What is the recommended management for an intubated patient undergoing uneventful monitoring in the ward?

Ward Monitoring of Intubated Patients

For intubated patients undergoing uneventful monitoring on the ward, continuous waveform capnography is mandatory, along with standard vital signs monitoring, systematic airway assessment, and daily evaluation of sedation levels and readiness for weaning. 1

Essential Monitoring Requirements

Continuous Monitoring

• Waveform capnography must be used for all intubated patients as it is the expected standard and has the greatest potential to prevent deaths from airway complications outside operating theaters 1
• Pulse oximetry should be continuously monitored, though it alone is insufficient for detecting respiratory compromise 2
• Cardiac monitoring is indicated for critically ill patients undergoing mechanical ventilation, as they are at significant risk for cardiac arrest or respiratory arrest 1
• Standard monitoring includes ECG, non-invasive blood pressure, pulse oximetry, and capnography 3

Intermittent Assessments

• Document and verify endotracheal tube depth at each shift change and whenever respiratory deterioration occurs 1
• Monitor level of consciousness, respiratory rate, heart rate, blood pressure, peripheral oxygen saturation, temperature, and pain score 3
• Maintain cuff pressure at 20-30 cm H₂O, checking regularly 1
• Perform daily assessments for readiness for weaning using low-level pressure support 4

Critical Airway Red Flags

Immediately investigate if any of these occur 1:

• Absence or change of capnograph waveform with ventilation
• Absence or change of chest wall movement with ventilation
• Increasing airway pressure or reducing tidal volume
• Inability to pass a suction catheter
• Obvious air leak or vocalization with inflated cuff
• Discrepancy between actual and recorded tube insertion depth
• Surgical emphysema

Systematic Deterioration Assessment (DOPE Mnemonic)

If an intubated patient's condition deteriorates, systematically evaluate 1:

• Displacement of the tube
• Obstruction of the tube
• Pneumothorax
• Equipment failure

This structured approach prevents task fixation and ensures rapid identification of correctable problems.

Sedation Management

Daily Sedation Protocol

• Evaluate sedation level and CNS function daily to determine the minimum propofol dose required 5
• For mechanically ventilated adults, maintain rates of 5-50 mcg/kg/min (0.3-3 mg/kg/h), individualized to clinical response 5
• Never exceed 4 mg/kg/hour unless benefits clearly outweigh risks due to Propofol Infusion Syndrome risk 5

Critical Sedation Warnings

• Avoid abrupt discontinuation of sedation as this causes rapid awakening with anxiety, agitation, and resistance to mechanical ventilation 5
• Maintain minimal sedation levels during weaning and daily assessments 5
• Monitor for Propofol Infusion Syndrome signs: severe metabolic acidosis, hyperkalemia, rhabdomyolysis, hepatomegaly, renal failure, or cardiac failure 5

Communication and Documentation

Ward Round Safety Briefings

• The ICU consultant must ensure the team knows which patients have difficult airways 1
• Handover should include patient-specific strategies for preventing and managing airway risks, including device displacement or blockage 1
• Document a re-intubation strategy and extubation plan 1
• Communication must include relevant clinicians, nurse in charge, bedside nurse, and physiotherapist 1

Bedside Documentation

• Display bedhead signage identifying airway difficulty to reduce adverse incidents 1
• Document tube depth on bedside chart and verify each shift 1
• Ensure appropriately skilled clinicians and immediately available equipment are documented and visible at bedside 1

Equipment Requirements

Immediately Available at Bedside

• Difficult airway trolley with relevant items 3
• Suction equipment
• Bag-mask ventilation equipment
• Emergency medications
• FONA (Front of Neck Airway) equipment for emergencies 1

Tube Security

• Secure tubes using established methods, though no single method is superior 1
• Maintain head in neutral position; neck flexion pushes tube deeper, extension may dislodge it 1

Common Pitfalls to Avoid

• Never rely on pulse oximetry alone - it may not decline for up to 3 minutes after effective ventilation ceases, especially following hyperoxygenation 1
• Do not delay recognition of tube displacement - assume apparent cuff leak is partial extubation until proven otherwise 1
• Avoid task fixation when deterioration occurs - systematically work through DOPE mnemonic 1
• Never share ventilators between multiple patients 4
• Over 80% of airway-related critical incidents in ICU occur after initial intubation, with 30% being serious 1

Risk Stratification

• Unanticipated respiratory compromise requiring unplanned intubation carries 49.1% mortality 6
• Approximately 46.3% of patients show no significant vital sign changes before acute deterioration 6
• This underscores the importance of continuous capnography rather than relying solely on intermittent vital signs 1