End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

Pediatr Crit Care Med. 2018 Feb;19(2):98-105. doi: 10.1097/PCC.0000000000001372.


Objective: Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.

Design: A multicenter retrospective cohort study.

Setting: Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

Patients: Primary tracheal intubation in children younger than 18 years.

Interventions: None.

Measurements and main results: Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

Conclusions: Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Capnography / methods
  • Capnography / statistics & numerical data*
  • Carbon Dioxide / analysis*
  • Child
  • Child, Preschool
  • Cohort Studies
  • Colorimetry / methods
  • Colorimetry / statistics & numerical data*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Intensive Care Units, Pediatric
  • Intubation, Intratracheal / adverse effects*
  • Male
  • Practice Patterns, Physicians' / statistics & numerical data
  • Quality Improvement
  • Registries
  • Retrospective Studies


  • Carbon Dioxide