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Algorithm of Hosking et al for Troubleshooting Difficult Ventilation in a Patient with an Endotracheal Tube

Purpose: To troubleshoot a patient with an endotracheal (ET) tube who is proving difficult to ventilate based on the algorithm of Hosking et al.

Description

Hosking et al developed a flow diagram for troubleshooting difficult ventilation of a patient with an endotracheal tube. This is intended for use in forward military hospitals. The authors are from the Mayo Clinic, University of South Dakota, and the Veterans Administration Hospital in Minneapolis.


Patient selection: difficulty ventilating a patient with an endotracheal tube

 

Parameters:

(1) ability to manually ventilate

(2) breath sounds

(3) ability to pass a suction catheter down the length of the endotracheal tube

(4) easy ventilation of the patient

 

Manual Ventilation

Breath Sounds

Passing a Suction Catheter

Easy Ventilation of Patient

Node

resolves problem

NA

NA

NA

A

does not resolve

unilateral

NA

NA

B

does not resolve

bilateral

unable

NA

C

does not resolve

bilateral

easy

yes

D

does not resolve

bilateral

easy

no

E

 

 

Node

Considerations

A

Check the breathing circuit.

B

Pulling back the tube will correct endobronchial intubation. If this does not correct the problem, try (a) pulling the tube back further or (b) do a fiberoptic exam of the endotracheal tube for an obstruction.

C

Correction by deflating the cuff indicates cuff herniation. If this does not resolve the problem, try (a) replacing the tube or (b) do a fiberoptic exam of the endotracheal tube for an obstruction.

D

Suction out any secretions. Recheck breath sounds.

E

Consider (a) bronchospasm, (b) pulmonary edema, (c) pneumothorax, (d) interstitial fibrosis, (e) other pulmonary diseases.

 


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Specialty

Objective

ICD-10