physicians had access to the capnography and a blinded group in which they did not . All patients received supplemental oxygen ( 3 L/minute ) and opioids greater than 30 minutes before . Propofol was dosed at 1.0 mg/kg , followed by 0.5 mg/kg as needed .  Capnographic and SpO2 data  were recorded electronically every 5 seconds . Hypoxia was defined as SpO2 less than 93 % ; respiratory depression , as end tidal CO2 ( ETCO2 ) greater than 50 mm Hg , ETCO2 change from baseline of 10 % , or loss of the waveform . RESULTS One hundred thirty-two subjects were evaluated and included in the final analysis . We observed hypoxia in 17 of 68 ( 25 % ) subjects with capnography and 27 of 64 ( 42 % ) with blinded capnography ( P=.035 ; difference 17 % ; 95 % confidence interval 1.3 % to 33 % ) . Capnography identified all cases of hypoxia before onset ( sensitivity 100 % ; specificity 64 % ) , with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds ( range 5 to 240 seconds ) . CONCLUSION In adults receiving ED propofol sedation , the addition of capnography to st and ard monitoring reduced hypoxia and provided advance warning for all hypoxic events BACKGROUND Pulse oximetry is a widely accepted procedure for ventilatory monitoring during gastrointestinal endoscopy , but this method provides an indirect measurement of the respiratory function . In addition , detection of abnormal ventilatory activity can be delayed , especially if supplemental oxygen is provided . Capnography offers continuous real-time measurement of expiratory carbon dioxide . OBJECTIVE We aim ed at prospect ively examining the advantages of capnography over the st and ard pulse oximetry monitoring during se date d colonoscopies . PATIENTS AND METHODS Fifty patients undergoing colonoscopy  were simultaneously monitored with pulse oximetry and capnography by using two different devices in each patient . Several sedation regimens were administered . Episodes of apnea or hypoventilation detected by capnography were compared with the occurrence of hypoxemia . RESULTS Twenty-nine episodes of disordered respiration occurred in 16 patients ( mean duration 54.4 seconds ) . Only 38 % of apnea or hypoventilation episodes were detected by pulse oximetry . A mean delay of 38.6 seconds was observed in the events detected by pulse oximetry ( two episodes of disturbed ventilation were simultaneously detected by capnography and pulse oximetry ) . CONCLUSIONS Apnea or hypoventilation commonly occurs during colonoscopy with sedation . Capnography is more reliable than pulse oximetry in early detection of respiratory depression in this setting Background This study investigated whether early intervention based on additional use of sidestream capnography could reduce the incidence of oxygen desaturation and hypoxic events in patients receiving propofol anesthesia during surgical abortion . Material / Methods We recruited 704 ASAI-III female patients , 18–52 years old and scheduled for planned painless surgical abortion , and r and omized them into a control group ( n=359 ) receiving st and ard monitoring and an experimental group ( n=341 ) receiving st and ard monitoring and additional capnography .  Exclusion criteria were preexisting cardiovascular disease , preexisting hypotension , bradycardia or arrhythmia , and drug allergy . Anesthesia was induced in all patients with propofol using target-controlled infusion at a target propofol plasma concentration of 4 μg/ml . All patients received flurbiprofen axetil 50 mg and 0.5 μg/kg fentanyl 5 min before anesthesia . Bispectral index was used and maintained between 45 and 60 . Main outcome measures were apnea or abnormal ventilation status , rate of oxygen desaturation , occurrence of hypoxia and severe hypoxia , and perioperative side effects . Results The experimental group had significantly higher rate of apnea or abnormal ventilation , significantly lower rate of oxygen desaturation , and significant lower occurrence of hypoxia and severe hypoxia compared to the control group . We found no statistically significant differences between the 2 groups in the rates of increased oxygen supplementation , assisted ventilation , bradycardia , hypotension , dosage of atropine , dosage of ephedrine or phenylephrine , and the amount of propofol consumed . Conclusions Sidestream capnographic monitoring improves early detection of alterations in ventilation parameters and reduces the incidence of oxygen desaturation and hypoxemia result ing from propofol anesthesia during surgical abortion OBJECTIVES : The aim of this r and omized study was to