Vent Alarms should be Regarded as Code Blue
If you cannot instill this into your culture, patients will die
If they are crashing, do DOPES
ETCO2 on any Vented Pt
This is what the real alarm should be
High (Peak) Pressure
Dyssynchrony
Peak Only
- Check the circuit
- fluid pooling in circuit
- fluid pooling in filter
- kinking of circuit
- Tube too small or biofilmed
- Bronchospasm
- Biting on ETT
Peak & Plat High
- Tube in Mainstem
- Pneumothorax
- Bad Lungs >> Turn down the Vt
- Abd Compartment
Low Peak Pressure
- Disconnect
- ETT Cuff Deflated
- Pt effort
Low Ve/Vt
- Cuff Issues (See EMCrit Wee )
- Bronchopleural Fistula
Low O2 Alarm
- Not hooked Up
- Gases Messed Up
- Sensor Messed up
What to Do with Continued Alarms Despite Sedation, Equipment Check, Suctioning
- Consider Bronchoscopic Assessment
- If Patient begins to crash, consider tube exchange if bronch not available
Breakdown on Alarm Types
See More
1.
Cvach M, Stokes J, Manzoor S, et al. Ventilator Alarms in Intensive Care Units: Frequency, Duration, Priority, and Relationship to Ventilator Parameters. Anesth Analg. September 2018. [PubMed]
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An ED Intensivist from NY. No conflicts of interest (coi).
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In my mind, part of the problem is that the vent does not distinguish between alarms.
For example, I’d rather not turn off alarms for high respiratory rate – somebody should take a look. But this has the exact same sound as the disconnection or obstruction alarms. Which means the only way to prevent alarm fatigue is to make yourself unaware of more common, but less serious threats.
On the topic of alarms in general, I feel 2 buttons are missing from the monitor :
– button A: this is the patient ‘s known acute physiology. For the next hour, please let me know if vital signs start to deviate from this (far safer than setting HR alarm to 190,then forgetting about it).
– button B: wrong interpretation. This would teach the monitor that what it’ s calling VT is really Sinus tach with Lbbb.
Hi Maarten,
Many ventilators have the ability to set various priorities of alarm (eg level 1, level 2, level 3) with different volumes and colour alerts for each. So you could set you disconnect and high peak alarms to high priority, high resp rate for middle and ‘needs service’ alarm to a low level, for example. It’s really very useful!! You could inquire with your product rep.
In my mind, part ff the problem is that the vent does not distinguish between alarms.
For example, I’d rather not turn off alarms for high respiratory rate – somebody should take a look. But this has the exact same sound as the disconnection or obstruction alarms. Which means the only way to prevent alarm fatigue is to make yourself unaware of more common, but less serious threats.
On the topic of alarms in general, I feel 2 buttons are missing from the monitor :
– button A: this is the patient ‘s known acute physiology. For the next hour, please let me know if vital signs start to deviate from this (far safer than setting HR alarm to 190,then forgetting about it).
– button B: wrong interpretation. This would teach the monitor that what it’ s calling VT is really Sinus tach with Lbbb.
How do you feel about clamping the ETT with patients on high PEEP before disconnecting the vent?
Do you mean when switching to a portable vent?
if PEEP > 10, we clamp for any circuit disconnects
Do you paralyse prior to tube-clamping? Seems to me that an inspiratory effort against a clamped tube would lead to more negative pressure than if left open to air.
Thanks for another great podcast!
I loved the idea of vent alarms being taken as seriously as a code! Indeed some of these situations could very quickly become codes if simple but for a simple remedy in a timely manner.
I do wonder if a systematic approach was a little lacking in the presentation. In anaesthesia (at least in Aus) we teach sustematic approaches to some of these alarms that ensure rapid optimisation of safety (eg FiO2 1.0) and then systematic troubleshooting. Possible causes should be ranked in order of likelihood and importance. For example, a bronchoplueral fistual should be way down the list for a vent leak (because it’s rare and largely uncorrectable), and a 6.0 ETT per se is not the cause of a high pressure alarm (will exacerbate another underlying cause, of course, but in normal physiology are used routinely with no problems).
The systematic approach lessons have been hard learned by, for example, HME/filter obstructions not being detected. Is this something that would lend itself to a few stepwise short checklists that could be both memorised and hung on the ventilator? Would be happy to look for anaesthesia-based resources if you’d be interested.