Desaturation in the Intubated Patient in the PICU

Nov 23, 2025

The hosts tackle a gripping case of a 10-year-old boy facing post-intubation desaturation. They introduce the DOPE mnemonic to swiftly diagnose issues like displacement and obstruction. Key discussions include the pivotal role of capnography and manual ventilation in emergencies. Techniques to prevent unplanned extubation are highlighted, alongside the importance of teamwork and simulation training. Listeners learn about critical bedside tools and the necessity for a structured approach to managing acute crises in pediatric care.

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ADVICE

Disconnect And Bag Immediately

Disconnect the ventilator and bag with 100% oxygen and a PEEP valve immediately when an intubated child acutely desaturates.
Use manual ventilation to oxygenate and to rapidly distinguish equipment from patient causes while running DOPE.

INSIGHT

Equipment Failures Now Look Different

Modern ventilator circuits introduce new equipment failure risks like occluded HMEs and inline filters.
Emphasize equipment checks in DOPE since filter occlusion can mimic tube obstruction.

ADVICE

Test Suction Early And Replace If Needed

If a suction catheter won't pass, immediately disconnect and bag the patient while applying chest physiotherapy and suction again.
Replace the endotracheal tube if obstruction persists and manual ventilation fails to deliver chest rise.

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Today, Dr. Monica Gray, Dr. Pradip Kamat, and Rahul Damania discuss a critical case involving a 10-year-old boy who developed post-intubation desaturation. Using the DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure), they systematically troubleshoot the emergency, highlighting the importance of teamwork, capnography, and manual ventilation. The team emphasizes structured approaches, simulation training, and essential bedside tools to ensure rapid, effective management of acute deterioration in intubated children, turning a life-threatening crisis into a controlled, solvable situation.

Show Highlights:

Clinical case discussion of a ten-year-old boy with post-intubation desaturation in the pediatric ICU
Use of the "DOPE" mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) for troubleshooting
Systematic approaches in emergency situations in pediatric critical care
Assessment and management of sudden desaturation in intubated patients
Evaluation of potential causes of desaturation, including tube displacement and obstruction
Role of equipment failure in acute deterioration and strategies to address it
Significance of continuous capnography and manual ventilation techniques
Prevention strategies for unplanned extubation in pediatric ICU settings
Emphasis on teamwork, communication, and simulation training in crisis management
Review of literature insights related to hypoxemia and equipment issues in pediatric intubation

References:

Topjian AA, et al. Part 4: Pediatric Basic and Advanced Life Support—2020 AHA PALS Guidelines. Circulation. 2020.Foundational pediatric resuscitation guidance endorsing early switch to manual ventilation and structured troubleshooting for the deteriorating intubated child.
Cook TM, et al. Major complications of airway management in the UK: NAP4. British Journal of Anaesthesia. 2011.Seminal audit highlighting ICU/ED airway failures and the critical role of waveform capnography in preventing unrecognized esophageal intubation.
Volpicelli G, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Medicine. 2012. High-impact consensus placing lung ultrasound at the bedside to rapidly diagnose pneumothorax during post-intubation deterioration.
Prekker ME, et al. Video vs direct laryngoscopy for ED intubation—randomized trial. New England Journal of Medicine. 2023.NEJM RCT showing higher first-pass success with video laryngoscopy—relevant to preventing displacement/misplacement drivers of desaturation.
Chrimes N, et al. Preventing unrecognised oesophageal intubation: consensus guideline. Anaesthesia. 2022.Modern, practice-changing guidance: sustained waveform capnography is the mainstay to exclude esophageal placement and avert catastrophic hypoxemia.