see also:

• rapid sequence induction (RSI) for emergency intubation
• assisted ventilation
• extubation

• initial confirmation of successful intubation of the trachea
  • end-tidal CO2 (EtCO2) determination (either colorimetric or quantitative) is the most accurate means of confirming ETT placement in most circumstances and should be used for every intubation
    • EtCO2 methods may not be useful in patients in cardiac arrest if CO2 is not detected
  • traditional clinical indicators as below cannot be relied upon alone:
    • visualization of the ETT through the cords
    • misting of the tube with ventilation
    • auscultation of breath sounds over the lung fields
  • check that ETT has not been inserted too far and has gone into R main bronchus:
    • most adults should have a lip level of ~21cm
    • check for breath sounds on L chest
    • CXR confirmation once NGT has been placed
• inflate ETT cuff
• check cuff pressure and ensure no air leak
• ventilate patient
  • initially via bag unless ventilator has been set up prior
• secure tube
• commence ongoing sedation infusion
• consider longer acting muscle relaxant
• place nasogastric tube
• CXR to confirm ETT depth, NGT position and evidence of pneumothorax or aspiration
• blood gases to confirm adequate ventilation

• persisting hypotension from induction agents
  • Rx with iv fluids, consider metaraminol (Aramine) 0.5mg iv doses
• hypotensive effect of sedative infusion
  • consider changing from propofol to morphine/midazolam
• neuro-muscular blockers
  • paralysis is often followed by a period of hypotension, consider iv fluid bolus +/- metaraminol (Aramine)
• reduced venous return from mechanical ventilation
  • check airway pressures and PEEP
  • patients with obstructive airways disease such as asthma need prolonged expiratory phase and slow respiratory rate to avoid excessive pressures do not cause impaired venous return and asystole
• tension pneumothorax due to mechanical ventilation
• reduced venous return from intra-abdominal gas due to BVM ventilation or ETT cuff failure
  • ensure NGT is placed, draining and correctly position in stomach
  • re-check ETT cuff for air leak
• underlying hypovolaemia
  • give iv fluids, or if blood loss, give blood transfusion
• cardiac ischaemia
• depletion of endogenous catecholamines in the critically ill patient
  • commence inotropes such as noradrenaline / norepinephrine
• could it be due to underlying disease process causing the shocked hypotensive patient

• re-check ETT placement
  • check EtCO2 trace and level
• re-check ETT depth
• re-check ETT cuff air leak
• abrupt changes in the airway pressure in a patient receiving volume limited ventilation, or in tidal volumes in a patient receiving pressure limited ventilation, should prompt an immediate search for a cause of an acute change in compliance
  • is the endotracheal tube obstructed
    • suction it
  • is there a tension pneumothorax caused by mechanical ventilation
  • is there a tense air-filled abdomen splinting the chest
    • ensure NGT position, draining and no air leaks from ETT cuff
  • is patient fighting against ventilation
    • ensure adequate sedation +/- paralysis
• when in doubt, take patient off ventilator and hand ventilate with bag to better assess situation
• those with bronchospasm need this treated
  • nebulisers
  • consider iv ketamine, iv adrenaline / epinephrine or iv beta 2 adrenergic agonists, etc
  • ensure prolonged expiratory phase and slow resp. rate
• see also: managing ventilator problems

• ongoing sedation infusion
  • eg. morphine/midazolam infusion or propofol infusion
• consider longer acting muscle relaxant
  • neuro-muscular blockers such as bolus dose vecuronium 10mg for adults
  • consider particularly prior to inter-hospital transfer
• lung protective ventilator settings
  • most now recommend initial tidal volumes of 8ml/kg ideal body weight for height
    • for average height 5'7“ man, this is 550ml (700ml if 6'4”)
    • for average height 5'5“ woman, this is 480ml (390ml if 5'2” or 550ml if 5'10“)
  • if using Pressure Support Ventilation (PSV) then aim for plateau pressure - PPlat <30 cmH2O
  • see lung protective ventilation to reduce lung injury in ARDS
• head up 30-45°
• warmed humidified air (HME filter)
• suction including mouth
  • at least hourly
• stress ulcer prevention
• DVT prophylaxis
• treat underlying illness
  • eg. nebulisers if asthma/exacerbation COPD