OUTCOMES: While receiving ventilatory assistance, the patient will experience an adequate supply of oxygen and concurrently, adequate elimination of carbon dioxide at the cellular level. Any mechanical; physical or psychological barrier to effective respiration will be identified and corrected promptly.

EQUIPMENT: Laerdal resuscitator (with mask and oxygen flow tubing)
High volume, low pressure cuff manometer

Suction equipment (refer to policy/procedure: Suctioning A Patient With A Endotracheal / Tracheostomy Tube)
Stethoscope
12 g. Dwellcath cannula. R : 2.1
PROCEDURE:
* Problems Associated With Mechanical Ventilator:
- Detach patient from ventilator and manually ventilate patient using Laerdal Silicone Resuscitator (attached to endotracheal tube) and high flow oxygen.
- If the patient is "easy" to manually ventilate and settles once removed from the ventilator - the ventilator has been identified as the primary source of the ventilator emergency.
- While one nurse manually ventilates the patient, a second skilled nurse inspects the ventilator and attends performance check (as per manufacturer's guidelines).
- If the problem cannot be identified and rectified, the ventilator is replaced with another.
- The malfunctioning ventilator is sent to biomedical engineering for review.

* Problems Associated With The Endotracheal Tube:
- If the patient is "easy" to manually ventilate but an audible air leak is present, check cuff pressure with manometer.
- If the leak persists or is unsealable, check tube position / length and air entry.
- Reinsert tube to correct length.
- Check for absence of cuff leak and equal air entry.
- Document event.
* If the patient is "difficult" to ventilate, attempt to pass suction catheter.
* If the suction catheter cannot be passed further than 5 cm - verify that the patient is not biting on the tube. Insert oropharyngeal airway and attempt to suction patient again. If difficulty persists: proceed.
* If the suction catheter cannot be passed further than 10-15 cm:
- Position patient's head / neck in a position of neutral alignment and attempt to suction patient again.
- If difficulty persists: proceed.
* If the suction catheter cannot be passed further than the tip of the endotracheal tube:
- Deflate cuff.
- Pass suction catheter. - Reinflate cuff to pressure of 15 to 25 cm H2O.
- Attempt to pass suction catheter again.
- If passage of catheter is impossible and ventilation is absent: remove tube.
R : 2.2
- Call for assistance of Director of ICU immediately.
- Manually ventilate patient using Laerdal Silicone Resuscitator and appropriately sized mask.
- Prepare for reintubation.

Problems Isolated Within The Chest Cavity:
- If ineffective ventilation continues, inspect and auscultate the patient's chest for equal and adequate air entry.
- If there is unequal chest wall movement and / or decreased air entry on one side, exclude the following causes:

Malpositioned Tube:
Signs: chest movement and air entry on one side.
Actions: - Summon the assistance of the Director of ICU
- Reposition and resecure tube (refer to the policy / procedure: Securing and Care of an Endotracheal/Tracheostomy Tube.)
- Recheck chest movement and air entry.
Atelectasis :
Signs: no chest movement over the affected side;
no air entry over the affected side;
dull sound on percussion over the affected side;
tracheal shift towards the affected side.
Actions: - Aggressive endotracheal suctioning including the use of saline lavage.
- Aggressive chest physiotherapy.
- Notify the Director of ICU

Tension Pneumothorax:
Signs: no chest movement over the affected side;
no air entry over the affected side;
hyper resonant sound upon percussion;
tracheal shift away from the affected side.
R : 2.3

Actions: - Summon medical assistance.
- Insert 12g. dwellcath needle into the second intercostal space, mid-clavicular line.
- Observe patient for a large "hiss" of air.
- Prepare for the introduction of an intercostal catheter attached to underwater sealed drainage.

Problems Associated With The Central Nervous System:
- If ineffective ventilation continues and no physical or mechanical cause can be found, sedate patient as per medication chart.

R : 2.4