COVID-19 TRAINING FOR HEALTHCARE WORKERS 

Ventilator Management 
Part 2: Troubleshooting Common Ventilator 
Problems 
J. Becker MD 
J. Kalanzi MD 
 
LEARNING OBJECTIVES 
At the end of this lecture, the learner will be able to: 
1. Recognize commonly encountered problems managing patients on ventilators  
2. Troubleshoot common ventilator issues encountered in ventilated patients 
 
A SYSTEMATIC APPROACH IS KEY: THE VENTILATOR CIRCUIT 
1. Any decompensation in the condition of a patient should prompt a focused cardiopulmonary 
examination of the patient and an evaluation of the entire ventilator circuit 
2. Examine the patient’s lungs and heart. Be especially attentive to the presence of a 
pneumothorax or airway obstruction 
3. Examine the entire ventilator circuit, including the electrical power and oxygen connections 
from the wall/power source. 
4. Follow the ventilator tubing to the patient and back to the ventilator. Check the ventilator 
tubing for occlusion or kinking.  The endotracheal tube should be checked as well to assure 
that the balloon is inflated and that the tube is secured in place 
 
 
FIRST STEPS 
1. If a problem is not readily identified, then the next step should be to remove the patient from 
the ventilator and to provide manual bag valve breaths with direct, 100% oxygen. 
 2. Removing the patient from the ventilator and providing manual breaths with a bag valve is a 
good way to exclude any potential mechanical problems with the vent or its power source, or 
if there is a problem with any of the ventilator tubing.  
3. This will allow you to feel how easy it is to bag the patient and if there is adequate chest rise.  A 
significant amount of resistance could indicate that there is an obstruction in the 
endotracheal tube such as a mucus plug.  Lack of resistance and chest rise could indicate that 
the endotracheal tube balloon is deflated or that there is a leak. 

 
DOPES CHECKLIST 

D  Displaced endotracheal tube or Deflated cuff 

O  Obstruction 

P  Pneumothorax 

E  Equipment Malfunction 

S  Breath Stacking (discussed below) 

 
The DOPES is a checklist that helps identify common problems patients encounter while on the 
vent.  If a problem is identified using the DOPES Checklist, the DOTTS Checklist can be used to 
intervene.   

 
DOTTS CHECKLIST 

D  Disconnect patient from the ventilator 

O  Oxygenate the patient with a bag-valve and feel for resistance to bagging 

T  Tube position (check for kinking, obstruction, etc) 

T  ‘Tweak’ the vent settings (see below) 

S  Sonogram: look for pneumothorax or a mainstem intubation 

 
DOTTS is the checklist we use to organize our approach after performing the DOPES checklist. DOTTS 
helps us avoid forgetting important interventions in checking the vent system.  
See below for more discussion of ‘Tweaking’ vent settings 

 
COMMON VENTILATOR ALARMS 
1. Alarms can be set for pretty much any variable.  It is important to set alarms appropriately.  An 
alarm sounding should trigger a response from you or other clinical staff attending to the 
patient.  If alarms are set poorly and a ventilator is always alarming, it will be less likely for 
clinical staff to respond to an alarm. Thus, it is important to make sure alarms are set so that 
when they alarm they indicate that there is a real problem.   
2. Respiratory Rate/Apnea​: Many ventilators will have some form of respiratory rate 
monitoring.  Patients who’s respiratory rate falls below a set value will trigger the alarm. 
Apneic patients who either have no respiratory drive or who have been sedated or paralyzed 
and have lost respiratory drive may trigger these alarms frequently unless the alarm is set 
appropriately.  Some vents alarm at low tidal volume or minute ventilation which can reflect 
apnea.   
3. Pressure Alarms​: ​Secretions, water or kinks in the tubing can cause high pressure. In these 
cases the patient should be suctioned. Low pressure alarms are also important and can 
indicate a leak in the system, such as a deflated endotracheal tube balloon, or a disconnection 
in the tubing.  
4. Expiratory Volume:​ Decreasing expiratory volumes indicate that there is a leak somewhere 
in the system, similar to low airway pressure alarms.  High expiratory volumes can indicate 
patient distress, agitation, and high demand for air.   

