Deterioration after intubation: Difference between revisions
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(https://rebelem.com/rebel-cast-ep-46b-vent-management-crashing-patient-haney-mallemat/) | |||
**DOPES = Displaced ET tube or cuff, Obstructed ET tube: pt biting tube, kink in tube, mucous plug, Pneumothorax, Equipment: Tube from ETT to Vent, Stacked breaths: auto-PEEP (typically asthma/COPD, results from decreased ability to expire air) | |||
**DOTTS = Disconnect from vent (can push down on pt’s chest if concern for auto-PEEP), FOR COVID-19 SKIP Oxygenate with 100% BVM (evaluates for ETT dislodgement, bilateral breath sounds, cuff leak, crepitus, difficulty bagging), Tube check for mucous plug or kink or dislodgement, Tweak vent for autoPEEP (decreased RR, decreased inspiratory time with changing E:I ratio), Sonography for pneumothorax. | |||
Revision as of 21:44, 21 March 2020
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[1][2]
- 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
- Mechanical ventilation (main)
- Miscellaneous
References
- ↑ EMRA Critical Care Handbook
- ↑ Monica E. Kleinman et al. Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. AAP. 2010. http://pediatrics.aappublications.org/content/126/5/e1361.full
(https://rebelem.com/rebel-cast-ep-46b-vent-management-crashing-patient-haney-mallemat/)
- DOPES = Displaced ET tube or cuff, Obstructed ET tube: pt biting tube, kink in tube, mucous plug, Pneumothorax, Equipment: Tube from ETT to Vent, Stacked breaths: auto-PEEP (typically asthma/COPD, results from decreased ability to expire air)
- DOTTS = Disconnect from vent (can push down on pt’s chest if concern for auto-PEEP), FOR COVID-19 SKIP Oxygenate with 100% BVM (evaluates for ETT dislodgement, bilateral breath sounds, cuff leak, crepitus, difficulty bagging), Tube check for mucous plug or kink or dislodgement, Tweak vent for autoPEEP (decreased RR, decreased inspiratory time with changing E:I ratio), Sonography for pneumothorax.