Copyright 2011, American College of Emergency Physicians. All rights reserved.

No part of this chapter may be copied or distributed without express written permission from ACEP.

CH APTE R 3

The Crashing Ventilated Patient
Jairo I. Santanilla, MD

In this chapter

Evaluation of hemodynamically unstable ventilated patients in distress
Management of hemodynamically unstable ventilated patients
Special scenarios: pediatric patients and patients with a tracheostomy

Introduction tilated patient is, by definition, critically ill. However, he or
she can fall anywhere on the spectrum from being ventilated
Critically ill patients present to the emergency department
for airway protection, with normal vital signs, blood pressure,
every day. Some of them required intubation in the prehospi-
and oxygen saturation, to being ventilated and in cardiac ar-
tal setting; others are intubated on arrival or during emergency
rest. Determining where the patient is on this spectrum, in-
department evaluation. After their airways have been secured
cluding assessing for hypotension and hypoxia, will dictate how
and their conditions stabilized, patients can remain in the
much time the practitioner has to implement rescue strategies.
emergency department because of a lack of critical care beds. In
In addition, it is important to anticipate the patient’s clinical
some hospitals, a dedicated intensivist will take charge of these
course. The approach to a patient who is intubated for hypoxia
patients, but in others this type of coverage is not available at all
stemming from pneumonia and whose blood pressure and oxy-
or not around the clock. Thus, acute complications or deteriora-
genation gradually trend down over hours or days is different
tions must be handled by emergency physicians.
from the approach to a patient who is declining over a span of
This chapter provides a framework for managing the crash-
minutes (Figure 3-1).
ing mechanically ventilated patient. The information provided
As a general rule, the following evaluation should be per-
will assist the practitioner in determining if the patient’s con-
formed within 1 hour on patients with new unexplained hypo-
dition is related to the underlying pathology that necessitated
tension (systolic blood pressure [SBP] <90 mm Hg), new unex-
mechanical ventilation or if it is being caused by mechanical
plained hypoxia (Sao2 <90%), or a new marked change in vital
ventilation itself. This chapter does not fully address basic ven-
signs (a drop in SBP by more than 20 points or a drop in Sao2
tilator management, noninvasive positive-pressure ventilation,
by more than 10%). Patients with stable SBP between 80 and 90
advanced trauma life support, or advanced cardiac life support
mm Hg and Sao2 between 80% and 90% should be evaluated
(ACLS).
expeditiously, with the hope of halting the decline. Those with
Determine Hemodynamic Stability SBP <80 mm Hg or an Sao2 <80% and those who continue to
The initial step in managing the crashing ventilated patient decline rapidly should be evaluated quickly, with consideration
is to determine the patient’s hemodynamic stability. The ven- given to entering the cardiac arrest/near arrest algorithm. These

15

and ultrasound image. The crashing ventilated patient algorithm. Step 3: Check gas exchange. • Look for unequal chest rise Improvement • Listen for air leakb and unequal breath sounds • Feel for difficulty to Step 4: Check respiratory mechanics. The steps are discussed in more detail in the main text. or re-intubate. American College of Emergency Physicians . page 20. No improvement Step 3: Determine that the ET tube is Step 6: Evaluate chest radiograph functioning and in proper position. with 100% oxygen.Emergency Department Resuscitation of the Critically Ill Figure 3-1. b For air leak. see Key Point. see Table 3-2. For the differential diagnosis in difficult-to-ventilate patients. exchange. • Pass suction catheter • Pass intubating stylet or direct visualization Step 7: Evaluate sedation. 16 Copyright 2011. ventilate and crepitus Step 5: Observe waveforms. Cardiac arrest/near arrest Stable/near stable Determine hemodynamic stability Rush of air. No improvement Improvement. see Figure 3-2. Step 1: Disconnect from ventilator. adjustment. c For needle decompression. settings and ventilator Step 2: Perform physical examination. unclear if auto-PEEP Step 2: Hand ventilate Check settings and ventilator. needle decompressionc a For auto-PEEP. improvement Likely auto-PEEPa: check Step 1: Obtain a focused history. chest radiograph. see Table 3-1. ET tube functioning ET tube not functioning and in proper position or not in proper position Step 4: Special procedures Evaluate for ET tube position ultrasound.

