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Increased Airway Pressure

 

 

Differential diagnosis

 

  • Circuit or machine problem:

    • Ventilator/bag switch in wrong position

    • Stuck valve (inspiratory/expiratory/APL)

    • Oxygen flush valve stuck in "on" position

    • Kinked/misconnected hose in circuit/scavenge limb

    • Failure of check valves/regulators in machine, allowing high-pressure gas into low-pressure circuit

    • PEEP valve accidentally placed in inspiratory limb

  • ETT/supraglottic airway problem:

    • Kinked tube

    • Malpositioned supraglottic airway

    • Endobronchial, esophageal, submucosal intubation

    • Herniated cuff obstructing end of tube

    • Dissection of interior surface of tube leading to airway narrowing

  • ↓ pulmonary compliance:

    • ↑ intra-abdominal pressure

    • Pulmonary aspiration

    • Bronchospasm 

    • ↓ chest wall compliance

    • Pulmonary edema

    • Pneumothorax

  • Drug-induced problem:

    • Opioid-induced chest wall rigidity

    • Inadequate muscle relaxation

    • Malignant hyperthermia

  • Laryngospasm (if using supraglottic airway)

 

 

Management

 

  • ↑ FiO2 to 100%

  • Verify the peak inspiratory pressure

  • Switch to manually using reservoir bag; assess pulmonary & circuit compliance

  • Disconnect circuit from ETT & squeeze bag:

    • If PIP still high, obstruction in circuit; ventilate using BVM connected to 100% FiO2

    • Get help to replace/repair circuit

  • Auscultate chest & neck:

    • Listen for symmetry (endobronchial, tension, or simple pneumothorax) & for adventitious sounds (pulmonary edema, bronchospasm)

    • Listen for stridorous sound of laryngospasm

  • Examine trachea for deviation, check HR & BP

  • Exclude ETT obstruction:

    • Pass suction catheter down ETT & apply suction to clear secretions

    • If ETT obstructed, deflate cuff & repeat

    • Consider fiberoptic bronchoscopy to elucidate problem

    • Remove & reintubate if necessary

  • Check for other causes of ↓ chest compliance:

    • Malignant hyperthermia

    • Aspiration

    • Inadequate muscle relaxation

    • Opiates

    • Excessive surgical retraction

    • Abnormal anatomy (ie: scoliosis)

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