Managing the Crashing Intubated Patient

OVERVIEW

Intubation is a procedure we see on a regular basis. Most of the time, we intubate with ease, and our patient stabilizes. But what happens when they don't? Today EMRA*Cast host Dr. Kyle Duke sits down with Dr. Andrew Phillips, an EM/CC trained physician in Edinburg, TX. We discuss how to approach the crashing intubated patient and a mnemonic that we all should keep in our back pocket. Dr. Phillips also gives us a refresher on some ventilator terminology and physiology that we might have forgotten if we've been out of the ICU for too long. So sit back, enjoy, and don't forget to PPPUSH 100%. 

TAKE-HOME POINTS

Ventilator Terminology/Physiology

• PEEP: This is the positive end expiratory pressure. This is the pressure that is coming from the ventilator constantly whether the patient is inhaling or exhaling.
• Auto-PEEP (Intrinsic PEEP): A new breath that starts before the previous breath finishes. This is measured by an expiratory hold, to see the pressure of the system with no added breath.
• Plateau pressure: Measured with an inspiratory hold. This measurement combines the PEEP, which is a constant pressure, along with the added pressure from the tidal volume. A normal plateau pressure is <30.
  • The plateau pressure is the pressure that the alveoli are feeling.
• Peak pressure: A dynamic pressure. This measures the flow through the tubing. Anything from stepping on the tubing, the patient biting the ET tube, a mucus plug, these can all lead to an increase in peak pressure. A normal peak pressure is <40. This will be your most common alarm.

Pressure Checks

• Make sure you check your plateau pressure and coordinate with your peak pressure.
• Remember, the plateau pressure is a static pressure while the peak pressure is a  dynamic pressure. If your peak pressure is high but your plateau pressure is low to normal? Think of something in the tubing (circuit blockage, biting tube, asthma, etc.).
• If your peak pressure is high AND your plateau pressure is high? This is a compliance issue (Auto PEEP, etc.).

PPPUSH 100%

• If you have a hypoxic intubated patient with no clear etiology? Think PPPUSH 100%.  There are no absolute contraindications for this mnemonic. These steps can be performed on all intubated patients.  
  • P - Plateau pressure
  • P - Intrinsic PEEP (auto peep)
  • P - Paralyze and sedate
  • U - Ultrasound/Chest XR to evaluate for pneumo
  • S - Suction. It may take multiple passes to break up mucous plug
  • H - Head of bed ~30 degrees or high. Reverse trendelenburg for spinal precaution patients
  • 100% - Always bump the FiO2 to 100%

Patient-Specific Tip

• If you have a morbidly obese patient, it is important to get that PEEP up! At LEAST 10, if not 15. Do not put these patients on a PEEP of 5.
• It is also important to get their head of bed elevated, as well to shift their body weight off of their chest.