Not in the trachea Re-intubation is required. the ET tube must be replaced. or the pilot balloon deflates with time and the air leak returns with time. there is a defect in the pilot balloon- cuff apparatus or the ET tube has migrated out of the trachea. If air leak persists after repair or if repair is not possible. If this stops the air leak. Copyright 2011. Determine the ability to repair the pilot balloon mechanism with commercially available kit. Approach to the ventilated patient with an air leak Cardiac arrest/near arrest Stable/near stable Determine hemodynamic stability. American College of Emergency Physicians 17 . The Crashing Ventilated Patient Figure 3-2. Determine whether the ET Feel the pilot balloon. the pilot balloon does not inflate. If air leak persists. document that air was added to the balloon. Add air (2-5 mL) to the pilot balloon. tube is in the trachea Note if it is deflated. Intubating stylet Direct visualization Fiberoptic scope (if time allows) Be prepared to re-intubate.

The crashing ventilated patient could simply be growing worse from the primary pathology. dence over clinical judgment. 18 Copyright 2011. Additionally. If severe enough. Patients on in- instability and address the problems? haled nitric oxide should not be removed from the nitric oxide The Cardiac Arrest/Near Arrest Patient abruptly. special circumstances that the ventilator can precipitate. by trapped volume in the pulmonary system. PEEP valves may be used to maintain the extrinsic During each step. American College of Emergency Physicians . tion. PEEP valves can be to run through the differential diagnosis. In addition. ruled out. such as those with acute respiratory distress syndrome (ARDS). This is perhaps the easiest step to perform. care should Time is of the essence in the patient with cardiac arrest or be taken when disconnecting patients who are on high PEEP near arrest. Step 1: Disconnect the patient from the ventilator. and feel” PEEP levels and thus avoid derecruitment. Monitor ventilator flow-time waveform In critically ill ventilated patients who develop respiratory Consider changing to synchronized intermittent ventilation distress and are hemodynamically unstable. • How stable is the patient? Patients undergoing cardiopulmonary resuscitation (CPR) • How rapidly is the patient deteriorating? should not be connected to a ventilator. it is important to increase intrathoracic pressures and thereby decrease venous re- keep in mind the original pathology that necessitated intuba- turn. the practitioner should “look. the endotracheal (ET) tube can be diagnostic of ventilator-in- duced auto-PEEP (Table 3-1). those on volume-targeted modes receiving a high minute ventilation.1 Auto-PEEP (also referred to as intrinsic PEEP. A The initial step in managing the crashing ventilated patient is quick rush of air or a prolonged expiration of trapped air from to determine the patient’s hemodynamic stability. as they could During the stabilization of these patients. source control. ACLS algorithms should be implemented quickly. high patient respiratory rate. rate Optimize sedation Pearl • Use opiates to control respiratory rate Tension pneumothorax and severe auto-PEEP are important causes of ventilator-induced hemodynamic instability. and Inhaled nitric oxide should not be discontinued abruptly the septic patient could be deteriorating clinically from lack of because this could cause rebound pulmonary hypertension. It can be both Pearl diagnostic and therapeutic in the crashing ventilated patient. or dynamic hyperinflation) is caused Table 3-1. and those receiving Consider decreasing the set respiratory rate inverse-ratio ventilation are at risk for auto-PEEP (breath • Will be ineffective in assist-control mode with a high intrinsic stacking). it is also important to determine and address bag-valve system. derecruitment could oc- hemodynamically unstable. Return of hemodynamic stability Important questions to ask: implies that the maneuver was successful. Determine what caused the auto-PEEP • High set respiratory rate. The intrathoracic pres- sure variations caused by CPR will trigger ventilator breaths at • How much time is there to determine the cause of the high rates if the ventilator is set on assist-control. The most significant of these are tension pneumothorax and severe auto-positive end-expiratory pressure (auto-PEEP). Dealing with auto-PEEP it will eventually lead to increased intrathoracic pressure. breath stacking. there are some key points to remember in the Although it is important to disconnect the patient from the ven- ventilated patient who has a cardiac arrest or becomes acutely tilator to address causes of auto-PEEP. the following steps will assist the emergency physician in determining the cause of Consider chemical paralysis decompensation (Figure 3-1). listen. Once auto-PEEP has been titioner should develop a step-wise approach in this situation. The multitrauma patient Pearl could have an intrathoracic or intraabdominal catastrophe. and efforts should be made to quickly reestablish the supply through the bag-valve system. Administration should be reestablished quickly through the However.2 obstructive airway disease KEY Point Consider decreasing the tidal volume in patients with obstructive Patients on volume-targeted modes with obstructive or or reactive airway disease reactive airway disease. problematic in the markedly hypotensive patient. Tension pneumothorax can lead to marked hypotension because of de- creased cardiac output and marked hypoxia from ventilation perfusion mismatch. tion perfusion mismatch. A few seconds of observation can KEY Point determine if this is the case.Emergency Department Resuscitation of the Critically Ill values are arbitrary demarcation points and do not take prece. The emergency department prac- cur and hypoxia could be worsened. This can cause hypotension and decreased cardiac output from de- creased venous return as well as marked hypoxia from ventila.

