The Use of Capnography in the CCU Setting: ETCO2 Levels

Subject: Other Medical Specialties
Pages: 18
Words: 7175
Reading time:
28 min
Study level: PhD

Literature Review

In the CCU setting, patients are especially vulnerable due to the vastly negative effects that specific external factors may have on their health status. The changes in end-tidal (ET) CO2 levels are particularly important to determine since they allow improving the opportunity for performing the return to spontaneous circulation (ROSC) in CCU patients in case of a heart attack or a similar dysfunction (Cook, 2016; Langhan, Kurtz, Schaeffer, Asnes, & Riera, 2014). Among the existing tools for ETCO2 evaluation, capnography is regarded as a possibly beneficial one. However, the proposed technique requires further assessments to ensure that it meets the existing quality standards and provides CCU nurses with the information required to make a proper choice and perform ROSC in a timely fashion.

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The research questions that the studies under analysis seek to answer mostly concern the effects of capnography on the process of monitoring the levels of ETCO2 in patients whose state can be determined as critical. Particularly, the setting of the emergency room, the operating theater, or ICU is considered in nearly every study. It is remarkable that a significant number of articles focus on managing the needs of post-operative patients (Carlisle, 2015). The specified tendency can be explained by the exposure to a wide range of negative effects that may affect a patient’s ETCO2 levels and cause a heart failure, requiring the further application of capnography and similar tools or the successful ROSC. For instance, Cook (2016) studies the general outcomes of capnography in nursing, emphasizing the significance of the specified tool as the measurement technique and the identification of threats to vulnerable groups’ well-being.

Concerning the limitations of the studies under analysis, the choice of methodology can be seen as the weakest aspect of each. Although every study uses its design to its advantage, maximizing its benefits, a significant portion of research articles suffers from the lack of representation in their samples. By using convenience sampling as the most common technique, a large number of the authors succumb to the problem of generalizing research outcomes to reduce the related biased, creating a rather commonplace approach toward handling the issue of capnography in the selected setting. However, the specified issue can be addressed when introducing capnography as a tool into the setting of contemporary nursing. Specifically, the outcomes of the analysis can be generalized to ensure that the research results meet the needs of as many patients as possible. In addition, by generalizing the results of a study, one can contribute to the development of a uniform strategy for managing CCU patients’ needs. As a result, a standardized framework for performing capnography in the clinical setting can be devised.

When setting the strategy for deploying the specified device in the CCU setting, one should consider exploring the concept of capnography readings improvement. Although it is critical to teach nurses to decipher the information provided during capnography, it is also imperative to ensure that all available measures are taken to improve the readings. Because of the abundance of factors that may hamper the decoding of the analysis results, the introduction of additional tools for data management is critical. Thus, nurses will have to be instructed in accordance with newly developed guidelines to add a nebulizer properly during capnography. Particularly, the research by Vinay (2017) indicates that there is a threat of misplacing the nebulizer, thus impeding the process of interpreting the information. The identified threat may lead to failure to locate a change in ETCO2 levels in a patient. Thus, the possibility of performing ROSC properly will drop unless proper tools for capnometer reading are introduced. Moreover, nurses will need additional training to learn to interpret the information provided during the analysis of capnography results. Therefore, the specified subtheme should be deemed as critically important for the improvement of ROSC rates among CCU patients. While capnography is a powerful tool for increasing the chances of a successful ROSC, it needs to be applied with due skills and high levels of proficiency.

At present, several key concepts with the associated subthemes can be located in modern literature. Specifically, the phenomenon of ETCO2 levels as a theme and the ETCO2 and alveolar CO2 tension levels respectively require closer scrutiny (Cook, 2016; Jooste et a., 2018; Carmichael & DeRego, 2017). Another important problem raised in modern research in regard to the management of CCU patients’ needs and the use of capnography concerns evaluating capnography in regard to other tools for ETCO2 management and meeting the needs of CCU patients. For instance, the application of jet nebulizer compared to capnography deserves further exploration (Lam et al., 2017; Vinay, 2018). Furthermore, one may need to compare capnography to pulse oximetry in order to determine which method is superior.

The tools associated with the successful management of capnography processes should be seen as the next crucial theme that warrants discussion. Although capnography might be the perfect device for assessing patients’ state and locating ETCO2-related problems during ROSC, detailed guidelines for introducing capnography are critical (Langhan et al., 2014; Kerslake & Kelly, 2017). Therefore, it is necessary to study the strategies used to enhance capnography outcomes in the clinical setting. Smyrnios et al. (2015) also address the specified issue, pointing to the urgency of assessing the tools’ sensitivity in regard to tube placement in the CCU setting. Therefore, extraneous factors associated with the specifics of the proposed ETCO2 management devices are an important subtheme.

In addition, studies show that nurses need to locate tools for monitoring capnography results in the post-op setting. The specified issue is linked directly to the problem of improving capnography results in the clinical context since it provides a chance to improve nurses’ awareness of the alarms that capnography provides, as well as administering the necessary actions to implement successful ROC in the realm of a CCU. Moses (2018) states explicitly that the current policies regarding the application of capnography require immediate reconsideration due to the lack of instructions regarding their use in the post-op setting. The alterations to the existing framework for capnography application imply determining a set of standards that will need to be met in order to deliver quality services. In addition, nurses will need to receive proper education and training that will allow them to apply the designated instructions properly. Particularly, it will be necessary to ensure that nurses apply the specified instructions properly to locate the problems in the patient’s ETCO2 levels and address the issue at the onset of its development. As a result, ROSC will be performed successfully, and the probability of returning the spontaneous circulation will rise exponentially.

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Moreover, the nurse education subtheme and the need to create the platform for teaching the essence of capnography application appears in arrange of other studies, signaling that there is a significant knowledge deficiency in a large number of experts. For instance, Pella et al. (2018) stress the need to develop a set of standards for capnography application along with a comparison of the effects of capnography and pulse oximetry in the clinical setting. The fact that new instructions will require substantial training and a shift in the current approach toward performing key actions in the CCU setting implies that additional training should be provided to nurses.

