The DOPES mnemonic helps clinicians rapidly troubleshoot and correct the underlying issues causing hypoxia.
DOPES
- D – Displacement
- O – Obstruction
- P – Pneumothorax
- E – Equipment Failure
- S – Stacked Breaths, Secretions or Stomach
Troubleshooting Steps:
A. Displacement
Assessment:
i. Verify Endotracheal Tube (ETT) Position:
- Check the depth marking on the ETT at the patient’s teeth or lips.
- Ensure it matches the documented insertion depth.
ii. Auscultate Breath Sounds:
- Listen for bilateral breath sounds.
- Check for absent or diminished sounds, especially on the left (indicating right mainstem intubation).
iii. Observe Chest Movement:
- Look for symmetrical chest rise and fall.
iv. Capnography:
- Confirm continuous end-tidal CO₂ (EtCO₂) waveform.
Actions:
i. Adjust ETT Position:
- If the tube has migrated, reposition it to the correct depth.
ii. Reintubate if Necessary:
- If the ETT is in the esophagus or dislodged, remove it and perform reintubation.
B. Obstruction
Assessment:
i. Inspect the ETT:
- Look for kinks, biting, or external compression.
ii. Assess for Secretions or Mucus Plugs:
- Difficulty ventilating may indicate blockage.
iii. Check Airway Pressures:
- Elevated peak inspiratory pressures suggest obstruction.
iv. Evaluate for Bronchospasm:
- Wheezing on auscultation.
Actions:
i. Suction the ETT:
- Use an inline suction catheter to clear secretions.
ii. Ensure the Tube is Not Kinked:
- Straighten the tube if bent or reposition patient’s head.
iii. Administer Bronchodilators:
- Give nebulized bronchodilators if bronchospasm is suspected.
iv. Replace the ETT:
- If obstruction persists, consider exchanging the tube.
C. Pneumothorax
Assessment:
i. Auscultate Breath Sounds:
- Absence or decreased sounds on one side.
ii. Percuss the Chest:
- Hyperresonance may indicate air accumulation.
iii. Observe for Signs of Tension Pneumothorax:
- Hypotension, tachycardia, tracheal deviation (late sign), distended neck veins.
iv. Monitor Ventilator Alarms:
- Sudden increase in peak pressures.
Actions:
i. Perform Needle Decompression:
- Insert a large-bore needle in the second intercostal space at the midclavicular line on the affected side.
ii. Insert a Chest Tube:
- Place a thoracostomy tube for definitive management.
iii. Provide Supplemental Oxygen:
- Increase FiO₂ to 100%.
D. Equipment Failure
Assessment:
i. Check Ventilator Function:
- Inspect for malfunction or disconnections.
ii. Examine Oxygen Supply:
- Ensure the oxygen source is connected and functioning.
iii. Inspect the Ventilator Circuit:
- Look for leaks, disconnections, or water accumulation.
Actions:
i. Disconnect and Manually Ventilate:
- Use a bag-valve-mask (BVM) with 100% oxygen.
ii. Inspect and Reassemble Equipment:
- Reconnect any disconnections, replace faulty components.
iii. Switch Ventilators if Necessary:
- Use an alternative ventilator if equipment failure persists.
E. Stacked Breaths (Auto-PEEP)
Assessment:
i. Monitor for Auto-PEEP:
- Elevated baseline airway pressures.
ii. Observe Expiratory Flow:
- Incomplete exhalation before the next breath.
iii. Signs of Hyperinflation:
- Hypotension due to decreased venous return.
iv. Assess Ventilator Waveforms:
- Flow does not return to baseline before next inspiration.
Actions:
i. Disconnect Ventilator:
- Allow complete exhalation.
ii. Adjust Ventilator Settings:
- Decrease respiratory rate.
- Increase expiratory time (adjust Iratio).
- Reduce tidal volume if appropriate.
iii. Sedation and Paralysis:
- Ensure adequate sedation to prevent patient-ventilator asynchrony.
F. Secretions
Assessment:
Gurgling sounds, increased airway pressures.
Actions:
- Suction the oropharynx and ETT.
G. Stomach (Gastric Distension)
Assessment:
Abdominal distension, reduced chest expansion.
Actions:
i. Insert a nasogastric or orogastric tube for decompression.
ii. Confirm ETT Placement:
- Rule out esophageal intubation.
Additional Management Steps
Consider Other Causes of Hypoxia
- Pulmonary Embolism: Sudden hypoxia with hemodynamic instability.
- Aspiration: History of vomiting or secretions in airway.