or mucus plug. can dislodge the tube. ing trauma to the glottis. • Partial mucus plugging Key Point Causes of high plateau pressures (low respiratory system Passage of an intubating stylet (gum elastic bougie or compliance. simple. Listen over the epigastric belief that the tube has not migrated. Patients with dislodged tubes should be treated as difficult intu- vertent rates as high as 40 breaths per minute are often used bations because unplanned extubations are notorious for caus- in codes. In addition. or atelectatic lung. tion should be given to the delivery of hand ventilation. ET tube is in the trachea. Particular atten. resistance. the intubating stylet may be catching on the tube. the stylet passes beyond 35 cm without passing down the esophagus. the tube is likely in the esophagus. tempt to correct a twisted or bent ET tube by repositioning the Ensure that 100% oxygen is being delivered and limit the patient’s head. pass the suction catheter and listen for an air leak (Figure (gum elastic bougie or Eschmann introducer) gently through 3-2). If resistance is sible to pass the suction catheter. Unfortunately. the • Obstruction of the ET tube by secretions. the best choice for at both sides of the chest to determine if there is equal chest determining that the ET tube is in the proper position is direct rise.6 leading to a decrease in venous return and cardiac output. To determine if it is functioning prop.7 If resistance is met at 30 cm. Its cuff attempts to create a seal between it and the readily available in an emergency department. Step 3: Airway—Determine that the endotracheal Other simple techniques may be used to confirm that the tube is functioning and in the proper position. particularly if the patient is thought to have a dif- Causes of high peak pressures (increased airflow resistance. tioning should be employed early enough in the code to correct Causes of decreased respiratory system compliance any airway issues. and turned for procedures or bathing. or twisted or the • Twisted ET tube Pulmonary patient is biting the tube.3. improper positioning should be confirmed before simply removing the tube and re-intubating the patient. transferred to and from stretchers for imag- for difficulty in hand ventilating (a sign of low dynamic or static ing studies. the ET tube is in that the ET tube is in the trachea because the catheter could be the trachea. pneumothorax. however. block. Inad. Listen for air escaping from the often omitted in the crashing ventilated patient because of the mouth or nose (a sign of an air leak). the tube is either dislodged. The Crashing Ventilated Patient Step 2: Breathing—Hand ventilate with 100% obstructed. leading to vocal cord edema. but this device is typically not trachea. Direct visualization of the carina with The ET tube functions by providing a conduit to the lower a fiberoptic scope is an option. met too soon. and readily available technique is to pass an intubating stylet erly. Decreased breath sounds could indicate nized ET tube migration can occur during routine care of the main-stem intubation. or twisted or the patient is biting the tube. and readily Pulmonary available technique for confirming that the ET tube is in the • ARDS/acute lung injury (ALI) • Atelectasis trachea. mucus. This visualization step can be performed while providing hand ventilation. Dislodged or obstructed ET tubes require re-intubation. • Biting on the ET tube Pearl • Bronchospasm If it is difficult or impossible to pass the suction catheter. Unequal chest rise can signify a main-stem intubation. Easy passage of the suction catheter does not guarantee the ET tube. all of which respiratory system compliance [Table 3-2]). Another quick inner wall of the trachea. • Pneumonia • Resistance should be encountered at approximately 30 • Pneumothorax cm. blood ET tube is either dislodged.4 Excessive rates will increase intrathoracic pressures. if the patient is biting on the tube. At- oxygen. if it is difficult or impos. This step is pneumothorax. Patients are frequently moved in and out for subcutaneous crepitus (a sign of pneumothorax) and assess of EMS vehicles. unrecog- area and in both axilla. decreased static compliance) Eschmann introducer) is a quick. Feel critically ill patient. ensuring proper placement of Copyright 2011. insert a bite respiratory rate to 8 to 10 breaths per minute. If however. At least one of these techniques to determine proper posi- Table 3-2. American College of Emergency Physicians 19 . • Pulmonary edema • Unilateral intubation • Passage of the stylet beyond 35 cm without resistance Chest wall implies that the ET tube is in the esophagus.5 Look In the cardiac arrest or near arrest patient. • Auto-PEEP • Gently pass the intubating stylet through the ET tube—do • Mucus plugging not force it. • Chest wall rigidity • Circumferential chest wall burn Step 4: Special Procedures • Obesity Other If the patient is still in cardiac arrest or near arrest after being • Abdominal distention/pressure disconnected from the ventilator. visualization of the tube passing through the cords. obstructed. decreased dynamic compliance) ficult airway (unless it is glaringly evident that the patient is Airway extubated).

