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
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
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