Question

A patient is intubated for respiratory failure and the post-intubation CXR is shown on the left. 30 minutes later the patient desaturates and another CXR is obtained (the one on the right). What’s the diagnosis and what should you do?

Answer

Mucus plug

There are several conditions to consider when patients are having difficultly being ventilated. The approach to such a patient can be remembered with a mnemonic found here.

In this case, conditions to consider are:

• right main-stem intubation (can be seen with ultrasound; here)
• mucus plug (shift is towards problem)
• tension pneumothorax (shift is away from problem); use ultrasound

Treating mucus plugs can usually be treated as follows:

• Deep tracheal suctioning
• Disconnecting patient from the vent and bagging
• Chest physiotherapy (i.e., percussing the chest) on the affected area
• Bronchoscopy, if above does not result in resolution

References

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