Question 27

You are called urgently to the bedside of an endotracheally intubated and ventilated 45 year old man, day 7 in ICU with respiratory failure secondary to community acquired pneumonia  who has suddenly become impossible to ventilate. Outline your management of this emergency situation.

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College Answer

Overview:       Is it machine, tubing or patient?

a)         Use 100% O2 with manual bag ventilation to exclude ventilator problem. If he ventilates, it’s a Ventilator problem.  Change/fix ventilator.

b)         Put a suction catheter down the endotracheal tube. If it passes easily, it is not a tube problem (kinked in mouth, bitten, blocked with blood/secretions from poor humidification). Ability to pass a suction catheter does not exclude a cuff prolapse or ball valve obstruction. If the catheter can’t be passed, quickly change it. If in doubt, consider a bronchoscopy

c)         If it is not the ventilator or the tube, it’s the patient! Look for causes (pneumothorax, bronchospasm) and treat appropriately.


A lot of the college questions have this pattern of "Mr so-and-so is impossible to ventilate - what will you do?".

A structured stereotypical approach is expected.

  • Troubleshooting the circuit:
    • disconnect the patient from the ventilator, and manually bag the patient with 100% FiO2
    • If the lung compliance is good, the patient's ventilator or its tubing is the problem, and you can keep bagging the patient until the ventilator is changed.
    • if the bag ventilation is difficult, one must conclude that the patient is the problem.
  • Troubleshooting the patient:
      • Airway:
        • suction the patient, removing sputum plugs and clearing the ETT.
        • if the suction catheter cannot pass easily, the ETT may be blocked. Is there a cuff  herneation?
          • check whether the patient is chewing on it. Paralyse them if this is the case.
        • Auscultate the chest, ensuring the ETT is not in the right main bronchus
      • Breathing:
        • Auscultate the chest and perform a CXR looking for pneumothorax
        • Look for bronchospasm and features of anaphylaxis
        • The CXR will also reveal pleural effusions, hemothoraces and mucus-plugged atelectasis
        • Consider bronchoscopy to relieve the mechanical obstruction.


Jairo I. Santanilla "The Crashing Ventilated Patient"; Chapter 3 in Emergency Department Resuscitation of the Critically Ill, American College of Emergency Physicians, 2011.