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Letters to the Editor

Adding an “R” in the “DOPE” Mnemonic for Ventilator

Troubleshooting
Sir, clinical information to be reported in the journal. The patients
A 20‑year‑old male was admitted in the emergency department understand that their names and initials will not be published
with a diagnosis of abdominal sepsis and septic shock. He was and due efforts will be made to conceal their identity, but
intubated in view of hemodynamic instability and started on anonymity cannot be guaranteed.
vasopressors. A computed tomography scan of the abdomen
was advised and was shifted to the radiology suite. The Financial support and sponsorship
patient was restless and was administered slow intravenous Nil.
midazolam 2 mg and fentanyl 100 µg for procedural sedation. Conflicts of interest
Patient developed desaturation on the ventilator. The transport There are no conflicts of interest.
ventilator was disconnected, and bag valve oxygenation was
initiated. No chest rise was noted. Suctioning of the airway Vimal Koshy Thomas, Siju Varghese Abraham
was performed and showed no obstruction or displacement. Department of Emergency Medicine,
Lung ultrasonography revealed normal lung sliding bilaterally. Jubilee Mission Medical College and Research Institute,
Thrissur, Kerala, India
A diagnosis of hypoxia due to chest wall rigidity was suspected
by fentanyl. Injection naloxone 0.2  mg was administered Address for correspondence: Dr. Vimal Koshy Thomas,
intravenously and patient saturation improved within a few Department of Emergency Medicine,
minutes. Jubilee Mission Medical College and Research Institute,
Thrissur, Kerala, India.
Troubleshooting the ventilator is an important intervention E‑mail: drvimal007@gmail.com
in patients who develop hypoxia postintubation. If
hypoxia remains undetected, it can be rapidly fatal References
without early intervention. A  structured approach to 1. Brady B, Charlton NP, Lawner BJ, Sutherland SF. Car-diac Arrest, An
concurrently identify and treat the underlying cause is Issue of Emergency Medi-cine Clinics-E-Book. Philadelphia: Else-vier
Health Sciences; 2012.
imminent. A helpful mnemonic is “DOPE,” which stands
2. Bailey  PL, Pace  NL, Ashburn  MA, Moll  JW, East  KA, Stanley  TH,
for displacement or obstruction of the endotracheal tube, et al. Frequent hypoxemia and apnea after sedation with midazolam and
pneumothorax, and ventilator or equipment failure. fentanyl. Anesthesiology 1990;73:826‑30.
[1]
Fentanyl is known to cause hypoxia and chest wall 3. Çoruh B, Tonelli  MR, Park  DR. Fentanyl‑induced chest wall rigidity.
Chest 2013;143:1145‑6.
rigidity and benzodiazepines accentuates its effect. [2,3]
Chest wall rigidity following administration of fentanyl
is a rare complication, but all physicians should be able
to recognize this complication and provide appropriate This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
management to prevent life‑threatening respiratory remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
compromise. Risk factors for developing opioid‑induced is given and the new creations are licensed under the identical terms.
rigidity include higher doses and rapidity of opioid
Access this article online
injection, extremes of age, patients with critical neurologic
Quick Response Code:
or metabolic illness, and usage of medications that are Website:
able to modify dopamine levels.[3] Management includes www.ijccm.org
supportive care and reversal with either naloxone or a
short‑acting neuromuscular blocking agent in extreme DOI:
cases.[3]  The mnemonic “DOPER” reminds you not only 10.4103/ijccm.IJCCM_501_17
to check for DOPE but also for rigidity of the chest wall.
Declaration of patient consent How to cite this article: Thomas VK, Abraham SV. Adding an “R” in the
The authors certify that they have obtained all appropriate “DOPE” mnemonic for ventilator troubleshooting. Indian J Crit Care Med
patient consent forms. In the form the patient(s) has/have 2018;22:388.
given his/her/their consent for his/her/their images and other © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow

388 © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow

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