Whitaker and Benson (2016) expand the specified idea, elaborating on the issue of improving the existing standards and guidelines of the use of capnography. Specifically, the study provides the subtheme of nurse education, as well as the idea of reconsidering the current capnography standards. The specified change is particularly important for the CCU setting, in which nurses have to make decisions fast. Therefore, future studies in the specified realm will have to be focused on the redesign of the current standards and the selection of improved strategies that allow nurses to use capnography properly. Since the current monitoring strategies do not imply the use of capnography as an intrinsic element of identifying a change in a patient’s ETCO2 levels, it will en necessary to redesign the existing approach and introduce the key stages of capnography in it. While being restricted to four primary steps, capnography will require a significant alteration in the current framework of TCO monitoring.

In turn, Carlisle (2015) posits that the process of monitoring capnography outcomes will require a shift in the current organization of nurses’ work. Similarly, Kersklake and Kelly (2016) raise the topic of improving the current guidelines for implementing capnography in the CCU environment. For instance, the authors of the study posit that the process of establishing the capnography trace and deploying the proposed technique to locate the threats to a patient’s ETCO2 levels requires completing four key stages.

Although the idea of reducing the instructions for capnography as a guide for nurses to four steps seems to be an instance of oversimplification, the specified subtheme deserves to be mentioned. Specifically, one must give Kerslake and Kelly (2016) credit for introducing methods for measuring capnography and incorporating different types of analyzers into the CCU setting. The specified instruction for nurses is of particularly big importance since the current CCU environment lacks detailed instructions on the application of capnography and, therefore, one needs to design a support system for nurses. The discussion of the analysis techniques, in turn, enables nurses to evaluate the existing approaches critically and select the one that will be the most suitable in a specific setting.

In addition, it is noteworthy that a range of studies points to the superiority of capnography over other tools for monitoring a patient’s well-being in the CCU context. For instance, Carlisle (2015) presents capnography as superior to pulse oximetry, which, according to the author, provides significantly fewer chances to perform successful ROSC in the CCU context. Specifically, it is specified that “Continuous capnography detects signs of compromised ventilation earlier and more effectively than either visual respiratory assessments or pulse oximetry” (Carlisle, 2015, p. 202). Thus, the role of capnography in the CCU setting should be regarded as very important.

The identified subtheme should gain particular significance since it provides both opportunities and numerous challenges for nurses. Due to the introduction of a new source of information, namely, visual elements, into the setting where nurses have to focus on every possible detail, the use of capnography can be regarded as a threat to the efficacy and accuracy of nurses’ actions. With the increase in the number of issues to which nurses will need to pay attention in the clinical environment, the probability of a medical error rises exponentially. As a result, the quality of care may be questioned. Encouraging nurses to develop the skills associated with the management of capnography as a process that will be needed to maintain control over a patient’s well-being during the surgery should be seen as particularly important. It is critical to ensure that nurses are aware of the key characteristics based on which capnography can be defined as successful. Thus, nurses will receive an opportunity to evaluate their performance independently and build the required skill set will become even more possible.

However, the described way of integrating capnography into the clinical environment and the CCU setting also implies giving nurses a chance to analyze the available data in depth. With the rearrangement of roles and responsibilities in the nursing setting, one will acquire the ability to monitor the changes in patient data, while other nurses will focus on managing other tasks associated with the CCU setting. As a result, the probability of detecting the factors that may influence a patient’s pressure and heartbeat will be identified at a very early stage of development. Consequently, with appropriate measures undertaken, the threat of failing to perform ROSC on a CCU patient will be reduced to a minimum.

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The need for introducing capnography as one of the tools for managing the process of ROSC in people placed in the CCU environment also implies addressing the subtheme of providing nurses with detailed instructions concerning the use of capnography in the CCU setting. Specifically, rigid guidelines have to be designed in order to prevent medical errors and help nurses to use capnography to its maximum capacity. Particularly, it is imperative to outline the key stages of monitoring, including the management of the relevant tools. The described issue is paralleled with the concept of nurse education as one of the crucial aspects of improving the current framework for addressing the needs of patients in the CCU setting. The lack of opportunities for introducing nurses to the idea of consistent learning and the development of new skills in regard to addressing the needs of CCU patients is a rather problematic issue that could be seen as one of the key subthemes addressed in recent studies (Langhan et al., 2014). Therefore, there is the need to incorporate the principles of continuous learning and especially interdisciplinary practice into the current CCU setting (Pella et al., 2018).

The issue of interdisciplinary collaboration is, in fact, one of the primary concepts that have been rendered in some of the studies under analysis (Cook, 2016). Therefore, the issues associated with addressing nurse communication and, particularly, the promotion of an unceasing dialogue and knowledge sharing between nurses can be regarded as critical (Jooste et al., 2018). Therefore, encouraging the connection between nurses within the CCU setting, as well as ensuring that no conflicts occur between nurses and other healthcare staff members, is critical to the successful delivery of appropriate services, which in this case involve ROSC. Since a patient’s life hinges on the efficacy of collaboration between nurses in a multidisciplinary setting, the next subtheme that concerns negotiation and conflict management has to be explored. Although the specified theme appears only once in the selected articles, it nonetheless has a tremendous impact on the patient outcomes due to the opportunities that it provides.

Particularly, the promotion of nurse education is likely to affect the overall environment of the CCU positively and increase the chances to deliver the best services possible to the vulnerable demographic. It is critical for nurses to receive proper instructions and develop the ability to utilize the recently developed skills in the clinical setting, particularly, the CCU environment. Although the existing studies do not provide specific recommendations concerning the promotion of education among nurses, it can be assumed that the identified step can be accomplished by providing nurses with detailed instructions concerning the types of capnography and the circumstances in which each type should be applied. For instance, it is strongly recommended to incorporate both blinded and open capnography arms techniques into the process of nurse education to ensure that they can select an appropriate framework in a specific setting (Pella et al., 2018). Studies show that nurse education needs to foster the ability to select an appropriate method for addressing patients’ needs and locating the immediate threats to their well-being, which capnography provides.

