UMEM Educational Pearls

There are several reasons why a mechanically ventilated patient may decompensate post-intubation. Immediate action is often needed to reverse the problem, but it can be difficult to remember where to start as the vent alarm is sounding and the patient is decompensating.

Consider using the mnemonic “D.O.P.E.S. like D.O.T.T.S.” to assist you in first diagnosing the problem (D.O.P.E.S.) and then fixing the problem (D.O.T.T.S.). You can view an entire lecture on the Crashing Ventilated Patient here.

Step 1: Could this decompensation be secondary to D.O.P.E.S.?

  • Displaced ET tube / ET tube cuff not inflated or has a leak
  • Obstruction of ET tube
  • Pneumothorax
  • Equipment malfunction (disconnection of the ventilator, incorrect vent settings, etc.)
  • Stacking (breath stacking / Auto- PEEP; click here for a review)

Step 2: Fix the problem with D.O.T.T.S.

  • Disconnect – Disconnect patient from the ventilator
  • Oxygen – Oxygenate patient with a BVM and feel for resistance as you bag
  • Tube position / function – Did the ET tube migrate? Is it kinked or is there a mucus plug?
  • Tweak the vent – Are the settings correct for this patient?
  • Sonogram (ultrasound) – Sonogram to look for pneumothorax, mainstem intubation, etc. 


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