Can Intubate, Cannot Ventilate: A Proposed Algorithm for Post-Intubation Ventilation and Oxygenation Issues
Authors: Kjetil Fosse, Magnus Salomonsen, Sven Erik Gisvold, Bjørnar Gundersen, Trond Nordseth
Journal: Acta Anaesthesiologica Scandinavica, March 2025
Conclusions:
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The CICV scenario is a critical emergency that requires a structured approach.
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Key principles: Rule out equipment failure and airway obstruction before diagnosing medical causes of ventilatory failure.
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The proposed algorithm provides a stepwise approach for rapid evaluation and intervention to improve ventilation and oxygenation post-intubation.
Proposed Algorithm for CICV
In an intubated patient, the airway should be assessed as a continuum from the ventilator to the alveoli, and the problem can occur at any level:
Ventilator → Hoses → Filter → Tracheal Tube (TT) → Trachea → Bronchi → Bronchioles → Alveoli
1️⃣ Confirm Correct Endotracheal Tube (ETT) Placement
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Primary marker: Positive capnography waveform
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Further confirmation: Direct or video laryngoscopy
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If uncertain: Remove ETT and reintubate
2️⃣ Disconnect from Ventilator & Manually Ventilate
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Use bag-valve-mask (BVM) with 100% oxygen
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If chest rise is absent → Perform immediate airway assessment
3️⃣ Check for Equipment or Airway Obstruction
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Verify an open ETT by passing a suction catheter through the tube
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Inspect ventilator hoses, filters, and tubing for blockages
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If obstruction is suspected but cannot be cleared, replace ETT
4️⃣ Consider & Treat Differential Diagnoses
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Bronchospasm: Listen for wheezing, treat with bronchodilators
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Anaphylaxis: Administer epinephrine if allergic reaction suspected
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Pneumothorax: Assess for absent breath sounds, perform needle decompression if indicated
5️⃣ Optimize Gas Exchange & Circulation
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Reassess oxygenation & ventilation strategy
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If no improvement, consider advanced interventions (e.g., proning, ECMO referral in refractory hypoxia)
Fosse, K., Salomonsen, M., Gisvold, S.E., Gundersen, B. and Nordseth, T., 2025. Can intubate, cannot ventilate: A proposed algorithm to handle problems with ventilation and oxygenation after intubation. Acta Anaesthesiologica Scandinavica, 69(3), p.e70007.