When the Ventilator Alarm Sounds: Troubleshooting the Intubated Patient

Jairo I. Santanilla, MD

Section of Critical Care Medicine
Ochsner Medical Center
&

Clinical Assistant Professor of Medicine
Section of Emergency Medicine
Section of Pulmonary/Critical Care Medicine
LSUHSC New Orleans

Disclosures
No Conflicts of Interest to Disclose

Goals and Outline

Provide a framework for troubleshooting the mechanically ventilated patient Focus on the Cardiac Arrest/Near Arrest patient and the Near Stable/Stable patient Like ACLS and ATLS, this is a framework Bedside clinical judgment supersedes Often perform several steps in tandem, instead of in sequence.

Cardiac Arrest/Near Arrest

Determine Hemodynamic Stability Rush of Air, Improvement Likely Auto-PEEP Check Settings and Ventilator Improvement, Unclear if Auto-PEEP

Stable/Near Stable

Disconnect from Ventilator) No Improvement Hand Ventilate with 100% Oxygen Look for unequal chest rise Listen for air-leak and unequal breath sounds Feel for difficulty to ventilate and crepitus No Improvement

Focused History and Physical Exam

Check Gas Exchange Improvement Check Settings and Ventilator

Determine that the ETT is functioning and in proper position Direct Visualization or Pass Suction Catheter or Pass Intubating Stylet

Check Respiratory Mechanics and Waveforms

ETT functioning & in proper position

ETT NOT functioning or NOT in proper position

Evaluate US and CXR

Special Procedures: Ultrasound, CXR, Needle Decompression

Evaluate for ETT position adjustment, exchange, or re-intubation

Evaluate Sedation

When you hear the alarms

Look at the patient and the monitor Try not to focus on the vent

Determine Hemodynamic Stability

All intubated patients are critically ill Some more than others
Cardiac Arrest/Near Arrest Near Stable/Stable

How stable is the patient? How quickly is the patient deteriorating? How much time do I have to find cause and address problems?

SBP < 70 POx < 70%

SBP > 90 Pox > 90%

Troubleshooting
During your evaluation, pt may transition from stable to unstable and back and forth. If unsure start with Near Arrest Be flexible in your thoughts and actions Constantly add to your differential and re-arrange most likely choice Keep in mind condition that necessitated intubation, pt may simply be worsening from this.

Cardiac Arrest/Near Arrest

Time is of the essence Disconnect patient from vent This can be diagnostic and therapeutic A quick rush of air or prolonged expiration of air can diagnose and treat Auto-PEEP (within a few seconds) Success = Return of hemodynamic stability

Pearls to disconnecting
Pts undergoing CPR should not be connected to ventilator Pts on high PEEP secondary to ARDS can derecruit quickly. Rule out Auto-PEEP quickly and use PEEP valve if severely hypoxic. Hypotension can be worsened by PEEP valves Patients on inhaled NO can have rebound pulmonary hypertension if abruptly disconnected.
Re-establish through the BV system

Fluid bolus and vasopressors may be needed quickly

Hand Ventilate with 100% O2

Look for unequal chest rise
DDx: Pneumothorax, mucus plug, mainstem intubation

Listen for air escaping from around the ETT or through the nose (air leak)
DDx: Extubation, Pilot balloon or cuff failure

Listen over the epigastrium and both axilla

Hand Ventilate with 100% O2

Feel the ease of hand ventilation
Stiff lungs can be due to mucus plug, bronchospasm, pneumothorax, auto-PEEP, decreased respiratory system compliance

Feel for subcutaneous crepitus

Search for pneumothorax

Keep respiratory rates 8-10 bpm

Determine ETT is Functioning and in Proper Position

Direct Visualization
DL or visualize carina with fiberoptic scope

Pass the suction catheter

Easy: may or may not be in proper position Difficult: ETT is dislodged, obstructed, twisted, or pt biting.

Gently pass GEB or Eschmann introducer

Resistance should be met at approx 30 cm Passage without any resistance implies esophagus

Troubleshooting
Twisted/bent ETT reposition pts head Biting on ETT bite block, consider sedation Obstructed ETT reintubation, if cant quickly clear with suction catheter Dislodged ETT reintubation; prepare for difficult airway.
If not fully dislodged, deflate cuff, pass suction catheter, and advance ETT.