Overall, the review has shown that capnography is viewed as a very useful way of measuring ETCO2 levels. The specified tool is particularly important in handling the scenarios that involve ROSC since capnography allows noticing the slightest changes in the ETCO2 levels. As a result, the outcomes of ROSC become significantly better, with the chances for rescuing a patient rising consistently. Therefore, there are strong indications in the existing literature that capnography has to be incorporated into the contemporary CCU environment to ensure improved quality of care. The specified ideas can be regarded as the extension of the subthemes of life support and basic life support as the mechanisms for improving the quality of ROSC.

Therefore, there are strong indications that capnography should be applied to managing the problem of RISC in CCU patients. Because of the wide array of factors affecting the chances for survival among CCU patients suffering tom a heart attack, the ability to locate a threat at a comparatively early stage and address it respectively is crucial. Capnography, in turn, provides such an opportunity by offering a way of monitoring the slightest changes in the ETCO2 levels in patients. Consequently, the proposed device should be integrated fully into the CCU setting, with detailed instructions being provided to nurses for coordinating capnography with ROSC-related procedures. With the introduction of a cohesive leadership framework and the promotion of change in the CCU environment, the successful use of capnography in managing ROSC is expected. As a result, the number of cases involving fatal outcomes will drop significantly.

Concerning the recommendations for further research, one should focus on the evaluation of capnography as a means of improving ROSC. Particularly, the methods of teaching nurses to utilize capnography in the clinical setting and especially in the CCU context will need to be studied. In addition, it is necessary to study the issues that may occur during the implementation of capnography in the CCU context. Because of the importance of performing capnography properly and locating the threat of heart failure immediately, one will need to explore all possible hindrances that may occur during the specified process and determine the ways of addressing them respectively. The specified step will contribute to a rise in the efficacy of capnography in the CCU environment and the introduction of the appropriate tools for monitoring the process.

Overall, the problem of capnography use during RODC needs to be studied in depth. While there is evidence that supports the application of the proposed technique in the ROSC setting, it is necessary to determine the methods of integrating it into the existing instructions for performing RISC, as well as teaching nurses to monitor the changes in capnography records. With the introduction of the specified changes in the design of CCU nursing, one will be able to promote change in the identified setting.

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Research Article Chart

Abstract Introduction Methods Results Conclusion References
Article 1:Cook (2016) Expectations: identifying the potential of capnography Purpose: predicting the outcomes of universal capnography in nursing; Hypothesis: universal capnography will advance capnography as the tool for end-tidal (ET) CO2 measurement. Terms: end-tidal carbon
dioxide tension; alveolar carbon dioxide
Review of Literature: present and comprehensive
Population sample: no sample was selected
Data collection: literature review
Hypothesis confirmation: initial hypothesis conformed Summary:
  • capnography will have a positive effect on nursing quality;
  • ETCO2 pressure levels require measurement;
  • Capnography is a good monitoring tool

Future studies: a test of capnography efficiency is required.

1. Conway, A., Douglas, C., & Sutherland, J. (2015). Capnography monitoring during procedural sedation and analgesia: A systematic review protocol. Systematic Reviews, 4(1), 456–460.
2. Whitaker. D. K. (2011) Time for capnography – Everywhere. Anaesthesia, 66,
Article 2:Jooste et al. (2018) Expectations: determining the outcomes of the Global Capnography project (GCP) Purpose: evaluating the efficacy of GCP
Hypothesis: Capnography can be introduced as the tool for managing CCU patients’ needs in low-income countries
Terms: GCP; Oesophageal intubation
Review of Literature: present and comprehensive
Population sample: 32
Data collection: a prospective study (questionnaire)
Hypothesis confirmation: confirmed Summary:
GCP affects patient outcomes in low-income areas positively.
Future studies: a follow-up study is required.
2. Eichhorn, J. H. (1989). Prevention of intraoperative anesthesia accidents
and related severe injury through safety monitoring. Anesthesiology, 70, 572–7.
9. Whitaker, D. K. (2011). Time for capnography – Everywhere. Anaesthesia, 66, 544–549.
Article 3:Carmichael & DeRego,2017 Expectations: Capnography has a positive effect on PACU patients Purpose: Determining the outcomes of capnography use in PACU Hypothesis: Capnography improves patient outcomes in PACU
Terms: self-learning module; capnography monitoring
Review of Literature: present and comprehensive
Population sample: not specified
Data collection: literature review
Hypothesis confirmation: confirmed Summary:
  • Capnography should be used to manage PACU;
  • Learning-oriented leadership skills are required

Future studies: effects of various learning tools on capnography efficacy could be explored

67. Galvagno Jr, S. M., Duke, P. G., Eversole, D. S., & George, E. E. (2016). Evaluation of respiratory volume monitoring (RVM) to detect respiratory compromise in advance of pulse oximetry and help minimize false desaturation alarms. Journal of Trauma and Acute Care Surgery, 81(5), S162-S170.
68. Slight, S. P., Franz, C., Olugbile, M,. Brown, H. V., Bates, D. W., & Zimlichman, E. (2014). The return on investment of implementing a continuous monitoring system in general medical-surgical units. Crit Care Med,42, 1862–1868.
Article 4:Lam et al. (2017) Expectations: a comparison of pulse oximetry and capnography Purpose: determining whether capnography is better than pulse oximetry
Hypothesis: capnography is superior to pulse oximetry
Terms: capnography; pulse oximetry; Review of Literature: present and comprehensive
Population sample: 13
Data collection: a systematic search of the literature databases
Hypothesis confirmation: confirmed Summary: capnography provides a chance to locate oxygen desaturation during PORD
Future studies: comparison of capnography and other tools during PORD
6. Whitaker, D. K., & Benson, J. P. (2016). Capnography standards for outside the operating room. Current Opinion in Anesthesiology, 29(4), 485-492.
7. Kodali, B. S. (2013). Capnography outside the operating rooms. Anesthesiology: The Journal of the American Society of Anesthesiologists, 118(1), 192-201.
Article 5: Vinay, 2018 Expectations: exploring the effects of PETCo2 levels assessment Purpose: Determining the effects of PETCo2 levels rise with the help of different tools in mechanically ventilated patients
Hypothesis: PETCo2 levels assessment helps manage ICU patients’ needs better
Terms: PETCo2, jet nebulizer
Review of Literature: present and comprehensive
Population sample: 20
Data collection: questionnaire
Hypothesis confirmation: confirmed Summary:
  • Capnography should be deemed as a superior tool for ETCO2 assessment;
  • ETCO2 evaluation allows for improving patient outcomes.

