Poor tolerance after previous good tolerance

If agitation occurs in a patient who has previously tolerated mechanical ventilation, either the patient's condition has deteriorated or there is a problem in the ventilator circuit (including artificial airway) or the ventilator itself.

• The patient should be removed from the ventilator and placed on manual ventilation with 100% oxygen while the problem is resolved. Resorting to increased sedation ± muscle relaxation in this circumstance is dangerous until the cause is resolved.

• Check patency of the endotracheal tube (e.g. with a suction catheter) and re-intubate if in doubt.

• Consider malposition of the endotracheal tube (e.g. cuff above vocal cords, tube tip at carina, tube in main bronchus).

• Seek and treat and changes in the patient's condition, e.g. tension pneumothorax, sputum plug, pain.

• Where patients are making spontaneous respiratory effort consider increasing pressure support or adding mandatory breaths.

• If patients fail to synchronise with IMV by stacking spontaneous and mandatory breaths, increasing pressure support and reducing mandatory rate may help; alternatively, the use of PSV may be appropriate.

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