determine whether intervention based on additional capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol sedation for colonoscopy . METHODS : Patients ( American Society of Anesthesiologists classification ( ASA ) 1–3 ) scheduled for colonoscopy under propofol sedation  were r and omly assigned to either a control arm with st and ard monitoring ( st and ard arm ) or an interventional arm in which additional capnographic monitoring ( capnography arm ) was available . In both study arms , detection of apnea or altered respiration induced withholding propofol administration , stimulation of the patient , chin lift maneuver , or further measures . The primary study end point was the incidence of arterial oxygen desaturation ( defined as a fall in oxygen saturation ( SaO2 ) of ≥5 % or < 90 % ) ; secondary end points included the occurrences of hypoxemia ( SaO2 < 90 % ) , severe hypoxemia ( SaO2 ≤85 % ) , bradycardia , hypotension , and the quality of sedation ( patient cooperation and patient satisfaction ) . RESULTS : A total of 760 patients were enrolled at three German endoscopy centers . The intention-to-treat analysis revealed a significant reduction of the incidence of oxygen desaturation in the capnography arm in comparison with the st and ard arm ( 38.9 % vs. 53.2 % ; P<0.001 ) . The numbers of patients with a fall in SaO2 < 90 % and ≤85 % were also significantly different ( 12.5 % vs. 19.8 % ; P=0.008 and 3.7 vs. 7.8 % ; P=0.018 ) . There were no differences regarding the rates of bradycardia and hypotension . Quality of sedation was similar in both groups . Results of statistical analyses were maintained for the per- protocol population . CONCLUSIONS : Additional capnographic monitoring of ventilatory activity reduces the incidence of oxygen desaturation and hypoxemia during propofol sedation for colonoscopy Background The use of carbon dioxide ( CO2 ) insufflation during endoscopic procedures is effective in reducing patient discomfort caused by bloating . However , transcutaneous arterial CO2 ( PtCO2 ) monitoring usually is required for safety during long endoscopic procedures . To evaluate a new capnometer for monitoring end-tidal carbon dioxide ( EtCO2 ) concentrations and to compare PtCO2 with EtCO2 measured in the same patient , a prospect i ve comparative study of EtCO2 and PtCO2 values measured simultaneously was design ed . Methods The study enrolled 20 consecutive patients ( 18 men and two women ; mean age , 70.1 years ) with upper gastrointestinal neoplasms scheduled for endoscopic submucosal dissection ( ESD ) using conscious sedation with CO2 insufflation , and EtCO2 and PtCO2 were simultaneously measured by each capnometer . Patient status was evaluated before ESD by the American Society of Anesthesiologists ( ASA ) physical status classification system , and eight patients were judged as class 1 , nine patients as class 2 , and three patients as class 3 . The exclusion criteria ruled out patients with chronic obstructive pulmonary disease or ASA class 4 or 5 physical status . The correlation between EtCO2 and PtCO2 values and the availability of EtCO2 capnography were investigated . Results The mean EtCO2 value during ESD was 34.7 ± 4.5 mmHg , and the mean PtCO2 value was 51.6 ± 2.4 mmHg . There was a statistically significant correlation between EtCO2 and PtCO2 ( r = 0.331 ; P = 0.002 ) . Hypoxic events ( < 90 % oxygen saturation [ SpO2 ] ) caused by decreased respiratory rate occurred for 12 patients . In 10 ( 83 % ) of 12 events , a significant reduction in EtCO2 was seen before the decrease in SpO2 . Conclusions The EtCO2 values correlated with the PtCO2 values , and the respiratory monitoring methods allowed earlier detection of hypoxia during ESD with conscious sedation than transcutaneous monitoring . The EtCO2 capnometer was considered to be available for the ESD procedure with the patient under conscious sedation using CO2 insufflation Episodes  of apnea in se date d patients represent a risk of respiratory compromise . We hypothesized that acoustic monitoring would be equivalent to capnography for detection of respiratory pauses , with fewer false alarms . In addition , we hypothesized that the patient state index ( PSI ) would be correlated with the frequency of respiratory pauses and therefore could provide information about the risk of apnea during sedation . Patients undergoing sedation for surgical procedures were monitored for respiration rate using acoustic monitoring and capnography and for depth of sedation using the PSI . A clinician blinded to the acoustic and sedation monitor