Page 17 - 2026 SMOG

VENTILATOR MANAGEMENT
˚ Displacement: Verify that ETT is in place, patient is not extubated/tube did not move during
transfer. If advanced—pull back to original length and attempt to bag; if the tube has pulled
further out of the trachea, DO NOT ATTEMPT TO ADVANCE IT without placement of
a bougie to verify tracheal placement. When advancing the bougie, feel for tracheal rings
or the carina stop. If in doubt, pull the tube and attempt to BVM. If this fixes the problem,
continue to bag the patient. Upon stabilization, consider alternative advanced airways
(supraglottic airway or cricothyroidotomy). If ETT moves freely, assess for ETT bulb
rupture via cuff manometer.
˚ Obstructions: Assess for secretions in the ETT. Suction if indicated.
˚ Pressure: Ensure that a tension pneumothorax/hemothorax has not developed (if a chest
tube is in place, ensure it is properly suctioning, not kinked or clamped). Auto PEEPing or
breath stacking can mirror the development of tension pneumothorax (disconnect circuit
and gently squeeze chest for full exhalation and adjust settings. See below for further
description). Assess the need for an escharotomy if circumferentially burned. Consider
additional paralysis and sedation if the patient does not tolerate ventilation. Consider
abdominal compartment syndrome, pulmonary edema, pulmonary contusion, ascites,
pneumonia, pleural effusion, and ARDS as other causes.
˚ Equipment: Ensure the ventilator did not fail, and the O tank is not empty. If the ventilator
2
is operational, trace all tubes to the patient connection (airway tube, transducer line,
exhalation line), ensuring patency and connections.
Additional Troubleshooting
• High-Pressure Alarms/Peak Airway Pressure Alarms (Peak Pressure >35cm H O):
2
Correct problems causing increased airway resistance and decreased lung compliance,
including pneumothorax or pulmonary edema. Check to ensure the ventilator is delivering
the prescribed tidal volume. Check for kinked/crushed tubing.
• Air Leaks Causing Low Pressure Alarms/Volume Loss: Assess, correct air leaks in ETT,
tracheostomy cuff, ventilator system; recheck ventilator to make sure prescribed tidal volume
is delivered.
• Ventilator Desynchrony: Agitation and respiratory distress that develop in a patient on a
mechanical ventilator who has previously appeared comfortable represent an important clinical
circumstance that requires a thorough assessment and an organized approach. The patient
should not always be automatically re-sedated; reevaluate the patient for several potentially life
threatening developments that can present in this fashion.
• Lung Hyperinflation/Air Trapping/Auto PEEP: Dynamic hyperinflation is associated with
positive end-expiratory alveolar pressure, or auto-PEEP. The physiological effects include
decreased cardiac preload because of diminished venous return into the chest. The reduced
cardiac output that results from the reduction in preload can lead to hypotension and, if severe,
to Pulseless Electrical Activity and cardiac arrest. Dynamic hyperinflation can also lead to
local alveolar overdistention and rupture. Manage lung hyperinflation by decreasing tidal
volume, changing inspiratory and expiratory phase parameters, switching to another mode, and
correcting physiological abnormalities that increase airway resistance.
(continues)

2026 Standard Medical Operating Guidelines (SMOG) • 9