Future studies: other strategies for ETCO2 management need to be considered.

6 Cook, T. M., Kelly, F. E., & Goswami, A. (2013). ‘Hats and caps’ capnography training on intensive care. Anaesthesia, 68(4), 421-421.
7 Birmingham, P. K., Cheney, F. W., & Ward, R. J. (1986). Esophageal intubation: A review of detection techniques. Anesthesia & Analgesia, 65(8), 886-891.
Article 6: Kerslake & Kelly, 2017 Expectations: evaluation of capnography efficiency in the CCU setting Purpose: determining the role of capnography in CCU; Hypothesis: capnography plays a huge role in managing CCU patients’ needs;
Terms: artificial airway; NAP4
Review of Literature: present and comprehensive
Population sample: not specified
Data collection: literature review
Hypothesis confirmation: confirmed Summary:
  • Capnography leads to a rise in positive outcomes;
  • Capnography is crucial in managing airway complications in CCU.

Future studies: assessment of capnography in a clinical trial

9 Sanders, A. B., Kern, K. B., Otto, C. W., Milander, M. M., & Ewy, G. A. (1989). End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: A prognostic indicator for survival. Jama, 262(10), 1347-1351.
10 Garnett, A. R., Ornato, J. P., Gonzalez, E. R., & Johnson, E. B. (1987). End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. Jama, 257(4), 512-515.
Article 7: Langhan et al. (2014) Expectations: exploring the factors associated with capnography Purpose: determining the need to include capnography into the national guidelines
Hypothesis: capnography is critical for ETCO2 management; Terms: capnography use variability; capnography equipment accessibility
Review of Literature: present and comprehensive
Population sample: 5
Data collection: interview
Hypothesis confirmation: confirmed Summary: the use of capnography for ETCO2 monitoring is highly recommended
Future studies: factors enhancing capnography effects
25. Kolb, D. (1984). Experiential learning. Upper Saddle River, NJ: Prentice Hall.
26. Sheckley, B., Kehrhahn, M., Bell, S., & Grenier, R. (2008). Trio: An emerging model of adult professional learning. In Proceedings of the 49th Annual Adult Education Research Conference (pp. 455-457). St. Louis, MO: University of Missouri.
Article 8: Whitaker & Benson (2016) Expectations: determining standards for applying capnography outside the OR Purpose: locating the guidelines for applying capnography outside the OR;
Hypothesis: emergency departments need to adopt capnography as a critical tool for ETCO2 measurement and heart attack prevention
Terms: operating theatre; outside factors
Review of Literature: present and comprehensive
Population sample: 20
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • Current standards for applying capnography to the CCU setting require improvements;
  • Using capnography outside of OR should become an option

Future studies: methods of applying capnography outside of OR

  1. Yusuff, H., Prakash, A., & Webb, S. (2016). Safe sedation for the non-anesthetist. Clinical Medicine, 16(2), 161-163.
  2. Doherty, C., Neal, R., English, C., Cooke, J., Atkinson, D., Bates, L.,… Bateman, N. (2018). Multidisciplinary guidelines for the management of pediatric tracheostomy emergencies. Anaesthesia, 73(11), 1400-1417.
Article 9: Moses, 2018 Expectations: studying the effects of capnography in the post-op setting Purpose: determining the benefits of capnography for post-op patients with heart issues
Hypothesis: capnography allows preventing post-op heart issues and administers ROSC
Terms: ROSC; post-op
Review of Literature: present and comprehensive
Population sample: 180
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • Capnography: an effective tool for managing post=op patients’ needs;
  • ROSC in a post-op setting with the help of capnography

Future studies:
Exploration of strategies for using capnography in post-op

  1. Mehta, P.P, Kochhar, G., Albeldawi, M., Kirsh, B., Rizk, M., Putka, B.,… Vargo, J. J. (2016). Capnographic monitoring in routine EGD and colonoscopy with moderate sedation: a prospective, randomized, controlled trial. The American Journal of Gastroenterology, 111(3), 395. Barnett, S., Hung, A., Tsao, R., Sheehan, J., Bukoye, B., Sheth, S. G., & Leffler, D. A. (2016). Capnographic monitoring of moderate sedation during low-risk screening colonoscopy does not improve safety or patient satisfaction: A prospective cohort study. The American Journal of Gastroenterology, 111(3), 388-394. doi: 10.1038/ajg.2016.2.
Article 10: Smyrnios et al. (2015) Expectations: determining the effects of using capnography in the context of a surgical setting (naso/orogastric (NG) tubes implantation) Purpose: identifying the existing misdirections in the naso/orogastric (NG) tubes integration into the air pathways of adults with the help of a capnograph
Hypothesis: self-inflating bulb syringe (SIBS) and CO2 levels can be managed with the help of a tube and identified with capnography
Terms: SIBS, naso/orogastric (NG) tube
Review of Literature: present and comprehensive
Population sample: 120
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • Introduction of NG tubes contributes to the management of ETCO2 levels and SIBS;
  • – capnography should be used for measuring ETCO2 rates

Future studies: exploring the methods of applying capnography during ROSC in patients with NG tubes

