Deterioration after intubation: Difference between revisions
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===Troubleshoot=== | ===Troubleshoot=== | ||
''Immediately disconnect from ventilator (allows for expiration of stacked breaths)'' | ''Immediately disconnect from ventilator (allows for expiration of stacked breaths)'' | ||
*D - Displacement of tube | *D - Displacement of tube or cuff | ||
**Attach end-tidal CO2 to verify and check depth (cm at lip) | **Attach end-tidal CO2 to verify and check depth (cm at lip) | ||
*O - Obstruction of tube/circuit | *O - Obstruction of tube/circuit | ||
**Use suction catheter to remove mucus plug, or make sure patient not biting down | **Use suction catheter to remove mucus plug, or make sure patient not biting down, look for kink in tube | ||
*P - Pneumothorax | *P - [[Pneumothorax]] | ||
**Verify via [[Ultrasound: Lungs|ultrasound]], CXR, or [[needle thoracostomy]] (high suspicion) | **Verify via [[Ultrasound: Lungs|ultrasound]], CXR, or [[needle thoracostomy]] (high suspicion) | ||
*E - Equipment failure | *E - Equipment failure | ||
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*O - Oxygen 100% BVM. Look for chest rise, listen and feel for cuff leak | *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 - 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) | *T - Tweak the vent. Usually need to decrease respiratory rate, decreased inspiratory time with changing E:I ratio (see below on breath-staking) | ||
*S - Sonography and CXR | *S - Sonography and CXR | ||
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==See Also== | ==See Also== | ||
{{Mechanical ventilation pages}} | {{Mechanical ventilation pages}} | ||
==External Links== | |||
*https://rebelem.com/rebel-cast-ep-46b-vent-management-crashing-patient-haney-mallemat/ | |||
==References== | ==References== | ||
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[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
Revision as of 21:48, 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 or cuff
- 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, look for kink in tube
- 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, decreased inspiratory time with changing E:I ratio (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
External Links
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