The approach to a patient who suffers sudden respiratory failure (or complains of difficulty breathing) while being ventilated via tracheostomy is composed of a series of steps, which are so standardised that they could almost be made into an algorithm or protocol pathway. In a manner similar to a primary survey or the ALS algoritm, one assesses the patient in an orderly fashion, moving from mst lifethreatening issues to least. The first step in most situations is to take the patient off the ventilator and manually ventilate themn, thereby both excluding a major list of differentials and at the same time providing 100% pure oxygen. The pathway for a tracheostomy patient typically leads to the exclusion of a dislodged or blocked tracheostomy, and ends up with the patient being reintubated orally (the dislodged tracheostomy scenario is discussed in the Airway Management section).

The college loves these questions. They have been repeated many times. The patient described in these scenarios is usually tracheostomised, and usually complains that they can't get enough air. Occasionally, patient-centered medicine is left out of it, and the scenario alerts you to the dterioration by way of desaturation and high airway pressures.

  • Question 23 from the second paper of 2016 ("can't get enough air")
  • Question 12 from the first paper of 2015 (suddenly impossible to ventilate)
  • Question 4 from the second paper of 2012 ("can't get enough air")
  • Question 26 from the second paper of 2009 (sudden onset of surgical emphysema)
  • Question 27 from the second paper of 2006(suddenly impossible to ventilate)

The most sensible-looking reference for this comes from Jairo Santanilla's "The Crashing Ventilated Patient". The structured approach suggested below has been based on this reference.

Troubleshooting the intubated patient suddenly impossible to ventilate

Immediate management:

  • Increase the FiO2 to 100%
  • Disconnect from the ventilator, and manually bag-ventilate them.
  • Simultaneously assess and manage threats to life in a systematic manner.
  • 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 or the tube are the problem.

If the bag ventilation is easy and the patient improves with it:

  • Machine factors are to blame.
  • Check the circuit:
    • Check for condensation in the ventilator tubing
    • Change HME 
    • Change the expiratory filter
    • If there is nothing obviously wrong with the tubing, the ventilator may be malfunctioning. Change the ventilator while manually bagging the patient.

If the bag ventilation is difficult and the patient is still unwell:

  • Patient factors are to blame.
  • Either the airway or the rest of the respiratory system is somehow compromised.
  • Address the airway first:
    • In the intubated patient:
      • Is the ETT blocked?
      • Pass a suction catheter down and suction the patient
      • Ensure the patient is not biting the tube.
      • Has the ETT migrated? Is there a cuff herneation?
      • Auscultate both lungs; ensure equal air entry
      • Listen for cuff leak
      • Ensure satisfactory cuff pressure
    • In the tracheostomy patient:
      • check tracheostomy diameter (too narrow?)
      • check inner cannula (encrusted with inspissated secretions?)
      • check tracheostomy patency (blocked with secretions?)
      • Check tracheostomy position (dislodged during last turn?)
      • Check for subcutaneous emphysema
      • Suction the patient, loking for fresh blood and clots (unrecognised pulmonary haemorrhage?)
  • Let's say the airway is fine. The rest of the respiratory system must be somehow compromised.  The possibilities include:
    • Bronchial occlusion, eg. by sputum plug or clot
    • Bronchospasm
    • Pulmonary embolism
    • Pulmonary oedema
    • Pleural pathology, eg. pneumothorax, haemothorax or pleural effusion
    • Abdominal pathology, eg. massive distension
  • These possibilities need to be investigated systematically:
    • Auscultation of the chest will immediately identify lateralising pathology, and may reveal pulmonary oedema
    • A bedside chest ultrasound will immediately confirm or exclude pneumothorax, haemothorax or large pleural effusion.
    • A bedside TTE should immediately exclude severe LV failure and massive PE.
    • ECG will exclude MI
    • ABG will identify metabolic acidosis
    • CXR to confirm/exclude large bronchus obstruction
    • Bronchoscopy to relieve this mechanical obstruction
  • If there is no problem with the respiratory system, but the patient is still "impossible to ventilate", consider the following extrapulmonary possibilities:
    • Patient-ventilator dyssynchrony
    • Pain of respiration (eg. in context of rib fractures or thoracotomy)
    • Increased ventilatory demand:
      • Severe agitation
      • Seizures
      • Fever and rigors
      • Metabolic acidosis


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

Wright, D., and M. Baruch. "Herniation of tracheal tube cuffs: a simple teaching model." Anaesthesia 56.3 (2001): 277-277.