Pick a case, choose your airway strategy, ventilate to target and get a graded debrief on your decisions.
Ventilator for this case
42-year-old woman with obesity hypoventilation syndrome, found unresponsive at home on her own bilevel machine after two days of increasing sleepiness. Slow snoring respirations, CO2 near 90 — the machine is not keeping up.
TeachesIn the massively obese patient, size the breath to predicted body weight, ramp the position, and use real PEEP — volumes sized to actual weight blow plateau pressures past safe limits.
The patient the case was written around.
69-year-old man with COPD placed on BiPAP after a two-day exacerbation. Ten minutes into transport he becomes drowsy, his rate falls, and the CO2 climbs — BiPAP is failing.
TeachesBiPAP is a trial with an exit plan. A falling respiratory rate with a rising CO2 in a drowsy COPD patient is fatigue, not improvement — intubate before the arrest, not after.
The patient the case was written around.
54-year-old man, post-ROSC and intubated, stable on the ventilator for five minutes of transport — until the circuit pulls away at the ET adapter and the low-pressure alarm sounds.
TeachesA low-pressure alarm is a circuit problem until proven otherwise. Bag the patient first, then troubleshoot from the tube outward — the patient should never wait for the machine.
The patient the case was written around.
61-year-old man with three years of ALS, now unable to cough after a choking episode at breakfast. Shallow paradoxical breathing and a CO2 in the sixties — the bellows are failing while the lungs are still normal.
TeachesIn neuromuscular failure the lungs are normal but the pump is gone — the ventilator must do all the work. And succinylcholine is forbidden: chronic denervation means fatal hyperkalemia.
The patient the case was written around.
28-year-old woman, 31 weeks pregnant, three days of worsening asthma that has stopped responding to everything. Tripoding, speaking single words, silent chest — she needs a tube with two patients in mind.
TeachesIn late pregnancy the chest is stiff, the oxygen reservoir is small, and there are two patients on the tube. Pre-oxygenate perfectly, keep the pressure capped, and hold the EtCO2 low enough to protect uterine blood flow.
The patient the case was written around.
66-year-old woman, intubated for severe pneumonia and stable in transport, until the exhaled volume alarm trips and a wet leak is heard at the mouth with every breath.
TeachesFalling exhaled volume with an audible leak is a cuff or tube problem, not a lung problem. Check the pilot balloon, add air, and confirm the volumes match — be ready to exchange the tube if the leak will not seal.
The patient the case was written around.
38-year-old carried out of a house fire with facial burns, soot around the mouth and hoarseness progressing to stridor on scene.
TeachesAn airway burn closes from above: secure the tube early, then ventilate the chemical injury underneath like ARDS.
The patient the case was written around.
58-year-old man in refractory ventricular fibrillation, intubated during ongoing resuscitation, with ROSC achieved after the fourth shock.
TeachesAfter a long arrest, hold a normal CO2 and avoid both too little and too much oxygen.
The patient the case was written around.
33-year-old driver intubated after a head-on collision who becomes suddenly impossible to ventilate minutes into the transport.
TeachesThe first minutes of positive pressure can create a tension — recognize the pattern early and decompress.
The patient the case was written around.
24-year-old pulled from a cold lake after a prolonged submersion, profoundly hypoxemic with copious pink froth in the airway.
TeachesDrowning behaves like ARDS from the first minute: the surfactant is washed out, and PEEP is what reopens the lung.
The patient the case was written around.
26-year-old motorcyclist with an open pelvic fracture, profoundly hypotensive and tachycardic, with only crystalloid available.
TeachesLow preload with normal lungs: keep the pressures minimal and treat the shock with volume, not with the ventilator.
The patient the case was written around.
45-year-old woman with angioedema of the tongue and lips after a shellfish meal, whose stridor is worsening despite repeated epinephrine.
TeachesEpinephrine first, airway second — and the tube goes in before the swelling closes it.
The patient the case was written around.
48-year-old woman with aspiration pneumonitis after a drug overdose who has progressed to refractory hypoxemia despite escalating oxygen.
TeachesA stiff, flooded lung is managed with low volumes and enough PEEP — chasing a perfect saturation with pressure causes harm.
The patient the case was written around.
A 41-year-old with a gunshot wound to the abdomen, profoundly hypotensive and tachycardic at the scene, now intubated and ventilated en route to the trauma center.
TeachesPositive pressure steals preload — in shock the ventilator can deepen the very hypotension it was meant to treat.
The patient the case was written around.
36-year-old man with rapidly ascending weakness who has lost the ability to cough, swallow or breathe adequately.
TeachesWhen the lungs are normal and the pump has failed, the patient needs full support — not a weaning mode.
The patient the case was written around.
34-year-old restrained driver trapped in a high-speed MVC. Paradoxical chest wall movement on the right with severe pain and hypoxia at the roadside.
TeachesA broken chest wall wants low volumes and low pressures — the ventilator can turn a rib fracture into a tension pneumothorax.
The patient the case was written around.
