TROUBLESHOOTING

AIRWAY COMPROMISE OR LOST AIRWAY

If at any time the patient begins to de-saturate or develop respiratory problems, immediately disconnect the ventilator, and manually ventilate the patient with BVM (with PEEP valve if available) and 100% O2 while correcting issues utilizing the following D.O.P.E. algorithm.1

- Displacement: Verify that ETT is in place, patient not extubated/tube did not move during transfer.
  - Check depth of the ETT by evaluating the numbers on the ETT. To confirm it is in the trachea, you must directly visualize the ETT’s position using direct or video laryngoscopy. If the ETT has advanced – pull back to original length and attempt to bag; if tube has pulled farther out of trachea, DO NOT ATTEMPT TO ADVANCE the ETT without laryngoscopy or placement of bougie to verify tracheal placement. When advancing the bougie, feel for tracheal rings or stop/ resistance at the carina. If in doubt, remove the endotracheal tube and attempt BVM. If air movement is adequate, continue to bag ventilate the patient. Upon stabilization, consider alternative advanced airways (supraglottic airway or cricothyroidotomy).**If ETT moves freely, access for ETT bulb rupture via cuff manometer.5
- Obstructions: Assess for secretions in ETT. Suction if indicated.
- Pressure: Ensure that a tension pneumothorax / hemothorax has not developed (if the chest tube is in place, ensure it is properly suctioning, not kinked or clamped). If tension pneumothorax / hemothorax is suspected, perform immediate needle thoracentesis. Auto PEEPing or breath stacking can mirror development of a tension pneumothorax (disconnect circuit and gently squeeze chest for full exhalation and adjust settings see below for further description). Assess the need for escharotomy if circumferentially burned. Consider additional paralysis and sedation if patient does not tolerate ventilation.5,6
- Equipment: Ensure that ventilator did not fail; O2 tank not empty. If ventilator is operational, trace all tubes to the patient connection (airway tube, transducer line, exhalation line) ensuring patency and connections.1
- Waveform Capnography: The utilization of concurrent waveform capnography may assist in determining the causative issue while working the D.O.P.E mnemonic.

ALARMS

High pressure alarms/Peak airway pressure alarms (Peak pressure >35 cm H2O): Correct problems causing increased airway resistance and decreased lung compliance, including pneumothorax or pulmonary edema. Check the ventilator to ensure the prescribed tidal volume is being delivered. Check for linked/crushed tubing.

AIR LEAKS

Air leaks causing low pressure alarms/volume loss: ETT cuff malfunction/rupture is most commonly identified through loss of VT or audible leak. Assess, correct air leaks in endotracheal tube, tracheostomy cuff, ventilator system; recheck ventilator to make sure prescribed tidal volume is delivered.3

VENTILATOR DYSSYNCHRONY

Ventilator dyssynchrony is a clinical entity in which ventilator gas delivery and patient respiratory mechanics are not matched. Agitation and respiratory distress that develop in a patient on a mechanical ventilator who has previously appeared comfortable represents an important clinical circumstance that requires a thorough assessment and an organized approach. The patient should not always be automatically re-sedated but must instead be evaluated for several potentially life-threatening developments that can present in this fashion.7

LUNG HYPERINFLATION

Lung hyperinflation (air trapping) and auto-PEEP: Dynamic hyperinflation is associated with positive end-expiratory alveolar pressure, or auto-PEEP. The physiologic effects of air trapping include decreased cardiac preload because of diminished venous return into the chest. This can lead to hypotension and, if severe, to pulseless electrical activity and cardiac arrest. Dynamic hyperinflation can also lead to local alveolar over-distention and rupture. Prevent and manage lung hyperinflation by decreasing tidal volume, changing inspiratory and expiratory phase parameters, switching to another mode, and correcting physiological abnormalities that increase airway resistance.8,9 In an emergency, auto-PEEP from air trapping can be relieved by simply disconnecting the circuit from the endotracheal tube for 3-5 seconds, and then reconnecting.