Migrated ETT on Transfer

I: You are the ICU doctor receiving the patient back from the CT scanner. The doctor performing the transfer has handed over to the bedside nurse and left.

S: Bedside nurse is transferring patient back onto ICU ventilator from transfer ventilator and notes tidal volume less than when they left

B: 65 year old patient admitted to ICU with hypoxaemic respiratory failure due to a presumed CAP. CTPA to exclude pulmonary embolism.

A: Low tidal volumes on portable ventilator with high airway pressures.

R: Called for help

• Initially A ETT 24cm at lips, B SpO₂ 99% on FiO₂ 1.0 PSIMV at 16bpm, low tidal volumes, ETCO₂ 5 kPa, no breath sounds left side, C HR95bpm SR, BP 118/62, D Deeply sedated (not paralysed)
• Low VTs, climbing ETCO₂, slow desaturation
• No change on ICU ventilator. Nurse reports settings same as before transfer
• Examination- patent ETT 24cm at lips, tube loosely secured, silent left lung, unilateral chest expansion on right side
• Saturations continue to fall despite 100% FiO2
• ETT patent- can pass suction catheter
• If ETT withdrawn- ventilation improves and saturations climb

• Initial settings:    
  • SpO₂ 95% on FiO₂ 1
  • ETCO₂ 5.1kPa
  • RR 16/min
  • Quiet breath sounds left lung
  • HR 95bpm
  • BP 118/62

• Progress to:    SpO₂ 92% on FiO₂ 1.0
  • ETCO₂ 6.0kPa
  • No breath sounds left lung/ not expanding
  • HR 100bpm
  • BP 105/60

• Progress to:    SpO₂ 85% on FiO₂ 1.0
  • ETCO₂ 6.9kPa
  • No breath sounds left lung/ not expanding
  • HR 118bpm
  • BP 95/60

• On withdrawal of ETT (remove restriction on lung simulator)
  • SpO₂ climb to 94% on FiO₂ 1.0
  • ETCO₂ 5.6kPa
  • Breath sounds bilaterally but reduced left base. Bilateral expansion
  • HR 108bpm
  • BP 108/68

Bedside Nurse 1:

• You are an ICU nurse who has recently completed your transfer training
• You have returned from transferring a 65M with presumed CAP back to ICU with one of the registrars
• You have no concerns except that the tidal volumes are a little less than before transfer
• If asked why you think the tidal volumes are low volunteer that the patient may have “de recruited” on switching ventilators
• If the candidate asks guide the participant to where the ETT depth is documented as “21cm at the teeth” within the bedspace

Bedside Nurse 2:

• You are a student nurse on critical care placement
• You are responsible for manipulating the lung simulator if using simple test lung as per videos