  1. Burns, S. M., Carpenter, R., Blevins, C., Bragg, S., Marshall, M., Browne, L.,… Truwit, J. D. (2006). Detection of inadvertent airway intubation during gastric tube insertion: Capnography versus a colorimetric carbon dioxide detector. American Journal of Critical Care, 15(2), 188-195.
  2. Munera-Seeley, V., Ochoa, J. B., Brown, N., Bayless, A., Correia, M. I. T., Bryk, J., & Zenati, M. (2008). Use of a colorimetric carbon dioxide sensor for nasoenteric feeding tube placement in critical care patients compared with clinical methods and radiography. Nutrition in Clinical Practice, 23(3), 318-321.
Article 11: Adams, Butas, and Spurlock, 2015 Expectations: understanding the effects of capnography on the provision of TEE in inpatients. Purpose: exploring the effects of capnography on the introduction of transesophageal echocardiography (TEE) in patients. Hypothesis: Capnography allows for an uninhibited performance of TEE.
Terms: transesophageal echocardiography (TEE); sedating medications
Review of Literature: present and comprehensive
Population sample: 200
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
Capnography has an appositive effect on introducing TEE; Future studies:
Inspecting the outcomes of capnography on TEE implementation among patients with heart issues.
16. Rogers, E. M. (1995). Diffusion of innovation theory. New York, NY: Free Press.
17.Cowan, D. T., Norman, I., & Coopamah, V. P. (2005). Competence in nursing practice: A controversial concept – A focused review of the literature. Nurse Educ Today, 25, 355–62.doi:10.1016/j.nedt.2005.03.002
Article 12:Clark et al. (2018) Expectations: enhancing nurses’ understanding of the significance of capnography Purpose:
Determining the nurses’ perception regarding the use of capnography in clinical settings
Hypothesis: nurses’ concept of the importance of capnography has direct effects on their ability to perform the procedure properly and cater to the needs of CCU patients
Terms: floor patients; capnography monitoring
Review of Literature: present and comprehensive
Population sample: not stated
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
Direct connection between nurses’ perception of capnography and its effects;
Need for nurse education techniques and tools for increasing nurses’ capnography-related competencies
Future studies: focus on strategies for promoting nurse education in relation to capnography
20. Pisano, G. P., Bohmer, R. M., & Edmondson, A. C. (2001). Organizational differences in rates of learning: Evidence from the adoption of minimally invasive cardiac surgery. Management Science, 47(6), 752-768. doi:10.1287/mnsc.47.6.752.9811
21. Attia, A. K., Abd-Elaziz, W. W., & Kandeel, N. A. (2013). Critical care nurses’ perception of barriers and supportive behaviors in end-of-life care. American Journal of Hospice and Palliative Medicine®, 30(3), 297-304.
Article 13: Pella et al. (2018) Expectations: providing recommendations for managing the process of capnography Purpose: improving the existing guidelines for performing capnography for ROSC
Hypothesis: by introducing more detailed guidelines, one will be able to use capnography for ROSC and CCU patients’ needs
Terms: Review of Literature: present and comprehensive
Population sample: not stated
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • The current CCU setting requires clear instructions and guidelines for using capnography;
  • Setting uniform standards for performing capnography will allow improving ROSC rates.

Future studies: tools for improving the current guidelines and instructions will need to be identified.

  1. Barnett, S., Hung, A., Tsao, R., Sheehan, J., Bukoye, B., Sheth, S. G., & Leffler, D. A. (2016). Capnographic monitoring of moderate sedation during low-risk screening colonoscopy does not improve safety or patient satisfaction: A prospective cohort study. The American Journal of Gastroenterology, 111(3), 388.
  2. Wolf, L., Coughlin, K., & Devaux, D. (2015). Capnography for the perioperative nurse. Journal of PeriAnesthesia Nursing, 30(4), e18-e19.
Article 14: Bovino et al. (2018) Expectations: an exploration of the effects of waveform capnography on ROSC among patients Purpose: studying the effects of waveform capnography the tool for administering sedation to patients;
Hypothesis: waveform capnography allows improving the process of patient sedation and makes the transition to the surgery seamless
Terms: Waveform capnography; pulse oximetry
Review of Literature: present and comprehensive
Population sample: 200
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • Waveform capnography is a perfect tool for testing respiratory rates in patients;
  • Capnography should be utilized in the surgical setting to ensure that problem in heart functioning in patients is identified and managed respectively.

Future studies: defining the strategies for introducing capnography into the surgical setting

  1. Cavalcante, A. M. R. Z., Brunori, E. H. F. R., Lopes, C. T., Silva, A. B. V., & Herdman, T. H. (2015). Nursing diagnoses and interventions for a child after cardiac surgery in an intensive care unit. Revista Brasileira De Enfermagem, 68(1), 155-160.
  2. Riley, C. M. (2017). Continuous capnography in pediatric intensive care. Critical Care Nursing Clinics, 29(2), 251-258.
Article 15: Carlisle, 2015 Expectations: studying the effects of capnography on the OIRD condition and its further management. Purpose: determining the effects of capnography as the tool for ETCO2 measurement in addressing the cases of OIRD
Hypothesis: Terms: Opioid-induced respiratory depression (OIRD); portable capnography monitors
Review of Literature: present and comprehensive
Population sample: 171
Data collection: convenience sampling
Hypothesis confirmation: confirmed Summary:
  • Capnography can be used to address the problem of OIRD in inpatients;
  • Capnography application requires the introduction of standardized rules and guidelines.

Future studies: design of standardized rules for performing capnography-based patient monitoring.