27-year-old woman in status asthmaticus, intubated on scene after a silent chest and exhaustion. Airway pressures are extremely high on the first breaths in the truck.
TeachesIn severe obstruction, control the pressure and accept a high CO2 — a normal CO2 bought with a tensioned chest kills.
The patient the case was written around.
55-year-old collapsed at an airport gate after a long-haul flight. Sudden dyspnea, presyncope and a saturation of 82% on room air, now profoundly hypotensive.
TeachesWhen the lungs sound clear but the blood is blocked, a low EtCO2 means dead space, not hypoventilation — more rate will not fix it.
The patient the case was written around.
71-year-old man with a severe COPD exacerbation who has failed non-invasive support and is now barely rousable.
TeachesIn a chronic retainer the CO2 target is their own baseline, not 40 — and a slow rate is what lets the lung empty.
The patient the case was written around.
A 24-year-old motorcyclist, helmet ejected, GCS 7 at the roadside. You intubate on scene and the peak pressure jumps on the first breaths in the back of the truck.
TeachesA sudden rise in pressure with a falling blood pressure is a needle problem, not a ventilator problem.
The patient the case was written around.
22-year-old man in a severe asthma attack at a bus stop, now with minimal air movement and a silent chest.
TeachesA silent chest means almost no air is moving — the quietest asthma is the most dangerous. Slow the rate and let the breath out.
The patient the case was written around.
62-year-old woman who collapsed at a bus terminal with sudden dyspnea and presyncope, now profoundly hypotensive with a low EtCO2.
TeachesA failing right ventricle cannot tolerate pressure inside the chest — keep PEEP and tidal volumes low.
The patient the case was written around.
41-year-old whose family called 911 after three days of ascending weakness, now unable to lift their head off the pillow and with a weak, ineffective cough.
TeachesA falling vital capacity, not a falling saturation, is what signals the need for ventilation.
The patient the case was written around.
29-year-old motorcyclist thrown over the handlebars, with a bruised and tender left chest and worsening hypoxemia.
TeachesA normal saturation on scene does not mean a normal lung — contusion declares itself later.
The patient the case was written around.
71-year-old man with abdominal pain and fever, now confused, tachypneic and acidotic, with clear lungs and a normal saturation.
TeachesNormal lungs with high CO2 production — a low EtCO2 here can mean low cardiac output rather than good ventilation.
The patient the case was written around.
49-year-old woman in cardiac arrest with ROSC after three shocks, now intubated in the back of the truck en route to a tertiary center.
TeachesAfter ROSC the brain is vulnerable to both too little and too much oxygen — hold a normal CO2 and wean the oxygen down.
The patient the case was written around.
37-year-old found unresponsive after a mixed overdose, who vomited and aspirated before the crew arrived.
TeachesProtect the airway first, then ventilate a chemically injured lung.
The patient the case was written around.
34-year-old man after an MVC with a severe head injury. GCS 6 at the roadside, requiring airway protection and controlled ventilation.
TeachesA blown pupil means herniation — brief hyperventilation buys time while the cause is treated.
The patient the case was written around.
A stable, ventilated adult in the back of the truck with normal lung mechanics and no clinical target.
TeachesA normal lung is the baseline — learn what each setting does to pressure, flow and volume before anything goes wrong.
The patient the case was written around.
44-year-old found seizing at home, now post-ictal and hypoxemic after vomiting, with gastric contents suctioned from the airway on scene.
TeachesAspiration injures the lung from the inside — expect it to behave like a stiff, shunting lung.
The patient the case was written around.
33-year-old man with two days of worsening wheeze, now tiring with a rising CO2 despite continuous nebulizers.
TeachesFatigue is the warning sign: a tiring asthmatic needs pressure control and time to exhale.
The patient the case was written around.
35-year-old found slumped behind the wheel at a red light by a passer-by, with pinpoint pupils, blue lips and a respiratory rate of 5.
TeachesA slow rate with a rising CO2 is hypoventilation — count the breaths before you reach for the ventilator.
The patient the case was written around.
19-year-old pulled from a lake after four minutes of submersion. GCS 5, copious frothy secretions, and profound hypoxemia immediately after intubation on the shoreline.
TeachesAfter a submersion the hypoxemia outlasts the event — PEEP keeps the flooded units open.
The patient the case was written around.
68-year-old woman with known myasthenia gravis, now unable to swallow her secretions or lift her head off the pillow.
TeachesA failing pump with normal lungs needs full support and close attention to secretions.
The patient the case was written around.
55-year-old man with pneumonia progressing to ARDS physiology. Bilateral infiltrates, refractory hypoxemia and a P/F ratio of 120, now being transported to a tertiary center.
TeachesARDS physiology on a transport: low volumes, adequate PEEP, and a plateau pressure that stays under 30.
The patient the case was written around.
28-year-old found unresponsive in a park with pinpoint pupils and a respiratory rate of 6 after a suspected heroin overdose. Naloxone has been given, but ventilation remains inadequate.
