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.
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:
- 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
- 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.