  1. Langhan, M. L., Li, F. Y., & Lichtor, J. L. (2014). Respiratory depression detected by capnography among children in the postanesthesia care unit: A cross‐sectional study. Pediatric Anesthesia, 26(10), 1010-1017.
  2. Casey, G. (2015). Capnography: Monitoring CO^ sub 2^. Kai Tiaki: Nursing New Zealand, 21(9), 20-24.
Article 16 (Kodali & Uman, 2014): Expectations: determining the correlation between two factors. Purpose: locating the connection between the end-tidal CO2 (PETCO2) and the cardiac output rates among patients
Scope: local hospital
Rationale: increasing ROSC
Hypothesis: PETCO2-cardiac output correlation exists
Terms: PETCO2, extracorporeal life support (ECLS) in refractory cardiac arrest (RCA)
Review of literature: present
Population sample: 200
Data collection: a narrative review
Hypothesis confirmation: correlation between -tidal CO2 (PETCO2) and the cardiac output confirmed Summary: An overview of existing studies shows that there is a tangible correlation between end-tidal CO2 (PETCO2) and cardiac output.
Future studies: Further clinical trials are needed to determine the efficacy of capnography in locating the end-tidal CO2 (PETCO2).
Number: 47
17. Walsh, T. S., Wyncoll, D. A., Stanworth, S. J., Bateman, A. P., McArdle, F., Walsh, T. S.,… Weinerman, A. S. (2015). Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Journal of the Intensive Care Society, 16(4), 16-21.
18. Phelan, M. P., Ornato, J. P., Peberdy, M. A., Hustey, F. M., & American Heart Association’s get with the Guidelines-Resuscitation Investigators. (2013). Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from in-hospital cardiac arrest. Resuscitation, 84(1), 31-36.
Article 17: Gutiérrez et al. (2018) Expectation: locating the efficacy of chest compression Purpose: Testing filtering techniques to suppress the chest compression
Scope: hospital
Hypothesis: Filtering techniques allow suppressing the artifact based on capnography waveform
Terms: chest compression artifact; capnography
Review of literature: present
Population sample: 202
Data collection: analysis of patients’ records
Hypothesis confirmation: confirmed Summary: The suite of filtering techniques contributes to the improvement of capnography outcomes and facilitates ROSC
Future studies: Future clinical trials are advised.
Number: 29
1. Nichol, G., & Baker, D. The epidemiology of sudden death. In Paradir, N. A., Halperin, H. R., Kern, K. B., Wenzel, V., & Chamberlain, D. (Eds.) (2007). Cardiac arrest: Science and practice of resuscitation medicine(pp. 26-50). Cambridge: Cambridge University Press.
2. Soar, J., Nolan, J. P., Böttiger, B. W., Perkins, G. D., Lott, C., Carli P, … Monsieurs, K. G. (2015). European Resuscitation Council guidelines for resuscitation 2015. Section 3. Adult advanced life support. Resuscitation, 95, 100–147.
Article 18: Pantazopoulos et al. (2015) Expectations: monitoring ETO2 levels Purpose: Studying the existing carbon dioxide monitoring options
Scope: general
Hypothesis: capnography is preferable to other CO2 monitoring techniques
Terms: chest recoil; hands-off time
Review of literature: present
Population sample: 737
Data collection: a narrative review
Hypothesis confirmation: The initial hypothesis was confirmed Summary: The progressive study has proven the efficacy of capnography in identifying ROSC-related risks
Future studies: An in-depth analysis of capnography in ROSC
Number: 78
Reinier, K., Thomas, E., Andrusiek, D. L., Aufderheide, T. P., Brooks, S. C., & Callaway, C. W. (2011). Resuscitation outcomes consortium investigators. Socioeconomic status and incidence of sudden cardiac arrest. CMAJ, 183, 1705–1712.
Rea, T. D., Eisenberg, M. S., Becker, L. J., Murray, J. A., & Hearne, T. (2003). Temporal trends in sudden cardiac arrest: A 25-year emergency medical services perspective. Circulation, 107, 2780–2785.
Article 19: Bullock, Dodington, Donoghue, and Langhan (2017) Expectations: exploring capnography effects Purpose: Capnography as a means of exploring ETT dislodgement
Scope: Local
Hypothesis: Capnography allows identifying the threat of ETT dislodgement
Terms: endotracheal tube (ETT); ETT dislodgement
Review of literature: present
Population sample: 34,000 patients
Data collection: a retrospective chart review
Hypothesis confirmation: confirmed Summary: The study has shown that capnography allows improving patient outcomes due to in-depth analysis of ETT dislodgement
Future studies: methods of managing ETT dislodgement using capnography
Number: 31
29. Heradstveit, B. E., Sunde, K., Sunde, G.A., Wentzel-Larsen, T., & Heltne, J.K. (2012). Factors complicating
interpretation of capnography during advanced life support in cardiac arrest– A clinical
retrospective study in 575 patients. Resuscitation, 83(7), 813–818.
30. Gregory, K. E., & Radovinsky, L. (2012). Research strategies that result in optimal data collection from the
patient medical record. Appl Nurs Res., 25(2), 108–116.
Article 20:Kiekkas, Stefanopoulos, Konstantinou, Bakalis, and Aretha, 2016 Expectations: assessing nurses’ skills Purpose: creating an instrument for assessing nurses’ knowledge of capnography (“Nurses’ Knowledge about Capnography Test” (NKCT)”)
Scope: local
Hypothesis: A 30-item tool will allow for an accurate assessment of nurses’ knowledge
Terms: capnography waveform, capnography function
Review of literature: present
Population sample: 103
Data collection: literature review
Hypothesis confirmation: confirmed Summary: In order to identify nurses’ ability to use capnography during ROSC, a 30-item scale should be deployed.
Future studies: Further tests of the proposed instrument’s efficacy are recommended.
Number: 33
Examples: Whitaker, D. K. (2011). Time for capnography — Everywhere. Anesthesia,
66(7), 544—549.
Zwerneman, K. (2006). End-tidal carbon dioxide monitoring: A VITAL sign worth watching. Critical Care Nursing Clinics of North America,
18(2), 217—225.
Article 21: Wiryana, Sinardja, GedeBudiarta, Widnyana, and Aryabiantara (2017). Expectations: ETCO2 rates analysis Purpose: locating the connection between ETCO2 rates and hyperlactatemia in people with
hemodynamic disturbance
Scope: local
Hypothesis: there is a direct correlation between ETCO2 rates and hyperlactatemia
Review of literature: present
Population sample: 70
Data collection: observational, cross-sectional study
Hypothesis confirmation: confirmed Summary: The study has shown that there is a direct connection between ETCO2 rates and hyperlactatemia in hemodynamic disturbancepatients
Future studies: further study of the effects produced by capnography are required
Number: 9
Agrawal, S., Sachdev, A., Gupta, D., & Chugh, K. (2004). Role of lactate in critically ill children. Indian Journal of Critical Care Medicine, 8(3), 173-178.
2. Malmir, J., Bolvardi, E., & Afzal Aghaee, M. (2014). Serum lactate is a useful predictor of death in severe sepsis and septic shock. Reviews in Clinical Medicine, 1(3), 97-104.
Article 22:
Guimarães et al., 2014
Expectations: sinus tachycardia analysis Purpose: studying cardiac receptor blockage mechanisms
Scope: local
Hypothesis: rocuronium incorporated the sinus tachycardia in the case under analysis
Review of literature: present
Population sample:1
Data collection: a case study
Hypothesis confirmation: confirmed Summary: The case has shown that, with the use of capnography, sinus tachycardia could be observed in rocuronium
Future studies: Exploration of the direct effects of capnography
Number: 9
McDonnell, N. J., Pavy, T. J. G., Green, L. K., & Platt, P. R. (2010). Sugammadex in the management of rocuronium-induced anaphylaxis. British Journal of Anaesthesia, 106(2), 199-201.
Kawano, T., Tamura, T., Hamaguchi, M., Yatabe, T., Yamashita, K., & Yokoyama, M. (2012). Successful management of rocuronium-induced anaphylactic reactions with sugammadex: a case report. Journal of Clinical Anesthesia, 24(1), 62-64.