TeachesThe lungs are healthy and the drive to breathe is gone — support the rate and volume, and give the antidote.
The patient the case was written around.
74-year-old man with severe COPD found drowsy in his armchair by his daughter, with a saturation of 96% on his home oxygen at 4 L/min.
TeachesIn a chronic retainer, oxygen is titrated to 88–92% — too much of it can blunt the drive to breathe.
The patient the case was written around.
72-year-old in a nursing facility with fever, productive cough and progressive dyspnea. SpO2 84% on a non-rebreather, tachypneic with accessory muscle use.
TeachesSepsis raises CO2 production and shunts blood past the lung — the numbers move for two reasons at once.
The patient the case was written around.
32-year-old stung by a bee at a park, now with urticaria, an audible wheeze and a hoarse, stridulous voice that is getting quieter.
TeachesTwo problems at once: an airway closing above and bronchospasm below.
The patient the case was written around.
66-year-old man who became acutely breathless at a wedding reception, now sitting bolt upright, drenched in sweat, with a blood pressure of 214/118.
TeachesThe heart is the problem — positive pressure buys time while the afterload comes down.
The patient the case was written around.
51-year-old man who had a generalized seizure at home and is now post-ictal and breathing shallowly, with no evidence of aspiration.
TeachesA sedated patient who has stopped breathing needs support until the drive comes back.
The patient the case was written around.
34-year-old unrestrained driver extricated from a high-speed collision. Bilateral lower-zone opacities and worsening hypoxemia in the back of the truck despite a high-flow mask.
TeachesA contused lung stiffens over hours — reassess the pressures as the case goes on.
The patient the case was written around.
63-year-old woman with three days of fever and myalgia who has deteriorated rapidly in the last two hours with bilateral infiltrates.
TeachesDeterioration within minutes in a case that looked stable — reassess the patient, not the settings.
The patient the case was written around.
57-year-old man found on the pavement after a ground-level fall, smelling of alcohol, with a head laceration and a GCS of 7.
TeachesCushing's response — high blood pressure with a slow pulse — is a late sign of rising pressure inside the skull.
The patient the case was written around.
62-year-old man on the second day after an open laparotomy, now drowsy and hypoxemic with shallow, splinted breathing.
TeachesPain splints the chest — the fix is analgesia plus support, not a bigger tidal volume.
The patient the case was written around.
68-year-old man with known COPD, increasing dyspnea and wheezing over the past day, found by a neighbor. Too breathless to speak in full sentences.
TeachesA tiring COPD patient on bilevel needs the pressures titrated against the CO2 — and a plan for when it fails.
The patient the case was written around.
78-year-old woman with acute decompensated heart failure, frothy sputum and orthopnea, found in bed struggling to breathe.
TeachesCPAP opens the flooded alveoli and reduces the work of breathing — watch for the blood pressure falling.
The patient the case was written around.
79-year-old woman in a care home with an acute COPD exacerbation who has a signed order declining intubation.
TeachesThe right answer can be non-invasive support and a ceiling of care — not every case ends with a tube.
The patient the case was written around.
46-year-old man pulled from a smoke-filled apartment, coughing soot-stained sputum with singed nasal hairs.
TeachesEarly stridor after a fire means the airway is closing, and carbon monoxide hides behind a normal saturation.
The patient the case was written around.
68-year-old with known COPD, two days of worsening breathlessness and a productive cough. The family called 911. Alert, sitting forward in a chair and using accessory muscles.
TeachesBilevel support offloads the work of breathing and often keeps a COPD patient off a tube altogether.
The patient the case was written around.
31-year-old man who fell from a ladder, with a head injury and a GCS of 8. Intubated on scene for airway protection, now in the truck.
TeachesA head injury wants a normal CO2 — hyperventilating a brain with normal pressure causes ischemia for no gain.
The patient the case was written around.
81-year-old resident of a care home with a two-day history of fever and a wet cough, now hypoxemic and mildly confused.
TeachesA low tidal volume per predicted body weight protects the lung even when the case looks straightforward.
The patient the case was written around.
58-year-old woman on hemodialysis who missed two sessions, now breathless at rest with bilateral crackles and a blood pressure of 188/104.
TeachesFluid in the alveoli is opened up with PEEP, and the same positive pressure unloads the heart.
The patient the case was written around.
40-year-old woman stung by a wasp at a barbecue, now with urticaria, vomiting and a wheeze that has developed over ten minutes.
TeachesEpinephrine is the treatment; the ventilator only supports the bronchospasm underneath it.
The patient the case was written around.
26-year-old woman with known asthma, wheezing heavily after two days of a cold, not improving after three nebulizers.
TeachesGive the breath time to leave the chest — rate and inspiratory time matter as much as the drug.
The patient the case was written around.
58-year-old with a BMI of 52, daytime somnolence and morning headaches, found drowsy with shallow breathing and CO2 retention during a chest infection.
TeachesA heavy chest wall needs a higher inspiratory pressure, and the target is the patient's own baseline CO2.
The patient the case was written around.