He Can’t Breath on the Ventilator – Cliff Reid

The third and last talk by Cliff Reid of Resus.me this time on managing the ventilated patient that you can’t ventilate.

Disconnect from ventilator, let them exhale, in case there is breath stacking


Hand ventilate.

Reintubate if flat trace.

Difficult to bag:

  • Suction the tube
  • ? tube too deep and causing bronchospasm -> withdraw tube a few cm
  • ? tube down R main bronchus ->
  • Pneumothorax: bed side ventilator

Too easy to bag = leak eg cuff leak, tube not through cords.  -> reinsert or replace ETT over bougie

Fighting the vent -> more analgesia and sedation +/- paralysis

Lung disease -> keep plateau pressure < 30cmH2O.  TV usually 6ml/kg IBW.  May need to increase PEEP to recruit alveoli.  Avoid derecruitment when changing circuits / ventilators: clamp the ETT.

Asthma and COPD: small tidal volumes, long expiratory time, low rate.  Permissive hypercapnia.  Low or zero PEEP.  If decompensates disconnect and let them exhale.

Extrinsic compression eg

  • Obesity -> ramp,
  • Full stomach -> gastric tube
  • Abdominal compartment syndrome -> surgeon.  May be helped (temporarily while waiting for surgical decompression) by increased analgesia +/- paralysis
  • Gravid uterus -> L lateral position

Back to the circuit: eg leak eg a suction port open, PEEP valve set too high.


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