Article 23:Langhan, Shabanova, Li, Bernstein, and Shapiro (2015) Expectations: determining the significance of capnography Purpose: studying the role of capnography in a pediatric environment
Scope: local
Hypothesis: Capnography is more useful in locating respiratory depression in young patients
Terms: respiratory depression, hypoventilation, oxygen desaturation.
Review of literature: present
Population sample: 154
Data collection: study protocol
Hypothesis confirmation: confirmed Summary: In children receiving sedation, hypopneas hypoventilation is a very common occurrence, which requires the use of capnography.
Future studies: approaches toward using capnography for hypopneic hypoventilation management need to be developed
Number: 52
Godwin, S. A., Caro, D. A., Wolf, S. J., Jagoda, A. S., Charles, R., Marett, B. E., & Moore, J. (2005). Clinical policy: Procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine, 45(2), 177-196.
34. Metzner, J., Posner, K. L., & Domino, K. B. (2009). The risk and safety of anesthesia at remote locations: The US closed claims analysis. Current Opinion in Anesthesiology, 22(4), 502-508.
Article 24:Lin et al. (2017) Expectations:locating the role of capnography Purpose: proving that capnography allows detecting hypoventilation in young patients
Scope: local
Hypothesis: In patients with bronchoscopic sedation, capnography helps locate instances of hypoventilation
Terms: bronchoscopic sedation, hypoventilation
Review of literature: present
Population sample:
Data collection:
Hypothesis confirmation: confirmed Summary: The study shows that the application of capnography leads to a drop in the risk of hypoventilation in a pediatric CCU setting.
Future studies: specific effects of capnography during bronchoscopic sedation need to be studied
Number: 27
16. Nagler, J., & Krauss, B. (2008). Capnography: a valuable tool for airway management. Emergency Medicine Clinics of North America, 26(4), 881-897.
17. Kodali, B. S. (2013). Capnography outside the operating rooms. Anesthesiology: The Journal of the American Society of Anesthesiologists, 118(1), 192-201.
Article 25: Sheak et al. (2015) Expectations: connecting ETCO2 and CPR Purpose: studying the correlation between end-tidal carbon dioxide and CPR efficacy
Hypothesis: measurement of end-tidal carbon dioxide levels has a direct effect on the outcomes of CPR
Terms: CPR, chest compressions
Review of literature: present
Population sample: 583
Data collection: a multicenter cohort study
Hypothesis confirmation: confirmed Summary: Chest compressions served as the means of locating the end-tidal carbon dioxide levels and thus determining the positive effects of CPR
Future studies: Evaluation of ETCO2 as a tool for improving patient care is needed.
Number: 26
Lewis, L. M., Stothert, J., Standeven, J., Chandel, B., Kurtz, M., & Fortney, J. (1992). Correlation of end-tidal CO2 to cerebral perfusion during CPR. Annals of Emergency Medicine, 21(9), 1131-1134.
Sanders AB, Ewy GA, Sanders, A. B., Ewy, G. A., Bragg, S., Atlas, M., & Kern, K. B. (1985). Expired PCO2 as a prognostic indicator of successful resuscitation from cardiac arrest. Annals of Emergency Medicine, 14(10), 948-952.
Article 26: Tobi and Amadasun (2015 Expectations:multidisciplinary cooperation analysis Purpose: Determining the effects of a multidisciplinary team on ROSC
Scope: local
Hypothesis: A cardiac arrest team (CAT) allows improving ROSC rates.
Terms: basic life support (BLS); advanced life support (ALS)
Review of literature: present
Population sample: 156
Data collection: patient records analysis
Hypothesis confirmation: confirmed Summary: The study shows that CAT contributes to a rise in ROSC success rates.
Future studies: strategies for CAT to use
Number: 24
12. Peatfield, R. C., Taylor, D., Sillett, R. W., & McNicol, M. W. (1977). Survival after cardiac arrest in hospital. The Lancet, 309(8024), 1223-1225.
13. Ridley, M., & Thomas, R. D. (1982). Cardiopulmonary resuscitation in general wards. The Lancet, 319(8269), 456.
Article 27: Venkatesh and Keating (‎2017) Expectations:ETCO2 and ROSC correlation Purpose: studying the effects of end-tidal CO assessment on ROSC rates
Scope: global
Hypothesis: ETCO2 allows determining ROSC
Terms: end-tidal CO; ROSC
Review of literature: present
Population sample: 232
Data collection: database search
Hypothesis confirmation: confirmed Summary: The study results indicate that ETCO2 evaluation allows enhancing ROSC rates.
Future studies: A more profound analysis of ETCO2 effects is advised.
Number: 51
37. Nakatani, K., Yukioka, H., Fujimori, M., Maeda, C., Noguchi, H., Ishihara, S.,… & Tase, C. (1999). Utility of colorimetric end-tidal carbon dioxide detector for monitoring during prehospital cardiopulmonary resuscitation. The American Journal of Emergency Medicine, 17(2), 203-206.
51. Touma, O., & Davies, M. (2013). The prognostic value of end-tidal carbon dioxide during cardiac arrest: A systematic review. Resuscitation, 84(11), 1470-1479.
Article 28:Hartmann, Farris, Di Gennaro, & Di Roberts, 2015 Expectations: ETCO2 and ROSC correlation Purpose: Studying the effects of ETCO2 on opportunities for ROSC
Scope: local
Hypothesis: Analysis of ETCO2 allows increasing the chances of ROSC
Terms: ETCO2; ROSC
Review of literature: present
Population sample: 20
Data collection: PubMed database search
Hypothesis confirmation: confirmed Summary: The study has indicated that there is a link between ETCO2 and ROSC opportunities.
Future studies: An in-depth exploration of ETCO2 enhancement strategies is needed
Number: 51
Aufderheide, T. P., & Lurie, K. G. (2004). Death by hyperventilation: A common and life-threatening problem during cardiopulmonary resuscitation. Critical Care Medicine, 32(9), 345-351.
49. O’Neill, J. F., & Deakin, C. D. (2007). Do we hyperventilate cardiac arrest patients? Resuscitation, 73(1), 82-85.
Article 29: Hamrick et al., 2017 Expectations: ETO2 chest compression analysis Purpose: ETO2 chest compression analysis
Terms: central venous pressure (CVP); intracranial pressure (ICP)
Review of literature: present
Population sample: 28
Data collection: pressure measurement
Hypothesis confirmation: confirmed Summary: The results have shown that chest compression based on ETCO2 allows increasing ROSC.
Future studies: ETCO2 management tools
Number: 42
Rivers, E. P., Wortsman, J., Rady, M. Y., Blake, H. C., McGeorge, F. T., & Buderer, N. M. (1994). The effect of the total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the post-resuscitation period. Chest, 106(5), 1499-1507.
42. Ryu, S. J., Lee, S. J., Park, C. H., Lee, S. M., Lee, D. H., Cho, Y. S.,… Jeung, K. W. (2016). Arterial pressure, end‐tidal carbon dioxide, and central venous oxygen saturation in reflecting compression depth. Acta Anaesthesiologica Scandinavica, 60(7), 1012-1023.
Article 30: Hassankhani, Aghdam, Rahmani, & Mohammadpoorfard, 2015 Expectations: nurse performance improvement Purpose: Exploring the effects of self-efficacy and motivation on nurses’ performance
Terms: self-efficacy; learning motivation
Review of literature: present
Population sample: 145
Data collection: descriptive-correlational study
Hypothesis confirmation: confirmed Summary: self-efficacy and motivation is linked directly to nurses’ performance
Future studies: tools for enhancing motivation among nurses
Number: 32
Asadzadeh, F., Mostafazadeh, F., & Sadeghi, S. (2012). A survey of the motivation of nursing students toward their field of study selection. Journal of Health and Care, 14(1), 9-15.
Kosgeroglu, N., Acat, M. B., Ayranci, U., Ozabaci, N., & Erkal, S. (2009). An investigation on nursing, midwifery, and health care students’ learning motivation in Turkey. Nurse Education in Practice, 9(5), 331-339.


