DOPE Mnemonic: Troubleshooting a Patient on an Advanced Airway

DOPE is a mnemonic for the four common reasons a patient with an advanced airway suddenly gets worse: Displacement of the tube, Obstruction of the tube, Pneumothorax, and Equipment failure. It is taught in PALS and in most paramedic and critical care transport courses, because a patient who was doing well on a tube or a ventilator and then desaturates needs a fast, ordered search for the cause, not guesswork. Some texts add an S, for stacked breaths or for the stomach, and call it DOPES.

When to run through DOPE

Use DOPE whenever a patient with an endotracheal tube, a supraglottic airway or a tracheostomy, whether on a bag or on a ventilator, deteriorates. The usual triggers are:

• A falling oxygen saturation.
• A change in the capnography waveform, or its sudden loss.
• Bagging that has become harder, or ventilator pressure alarms.
• A falling blood pressure or a changing heart rate.
• A patient who becomes agitated, starts to fight the ventilation or changes color.
• Any of the above just after the patient has been moved.

First, take the ventilator out of the question

A commonly taught first step, when a patient on a transport ventilator deteriorates, is to disconnect the ventilator, let the patient exhale, then ventilate by hand with a bag-valve device connected to oxygen. That does two things at once. It removes the ventilator and its circuit as a possible cause, and it lets you feel the lungs: a bag that is suddenly hard to squeeze points to an obstruction, a pneumothorax or stacked breaths, while a patient who improves as soon as you start bagging points to the equipment. Bag at a controlled rate and do not over-ventilate. As our Perfusion and Shock guide explains, positive-pressure breaths lower the return of blood to the heart.

The DOPE mnemonic, letter by letter

D: Displacement

A tube that was in the right place can come out with any move: onto the stretcher, down the stairs, into the ambulance, or when the patient turns their head. Continuous waveform capnography is the standard the AHA recommends for confirming and monitoring tube placement, and our EtCO2 and Capnography guide explains why: a waveform that disappears or falls to near zero in an intubated patient means the tube is out, in the esophagus, disconnected or blocked until you prove otherwise. Capnography shows a displaced tube the moment it happens rather than when the saturation falls.

• Look at the waveform. A normal, square waveform with a normal number (35 to 45 mmHg in a patient with a circulation) makes an esophageal tube very unlikely.
• Check the depth marking at the teeth or lips against the number documented when the tube was placed. A change in either direction matters.
• Watch for chest rise on both sides, and listen to both sides of the chest and over the stomach. Breath sounds alone do not confirm placement, but they can point to a problem.
• Breath sounds on the right and not the left can mean the tube has gone too far into the right mainstem bronchus, as our Lung Sounds guide describes.
• What you do with a displaced tube is your protocol's. When an advanced airway cannot be confirmed or kept, the commonly taught fallback is to remove it and return to bag-valve-mask ventilation with a basic airway, which our Airway Adjuncts guide covers.

O: Obstruction

An obstructed tube makes bagging hard and can flatten or lose the capnography waveform, just as a displaced one can. Look along the tube and the circuit for a kink, look at the mouth for a patient biting down, and try passing a suction catheter down the tube: one that will not pass suggests a blockage. Suctioning the tube, a bite block, and when to replace a tube that cannot be cleared are your protocol's. A sloping, shark-fin waveform is the pattern of obstruction to exhalation, which in an intubated patient can be bronchospasm or a partly blocked tube.

P: Pneumothorax

Every positive-pressure breath pushes air into the lungs under pressure, so a patient with a small injury to the lung, from trauma, from lung disease or from the ventilation itself, can develop a tension pneumothorax after they are intubated. Look for breath sounds that are diminished or absent on one side, bagging that becomes steadily harder, a falling blood pressure and distended neck veins. That is the obstructive shock picture our Perfusion and Shock and Lung Sounds guides describe. Tracheal deviation is a late sign and often hard to see; do not wait for it. Decompression is within paramedic scope in many systems under protocol, and how and where it is done is your protocol's.

E: Equipment failure

• Oxygen: is the cylinder empty, the regulator off, or the tubing disconnected from the bag or the ventilator? Check the supply before you check anything harder.
• Ventilator: a fault, a wrong setting, a drained battery or an alarm that has been silenced.
• Circuit: a disconnection or a leak at any joint between the ventilator and the tube.
• Cuff: a leaking or deflated cuff lets air escape around the tube, often audible at the mouth. Check the pilot balloon.
• Bag: a stuck valve or a missing part.
• Suction and monitoring: suction that has lost power, and a capnography sensor or line that is blocked or disconnected, which can look like a lost waveform.

Estimate how long an oxygen cylinder will last before you start a long transport

The S in DOPES: stacked breaths and the stomach

Texts that add an S use it for one of two problems, and both are worth knowing.

• Stacked breaths, also called breath stacking or air trapping: the next breath arrives before the last one has been fully exhaled, so air builds up in the chest. It is most common in a patient with asthma or COPD, whose narrowed airways empty slowly, and in a patient bagged too fast. The pressure in the chest rises, the return of blood to the heart falls, and the blood pressure drops. The commonly taught response is to disconnect the bag or ventilator briefly to let the patient exhale fully, then ventilate more slowly, as your protocol directs.
• Stomach: air pushed into the stomach during bagging distends it, presses up on the diaphragm, makes the lungs harder to inflate and raises the risk of vomiting. It is more common with bag-valve-mask ventilation before the airway was placed and in children. Decompressing the stomach with a gastric tube is done where your protocol allows.

When DOPE is clear

If the tube is in, the tube is clear, the chest sounds equal and the equipment works, look beyond the airway. The patient may be in shock, the rhythm may have changed, or the patient may be waking up and fighting the tube. Reassess the whole patient, not only the airway, and treat what you find as your protocol directs.

DOPE and scope of practice

Endotracheal intubation and transport ventilators are paramedic-level skills in most US systems, and some supraglottic airways are within EMT or AEMT scope in some states. DOPE is advanced airway management, but every member of the crew can help with it: checking the oxygen supply, ventilating with the bag, watching the monitor and saying out loud when something changes. Your scope and your protocol decide who does what.

For paramedics whose protocols include RSI: plan how you will confirm and monitor the tube

The short version

• DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure. Some texts add S for stacked breaths or the stomach.
• Run it whenever a patient with an advanced airway gets worse, and especially after any move.
• On a ventilator, a commonly taught first step is to disconnect and bag by hand with oxygen. It rules the ventilator in or out and lets you feel the lungs.
• A lost capnography waveform is a lost tube until proven otherwise. Check the waveform, the depth marking, chest rise and breath sounds.
• A tube that is hard to bag through and will not pass a suction catheter may be blocked.
• Harder ventilation, one-sided breath sounds and a falling blood pressure in a ventilated patient suggest a tension pneumothorax.
• Check the oxygen supply and every connection before anything harder.
• If DOPE is clear, look beyond the airway.