Tiny Tips: Approach to the Alarming Ventilator

In Tiny Tips by Brent Thoma4 Comments

The December edition of EM:RAP had a great segment with Haney Mallemat and Stuart Swadron that went over five “Critical Care Quickies.” One of them presented an approach to an alarming ventilator that really caught my eye.

The classic mnemonic that I was taught for this situation was

Differential for the Alarming Ventilator: DOPE(S)

DDislodged tube
OObstructed tube (mucous plug, blood, kink)
EEquipment failure (ventilator, tubing, etc)
S – Breath Stacking [breath] (Auto-PEEP)

This is certainly helpful for diagnosing an alarming ventilator, but it does not provide an approach to dealing with these problems. While it’s still a mnemonic that I am going to keep in the back of my mind, I really liked the DOTTS mnemonic that he offered to outline the things that you should do. While it could certainly be argued that if you know what you’re doing, DOPES will result in a similar approach, I liked the order and direction of DOTTS.

Approach to the Alarming Ventilator: DOTTS

DDisconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure)
OOxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff)
TTube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed)
TTweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time)
SSonography (assess for pneumothorax, mainstem intubation, plugging)

As usual, this Tiny Tip will be added to the Flashcard Deck that I am building. For more information and instructions on how to use them, check out the Boring Cards page. Thanks to the Haney Mallemat, Stuart Swadron and the rest of the EM:RAP team for the great tip and outstanding podcast!

Dr. Brent Thoma is a medical educator, blogging geek, and trauma/emergency physician who works at the University of Saskatchewan College of Medicine. He founded BoringEM and is the CEO of CanadiEM.