Procedures
After disconnecting from vent, hand ventilating, and checking proper placement: Consider Tension PTX and need for needle decompression
Focused Hx, Physical Exam Bedside US, CXR if time permits 14g, 5cm over-the-needle catheter preferred Requires subsequent chest tube placement

Near Stable/Stable Patient

Focused History Focused Physical Exam Check Gas Exchange Check Respiratory Mechanics Observe Waveforms Evaluate CXR and Ultrasound Evaluate Sedation

Focused History
Indication for intubation Difficulty of intubation
Useful if you need to re-intubate

Depth of ETT Vent Settings Recent Procedures or Moves

New central line, thoracentesis, chest tube or attempts. Chest tube removal or water seal. ETT manipulation, bed transfer, rotation, movement

Focused Physical Exam

General survey Is patient agitated, gasping for breaths (air hunger), tearing?
Hand ventilate, talk to pt, consider sedation/ analgesia

Focused Physical Exam

Airway Look, Listen and Feel to Evaluate ETT position and function
Look if ETT is deeper or shallower than documented Listen and Feel if there is an air-leak Feel the pilot balloon
If flat, add air at 1-2 ml aliquots

Pass the suction catheter, direct visualization, or GEB/Eschmann

Endotracheal Tube

Pilot Balloon

Focused Physical Exam

Breathing
Look for unequal chest rise Look for disconnected circuit, oscillating water Listen for air-leak Listen over the epigastrum and axilla Feel for ease of ventilation and crepitus

Focused Physical Exam

Circulation
Check pulses, cycle BP cuff, check a-line waveform and transducer level Bradycardia may be due to hypoxia, propofol, precedex Fluid bolus +/- vasopressor

Asses Gas Exchange

Pulse oximeter is adequate to determine oxygenation
Waveform should correlate with HR Pulse Ox may have 20-30 second lag time

Hypercapnia will be missed by POx If in doubt, place on 100% FiO2 and obtain ABG

Check Respiratory Mechanics

Check Peak and Plateau Pressures
Obtain in Volume-Targeted modes

Peak Pressures are a function of tidal volume, resistance to airflow and respiratory system compliance Plateau Pressures are obtained during an inspiratory pause, thus no airflow. Plateau Pressures are a function of tidal volume and respiratory system compliance

Pressures
Paw (cm H2O) Ppeak Inspiratory Hold Pplat

PEEP Time (sec)

Pearls
Plateau Pressure can never be higher than peak pressure If the Plateau Pressure increases, so will the Peak pressure Measurements are not reliable in the bucking patient

Increased Peak Pressure

Paw (cm H2O) Increased Ppeak Same Pplat

Time (sec)

Increased Peak Pressures (increased resistance to airflow)

Biting on ETT Obstruction of ETT by secretions, mucus, blood Twisted/kinked ETT Bronchospasm/Reactive Airway Disease Partial bronchial mucus plugging Increased Plateau Pressures

Increased Plateau Pressure

Increased Ppeak Paw (cm H2O) Increased Pplat

Time (sec)

Increased Plateau Pressures (decreased respiratory system compliance)

ARDS/ALI, Pneumonia, Pulmonary Edema Atelectasis, Mucus Plugging Pneumothorax Unilateral Intubation Auto-PEEP Chest wall rigidity, obesity, circumferential burn Intra-abdominal hypertension

Observe Ventilator Waveforms

Notching in the pressure-time or flowtime waveforms Double or triple stacking Inadequate exhilation of tidal volume

Negative pressure deflection showing air hunger

Paw (cm H2O)

Time (sec)

Flow (L/min)

Flow (L/min)

Time (sec)

Time (sec)

Flow (L/min)

Inspiration

Normal Patient

Time (sec) Expiration Air Trapping

Evaluate CXR and US

ETT Position Mainstem intubation Atelectasis Pneumothorax Worsening parynchemal or pleural process

ARDS

Aspiration

Major Trauma

Abdominal Sepsis

Pneumonia

Ultrasound

Seashore Sign

Barcode Sign

Evaluate Sedation
Sedatives
Propofol, Precedex, Ketamine, Benzodiazepines Sometimes less is more Goal is not a comatose patient

Analgesics
Fentanyl, Hydromorphone, Morphine

Treat underlying condition

Pain is under appreciated

Evaluate Sedation
Hypoxia can lead to agitation
Opiates are very useful as they blunt the drive to breath and dull dyspnea

Agitation is sometimes a normal response

Consider the need for extubation

Chemical weakening should be reserved as a final option

Dont forget sedation/analgesia

Five Most Common Vent Alarms

High Pressure Low Pressure Apnea Circuit Disconnect High Exhaled Tidal Volume

High Pressure Alarm

Coughing
Suction, ensure ETT is above carina, nebulized lidocaine, opiates

Biting on the ETT Decreased Lung Compliance Increased Secretions Alarm set too low

Low Pressure Alarm

Leak in the cuff Leak in the circuit Increased patient inspiratory effort Alarm set too low