• Prepare for chest tube thoracostomy. the cuff is deflated. Occasionally it may be possible to repair the pilot Use ultrasonography to quickly evaluate for pneumothorax. and the ET • Identify the second intercostal space. ing the suction catheter. If it is difficult or not possible to pass • Anesthetize the area if the patient is conscious and time the suction catheter. • Remove the needle while leaving the catheter in place. a clinical endotracheal tube manipulation. Observe for agitation. It is possible that it has mi- mode as the “seashore sign” (Figure 3-3). The patient should be placed on 100% (not to exceed 35 breaths/min) oxygen during this evaluation. If time permits. permits. Look at the ET tube. Table 3-3. sides of the chest should be considered if other more likely Add air to the pilot balloon. Fio2: 100% tory therapist. Listen for escaping air (an air leak) from the mouth or At times. escape of air. 20 Copyright 2011. Attempt to correct a twisted or bent ET tube by repositioning the head. needle decompression of both ure. The tearing of the eyes. • Insert an over-the-needle catheter over the rib. Any of the tech- • Puncture the parietal pleura while listening for a sudden niques discussed in the previous section may be used. • Titrate up based on protocol A focused history should be obtained from the practitioners most involved with the patient’s care (bedside nurse. Dislodged – A 14-gauge catheter. thoracentesis. This is a good option in patients who are difficult to intubate. chest tube Keep plateau pressures <30 cm H2O placement.8–10 essary. Adjust if nec- the “stratosphere sign/bar-code sign” (Figure 3-4). at least 5 cm is preferred or obstructed tubes require re-intubation. the clinical situation does not allow for imaging nose (Figure 3-2). – May need a different size needle depending on the If extubation is suspected at any point in the evaluation. If this stops the air leak. Key Point Pearl Needle Decompression If the pilot balloon does not inflate or deflates with time. depending on the urgency of the situation. attempts to pull at the ET tube and lines. Volume-targeted. Determine that the ET tube is functioning properly by pass- • Prepare the area with chlorhexidine if time permits. the depth of the ET tube. transport off stretcher. PEEP: 5–8 cm H2O Step 1: Obtain a focused history. line. American College of Emergency Physicians . the endotracheal tube is either dislodged. if it is deflated. and the focused history and physical examination may its seal with the trachea and occurs in extubation or cuff fail- not be helpful. and paramedic). the ventilator settings. bedside (the patient will have the mouth open and appear dyspneic). respiratory therapist.Emergency Department Resuscitation of the Critically Ill the ET tube. In these cases. or paramedic and a focused physical ex- Take a general survey of the patient. a focused history from the bedside nurse. in the midclavicular tube will likely need to be exchanged. If the pilot balloon does to remember that chest tube placement is required in patients not inflate or deflates with time. presence of a “lung-slide” artifact on bedside ultrasonography Airway. This typically signifies that the tube has lost studies. amination will indicate which side of the chest to decompress. the difficulty of the in- Flow rate: 60 L/min tubation. there • Determine which side to decompress first. assist control The Stable/Near Stable Patient Tidal volume: 6–8 mL/kg ideal body weight If the patient is deemed stable or near stable or quickly re. Initial ventilator settings for ALI/ARDS • Secure the catheter with a bandage or small dressing. balloon mechanism with commercially available kits. and hand ventilating with 100% oxygen. or chest radiograph). insert a bite block if the patient is biting on the tube. gasping for breath In addition. the event should be approached in a systematic Respiratory rate: Set to approximate baseline minute ventilation manner (Figure 3-1). obstructed. or twisted. resident. It is important note that air was added to the balloon. and ultrasonography and chest radiography may be employed. chest. and determine if it has mi- excludes pneumothorax. is a defect in the pilot balloon-cuff apparatus. • Can start at 8 mL/kg ideal body weight and work down to 6 gains stability after disconnection from the ventilator and hand within 4 hours ventilation. a procedure. removal or transition to water seal. there is a defect in the pilot after needle decompression. or the patient is biting the tube. Valuable information • Titrate down based on protocol includes the indication for intubation. de- size of the patient termine that the ET tube is in proper position. The lung slide artifact appears in M- grated from its previous position.11–13 balloon-cuff apparatus and the ET tube will likely need to be Pearl exchanged. Feel the pilot balloon. make a causes of acute decompensation are not found. respira. its absence appears as grated out of the trachea or into a main bronchus. and recent procedures or moves (central line insertion. Step 2: Perform a focused physical examination. rota- decision will be required regarding needle decompression of the tion for cleaning.