Adams, L., Butas, S., & Spurlock Jr, D. (2015). Capnography (ETCO2), respiratory depression, and nursing interventions in moderately sedated adults undergoing transesophageal echocardiography (TEE). Journal of PeriAnesthesia Nursing, 30(1), 14-22.

Bovino, L. R., Brainard, C., Beaumier, K., Concetti, V., Lefurge, N., Mittelstadt, E.,… Langhan, M. L. (2018). Use of capnography to optimize procedural sedation in the emergency department pediatric population. Journal of Emergency Nursing, 44(2), 110-116. Web.

Bullock, A., Dodington, J. M., Donoghue, A. J., & Langhan, M. L. (2017). Capnography uses during intubation and cardiopulmonary resuscitation in the pediatric emergency department. Pediatric Emergency Care, 33(7), 457-461. Web.

Carlisle, H. (2015). Promoting the use of capnography in acute care settings: An evidence-based practice project. Journal of PeriAnesthesia Nursing, 30(3), 201-208. Web.

Carmichael, A., & DeRego, B. (2017). Improving patient outcomes with capnography monitoring in the PACU. Journal of PeriAnesthesia Nursing, 32(4), 11-12. Web.

Clark, C. L., Weavind, L. M., Nelson, S. E., Wilkie, J. L., Conway, J. T., & Freundlich, R. E. (2018). Nursing attitudes towards continuous capnographic monitoring of floor patients. BMJ Open Qual, 7(3), 1-7. Web.

Cook, T. M. (2016). The winds of change‐progress in the implementation of universal capnography. Anaesthesia, 71(4), 363-368. Web.

Guimarães, E. F. O., Saldanha, M. M., Fortes, T. C., Grisolia, M., de Miranda, M. L., & Bersot, C. D. A. (2014). Sugammadex in the management of sinus tachycardia after rocuronium administration: A case report. Open Journal of Anesthesiology, 4(09), 203-206. Web.

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Langhan, M. L., Shabanova, V., Li, F. Y., Bernstein, S. L., & Shapiro, E. D. (2015). A randomized controlled trial of capnography during sedation in a pediatric emergency setting. The American Journal of Emergency Medicine, 33(1), 25-30. Web.

Lin, T. Y., Fang, Y. F., Huang, S. H., Wang, T. Y., Kuo, C. H., Wu, H. T.,… Lo, Y. L. (2017). Capnography monitoring the hypoventilation during the induction of bronchoscopic sedation: A randomized controlled trial. Scientific Reports, 7(1), 8685-8687. Web.

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Vinay, B. (2018). An abrupt reduction in end tidal carbon di oxide concentration in a mechanically ventilated patient in neurocritical care ward: A capnogram artifact. Journal of Clinical Monitoring and Computing, 32(2), 369-371. Web.

Whitaker, D. K., & Benson, J. P. (2016). Capnography standards for outside the operating room. Current Opinion in Anesthesiology, 29(4), 485-492. Web.

Wiryana, M., Sinardja, I. K., GedeBudiarta, I., Widnyana, I. M. G., & Aryabiantara, W. (2017). Correlation of end tidal CO2 (ETCO2) level with hyperlactatemia in patient with hemodynamic disturbance. Journal of Anesthesia & Clinical Research, 8(741), 2-4. Web.