Barriers and Facilitators to the Use of Capnography for Respiratory Monitoring by Nurses in Phase I Post-Anesthesia Care Unit: A Scoping Review

1. Introduction

The Post-Anesthesia Care Unit (PACU) is dedicated to the continuous monitoring and care of patients following anesthetic and surgical procedures, aiming to minimize complications and ensure a safe transition to subsequent care units [1,2,3].

Most complications occur within the first five hours after anesthesia [4] and may be surgical, anesthetic, or patient-related origin [5,6]. Phase I of the postoperative period refers to the immediate phase following surgery, during which the patient is transferred to the PACU. The primary goal is to ensure initial recovery from anesthesia and facilitate a safe transition to Phase II, thereby promoting continuity of care [7]. This phase requires close monitoring and specialized interventions to maintain hemodynamic stability, prevent complications, and ensure patient safety [7].

In the PACU, nurses hold a critical role in managing the immediate recovery of patients following anesthesia. Their responsibilities necessitate autonomous clinical monitoring, proficiency in the early identification of complications, and the capacity for prompt decision-making, all underpinned by the advanced specialized knowledge of perioperative nursing [8].

Common respiratory complications during this phase include post-extubation hypoxemia, bronchospasm, atelectasis, acute respiratory failure, pneumothorax, pleural effusion, exacerbation of underlying diseases, and airway obstruction [9,10].

Capnography is a non-invasive, continuous technique that assesses the effectiveness of ventilation [11] and enables early detection of respiratory changes, being more sensitive than pulse oximetry in identifying adverse events [11,12].

Studies show that capnography can detect respiratory adverse events 8 to 11 minutes earlier than conventional monitoring [13], identify more episodes of postoperative respiratory depression compared to oximetry, and is six times more accurate than other methods [14].

While not universally mandatory, the use of capnography is strongly recommended for patients receiving opioid analgesia, individuals with obstructive sleep apnea (OSA), and those requiring supplemental oxygen therapy, due to their increased risk for respiratory complications [15,16,17,18].

Despite its clinical relevance, capnography is not yet widely implemented in PACU [19,20]. Identifying barriers and facilitators can support a more effective and sustained implementation of this monitoring tool in clinical practice, ultimately enhancing patient safety and quality of care.

The methodology employed is a scoping review, following the methodology proposed by JBI. This scoping review aims to map the evidence on barriers and facilitators to the use of capnography for respiratory monitoring by nurses in Phase I PACU.

2. Methods

This scoping review was conducted in accordance with the methodological guidelines established by the Joanna Briggs Institute (JBI) [21]. Advance registration of the review protocol was not undertaken.

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines [22].

2.1. Identifying the Research Question

The JBI guidelines recommend employing the Population/Concept/Context (PCC) framework to guide the formulation of review questions (see Table 1).

The review question was: “What are the barriers and facilitators to the use of capnography for respiratory monitoring by nurses in Phase I PACU?”.

2.2. Identifying Relevant Studies

The literature search was conducted in MEDLINE (via PubMed), CINAHL Complete (via EBSCOhost), and Portuguese Open Access Scientific Repository (RCAAP). Search terms included: nurs*, capno*, "respiratory monitoring", "carbon dioxide", "end tidal carbon dioxide", "respiratory assessment", "respiratory complications", "postanesthesia", "recovery", "postoperative", PACU, "post anesthesia care unit", and "immediate postoperative". These were combined with specific Medical Subject Headings (MeSH) and CINAHL Subject Headings for each respective database, as detailed in Appendix A (see Table A1, Table A2 and Table A3). The search was conducted on January 2024.

2.3. Study Selection

Inclusion and exclusion criteria were based on population, concept, and context. Studies that included nurses—irrespective of their area of specialization—or multidisciplinary teams involving nurses were considered for inclusion. To be eligible, studies were required to focus on respiratory monitoring using capnography, addressing relevant barriers, facilitators, challenges, and limiting factors. Only studies conducted in perioperative settings involving adult patients (aged 18 and older) within Phase I PACU environments, defined as the immediate postoperative period, were included. Studies limited to preoperative or exclusively intraoperative contexts were excluded.

Only studies published in Portuguese, English, or Spanish were included, as these were the languages spoken by the reviewers. No time restrictions were applied.

All results from the different databases were exported to Rayyan QCRI (Qatar Computing Research Institute), where duplicates records were removed. A blinded and independent screening of titles and abstracts was conducted in duplicate by two reviewers (A.A. and L.C.) on January 18, 2024 to apply inclusion criteria.

Disagreements between reviewers were resolved through consultation with a third reviewer, ensuring impartiality and consensus. The third reviewer was not directly involved in the development of the manuscript and therefore is not listed as an author. However, they exclusively contributed by mediating decisions during the study selection process. The reviewers have academic training and clinical experience in post-anesthesia care, ensuring familiarity with the topic under study, and declared no conflicts of interest related to the included studies or the review topic.

