REBEL Cast Ep 46b: Vent Management in the Crashing Patient with Haney Mallemat

In Episode 46a we discussed respiratory failure and NIV.  In episode 46b we are going move on to the patient where you have tried NIV and your patient just doesn’t seem to be improving.  You decide to intubate your patient and connect them to the ventilator.  Now the ventilator starts beeping and your patient begins to decompensate.  What are the steps you use to assess the problem and fix it?

REBEL Cast Episode 46b – Vent Management in the Crashing Patient with Haney Mallemat

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Assessing Ventilator Problems in the Crashing Intubated Patient

Haney made an important distinction between the hemodynamically crashing patient (No time) vs the patient who is slowly starting to decompensate (You have time to get more data).  The algorithm below can be used for both, however a better solution in the patient who is slowly starting to decompensate is tweaking the vent:

The Crashing Intubated Patient (Peri-Arrest or Arrest):

DOPES then DOTTS: The first mnemonic is how to diagnose the problem and the second mnemonic is how to fix the problem:

Diagnosing the Problem:

D = Displaced Endotracheal Tube or Cuff

O = Obstructed Endotracheal Tube: Patient biting down, kink in the tube, mucus plug

P = Pneumothorax

E = Equipment Check: Follow the tubing from the ETT back to the ventilator and ensure everything is connected

S = Stacked Breaths: Auto-PEEP.  Patient unable to get all the air out from their lungs before initiating the next breath. Inspiratory time is much shorter than expiratory time (I/E ratio is anywhere from 1 to 3 or 1 to 4)

Fixing the Problem (Once you commit to this, do every step even if you fix the problem with one of the earlier letters):

D = Disconnect the Patient from the Ventilator: This fixes stacked breaths by decreasing intra-thoracic pressure and improving venous return

O = O2 100% Bag Valve Mask: The provider should bag the patient not anyone else because this lets you get a sense of what the potential problem is.  Look, Listen, and Feel

  • Look: Watch the chest rise and fall, look at ETT and ensure it is the same level it was at when it was put in
  • Listen: Air leaks from cuff rupture or cuff above the cords; Bilateral breath sounds; Prolonged expiratory phase
  • Feel: Feel the pressure of pilot balloon of endotracheal tube, crepitus; How is the patient bagging (Hard to bag or too easy to bag)

T = Tube Position/Function: Suction catheter to ensure tube is patent; Can also use bougie if you don’t have suction catheter, but be gentle (If to aggressive can cause potential harms); Ensure the tube is at the same level it was at when it was put in

T = Tweak the Vent: Decrease respiratory rate, decrease tidal volume, decrease inspiratory time.  Biggest bang for your buck is decreasing the respiratory rate.  This may cause respiratory acidosis (permissive hypercapnia)

S = Sonography: You can diagnose things much faster than waiting for respiratory therapist to come to the bedside or waiting for stat portable chest xray to be done.

The Slowly Decompensating Intubated Patient:

Peak Pressure: Maximum pressure the ventilator is seeing at inspiration.  Summation of compliance and resistance of lungs

Plateau Pressure: Pause inspiratory flow, if there is no flow then there is no resistance which leaves you with compliance of the lung only

  • High Peak Pressure and Plateau Pressure = Compliance Issue (i.e. Pneumothorax, Volume Overload, ARDS)
  • High Peak Pressure and Normal Plateau Pressure = Resistance Issue (i.e. kink in the tube, bronchoconstriction, or mucus plug)

Special Guest:

Haney Mallemat, MD
Emergency Medicine, Internal Medicine, and Critical Care Boarded
Cooper Medical School of Rowan University
Haddonfield, NJ
Twitter: @CriticalCareNow

  • Keynotable: Learn how to give powerful presentations
  • Resuscitation Leadership Academy (RLA):  Yearlong fellowship for those who want to do more resus and critical care but just don’t have the time to do an actual critical care fellowship or leave where they are at:
    • Monthly Curriculum
    • Video Chats with Critical Care Professors

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

Cite this article as: Salim Rezaie, "REBEL Cast Ep 46b: Vent Management in the Crashing Patient with Haney Mallemat", REBEL EM blog, March 12, 2018. Available at:

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