1. Cusma Piccione, Riccardo MSN, RN

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During the COVID-19 pandemic, the Italian health care system was strained as the number of critical care patients quickly exceeded the available intensive care unit (ICU) beds. Many nurses were involved in reorganizing wards and ICUs, increasing ICU beds as reported by Lucchini et al.1 Of concern, but out of necessity, non-critical care nurses from different departments (eg, operating department, ambulatories, medicine or surgical wards, emergency department) were moved to work in an ICU.


These conditions caused some difficulties related to human and structural resource management. The first step was geared to increasing ICU beds, both changing the specialist ICUs (eg, cardiovascular intensive care unit, neonatal ICU) to COVID ICUs and converting non-ICUs, such as operating theaters, dismissed wards, or other areas (eg, medicine or surgical units), into high-intensity medicine floors or ICU. These reorganizations created a unique set of problems related to limited bedside space, different types of ventilator machines, and overall unit operations.


A second step involved expanded staffing in ICU areas. Nurses not oriented to ICU care or experienced as critical care nurses were allocated to work in a critical care setting. However, most worked in miscellaneous teams, in which at least 1 ICU expert or specialized critical care nurse was present to support the team for critical thinking and ICU clinical practices, such as patient proning, management of ventilated patient, invasive monitoring, and management of emergency situations, such as difficult airway management or cardiac arrest.


To address this challenge, the ANARTI, the Italian Society of Critical Care Nurses, published a document to acquire a systematic approach to non-ICU nurses.2 In this document, knowledge was expanded and reported through evidence-based practice guidelines such as the ABCDE bundle. In every local hospital, critical care nurses complete training on the job to guarantee a relationship between theory and practice, in accordance to the ABCDE bundle, expounding all the single "letters" to reflect on the clinical practice. The addition of the letter F recognizes the need for family involvement. The ABCDEF bundle represents an evidence-based guide for clinicians to approach the organizational changes needed for optimizing ICU patient recovery and outcomes. The ABCDEF bundle is defined as follows: assess, prevent, and manage pain; both spontaneous awakening trials and spontaneous breathing trials; choice of analgesia and sedation; delirium: assess, prevent, and manage; early mobility and exercise; and family engagement and empowerment.3


Considering the initial assessment of a critical care patient by non-ICU nurses, an initial emergency assessment using the ABCDE approach was determined. In particular, the ABCDE approach is defined as airways, breathing, circulation, disability, and exposure.4


The ABCDE approach is applicable in acute care settings in assessing priority patients to avoid complications, to improve speed and the quality of assessment and treatment.


The mnemonic approach was invented in 1950 and was implemented as follows: A-B was described by Safar in 1950, implemented with C by Kouwenhoven, and extended to D-E by Styner in 1976.5 Finally, the ABCDE approach was used worldwide by emergency technicians, nurses, and physicians.6


The ABCDE approach was the preferred method in the rapid evaluation of a potential critical care patient, to recognize early a deterioration of vital signs and to apply an early resuscitation. Hospitals should improve the ABCDE approach not only to emergency situations but also for all initial critical care patient evaluations.7,8


In relation to ARDS due to Sars-Cov 2, an important step in assessment and treatments is represented by the letter "B," for breathing, in particular troubleshooting during mechanical ventilation. To improve situational awareness during complications in invasive ventilation, a mnemonic approach is represented by DOPES.9,10


The DOPES mnemonic represents the principal causes of ventilator troubleshooting, including the machine/patient system interface. The mnemonic serves as a troubleshooting guide for all staff caring for COVID-19 patients and is especially useful for providers new to critical care.


1. Dislocation: This represents endotracheal tube (ETT) or tracheostomy cannula disconnection, either from the patient or the ventilator circuit. First, observe all connections, checking the right place and right depth of the tube (especially after nursing hygiene or pronation) in relation to sex and type of ETT or the correct position of cannula in the tracheal stoma.11,12 Second, check the ventilator to analyze correct tidal volume, volume, and pressure lines. Last, but not the least, check that there is an effective closed circuit from the machine to the trachea, checking all connections and the adequate pressure and seal of the ETT cuff.


