34 year old male with PMHx quadriplegia 2/2 GSW 8 years prior, with elective tracheostomy after his early disease course was complicated by frequent intubations for sepsis, presents to ED from NH with fever x1 day.

On arrival, pt is febrile 38C, severely hypotensive 60/40’s and tachypnea to 24 BPM through his tracheostomy collar.

You go to work on establishing ultrasound IV access while the respiratory therapist attaches the patient to the patient the ventilator through his collar and leaves. After placing two large bore IV’s, starting IV fluids and antibiotics, the patient begins to complain that he “cant breathe.” You note that the ventilator alarm reads “low Vt.” Respiratory is called back to bedside, but they are now responding to a code on another floor.

Going through D.O.P.E.S. algorithm, you disconnect the patient from the ventilator and begin bagging, timing your respirations with the patient’s spontaneous breaths. There is almost no resistance as you bag. The patient then notes that that air is coming out of his mouth as you bag.

What could be the problem?

The patient has an un-cuffed tracheostomy tube. In order to provide adequate ventilation through positive pressure, the patient requires an inflated cuff. This patient’s trach did not have a balloon on it. ENT was asked to come down immediately and replace it with a cuffed trach.

A cuffed tube is required during mechanical ventilation to prevent air escape through the upper airways
A cuffed tube is required during mechanical ventilation to prevent air escape through the upper airways