cap-ONE Information

Vol.2

Ensure Quality of Careunder Sedation- Accurate respiratory monitoring with
optimal oxygen supply -cap-ONE Information Vol.2

Efficient Monitoring for Safer Pediatric Sedation— Don’t miss signs of respiratory depression —Pediatric sedation may involve serious risks including hypoventilation, apnea, airway obstruction andcardiopulmonary dysfunction1). Also, it has been shown that depth of sedation can be deeper than the intended
level in pediatric patients2). For safer patient management, it is essential to closely observe patients whileadministrating sedation. According to an analysis of adverse events related to pediatric sedation in the US, themost commonly observed adverse event is respiratory depression. It also reports that these adverse events canlead to serious incidents including death and permanent dysfunction in the absence of appropriate monitoring3).

— Fast, accurate detection of respiratory depression while
oxygen is supplied —Nihon Kohden has developed an extremely small mainstream CO2 sensor (cap-ONE) that can accurately measureoral as well as nasal exhaled CO2 in non-intubated patients4). After further development and evolution, the capONE is now available as the world’s smallest mainstream CO2 sensor weighing only 4 g with an original open
face oxygen mask (cap-ONE mask). Cap-ONE mask is easily used for pediatric patients who are receiving
supplemental oxygen, and the cap-ONE CO2 sensor reliably detects respiratory depression including apnea andhypoventilation while oxygen is supplied (Fig. 1).

CO2 sensor

Using this ultra-small mainstream CO2 sensor
together with cap-ONE mask, the sensor canaccurately catch oral and nasal exhaled CO2 andreliably detect respiratory variation.

PCO2 [mmHg]

50Reference

050 Nasal breathing

050 Oral breathing

O2 = 2L/min

Nasal breathing

O2 = 5L/min

Figure 1.
Oral breathing

O2 = 2L/min

The exhaled CO2 waveform (capnogram) simulated by aO2 = 5L/min

pediatric model mannequin and spontaneous breathinglung simulator in the presence of oxygen supplement.

0The cap-ONE sensor reliably detects exhaled CO2 during

010Time [s]010Time [s]oxygen administration and presents a quality capnogram
which agrees with a reference capnogram. (FromReference 5, with permission)

— Gentle oxygen supply from a mask with a wide opening —Gentle stream ofoxygen fromboth sides of themask

Consistent andstable oxygen
concentration

Less rebreathingof exhaled CO2even with low
oxygen flow

Lighter, freer,
less oppressive
feeling

CO2 partial pressure of exhaled gas
retained in the mask [mmHg ]It is recommended that oxygen flow should be more than 6L/min when using an oxygen mask in order to preventthe patient from rebreathing exhaled gas which is retained in the mask6). Cap-ONE mask has a wide opening in
the front to let oral and nasal exhaled gas out of the mask. This design prevents exhaled gas from remaining in
the mask even when oxygen flow is low (Fig. 2). Also, well dispersed oxygen is supplied from the sides ofcap-ONE mask, so oxygen concentration inside the mask remains consistent and stable7).
12
Conventional oxygen mask
cap-ONE mask

10A

8

Figure 2.

6Comparison of CO2 partial pressure in exhaled gas whileBadministrating oxygen using a conventional oxygen mask

4and cap-ONE mask (pediatric patients aged 1 to 8, CO2
partial pressure measured 5 minutes after the oxygen

20administration). Point A shows retained exhaled gas andincreased CO2 partial pressure in the conventional mask.

01234Administered oxygen [L/min]

56Point B shows that CO2 partial pressure remains low andrebreathing of exhaled gas is reduced. (From Reference 7,with permission)

Limitations of the Pulse Oximeter— Desaturation can be delayed during oxygen administration —The pulse oximeter is widely used to monitor vital signs in various clinical settings since it provides oxygen
saturation and pulse rate non-invasively and continuously with just a probe on the patient’s finger. However,
it is important to understand the limitations of pulse oximeters especially when using it as a respiratory
monitoring tool. It has been shown that when fraction of inspiratory oxygen (FiO2) is high, saturation levelremains high and does not decrease promptly even when pulmonary function is deteriorated8) (Fig. 3). This canlead to failure to detect respiratory depression and hypoventilation for a long time. There has been a reported
case where a post-operative patient who received high concentration oxygen developed serious and fatal
hypercapnia and acidosis in the recovery room9). Monitoring respiration only with a pulse oximeter can havepotential risks. It is important to understand that the pulse oximeter can be an excellent index of oxygenation
only when a patient breathes room air10).

