The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia but is rarely available in low-income countries.
The Global Capnography Project (GCAP) is an initiative started in 2016 in order to introduce capnography to low-income countries while assessing the feasibility and sustainability of doing so. The main aim was to determine whether introduction was feasible and could improve the early recognition of critical airway events. This is the first project worldwide to do so.
In January 2017, the GCAP team travelled to Malawi and provided capnography training courses. Pre and post course knowledge was assessed by MCQs. 40 capnographs donated but Medtronic were then given to eight hospitals in Malawi for use in their operating theatre and intensive care units.
In August 2017, GCAP returned in order to conduct a six month follow up study. Further workshop capnography training was also carried out. Follow up data was collected via logbooks, questionnaires and interviews of anaesthesia providers. Follow up visits to several hospital sites were also conducted.
The results of the project were impressive. Overall 97% and 100% capnography gaps were identified in the theatres and ICUs respectively. The capnography equipment performed well and six months following implementation 24 (77%) of anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed it had saved lives.
The reporting of 44 oesophageal intubations in a six-month period in Southern Malawi, with a population of 7.5 million, indicates a rate of 11.7 oesophageal intubations per million population per year. Assuming intubation rates and capnography use in Malawi to be representative of sub-Saharan Africa, population of 1022million, we estimate that over 11,000 oesophageal intubations could occur there each year. This high number of oesophageal intubations poses a very significant patient safety risk internationally that would most effectively be mitigated by the implementation of capnography as has happened in the high-income countries.
Following the Global Oximetry Project’s introduction of pulse oximetry into low-income countries in 2007 the present GCAP study demonstrates that similar success can be achieved when introducing capnography. It is reasonable to assume that the 70,000 operating theatres that Lifebox Foundation estimated did not have pulse oximetry will also have no capnography.
This study has identified a straightforward intervention to improve patient safety worldwide. The evidence provided supports the development of an international project to make global capnography become a reality so that like pulse oximetry it can be included in the WHO surgical safety checklist and improve patient safety worldwide.
All relevant organisations should consider taking this forward.