The • Rotate patient respiratory system incorporates the ventilator circuit. resistance to airflow. Louisiana State University Health Dr. Listen for air escaping from the mouth or nose (a be implemented in those found to have ALI or ARDS (Table sign of an air leak). In a few instances. – Disconnect from ventilator and provide hand ventilation Determine if the peak pressures and plateau pressures have at higher tidal volumes changed from their previous values. Peak pressures are a function of the volume. stem intubation. Christine Butts and Dr. and therefore reflects only the respiratory system com- transducer is level. Christine Butts and pneumothorax. Look at the Those with a ratio between 200 and 300 should be evaluated ventilator tubing and determine if there is an oscillating water for acute lung injury (ALI). The lung-slide artifact appears in stratosphere/barcode sign. an isolated increase in the Figure 3-4. Check for pulses. ABG measurement is beneficial in this event. ABG measurement is beneficial in this event. Feel for subcutaneous crepitus (a sign of pneumothorax). Decreased breath sounds may provide clues regarding imetry. Unequal chest rise can signify a main- Pao2/Fio2 ratio less than 200 should be evaluated for ARDS. An isolated increase in the peak pressure is indicative vasopressors. Airway pressures are a function of volume and respiratory system compliance. Image courtesy of Dr. Sciences Center. pulse oximetry is not reliable. Listen over the epigastric area and in both 3-3). These values should be • Provide frequent suctioning obtained on volume-targeted modes. Patients with a there is equal chest rise. Dealing with whole-lung atelectasis: • Use recruitment maneuvers Step 4: Check respiratory mechanics. Stratosphere/barcode sign. pneumothorax. If the patient has an arterial line. an arterial Breathing. bronchi. Matthew Bernard. pneumothorax. or atelectatic lung. Absence of the lung- slide artifact is identified in ultrasound M-mode as the Seashore sign. such as car- • Is it functioning properly? bon monoxide poisoning. of increased resistance to airflow.14 In these cases. The Crashing Ventilated Patient Key Points Step 3: Assess gas exchange. and cycle the blood pressure sure is obtained during an inspiratory pause. and respiratory system compliance. and the frequency of the waveform should match the heart – Did it migrate down into the main bronchus? rate on the cardiac monitor. This excludes excluded. Matthew Bernard. make sure the airflow. • Is the ET tube in proper position? Hypoxia can be diagnosed based on pulse oximetry if the – Did it migrate out of the trachea? waveform is reliable. Pearl Hypoventilation cannot be identified based on pulse Key Point oximetry. A set • Administer bronchodilators volume with a set system compliance results in a specific pres- • Perform bronchoscopy sure. ET tube. Image courtesy of Dr. American College of Emergency Physicians 21 . The waveform should not be highly vari- able.16 Hypoventilation cannot be identified based on pulse ox- axilla. Determine the need for fluid bolus and/or pliance. • Perform chest percussion trachea. pulmonary parenchyma. or if the pulse oximeter is not picking up. and chest wall. Figure 3-3. Louisiana State University Health Sciences Center. Look at both sides of the chest to determine if blood gas (ABG) sample should be obtained. The plateau pres- Circulation.15 A lung-protective strategy should collection. Pneumothorax cannot be ultrasound M-mode as the seashore sign. Copyright 2011. main-stem intubation. thus eliminating cuff frequently. or mucus plug.