observed the capnograph and patient to assess sedation and episodes of apnea . Another clinician retrospectively review ed the capnography and acoustic waveform and sound files to identify true positive and false positive respiratory pauses by each method ( reference method ) . Sensitivity , specificity , and likelihood ratio for detection of respiratory pause was calculated for acoustic monitoring and capnography . The correlation of PSI with respiratory pause events was determined . For the 51 respiratory pauses vali date d by retrospective analysis , the sensitivity , specificity , and likelihood ratio positive for detection were 16 , 96 % , and 3.5 for clinician observation ; 88 , 7 % , and 1.0 for capnography ; and 55 , 87 % , and 4.1 for acoustic monitoring . There was no correlation between PSI and respiratory pause events .  Acoustic monitoring had the highest likelihood ratio positive for detection of respiratory pause events compared with capnography and clinician observation and , therefore , may provide the best method for respiration rate monitoring during these procedures Apnea and airway obstruction are common during monitored anesthesia care ( MAC ) . Because their early detection is essential , we sought to measure the efficacy of capnography as an indicator of apnea during MAC at a variety of oxygen flow rates compared with thoracic impedance . Anesthesia care providers using st and ard American Society of Anesthesiologists monitors were blinded to capnography and thoracic impedance monitoring . Ten ( 26 % ) of the 39 patients studied developed 20 s of apnea ; none was detected by the anesthesia provider , but all were detected by capnography and impedance monitoring . There was no difference in detection rates between the two methods . Higher oxygen flow rates decreased the amplitude of the capnograph but did not interfere with apnea detection . This pilot study revealed that apnea of at least 20 s in duration may occur in every fourth patient undergoing MAC . Although these episodes were undetected by the anesthesia provider , they were reliably detected by both capnography and respiratory plethysmography . Monitoring of nasal end-tidal CO2 is an important way to improve safety in patients undergoing MAC Objectives : Regulatory changes requiring the use of capnographic monitoring for endoscopic procedures using moderate sedation have placed financial challenges on ambulatory and hospital endoscopy centers across the United States due to the increased cost of training endoscopy personnel and purchasing both capnography-monitoring devices and specialized sampling ports . To date , there has been no published data supporting the use of capnographic monitoring in adult patients undergoing routine endoscopic procedures with moderate sedation . The aim of this r and omized , parallel group assignment trial was to determine whether intervention based on capnographic monitoring improves detection of hypoxemia in patients undergoing routine esophagogastroduodenoscopy ( EGD ) or colonoscopy with moderate sedation . Methods : Healthy patients ( ASA Physical Classification ( ASAPS ) I and II ) ) scheduled for routine outpatient EGD or colonoscopy under moderate sedation utilizing opioid and benzodiazepine combinations  were r and omly assigned to a blinded capnography alarm or open capnography alarm group . In both study arms , st and ard cardiopulmonary monitoring devices were utilized with additional capnographic monitoring . The primary end point was the incidence of hypoxemia defined as a fall in oxygen saturation ( SaO2 ) to < 90 % for ≥10 s. Secondary outcomes included severe hypoxemia , apnea , disordered respirations , hypotension , bradycardia , and early procedure termination for any cause . Results : A total of 452 patients were r and omized ; 218 in the EGD and 234 in the colonoscopy groups ; 75 subjects in the EGD group ( 35.9 % ) and 114 patients ( 49.4 % ) in the colonoscopy group were male , and average body mass index was 27.9 and 29.1 ( kg/m2 ) , respectively . The blinded and open alarm groups in each study arm were similar in regards to use of opioids and /or benzodiazepines and ASAPS classification . There was no significant difference in rates of hypoxemia between the blinded and open capnography arms for EGD ( 54.1 % vs. 49.5 ; P=0.5 ) or colonoscopy ( 53.8 vs. 52.1 % ; P=0.79 ) . Conclusions : Capnographic monitoring in routine EGD or colonoscopy for ASAPS I and II patients does not reduce the incidence of hypoxemia ( Clinical Trials.gov number , NCT01994785 ) OBJECTIVES The value of ventilation monitoring with end-tidal carbon dioxide ( ETCO2 ) to anticipate acute respiratory events during emergency department ( ED ) procedural sedation and analgesia ( PSA ) is unclear . The authors sought to determine if ETCO2 monitoring would reveal findings indicating an acute respiratory event earlier than indicated by current monitoring practice s. METHODS The study included a prospect i ve convenience sample of ED patients undergoing PSA .  