Deterioration after intubation

Background

• There are multiple reasons for a patient to deteriorate while on mechanical ventilation
• A systematic method of evaluating this deterioration is the best way to identify/fix the causative problem

Clinical Features

• Desaturation, other vital sign abnormalities, or cardiac 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

• "DOTTS" Mnemonic
• D - Disconnect ventilator and put light pressure on patient chest
• O - Oxygen 100% BVM. Look for chest rise, listen and feel for cuff leak
• T - Tube position and patency. Pass bougie or suction all the way through tube to remove obstruction
• T - Tweak the vent. Usually need to decrease respiratory rate (see below on breath-staking)
• S - 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
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation