Global Capnography Project: implementation of capnography in Malawi – an international anaesthesia quality improvement project: a follow up

We previously described the introduction of capnography to a low-income country, resulting in early recognition of critical airway events [1]. We now describe findings from a follow-up survey in the same setting. The original study was carried out over two visits in early and late 2017. At that time, information on the ‘capnography gap’ (the gap between need and availability) was ascertained from eight government hospitals in southern Malawi by questionnaire survey. We supplied 32 anaesthesia providers with portable Nellcor N-85 hand-held capnographs (Medtronic Minimally Invasive Therapies, Dublin, Ireland), and provided training on their use through lectures and small-group workshops. In 2023, we surveyed 22 anaesthesia providers from the hospital sites which participated in the 2017 project.

While every respondent agreed that capnography improves patient safety, survey responses indicated that it is no longer widely available. The presence of capnographs was reported in only one of the eight institutions where the 2017 project had taken place. Three-quarters of respondents indicated that capnographs are difficult to find. Only one agreed that they use capnography in all patients having tracheal intubation, adding the caveat ‘if available’. In response to the statement “Have you ever had waveform capnography training?”, only eight (46%) replied in the affirmative.

Jooste et al. described early recognition of critical airway events due to the introduction of capnography, with 77% of respondents reporting oesophageal intubations and 81% reporting circuit disconnections [1]. In 2023 this was 50% and 59%, respectively, likely reflecting a reduction in capnograph availability.

It appears that, despite the initial success of the 2017 project, the capnography gap has widened. We read with interest the excellent work in the development of the Smile Train-Lifebox capnograph, particularly the focus on capnography education [2]. Future challenges predicted include “organising capnography educational activities” and “assessment of the impact of capnography on anesthesia practice and outcomes”. We have observed these challenges in our work. A decline in performance following initial improvement has also been described in other recent analyses [3].

Our survey indicates that, following the introduction of capnographs, both quantity and quality of capnography education are important not only to reinforce change in practice but also to reduce the attrition of the equipment. The challenge: “identifying lack of capnography as a problem and determining its extent” is described in bringing the project by Evans et al. to fruition [2]. Our subsequent observations show that overcoming this obstacle does not mean it has been permanently defeated. It requires continued attention and resources to maintain the benefits of initial intervention.