Clinicians performed ED PSA procedures with generally accepted patient monitoring , including oxygen saturation ( SpO2 ) , and clinical ventilation assessment . A study investigator recorded ETCO2 levels and respiratory events during each PSA procedure , with clinical providers blinded to ETCO(2 ) levels . Acute respiratory events were defined as SpO2 < or = 92 % , increases in the amount of supplemental oxygen provided , use of bag-valve mask or oral/nasal airway for ventilatory assistance , repositioning or airway alignment maneuvers , and use of physical or verbal means to stimulate patients with depressed ventilation or apnea , and reversal agent administration . RESULTS Enrollment was stopped after independent review of 20 acute respiratory events in 60 patient sedation encounters ( 33 % ) . Abnormal ETCO2 findings were documented in 36 patients ( 60 % ) . Seventeen patients ( 85 % ) with acute respiratory events demonstrated ETCO2 findings indicative of hypoventilation or apnea during PSA . Abnormal ETCO2 findings were documented before changes in SpO2 or clinical ly observed hypoventilation in 14 patients ( 70 % ) with acute respiratory events . CONCLUSIONS Abnormal ETCO2 findings were observed with many acute respiratory events . A majority of patients with acute respiratory events had ETCO2 abnormalities that occurred before oxygen desaturation or observed hypoventilation STUDY OBJECTIVE We determine whether supplemental oxygen reduces the incidence of hypoxia by 20 % compared with breathing room air in adult study patients receiving propofol for emergency department procedural sedation . METHODS Patients were r and omized to receive either supplemental oxygen or compressed air by nasal cannula at 3 L per minute . Physicians were blinded to the gas used and end tidal CO(2 ) ( etco(2 ) ) data . Respiratory depression was defined a priori as oxygen saturation less than or equal to 93 % , an etco(2 ) level of greater than or equal to 50 mm Hg , an absolute etco(2 ) change from baseline of greater than or equal to 10 mm Hg , or loss of the etco(2 ) waveform . RESULTS Of the 110 patients analyzed , 56 received supplemental oxygen and 54 received room air . Ten ( 18 % ) patients in the supplemental oxygen group and 15 ( 28 % ) patients in the compressed air group experienced hypoxia ( P=.3 , effect size=10 % , 95 % confidence interval -24 % to 7 % ) . Twenty-seven patients ( 20 supplemental oxygen ; 7 room air ) met etco(2 ) criteria for respiratory depression but did not become hypoxic . Physicians identified respiratory depression in 23 of 25 patients who developed hypoxia compared with only 1 of 27 patients who met etco(2 ) criteria for respiratory depression but who did not have hypoxia . One patient in the supplemental oxygen group experienced a transient arrhythmia and had a short apneic episode , both of which resolved spontaneously . The patient was admitted for observation . CONCLUSION Supplemental oxygen ( 3 L/minute ) trended toward reducing hypoxia in adult study patients ; however , the 10 % difference observed was not statistically significant and was below our a priori 20 % threshold . Blinded capnography frequently identified respiratory depression undetected by the treating physicians This assessment sought to identify and quantify complications that occur with anesthesia administration during dental treatment of consecutive patients who received care through the University of Pittsburgh School of Dental Medicine 's ( UPSDM ) Department of Anesthesiology . This prospect i ve study was completed by participating anesthesia caregivers at the UPSDM as a case-by-case evaluation . A st and ardized form delineating possible complications was used to collect data following 286 consecutive outpatient anesthetic cases administered within the UPSDM . After statistical analysis of five types of administered anesthesia , the overall complication rate was 22.4 % in 286 cases . All of the complications were considered to be mild ( 90.6 % ) or moderate ( 9.4 % ) ; there were no reports of severe complications . The complications encountered most frequently were airway obstruction ( 18 reports ) and occurrence of nausea/vomiting ( 12 reports ) . ASA classification , anesthetic technique , pre-existing medical findings , and the type of dental procedure performed all were variables that were found to affect the incidence of anesthesia-related complications . The overall complication rate from anesthesia administered during dental care is similar to or less than that reported within the hospital operating system environment AIM To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol . METHODS Consecutive patients undergoing routine colonoscopy were r and omly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme . All patients received 4 μg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen . Oxygen saturation ( SpO₂ ) was measured by  pulse oximetry ( POX )  , and capnography ( PcCO₂ ) was continuously measured using a combined dedicated sensor at the ear lobe . Instances of apnea result ing in measures such as stimulation of the patient , a chin lift , a mask maneuver , or withholding of sedation were recorded . PcCO₂ values ( as a parameter of sedation-induced hypoventilation ) were compared between groups at the following distinct time points : baseline , maximal rise , termination of the procedure and 5 min after termination of the procedure . The number of patients in both study groups who regained baseline PcCO₂ values ( ± 1.5 mmHg ) five minutes after the procedure was determined . RESULTS A total of 97 patients entered this study . The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems . Therefore , 83 patients ( mean age 62 ± 13 years ) were successfully r and omized to receive propofol ( n = 42 ) or midazolam ( n = 41 ) for sedation . Most of the patients were classified as American Society of Anesthesiologists ( ASA ) II [ 16 ( 38 % ) in the midazolam group and 15 ( 32 % ) in the propofol group ] and ASA III [ 14 ( 33 % ) and 13 ( 32 % ) in the midazolam and propofol groups , respectively ] . A mean dose of 5 ( 4 - 7 ) mg of IV midazolam and 131 ( 70 - 260 ) mg of IV propofol was used during the procedure in the corresponding study arms . The mean SpO₂ at baseline ( % ) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group . No cases of hypoxemia ( SpO₂ < 85 % ) or apnea were recorded . However , an increase in PcCO₂ that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone . The mean interval between the initiation of sedation and the time when the PcCO₂ value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol . The mean maximal rise was similar for both drugs : 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol . Five minutes after the end of the procedure , the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam ( 0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg , P = 0.0000169 ) , and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg ( 32 of 41 vs 12 of 42 , P = 0.0004 ) . CONCLUSION A significantly higher number of patients se date d with propofol  had normalized PcCO₂ values five minutes after sedation when compared with patients se date d with midazolam OBJECTIVE To prospect ively determine whether end-tidal carbon dioxide ( ETCO2 ) monitors can detect respiratory depression ( RD ) and the level of sedation in emergency department ( ED ) patients undergoing procedural sedation ( PS ) .  METHODS This was a prospect i ve observational study conducted in an urban county hospital of adult patients undergoing PS . Patients were monitored for vital signs , depth of sedation per the physician by the Observer 's Assessment of Alertness/Sedation scale ( OAA/S ) , pulse oximetry , and nasal- sample ETCO2 during PS .  Respiratory depression was defined as an oxygen saturation < 90 % , an ETCO2 > 50 mm Hg , or an absent ETCO2 waveform at any time during the procedure . The physician also determined whether protective airway reflexes were lost during the procedure and assisted ventilation was required , or whether there were any other complications . Rates of RD were compared with the physician assessment of airway loss and between agents using chi-square statistics . Spearman 's rho analysis was used to determine whether there was a correlation between ETCO2 and the OAA/S score . RESULTS Seventy-four patients were enrolled in the study . Forty ( 54.1 % ) received methohexital , 21 ( 28.4 % ) received propofol , ten ( 13.5 % ) received fentanyl and midazolam , and three ( 4.1 % ) received etomi date .  