A nurse is caring for a patient on mechanical ventilation who suddenly develops high peak inspiratory pressures and decreased tidal volumes. The ventilator alarm is sounding. What is the nurse's priority action?
The nurse notices the ventilator displaying peak inspiratory pressures of 45 cmH2O (normal 20-25 cmH2O) and tidal volumes dropping from 500 mL to 300 mL.
1Increase the ventilator rate to compensate for decreased tidal volume
2Suction the endotracheal tube to clear secretions
3Notify the respiratory therapist immediately
4Assess the patient and ventilator circuit for disconnections or obstructions✓ 정답
해설
High peak inspiratory pressures with decreased tidal volumes indicate a ventilator emergency like obstruction or disconnection, requiring immediate systematic assessment of patient and circuit. Other options (increasing rate, suctioning without assessment, notifying RT first) delay critical intervention.
Clinical Judgment
This question assesses systematic assessment and nursing action prioritization in a mechanical ventilation emergency. A high peak inspiratory pressure along with a decreased tidal volume means the ventilator is encountering resistance and is unable to deliver sufficient air to the patient. The most common causes are circuit disconnection, kinked tubing, secretion accumulation, and water in the circuit. The nurse's highest priority action is to immediately disconnect the patient and ventilate with a manual bag-valve-mask while simultaneously quickly assessing the patient and circuit to find the cause of the problem. This follows the basic principles of Airway, Breathing, Circulation and the Disconnect (check for disconnection) first approach to ventilator troubleshooting.
Memory Tip: Remember the ventilator troubleshooting mnemonic DOPE. However, before applying DOPE, you must first check for Disconnect (confirm the patient is disconnected from the ventilator). The key is to assess whether the problem is Disconnect (Dislodgement/Disconnection), Obstruction, Pneumothorax, or Equipment failure.
KR vs US: The basic principles of mechanical ventilator management are the same in both Korea and the US. However, in US clinical practice, the role of the Respiratory Therapist (RT) is very clear and independent, so the typical collaborative system is for the nurse to first perform the initial assessment and emergency measures (manual ventilation) and then notify the RT. Nurses must have basic knowledge and the ability to perform equipment troubleshooting.
Clinical Practice GuideStandard approach when a ventilator alarm sounds: 1) Disconnect the patient from the ventilator and ventilate with a manual bag (Ambu bag) supplying 100% oxygen. 2) Rapidly assess the patient's condition (breath sounds, chest movement, SpO2, level of consciousness). 3) Check the ventilator circuit from start to finish (wall oxygen source → humidifier → expiratory filter). Check connections, tube kinks, and water traps.Caution: In SATA (Select All That Apply) questions, the option "suction" is correct only if airway obstruction due to excessive secretions has been confirmed through assessment. Suctioning immediately when the alarm sounds can be dangerous. Also, the option "call the respiratory therapist" is an action to take after performing initial emergency measures (manual ventilation and assessment), so it is not appropriate as the sole top-priority action.
Peak Inspiratory Pressure — Peak inspiratory pressure. The maximum pressure reached when the ventilator delivers air into the patient's lungs. Normal is usually 20-25 cmH2O. Elevation suggests increased airway resistance or decreased lung compliance.
Tidal Volume — Tidal volume. The amount of air entering or leaving the lungs in a single breath. A decrease during mechanical ventilation may indicate ventilatory failure or a circuit/airway problem.
Ventilator-Associated Event — Ventilator-associated events. A term encompassing complications that occur during mechanical ventilation (e.g., pneumonia, lung injury). High pressure and low tidal volume may be early signs of potential problems.
Bag-Valve-Mask — Manual ventilation device. Used as an immediate means of ventilation in case of ventilator failure or patient disconnection. The first action in a ventilator emergency is to switch the patient to a BVM.
Auto-PEEP (Intrinsic PEEP) — Auto-PEEP (intrinsic PEEP). A phenomenon where the next breath begins before exhalation is fully complete, causing air to become trapped in the lungs. This can lead to an increase in PIP and a decrease in tidal volume, and is corrected by measures such as extending the expiratory time.