If the patient is in acute distress, do the following:
- If the patient is unstable, remember the ABCs.
- May need to increase sedation or consider temporary use of paralytics while troubleshooting, especially if patient is profoundly hypoxemic.
- If patient shows combination of respiratory distress and hypotension consider decreased venous return from high PEEP, high auto-PEEP (air trapping), or tension pneumothorax.
- Check to be sure that the airway is patent, the ET tube is appropriately placed and secured, and the circuit has no air leak.
- Brief physical exam (listen to the lungs and watch the chest rise). Disconnect the patient from the ventilator and ask for help from RT.
- Bag ventilate the patient by hand at 100% FiO2.
- Check peak pressure and plateau pressure (ask RT to show you how to do this):
- High peak pressure and high plateau pressure (stiff lung/chest wall): consider pulmonary edema, consolidation, ARDS, atelectasis, mainstem intubation, tension pneumothorax, and large pleural effusions.
- High peak pressure but low to normal plateau pressure (airway problem): consider bronchospasm, mucous plug, secretions, obstructed tubing, tube biting.
- Low peak pressure and low plateau pressure (disconnect problem): consider disconnected tubing or lost airway.
- Obtain an ABG and a chest x-ray.
- Peak inspiratory pressure (PIP): highest level of pressure applied to the lungs during inhalation. Measured in cmH2O.
- Plateau (static) pressure (PPLAT): static pressure applied to the small airways and alveoli when there is no gas flow. Measured in cmH2O and obtained by performing an inspiratory hold on the ventilator.
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Pressure-limited Ventilator Problems
- Tension pneumothorax: insert 14 gauge needle into 2nd intercostal space at midclavicular line, get CXR. Chest tube for decompression.
- Airway obstruction due to mucous plug, secretions, blood, etc.: aggressive suctioning.
- Tubing occlusion: check the tubing in the ventilator circuit.
- Mainstem bronchus intubation (usually right): pull back the endotracheal tube, check CXR.
- Agitation, pain, anxiety, tube biting, dyssynchrony with vent: treat as indicated.
- Auto-PEEP: diagnose with flow loop not returning to zero at end of breath. Disconnect from ventilator briefly, decrease set rate, decrease set amount of PEEP, decrease I:E ratio (increase time for exhalation), check for expiratory circuit obstruction.
- Wheezing/bronchospasm: treat with bronchodilators.
Non Pressure-limited Ventilator Problems
- Pneumothorax (non-tension): verify with CXR, insert chest tube for decompression.
- Large pleural effusions: thoracentesis.
- Disrupted tubing or ventilator malfunction: fix the problem or get a new ventilator, and ventilate by hand with 100% oxygen in the meantime.
- Cuff deflation: re-inflate cuff, confirm positioning, and change to 100% oxygen.
- Lost airway: re-intubate, though begin with mask ventilation with 100% oxygen.
- Air hunger/dyspnea: consider using a pressure-targeted mode to allow for higher flow rates versus deepening sedation with or without paralysis if still early in ARDS course.
- Pulmonary embolism: see Pulmonary: Pulmonary Embolism.
| Tip: Remember to increase FiO2 to 100% and use controlled mode during acute hemodynamic crisis. |
Other Ventilator Problems
- Low exhaled volume: check for cuff leak, bronchopleural fistula, and low flow rate.
- Increased respiratory rate: check for change in the patient's clinical status (pain, fever, etc.). Draw ABG to assess for need to increase set rate or tidal volume.
- High minute ventilation: check for hyperventilation (neurogenic, agitation, incorrect vent settings), hypermetabolic state (sepsis, fever, seizures, acidosis), or inefficient ventilation (increased dead space).