Oxygen Saturation (%)

In June 2011, the Anesthesia Patient Safety Foundation held a meeting titled “Essential Monitoring Strategies
to Detect Clinically Significant Drug-Induced Respiratory”. Different monitoring methods were compared(Table 1) and capnography (monitoring of exhaled CO2) was reported to be the most suitable method for
detecting respiratory depression during oxygen administration10).

10098969492
9088868482
80
7876
74
72
7068FiFiOOFi

2 02 0.3

O2 1.6.0

Figure 3.
Change of oxygen saturation plotted as a function ofincreasing intrapulmonary shunt from 0% at a rate of2%/min. With fraction of inspiratory oxygen (FiO2) of 1.0,0.6, and 0.3, it takes 16, 11, and 6 minutes for oxygen
05101520253035Time (mins)

saturation (SaO2) to decrease from 100% to about 97%,respectively. (From Reference 8 with permission, partlymodified)

Monitoring method

Sensitivity

Specificity

Reliability

Response time

PetCO2( intubated )HighHighHigh

FastPetCO2( not intubated )High

Moderate-High

Moderate

Fast

SpO2
( no O2 supplement )High

Moderate-High

High

Fast

SpO2
( with O2 supplement )Moderate

Moderate

High

Slow

Clinicalassessment byskilled clinician

Moderate

Moderate-High

Moderate

Slow

Thoracic
impedance

Low-Moderate

LowLowModerate

Table 1.
Monitoring methods for detecting opioid induced
respiratory depression in the postoperative period. (FromReference 10, with permission)Exhaled CO2 Monitoring Recommended by Anesthesia
Guidelines
Reflecting serious concerns about pediatric sedation outside the operating room, the American Academy ofPediatrics and the American Academy of Pediatric Dentistry updated their “Guidelines for Monitoring andManagement of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures”1) in2006. This guideline describes recommendations regarding monitoring of exhaled CO2 as well as monitoringof common vital signs including heart rate and oxygen saturation. Also, the “Standards for Basic Anesthetic
Monitoring” (revised July 2010 and effective July 2011) mandated that the adequacy of ventilation should beevaluated by exhaled CO2 in moderate to severe sedation11). Now, capnography is strongly recommended as ameans to continuously assess patients’ respiratory condition during procedures using sedation and anesthesia
which may be associated with risks of respiratory depression.

cap-ONE Product Line

cap-ONE CO2 sensor
P909 (TG-970P)

For intubated patients

For non-intubated pediatric patientsA

cap-ONE mask
V933 (YG-232T)

B

For child weighing20-40kg

Airway adapter
R805 (YG-211T) A
For adult and child weighing over 7kg

cap-ONE mask
V935 (YG-242T)
For child weighing
7-20kg

R806 (YG-213T) B
For infant weighing 2-7kg

cap-ONE Information Vol.2

References1 ) Cote CJ et al. Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic

Procedures: An Update (American Academy of Pediatrics). PEDIATRICS 2006; Vol.118, No.6: 2587-2602.

2) Motas D et al. Depth of consciousness and deep sedation attained in children as administered by non-anaesthesiologists in a children’s

hospital. Paediatr Anaesth 2004; Vol.14: 256-260.

3 ) Cote CJ et al. Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors. PEDIATRICS 2000; Vol.105,

No.4: 805-814.

4) Kasuya Y et al. Accuracy of Postoperative End-tidal PCO2 Measurements with Mainstream and Sidestream Capnography in Non-obese

Patients and in Obese Patients with and without Obstructive Sleep Apnea. Anesthesiology 2009; Vol.11, No.3: 609-615.

5 ) Takatori F et al. A Novel Mainstream Capnometer System for Non-intubated Pediatric Patients Requiring Oxygen Administration. IEEE Eng

Med Biol Soc. 2011; 2011; 1189-1192.

6 ) American Heart Association. Respiratory Management Resources 2006.
7) Abe. S et al. 2010. Japanese Society of Pediatric Intensive and Critical Care. A novel method for mainstream capnometer. Presentation.

November.

8 ) Downs JB, Smith RA. Increased inspired oxygen concentration may delay diagnosis and treatment of significant deterioration in pulmonaryfunction. Crit Care Med.1999 Dec;27(12):2844-6.

9 ) Ayas N et al. Unrecognized Severe Postoperative Hypercapnia: A Case of Apneic Oxygenation. Mayo Clinic Proceedings; Vol.73, No.1: 51-54.
10) Weinger MB et al. No Patient Shall Be Harmed By Opioid-Induced Respiratory Depression. APSF Newsletter 2011; Vol.26, No.2: 21-28.
11) American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. http://www.asahq.org/For-Members/Standards-

Guidelines-and-Statements.aspx

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