Deterioration after intubation

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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
  • 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

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