oxygen saturation

      •   Gurgling noise with every breath

      •   Low exhaled tidal volume alarm on ventilator

      •    plateau pressures

      •    peak pressures

      •    pressure or PEEP

      •    PCO₂/Respiratory acidosis

      •   Patient discomfort

Problems that need to be dealt with immediately (without waiting for CXR)

      •   Migration of ET tube (inwards or outwards)

      •   Blockage of ET tube

      •   Tension pneumothorax

Identifying a ventilator emergency

      •   Clinical findings

                        Dyspnea

                        Cyanosis

                        Diaphoresis

                        Absent or decreased breath sounds

      •   May resolve if you

                        Remove the patient from the ventilator

                        Bag manually with 100% O₂

                        Check ventilator connections and setting

                        Insert a catheter to the ETT to check for blockage

Outward migration of ET tube

      •   Physiology

                  Tidal volumes are not delivered

      •   Physical exam

                  ET tube marking at teeth usually significantly different

                  Cannot hear breath sounds when ventilating

                  Gurgling noise noted with each breath

      •   Ventilator findings

                  Expiratory tidal volume (V_TE) are very low or absent

                  High or low pressure alarm, depending on the position of tube

      •   Solution

                  Advance tube or replace tube

                  If you decide to advance the ET tube, do so only under direct vision with a laryngoscope or bronchoscope

Inward migration of ET tube

      •   Physiology

                  Results in right main stem intubation

                  Entire tidal volume goes to one lung and creates a shunt

      •   Physical exam

                  ET tube marking at teeth usually different

                  Asymmetric chest expansion/breath sounds. Usually more on right and less/absent on left

      •   Ventilator findings

                  May see high peak and plateau pressures

      •   Solution

                  Pull out tube (enough only, not all the way)

ET tube balloon rupture or failure

      •   Physiology

                  Tidal volume leaks around balloon, resulting in decreased tidal volumes and hypoventilation

      •   Physical exam

                  Gurgling sound with every breath

                  Decreased SaO₂

                  Inadequately inflated but properly functioning balloon, or an ETT with balloon above the vocal cords can present similarly

      •   Ventilator findings

                  Low exhaled tidal volume alarm on ventilator

      •   Solution

                  First try inflating the balloon. This usually solves the problem

                  Otherwise, need to replace ET tube

Other endotracheal tube related problems

      •   Patient biting on tube

                  Consider adjusting sedation

      •   Blocked tube from secretions/other causes

                  Frequent suctioning

      •   Failed connection

                  Adjust connection (by RT)

Non ETT related increase in airway resistance

      •   Sudden bronchospasm

                  Give bronchodilators

      •   Foreign bodies (very unlikely)

                  Remove foreign body

Tension Pneumothorax

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