Deterioration after intubation

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Background

Clinical Features

Differential Diagnosis

  • DOPE[1][2]
    • D - Displaced ETT
    • O - Obstruction (anywhere along circuit)
    • P - Pneumothorax
    • E - Equipment failure (ventilator malfunction or disconnect)

Diagnosis

Management

  • When in doubt, disconnect the pt from the ventilator and begin bag ventilation
    • Eliminates the vent (E) circuit as source of the problem
    • Helps gauge lung compliance
  • Airway
    • Is the tube still in? (D)
    • Is it patent? (O)
    • Auscultate and/or CXR
  • Breathing
    • Is the chest rising? Breath sounds equal b/l? (P)
      • Lung sounds not always reliable → get CXR if continued clinical concern


  • Immediately disconnect from ventilator (allows for expiration of stacked breaths)
  • "DOPES like DOTTS" Mnemonic

Troubleshoot

  • 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 pt not biting down
  • P - Pneumothorax
    • Verify via US
  • E - Equipment failure
    • Connect to BVM
  • S - Stacked breaths - Auto-PEEP especially in COPD/Asthma pts
    • Disconnect from ventilator

Fix

  • Disconnect vent and put light pressure on pt 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 resp acidosis, which is harmful in pts with increased ICP or tox ingestion
  • Sonography

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

References

  1. EMRA Critical Care Handbook
  2. 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