Last Updated on January 28, 2019 by frcemuser

Approach to cause for respiratory distress in intubated patients

Think ‘DOPES’

• Displacement of the tube
• Obstruction of the tube
• Patient — especially pneumothorax; also: pulmonary embolism, pulmonary oedema, collapse, bronchospasm
• Equipment — ventilator problems
• ‘Stacked breaths’ — a reminder about bronchospasm and ventilator settings.

Immediate assessment:

Think ‘MASH’

• Movement of the chest during ventilation — is it absent or is movement only on one side? Is the chest hyper-expanded?
• Arterial saturation (SaO2) and PaO2 — obtain an ABG sample
• The skin colour of the patient (is he turning blue or pinking up?) — the SO2 monitor lags behind the true oxygen saturation of the patient
• Hemodynamic stability

Tracheal tube displaced

The approach to Managing a patient with a tracheal tube displaced

Step 1:

• Call for Help
• Apply high flow oxygen
• Check Capnography (ETCO2) if not, put it on
• Call for Difficult airway trolley

Step 2:

Attach water circuits

Step 3:

Look

• is ETc02 trace a normal square wave?
• is water circuit moving with spontaneous respirations?
• is ETc02 trace a normal square wave?

ventilate using water’s circuit

• is ETc02 trace a normal square wave?
• is chest moving up and down and easy to ventilate?

if no,

Step 4

Suggest with a problem with the tracheal tube

• check tracheal tube at teeth has TT been pushed or fallen out?
• is Tracheal tube Blocked? – pass a suction catheter
• is patient bitting tube? – give atracurium 50mg iv
• has cuff herniated over the end of the tracheal tube? – deflate and inflate the cuff

Step 5

if doubt/ patient deteriorating

• Remove the tracheal tube and call for a senior anesthetist
• ventilate with 100% oxygen using bag and facemask with Guedel airway and two hands on the mask
• Consider LMA/i-gel/Pro seal LMA, await senior help
• oral intubation if you have the skill

if stable
100% oxygen, wait for a senior anesthetist

Patient Factor:  if the patient has Normal ETC02 tracing/Water Circuit Moving with Spontaneous Respiration/Normal Chest wall Moving up and down – tracheal tube displacement unlikely a patient problem is most likely. Perform a focused exam and urgently seek and treat the following life-threat

• pneumothorax (look for asymmetrical chest movement)
• lung collapse (look for asymmetrical chest movement)
• pulmonary edema
• bronchospasm (chest wall movement may be minimal — look for hyperexpansion)
• pulmonary embolus

asses breathing/circulation – follow ALS algorithm if necessary

Equipment: there may be a problem with the ventilator settings or there was an equipment failure.

• check ventilator settings
• trouble-shoot equipment failure

Blocked/displaced tracheostomy

The approach to Managing a patient with blocked/displaced tracheostomy

Step 1

• Call for Help
• Apply high flow oxygen to both the face and the tracheostomy
• Check Capnography (ETCO2) if not, put it on
• Call for Difficult airway trolley

Step 2

Attach water circuits

Step 3

Look

• is ETc02 trace a normal square wave?
• is water circuit moving with spontaneous respirations?
• is chest moving up and down and easy to ventilate?

Try tow Careful breath with water circuit

• is ETc02 trace a normal square wave?
• is chest moving up and down and easy to ventilate?

Look at the neck

• look at the neck, is it swelling or developing surgical emphysema with each breath

if no? suggest a problem with a tracheostomy

Step 4

• is tracheostomy blocked? – pass suction catheter via tracheostomy, ensure inner tube removed
• has cuff herniated over the end of the tracheostomy? – deflate and inflate the cuff

Step 5

if doubt/ patient deteriorating

• Deflate tracheostomy cuff and remove the tracheostomy
• cover tracheostomy with sterile gauze and occlusive dressing
• ventilate with 100% oxygen using bag and facemask with Guedel airway and two hands on the mask
• Consider LMA/i-gel/Pro seal LMA, await senior help
• intubate if you have the skill

Patient Factors: if yes( Normal ETC02 tracing/Water Circuit Moving with Spontaneous Respiration/Normal Chest wall Moving up and down) – tracheal tube displacement unlikely a patient problem is most likely. Perform a focused exam and urgently seek and treat the following life-threat

• pneumothorax (look for asymmetrical chest movement)
• lung collapse (look for asymmetrical chest movement)
• pulmonary edema
• bronchospasm (chest wall movement may be minimal — look for hyperexpansion)
• pulmonary embolus

asses breathing/circulation – follow ALS algorithm if necessary

Reading

Respiratory Distress in a Tracheostomy Patient

Post-intubation hypoxia

https://www.rcoa.ac.uk/system/files/CSQ-NAP4-Section3.pdf