Respiratory depression was seen in 33 ( 44.6 % ) patients , including 47.5 % of patients receiving methohexital , 19 % receiving propofol ( p = 0.008 ) , 80 % receiving fentanyl and midazolam , and 66.6 % receiving etomi date . No correlation between OAA/S and ETCO2 was detected . Eleven ( 14.9 % ) patients required assisted ventilation at some point during the procedure , all of whom met the criteria for RD . Pulse oximetry detected 11 of the 33 patients with RD . Post-hoc analysis revealed that all patients with RD had an ETCO2 > 50 mm Hg , an absent waveform , or an absolute change from baseline in ETCO2 > 10 mm Hg . CONCLUSIONS There was no correlation between ETCO2 and the OAA/S score . Using the criteria of an ETCO2 > 50 mm Hg , an absolute change > 10 mm Hg , or an absent waveform may detect sub clinical RD not detected by pulse oximetry alone . The ETCO2 may add to the safety of PS by quickly detecting hypoventilation during PS in the ED BACKGROUND & AIMS The Joint Commission on the Accreditation of Healthcare Organizations recommends ventilation monitoring during procedural sedation for gastrointestinal endoscopy . We sought to determine whether intervention , based on a microstream capnography-based ventilation monitoring system that has been shown to function as an early warning system for hypoxemia , would decrease hypoxemia during endoscopy . METHODS Subjects undergoing elective endoscopic retro grade cholangiopancreatography ( ERCP ) and endoscopic ultrasonography ( EUS ) under procedural sedation with a combination of opioid and benzodiazepine  were r and omly assigned to either a study arm in which the endoscopy team was blinded to capnography or an open arm in which the endoscopy team was prompted of capnographic changes . The primary end point was the occurrence of hypoxemia ; secondary end points were the occurrences of severe hypoxemia , apnea , and oxygen supplementation . RESULTS A total of 263 subjects were enrolled ; 247 were analyzed for efficacy . The numbers of hypoxemic events in the blinded and open arms were 132 and 69 , respectively ( P < .001 ) . Thirty-five percent of all hypoxemic events occurred with completely normal ventilation . Hypoxemia developed in 69 % of patients in the blinded arm compared with 46 % in the open arm ( P < .001 ) . Severe hypoxemia percentages in the blinded and open arms were 31 % and 15 % ( P = .004 ) , for apnea were 63 % and 41 % ( P < .001 ) , for oxygen supplementation were 67 % and 52 % ( P = .02 ) , and for recurrent hypoxemia after oxygen supplementation were 38 % and 18 % ( P = .01 ) , respectively . CONCLUSIONS Capnographic monitoring of respiratory activity improves patient safety during procedural sedation for elective ERCP/EUS by reducing the frequency of hypoxemia , severe hypoxemia , and apnea INTRODUCTION To evaluate the usefulness of capnography for early detection of respiratory depression during sedoanalgesia procedures in the pediatric emergency department . To assess whether the administration of oxygen during the procedure can modify monitored parameters , thus delaying detection of respiratory depression . MATERIAL AND METHODS A prospect i ve r and omized study was performed on children between 1 year and 16 years who underwent sedoanalgesia to perform diagnostic or therapeutic procedures . They were r and omized into two groups ( with or without supplemental oxygen ) . All patients were monitored by visual inspection , pulse-oximetry and non-invasive capnography . Monitoring was initiated prior to drug administration and continued until complete recovery of baseline . The main study variable was respiratory depression defined as apnea , hypoventilation or oxygen desaturation . RESULTS Twenty patients were included . Eleven patients were r and omized in the supplemental oxygen group . This study showed a statistically significant elevation of EtCO2 levels at 5 , 10 and 15min , compared with baseline . No significant change in the SatO2 mean was detected . No statistically significant differences were identified when comparing etCO2 mean and SatO2 mean in both groups . Two cases of respiratory depression were detected early by capnography . There was a statistically significant correlation between etCO2 at 5 and 10min , and the degree of sedation achieved . CONCLUSIONS The inclusion of capnography to routine monitoring for adequate sedation procedures could improve safety . Oxygen administration does not appear to modify the parameters monitored
BACKGROUND Patient safety is a priority in dentistry .
Evaluating the benefits and harms associated with the addition of capnography to st and ard monitoring during moderate sedation for adult patients in the dental practice setting is needed .