Full texts of potentially eligible studies were obtained and analyzed in detail. Reference lists of included studies were also reviewed to identify additional relevant literature. Although a formal blinded review of full texts was not implemented, the combination of independent duplicate review with mediation by a third reviewer was adopted to minimize the risk of bias and increase the reliability of the process.

2.4. Data Extraction and Comprehensive Analysis

Data from the included studies were independently extracted by two reviewers using a customized data extraction matrix, which included: author, year of publication, title, country, study design, objectives, participants, setting, and main findings related to the barriers and facilitators of capnography use.

In this study, barriers are defined as factors that limit, hinder, or negatively affect the effective use of capnography for respiratory monitoring by nurses in Phase I of the PACU. Facilitators are elements that help promote or facilitate the use of capnography. Barriers and facilitators are essential factors influencing the implementation process of healthcare practices [23].

2.5. Reporting the Results

The results are summarized and presented in a tabular form aligned with the objective of this scoping review. A narrative summary accompanies the tables and describes how the findings relate to the review’s objective and question.

3. Results

The results of the search and article selection process are presented using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart, adapted for scoping reviews.

Figure 1. PRISMA Flow Diagram for study selection.

Figure 1. PRISMA Flow Diagram for study selection.

The search process initially identified 200 articles. Of these, 28 were excluded as duplicates, leaving 172 articles for title and abstract screening. From these, 155 were excluded. After full-text reading of the remaining 17 eligible articles and applying the inclusion criteria, seven articles were included in the review.

Table B1, presented in Appendix B, contains the data extracted from the studies included in this scoping review, based on the customized data extraction matrix developed for this purpose. Table 2 provides a summary of the barriers and facilitators identified in each study regarding the use of capnography for respiratory monitoring by nurses in Phase I PACU.

The analysis of the seven studies included in this scoping review allowed the identification of a set of barriers and facilitators to the use of capnography for respiratory monitoring by nurses in Phase I of the PACU.

Among the identified barriers, high workload stands out, as nurses reported difficulties integrating capnography into daily practice due to competing demands, especially in the demanding PACU context, which can limit time and attention devoted to capnography monitoring [24]. Additionally, the perceived lack of patient adherence, caused by patients’ difficulties in complying with device use (e.g., keeping nasal cannulas in place) may discourage consistent monitoring [24,26,27]. Finally, lack of knowledge, manifested as limited understanding of the interpretation and application of capnography by nurses, constitutes a significant obstacle to its effective use [26,27].

Among the facilitators for the use of capnography, alarm sound plays a key role by enhancing vigilance and prompting timely interventions [24]. Patient education promotes adherence to capnography through patient instruction supporting successful monitoring and improving patients’ compliance with device use [24,26]. Nurses who anticipate patient clinical instability by using capnography to proactively identify deterioration perceive it as a valuable clinical tool [24,25,26,28]. Increased nurse confidence, gained through familiarity with the technology, boosts willingness to apply it in clinical practice [25,28]. The perception of enhanced safety leads nurses to associate capnography with increased patient safety [19,25,26,28,29]. Targeted nurse training equips professionals with the skills to interpret capnographic data and respond appropriately, with nurses receiving specific training demonstrating greater adherence to its use [19,25,27,28,29].

The integration of capnography supports continuous improvement in care delivery, aligning with broader goals of care optimization and innovation [28]. Effective communication and feedback, including sharing monitoring data and patient outcomes, strengthen interprofessional collaboration and reinforce capnography’s integration into practice [28]. Additionally, capnography promotes sustainable practices by supporting efficiency and resource stewardship in clinical settings, enabling early interventions, minimizing complications, and optimizing resources [28]. Finally, prior knowledge and exposure to capnography positively influence its adoption and routine use [29].

Table 3 provides a summary of the identified categories and the contributions of the seven included studies.

5. Conclusions

The findings from this scoping review have successfully addressed the research question, underscoring the critical role of integrating capnography into Phase I PACU for respiratory monitoring. By mapping the barriers and facilitators associated with capnography use, this review provides valuable insights into how facilitators can be strengthened and barriers reduced.

Although barriers such as limited knowledge, high workload, and the perceived lack of patient adherence were identified, several facilitators also emerged, including specific nurse training, prior experience with capnography, the ability to anticipate clinical deterioration, and the perception of increased safety in care delivery.

The findings of this scoping review show that capnography, when used alongside other monitoring methods, is recognized by nurses as a fundamental tool for the early detection of respiratory complications, reinforcing its relevance in promoting patient safety. Moreover, institutional factors such as effective interprofessional communication, continuous quality improvement projects, regular audits and feedback, as well as the reinforcement of nurses’ knowledge through ongoing education based on current scientific evidence, are key elements in consolidating its practical application in the PACU.

This study provides an innovative contribution to understanding the factors that influence nurses’ adoption of capnography in Phase I PACU, offering valuable guidance for future interventions in nursing clinical practice and the development of health policies.

The primary limitations of this scoping review include the limited number of databases consulted and the language restrictions, which may have impacted the breadth of the evidence identified.