CICM SAQ 2015.1 Q12
You are called to urgently review a 73-year-old female who is ventilated following admission with severe community-acquired pneumonia. She had a tracheostomy five days ago. She has now acutely desaturated and developed high airway pressures.
Outline your management of this problem.
Answer and interpretation
This is an emergency situation with the risks of hypoxia, hypoventilation and/or barotrauma.
Management consists of concurrent resuscitation and focussed assessment to identify the underlying cause with definitive management as indicated.
The differential diagnosis includes:
- Ventilator malfunction
- Obstruction/kinking of circuit including filter
- Displacement/blockage trache tube
- Increased airway resistance e.g. bronchospasm
- Decreased lung or chest wall compliance e.g. pneumothorax, lung collapse, intra-abdominal hypertension
Stepwise response (does not have to be in this order)
- Increase FiO2 to 1.0
- Assess patient for severity of insult – is there haemodynamic instability? Is the patient peri-arrest?
- Call for help and crash trolley / difficult airway trolley if indicated
- Disconnect patient from the ventilator and manually ventilate with FiO2 1.0 and assess resistance/compliance
- If resistance/compliance seems normal with reduction in airway pressures and improvement in saturations then cause is due to ventilator malfunction or inappropriate settings. Replace ventilator and/or review settings
- If resistance/compliance seems abnormal then systematic approach to look for cause
- Check circuit and filter for kinking/blockage and unkink/replace as indicated
- Assess trache for position and patency – remove inner cannula and pass suction catheter. If not patent and not cleared by suction or if displaced (may be evidence of subcutaneous emphysema) remove trache tube, occlude stoma and ventilate initially with bag-valve-mask and subsequently re-intubate with oral endotracheal tube
- If trache tube patent and correctly placed assess chest expansion and air entry to confirm/exclude bronchospasm, pneumothorax, lobar collapse, pleural effusion etc.
- Treat as appropriate – bronchodilators, thoracocentesis, physio, bronchoscopy, pleural drainage
- If decreased chest wall compliance consider sedation
- If increased intra-abdominal pressure, treat appropriately e.g. gastric decompression
- Re-assess patient after definitive management with investigations as indicated e.g. ABG and CXR.
- Review ventilator settings
- Be aware there may be more than one cause. If there is an obvious precipitating cause e.g. pneumothorax complicating difficult CVC insertion, tracheostomy displacement then treat this directly but then re-assess patient for resolution of hypoxia and high airway pressures
- Pass rate: 63%
- Highest mark: 8.5
- Candidates were expected to describe a systematic approach and consider the possibility of multiple causes
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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