 
OBSTRUCTION 
1. If there is difficulty in bagging the patient through the endotracheal tube, perform in-line 
suction through the endotracheal tube.  Mucus plugging is a common cause of airway 
obstruction either in the endotracheal tube or the larger airways.  Check patient positioning to 
make sure that there is no kinking in the endotracheal tube.   
 2. Check the ventilator tubing for water or condensation that can collect as this may trigger 
airway pressure or obstruction alarms.   

 
HYPOXIA 
1. Can be a symptom of a variety of problems with the ventilator or the patient.  Consider problems 
with the oxygen source (an empty bottle).    
2. Can indicate the presence of a pneumothorax, mucus plugging or inappropriate ventilator 
settings. 
3. Can reflect an overall worsening in patient condition, such as the development of a ventilator 
associated pneumonia, a pleural effusion or myocardial ischemia.   
 
AGITATED PATIENT 
1. Agitation is a frequent problem for vented patients. Agitation may be common in the case of 
central nervous system injury, intoxication or metabolic derangement. An endotracheal tube 
can be a source of discomfort for many patients.   
2. It is important to perform an in-depth assessment of the patient and the ventilator before 
simply sedating and/or paralyzing the patient. 
3. Double check all vent settings making sure that patients are receiving adequate respiratory 
rate, and tidal volume, and that there is adequate time for expiration.  
4. Address any ventilator alarms or problems in pressure or volume readings.  
5. Assess the patient for any sources of pain or discomfort.  
6. Assess if different ventilator settings might help to improve the patient agitation.   
7. If no cause for the patients agitation can be found then increasing or improving sedation or 
pain control should be considered.  Most patients who are on a ventilator should be receiving 
some sedation, but with agitation this may need to be increased.  
8. Pain control is critical, particularly if the patient has injuries or other sources of pain. 
9. In extreme cases where significant doses of multiple different sedatives have been tried and 
patient agitation persists, paralysis may be considered. Paralytics should never be used 
without accompanying sedatives.  

 
SHOCK 
 1. Consider pneumothorax: perform a STAT Chest X-Ray and performing a bedside ultrasound 
looking for sources of shock 
2. Most patients on a ventilator are receiving at least some PEEP (Positive End Expiratory 
Pressure).  In asthmatics, and patients with ARDS (Acute Respiratory Distress Syndrome) the 
amount of PEEP can get quite high.  
3. PEEP can significantly increase intrathoracic pressure which can impede the return of venous 
blood to the right side of the heart causing shock 
4. Make sure that asthmatic patients have adequate time to exhale, and they may require more 
than the typical 1:2, I:E (Inhalation:Exhalation) ratio that is typically set for patients with 
normal lungs.   
5. Inadequate time for exhalation where inspiratory volumes are not completely exhaled prior to 
receiving the next breath is called ‘breath stacking’ and it results in excessive PEEP, or 
‘auto-PEEP’.  .    
6. Auto-PEEP can be checked in a variety of ways, including an end-expiratory hold in which the 
PEEP is measured directly after exhalation.  If the PEEP is higher than the PEEP set on the 
ventilator, then you know there is auto-PEEP.  Significant PEEP can also be seen on Chest 
X-ray as well with large, distended lungs.   
7. In the case of suspected auto-PEEP, remove the patient from the ventilator and just leave the 
endotracheal tube open to the air, allowing the pressure in the lungs to release.  Afterwards, 
the patient can be reconnected to the ventilator, with appropriate PEEP and I:E ratio settings.   
8. Consider all potential causes of shock including hemorrhagic shock, obstructive shock or 
distributive shock 
 
