Page 199 - 2023 SMOG Digital

Troubleshooting: Airway compromise or lost airway in-flight
• If at any time patient begins to desaturate or develop respiratory problems, immediately disconnect ventilator and ventilate
patient with BVM (with PEEP valve if available) and 100% O2 while correcting issues utilizing the D.O.P.E. algorithm:
o Displacement: ETT in place, patient not extubated/ tube did not move during transfer. If advanced – pull back to
original length and attempt to bag; if tube has pulled farther out of trachea, DO NOT ATTEMPT TO ADVANCE IT
without placement of bougie to verify tracheal placement. When advancing bougie, feel for tracheal rings or carina
stop. If in doubt, pull tube and attempt BVM. If this fixes problem, continue to bag patient. Upon stabilization,
consider alternative advanced airways (extraglotic airway or cric).
**If ETT moves freely, access for ETT bulb rupture.
o Obstructions: Assess for secretions in ETT. Suction if indicated.
o Pressure: Ensure that a tension pneumothorax / hemothorax has not developed (if chest tube in place, ensure it is
functioning/ not kinked or clamped). If tension pneumo/hemothorax suspected, perform immediate needle
thoracostomy. Assess the need for escarotomy if circumferential burn. Consider additional paralysis and sedation if
patient does not tolerate ventilation.
o Equipment: Ensure that vent did not fail; O2 tank not empty. If ventilator is operational, trace all tubes to the patient
connection (airway tube, transducer line, exhalation line) ensuring patency and connections.
• High pressure alarms / Peak airway pressure alarms (Peak pressure >35cm H2O): Correct problems causing increased
airway resistance and decreased lung compliance, including pneumothorax or pulmonary edema. Check ventilator to make
sure prescribed tidal volume is being delivered. Check for linked/crushed tubing.
• Air leaks causing low pressure alarms / volume loss: Assess, correct air leaks in endotracheal tube, 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 represents an important clinical circumstance that requires a thorough assessment and an
organized approach. The patient should not always be automatically re-sedated but must instead be evaluated for several
potentially life-threatening developments that can present in this fashion.
• Lung hyperinflation (air trapping) and auto-PEEP: Dynamic hyperinflation is associated with positive end-expiratory
alveolar pressure, or auto-PEEP. The physiologic 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 over-
distention and rupture. Prevent, 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.
• Document procedure, results, and vital signs.

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