Deterioration after intubation

Clinical Features

• Desaturation, other vital sign abnormalities, or full arrest while on mechanical ventilation

Differential Diagnosis

DOPE

• Displaced ETT
• Obstruction (anywhere along circuit)
• Pneumothorax
• Equipment failure (ventilator malfunction or disconnect)

Evaluation

• Clinical

Management

Troubleshoot

Immediately disconnect from ventilator (allows for expiration of stacked breaths)

• D - Displacement of tube
  • Attach end-tidal CO2 to verify and check depth (cm at lip)
• O - Obstruction of tube/circuit
  • Use suction catheter to remove mucus plug, or make sure patient not biting down
• P - Pneumothorax
  • Verify via ultrasound, CXR, or needle thoracostomy (high suspicion)
• E - Equipment failure
  • Connect to BVM
• S - Stacked breaths - Auto-PEEP especially in COPD/Asthma
  • Disconnect from ventilator

Fix

• Disconnect ventilator and put light pressure on patient chest
• Oxygen 100%
  • Bag and take time to evaluate your patient
• Tube Position & Function
  • Pass bougie or suction all the way through the tube, OR take a look with DL
• Tweak Vent Settings
  • Drop TV, then decrease RR, and then increase flow rate
  • Caution as it causes hypercapnia and respiratory acidosis, which is harmful in patients with increased ICP or tox ingestion
• Sonography and CXR

Auto-PEEP (Breath stacking) troubleshooting options

• Bronchodilators if COPD/asthma
• Decrease RR
• Decrease I:E ratio (increase expiratory time)
• Quicker inspiratory flow rate
• Decrease TV
• Increase sedation

See Also

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Rapid Sequence Intubation (RSI)
  • Difficult airway algorithm
  • Supraglottic airway
  • Nasal intubation
• Deterioration after intubation
• Ventilation settings
• Ventilation modes
• Ventilator high pressures
• Ventilator associated lung injury (VALI)
• Recruitment maneuver
• Ventilation weaning
• Extubation

References

Authors

Michael Holtz, Ross Donaldson