PRESSURE ASSESSMENTS 
1. There are two critical pressure variables that can be obtained on many ventilators: Peak 
Inspiratory Pressure (PIP) and the Plateau Pressure (Pplat).   
2. The PIP is the maximal pressure obtained on inspiration.   
3. The Pplat is the pressure in the lungs and system after inspiration.   
4. Evaluation of  pressure-volume waveforms for vented patients can yield a lot of information, 
but some vents do not provide waveform analysis, and some just provide numerical feedback 
of these values.   
High PIP/Normal  Problems of resistance: bronchospasm, obstruction, secretions 
Pplat 

High PIP/High  Problems of lung compliance: patient positioning, patient body 

Pplat  habitus, auto-PEEP, pneumothorax 

Low PIP  Leak in the system: hole in the ventilator tubing, or endotracheal tube, 
or a deflated balloon 

VENTILATOR HYGIENE 

1. Patients who are vented for anything more than a few hours will require attention to hygiene. 
Endotracheal tubes can, over the course of hours and days, erode through lips and cause 
sores to the tongue and oropharynx.  
2. Patients on vents should have an oral care routine including every 4-6 hours chlorhexidine 
mouthwash and tooth brushing. In the absence of chlorhexidine, another oral antiseptic 
solution or sterile water may be used.  
3. Patients should not be left with an endotracheal tube for more than two weeks. Different 
hospitals have different protocols, but in general the longer an endotracheal tube is in place 
the more likely patients are to have complications.  

 
TAKE HOME POINTS 
1. If there is concern for patient oxygenation, or vent malfunction (low pulse oxygenation), 
remove patient from vent and provide bag-valve ventilation (with a viral filter attached to the 
exhaust port of the bag-valve) of the inflated endotracheal tube with 100% oxygen 
2. Changes in patient clinical condition or blood pressure/heart rate should prompt assessment 
of excessive PEEP or pneumothorax 
3. Use of checklists to assess different ventilator alarms 
- High Airway Pressures 
- Low Airway Pressures 
4. DOPES and DOTTS Checklists 
 5. Assessment of the Peak Inspiratory Pressure (PIP) and the Plateau pressure Pplat 
- High PIP/Normal Pplat: Problems of resistance (bronchospasm, obstruction, 
secretions) 
- High PIP/High Pplat: Problems of compliance (Patient position, patient body 
habitus, auto-PEEP, pneumothorax) 
- Low PIP: Leak in the system (tubing/balloon, tube dislodgement) 
6. Agitation 
- Check the patient and the ventilator circuit 
- Check ventilator settings 
- Consider improved pain control and sedation 
7. Shock 
- Consider pneumothorax 
- Consider breath stacking and excessive PEEP 
- Consider all causes of shock, including hemorrhagic and obstructive shock 
8. Ventilator Hygiene 
- Make sure there is an oral hygiene routine for vented patients 
- Endotracheal tubes should not remain in place for more than 1-2 weeks. 
Tracheostomy should be considered thereafter.   
 
REFERENCES/SUGGESTED READING: 
1. Owens, W, et al. ​Ventilator Management and Troubleshooting in the Emergency Department. 
EM Critical Care. Sept/Oct 2014 Vol 4, No 5. 
2. African Federation of Emergency Medicine – ​Ventilator Basics and Troubleshooting.​ AFEM Core 
Curriculum, Respiratory Module. ​https://afem.africa/resources/​. April 20, 2020.  
3. COVID-19 Ventilator Course: Learn or Review Mechanical Ventilation. MedCram.   
https://www.youtube.com/watch?v=mnIpD1VwyMo​. April 20, 2020.   
4. Covid 19 Airway and Ventilator Management Thoughts. W
​ eingart S. EMCrit. 
https://emcrit.org/emcrit/covid-airway-management/​. April, 20, 2020. 
5. Spinning Dials: How to dominate the ventilator. W
​ eingart, S. 
http://emcrit.org/wp-content/uploads/vent-handout.pdf​. April 20, 2020.   
 6. COVID-19 Ventilation Clinical Practice Guidelines (ESICM, 2020​). European Society of Intensive 
Care Medicine, Society of Critical Care Medicine. 
https://reference.medscape.com/viewarticle/928191​. Accessed April 20, 2020.