Careful consider- ation should be given prior to this step. It is commonly seen in volume-targeted modes. Air hunger on ventilator waveform Pressure-time curve indicating inspiratory hold and plateau pressure 22 Copyright 2011. and morphine. Step 6: Imaging Studies—Chest Radiograph and tem compliance (Table 3-2). in volume-targeted modes. Peak pressures and plateau pressures can be obtained only Step 7: Evaluate sedation. and worsen- in mind the relationship of the ∆ (peak pressure – plateau pres. The flow-time curve make the ET tube and ventilation tolerable. Patients who are being sedated and require deep stimula- frequently seen in low-tidal-volume ventilation. Double triggering can also be seen on ventilator waveforms. however.Emergency Department Resuscitation of the Critically Ill plateau pressure is indicative of a decrease in respiratory sys. or parenchymal processes (Figures 3-3 and Pearl 3-4). Proper se- sentially twice the set tidal volume. lung atelectasis. such as those with drug overdoses or trau- matic head injuries. to gentle stimulation but will return to a sedated state when left diately gives a second mechanical breath (Figure 3-7). Note that the plateau pressure can Bedside Ultrasonography never be higher than the peak pressure and that if the plateau Evaluate the chest radiograph for ET tube position. This has important ramifi. The pressure-time curve can Agents should be chosen based on the desired effect. It is important to keep stem intubation. Figure 3-5. and opiates are often required with emphasis on blunting the respiratory drive with opiates to control respiratory rates. ever. and dexmedetomidine should be used. tients with ARDS and status asthmaticus. ing parenchymal process. Increasing the For example. Some patients. sedative-hypnotics such as benzodiaz- (Figure 3-5). Bedside ultrasonography. ing with intermittently dosed paralytics can be required if pa- tients have had a good trial of sedation. analgesia. as prolonged paralysis Figure 3-6. Also note that these measurements assume a comfortable is typically quicker in evaluating for pneumothorax. The goal of sedation and an- This occurs when the patient desires a higher tidal volume than esthesia in ventilated patients who are not being evaluated for the ventilator is set to deliver. epines. as used for pa. In this situation. can be given a trial of opiates to relieve symptoms. for pain control. tive doses and still appears agitated.18 lung atelectasis. Opiates that can usually be used are fentanyl. or changing from cesses such as mass effect and hemorrhage. how- A notching in the pressure-time curve during inspiration ever. increasing the tidal volume by 1 include those with hepatic encephalopathy or intracranial pro- mL/kg predicted body weight up to 8 mL/kg. Hypercapnia is a powerful the goal is lower tidal volumes. the agitated patient with a femur fracture and re- flow rate will often alleviate this phenomenon. Typically. ceiving high-dose benzodiazepines may simply need an opiate tion is to change to a pressure-targeted mode. the “bucking” patient. If a be used to determine plateau pressures with an inspiratory hold patient appears agitated. consider pain as a cause. The patient is still inspiring when extubation is to achieve a state in which the patient will arouse the first breath has finished cycling and the ventilator imme. the patient desires a analgesic component. Others may Step 5: Observe ventilator waveforms. dation and analgesia are paramount in patients being treated cations for patients with ARDS and obstructive processes such with a strategy that allows or induces hypercapnia such as those as asthma and chronic obstructive pulmonary disease in which with status asthmaticus and ARDS. improved sedation stimulus to the respiratory drive. and ventilator changes and are still markedly tachypneic. main- pressure rises. Another solu. tolerate intubation quite well while almost fully awake. propofol. can be used to detect air trapping. tion to get a response are oversedated. Peak pressures and plateau pressures are not reliable in it will not provide information on the location of the ET tube. Chemical weaken- a volume-targeted mode to a pressure-targeted mode. pneumothorax. if available. most patients require some form of sedation or analgesia to time curve and the pressure-time curve. hydromorphone. How- The two most helpful ventilator waveforms are the flow.17. patient. This is alone. sure). Other adjustments that could help to control (besides those with status asthmaticus and ARDS) are increasing the flow rate. it is important to note that these agents do not provide an can signify air hunger. American College of Emergency Physicians . so will the peak pressure. Patients who tend to be difficult alleviates double triggering. If a patient is being given adequate seda- higher flow rate than the ventilator is delivering (Figure 3-6). may not require any sedation. It is important to Patients who display air hunger and a high respiratory rate recognize because the actual tidal volume being provided is es.