Apnea Alarm
No inspiratory trigger by patient or machine in a set time (usually 20 sec) Flow greater than patient effort Alarm time interval set too short

Circuit Disconnect
ETT disconnected from ventilator circuit Circuit disconnected from ventilator

High Exhaled Tidal Volume

Increased compliance Decreased resistance In-line aerosol treatment increasing volume

Special Considerations
Children
ETT migrate in/out with flexion/extension Place C-collar to stabilize head position Most intubating stylets and fiberoptic scopes are too large for pedi tubes

Tracheostomy
If trach dislodged, quickly decide if you will orally intubate or replace through stoma Determine reason for trach
Laryngectormy (imposible); Difficult Airway Most are for chronic respiratory failure

Determine Age of Trach

Less than 1 week, immature, high risk for creating false tract

Gently place 6.0 ETT through stoma

Stop if resistance Confirm with fiberoptic

Tracheostomy
Obstruction
Remove inner cannula Replace with same sized cannula

Case 1
Called to bedside because pt started desaturating from 100% to 85%. BP is stable. You quickly note that vent is alarming Low Pressure Youre not sure whats happened so Disconnect pt from vent
No rush of air and no quick improvement

Hand Ventilate with 100% O2

Easy Bag, Equal Chest Rise and BS, but audible gurgle

Case 1
POx improves slightly and BP remains steady
You quickly determine that you have time Placed back on vent (same alarm)

Focused Hx: pt had been intubated for pneumonia, no recent moves or procedures, easy airway, ETT secured at 22cm Focused Exam: ETT same position, pilot balloon deflated. Volume added but remains deflated. Suction catheter passes easily. ETCO2 has good waveform, VTE is 200 ml, set at 500

Cardiac Arrest/Near Arrest

Determine Hemodynamic Stability

Stable/Near Stable

Determine that the endotracheal tube is in the trachea Intubating stylet Direct visualization Fiberoptic scope (if time allows) Be prepared to re-intubate

Feel the pilot balloon. Note if it is deflated

Add air (2-5ml) to the pilot balloon. If this stops the air-leak, document that air was added to the balloon

Not in the trachea

Re-intubation is required

If air leak persists, the pilot balloon does not inflate 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 endotracheal tube has migrated out of the trachea

Dealing with Air Leak

Determine the ability to repair the pilot balloon mechanism with commercially available kit

If air leak persists after repair or repair not possible, the endotracheal tube will need to be replaced

Case 2
Called to bedside because change is status Pox 82% (95%), BP 90/45 (110/65), HR 130s (110),Vent Alarming High Pressure Disconnect from vent
No rush of air and no quick improvement

Hand Ventilate with 100% O2

Mild resistance to Bag, Equal Chest Rise and decreased BS on Left , no audible air-leak, no crepitus DDx: : Pneumothorax, mucus plug, mainstem intubation

Case 2
POx and BP improve
You quickly determine that you have time Placed back on vent (same alarm)

Focused Hx: pt had been intubated for COPD, no recent moves or procedures, easy airway, ETT secured at 21cm Focused Exam: ETT same position, pilot balloon inflated. Suction catheter passes easily. ETCO2 has good waveform

Case 2
Peak and Plateau pressures have increased by the same amount (implies decreased compliance) US Shows CXR:

Whole Lung Atelactasis

Recruitment Maneauvers
Hand Ventilate, Provide PEEP

Suctioning Rotate Patient Chest Percussion Bronchodilators Bronchoscopy

Case 3
Called to bedside, pt is Crashing POx 85,80,70poor waveform HR 120s140s; BP 70s/palp No Time. Disconnect no improvement Hand Ventilate, Look, Listen, Feel. No leak, equal distant BS bilaterally, no crepitus. Difficult to bag. (decreased complaince). Pilot ballon inflated.

Case 3
GEB meets resistance at 28cm (ETT in place) Continues to decline, about to arrest Fluid bolus by pressure bag Decision time is current issue due to ventilator or not? Such a rapid decline implies auto-PEEP, tension PTX, ETT not functioning or dislodged, atelectasis, PE, or bleed

Case 4
Called to bedside because pt worsening Pox 80% , BP 80s systolic and HR 130s Disconnected from vent and prolonged expiration with air rush from ETT. POx and BP improve Auto-PEEP (breath-stacking, dynamic hyperinflation, intrinsic PEEP)

Auto-PEEP
Look for causes: high set respiratory rate, high intrinsic rate (AC), obstructive airway disease Monitor flow-time waveform Consider bronchodilators Consider decreasing tidal volume and respiratory rate in patients with RAD
Decreasing set RR, ineffective in patients with high intrinsic rate while on volume-targeted AC

Optimize sedation, esp opiates