• Don PPE

  • DO NOT RUSH - Ensure PPE is donned correctly!​

  • D for Danger comes before ABC​

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• Call for help early!

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• Optimise oxygenation

  • Boost FiO2 to 100%​

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• Confirm tube placement and patency

  • Check capnograph trace (if utilised) - confirms correct tube placement

  • Check tube position

    • Has ETT migrated further in?​

  • Suction endotracheal tube

    • Confirms ETT patency

    • May clear sputum/secretion obstruction

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• Reduce tidal volume to minimum (4 - 8 ml/kg IBW)

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• Increase Sedation and consider paralysis

  • Bolus sedation (eg. 20mg propofol, 1-3x)​

  • Paralysis: rocuronium or vecuronium or cisatracurium

    • Requires deep sedation​

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• Perform plateau pressure measurement

  • Airway pressure following > 1 second inspiratory hold manouvre​

  • Represents alveolar pressure during no-flow state rather than pressure generated by flow against bronchiole airway resistance​

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Plateau Pressure > 30 cmH2O (or unable to complete inspiratory hold)

• If concurrent significant haemodynamic instability; immediately disconnect patient from ventilator

  • DO NOT DISCONNECT A SUSPECTED OR CONFIRMED COVID-19 PATIENT 

    • In that case, place ventilator in standby mode for 30 seconds

    • Alternatively, reduce respiratory rate to 6 breaths per minute

• Prolong Expiration - Reduce respiratory rate / prolong I:E ratio (> 1:3)

  • Elevated pressure may be due to breath stacking/dynamic hyperinflation​

    • Occurs where inspiration begins before patient has fully eliminated breath (expiration is a passive process)​​

      • Gas accumulates within lungs

    • May occur if expiratory time too short (eg. Inappropriately high respiratory rate set, tachypnoea) or in airways obstruction

    • Give bronchodilators for bronchospasm

• Reduce tidal volumes

  • In a patient with significantly reduced lung compliance (eg. ARDS), low tidal volumes may be tolerated, assuming adequate oxygenation can be achieved​​​

• Investigate and treat other causes:

  • CXR and/or lung US (if competent)​

  • Exclude:

    • Pneumothorax​

    • Endobronchial intubation

      • Usually R main bronchus​

    • Lobar collapse

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Plateau Pressure < 30 cmH2O​

• Check for circuit obstruction

• Check for tube-biting or patient-ventilator dysynchrony

  • Treat with sedation boluses and/or increase sedation rate​

    • Eg. 20mg propofol bolus, may be repeated up to 3 times​

• Assess for evidence of bronchospasm

  • Wheeze, saw-tooth capnograph trace​

  • Treat with bronchodilators +/- corticosteroids

  • Reduce respiratory rate

    • Especially if any evidence of inadequate expiratory time/development of dynamic hyperinflation

• In bronchospastic patients, high peak airway pressures may be tolerated if plateau pressures remain < 30 cmH2O

  • Requires frequent monitoring of plateau pressures

  • High pressures should only be tolerated if DISCUSSED WITH ICU CONSULTANT!