0 ET tube in the stoma. Finally. small ET tubes are often un- continuous infusions should be held in these cases. These are important questions because patients with a laryngec- Pearl tomy cannot be intubated orally. Usually. Table 3-4. Special scenarios Children Figure 3-7. – May confirm with fiberoptic visualization. sedatives and anal- of the head and neck. Patients who are agitated and hypotensive Important questions that have ramifications for the care of may respond well to a low-dose benzodiazepine and opiate if the the crashing ventilated patient with a tracheostomy are these: agitation is a precipitant of hypotension. A simple solution is to use a cervical col- gesics can precipitate or worsen hypotension. Air leaks in this scenario are hypoxic and agitated. Patients who cuffed and do not have a pilot balloon. Second. and the second is the pa- paralysis in these patients is to weaken them enough to control tient with a tracheostomy (Table 3-4). and the track in a patient with a recent tracheostomy (less than 1 week) may not have key Point matured enough to safely reintroduce a tracheostomy tube. it is 1) Does the patient have a laryngectomy? 2) Why does the pa- imperative to determine if sedation is a factor in the decompen- tient have a tracheostomy? and 3) How old is the tracheostomy? sation. The Tracheostomy Patient – Obstruction • Remove inner cannula and replace with same-sized cannula. expert consultation should be obtained prior to pro- Two special scenarios should be mentioned. The Tracheostomy Patient – Unintentional Extubation • Determine if patient had a laryngectomy. there are a quire a full dose of the paralytic. the patient is oversedated. If deep stimulation is required to get a response. – Oral intubation is an option if the patient did not have a laryngectomy. by their agitation. could benefit should prompt the clinician to consider that the tube is either from improved sedation. The previously described their interaction with the ventilator. – Stop if there is any resistance. lar for immobilization. As a general rule. • Determine reason for tracheostomy. The first is to recog- Hemodynamic instability in mechanically ventilated and se- nize that ET tube migration is common with small movements dated patients can be a result of medication.20 In Special Scenarios addition. The goal of sedation is a patient who arouses to gentle stimulation but returns to a sedated state when left alone. difficult or failed airway – oral intubation may not be an option – Traumatic brain injury. high risk of creating false tract • Gently place a 6. • Most readily available intubating stylets and fiberoptic scopes are too large for pediatric ET tubes. but not hypotensive. The goal of chemical crashing intubated pediatric patient. however. few caveats that can improve the approach. ET tubes migrate in and out of position with small manipulations of head position. patients with a tracheostomy Hemodynamic instability in mechanically ventilated and secondary to anatomic considerations or difficult/failed airway sedated patients could be a result of medication. Chemical paralysis should be reserved as a final option. can be difficult to intubate orally. One is the longed paralysis of neurosurgical patients. – <1 week – site may not be mature enough for manipulation. American College of Emergency Physicians 23 . It is possible that their pulmonary sta- dislodged or too small. The Crashing Ventilated Patient has been implicated in critical illness polyneuropathy. • Document that the purpose is not for cervical spine protection. Double-triggering ventilator waveform • Place a cervical collar to help stabilize head position. • Small ET tubes are uncuffed. • Commonly.19. specialized equipment such as tus is so tenuous that they are agitated from the hypoxia and intubating stylets and fiberoptic scopes are typically not avail- their condition is worsened by the oxygen consumption caused able for pediatric sizes. – Anatomic reason. chronic respiratory failure – oral intubation may be an option • Determine age of tracheostomy. In all these cases. this does not re- approach can be used in pediatric patients. Copyright 2011.

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