2. Obstruction: Obstructions may be due to dense secretions or kinking of the ETT or circuit. In COVID patients, secretions are often dense, causing a crisis event of partial or total obstruction, especially in tracheostomy. Adequate humidification and suctioning may be required.


3. Pneumothorax: In patients with high airway pressure, inadequate tidal volume may be associated with general signs of pneumothorax (eg, agitation in a conscious patient, tracheal contralateral deviation, dyspnea, desaturation, tachycardia, hypotension, subcutaneous emphysema), making ventilation difficult because of the pathophysiological mechanism of a "block of air" that cannot enable correct pulmonary function with mediastinal deviation and great vessel compressions.


4. Environment: Ventilator machines can fail for intrinsic or extrinsic causes; for example, centralized electrical connection problems and a malfunction in gas systems (eg, no dispense or low central gas pressures) are extrinsic problems. Intrinsic problems are represented by internal oxygen cell due to calibration errors and administration of lower oxygenation than FiO2 set-up on the ventilator.


5. Stomach: Diaphragmatic thoracic excursions limit the physiological work of the lungs. It can be caused by abdominal hemorrhage or simply by massive presence of gas insufflated into the stomach by positive pressure ventilation.



A recent case13 reported difficult ventilation due to fentanyl administration, which caused chest wall rigidity, adding an "R" to the DOPES acronym. However, in our clinic, this pharmacological event was not replicated, although we know that this is a possibility associated with fentanyl administration. At this time, the sense of "R," chest rigidity, or pulmonary rigidity, determined by low compliance with a stiff lung, was not considered as a first-line issue in our rapid assessment.


In conclusion, the detailed analysis of "B" is enhanced by using the acronym DOPES. It has been used to improve situational awareness, to standardize the work of nurses transferred from different areas of the hospital. The DOPES mnemonic is a technique that can be used to educate nurses and to guide teams to troubleshoot mechanical ventilation complications. The format considers many factors from airways to ventilation, considering the entire patient-machine system.


Riccardo Cusma Piccione, MSN, RN


Cardiothoracic Vascular - Heart


Transplant Intensive Care Unit


Department of Anesthesia and


Intensive Care Unit III[degrees]


ASST Grande Ospedale




Niguarda Milan, Italy




1. Lucchini A, Giani M, Elli S, Villa S, Rona R, Foti G. Nursing activities score is increased in COVID-19 patients. Intens Crit Care Nurs. 2020;59:102876. doi:. [Context Link]


2. Bambi S, Peduto C, Dammiano P, Bardacci Y, Ballerini L, Mattiussi E. Schema di approccio al nursing di routine per il paziente in Terapia Intensiva. (2020). [Context Link]


3. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225-243. doi:. [Context Link]


4. Resuscitation Council UK. The ABCDE approach. 2015. Accessed November 5, 2020. [Context Link]


5. Safar P, Brown TC, Holtey WJ, Wilder RJ. Ventilation and circulation with closed-chest cardiac massage in man. JAMA. 1961;176:574-576. [Context Link]


6. Thim T, Krarup ELG, Rohde CV, Lofgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117-121. [Context Link]


7. European Council of Resuscitation. European Resuscitation Council guidelines for resuscitation 2015 Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015;95:81-99. [Context Link]


8. Olgers TJ, Dijkstra RS, Drost-de Klerck AM, ter Maaten JC. The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study. Neth J Med. 2017;75(3):106-111. [Context Link]


9. Hofstetter C, Scheller B, Hoegl S, Mack MG, Zwissler B, Byhahn C. Cuff overinflation and endotracheal tube obstruction: case report and experimental study. Scand J Trauma. 2010;18(18). [Context Link]


10. Kashani P, Mirbaha S. Confusing hypoxia in a 21-year-old intubated multiple trauma patient. Emergency. 2014;2(2):104-105. [Context Link]


11. Landsperger JS, Byram JM, Lloyd BD, Rice TW. The effect of adhesive tape versus endotracheal tube fastener in critically ill adults: the endotracheal tube securement (ETTS) randomized controlled trial. Crit Care. 2019;23:161. [Context Link]


12. Evron S, Weisenberg M, Harow E, et al. Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements. J Clin Anesth. 2007;19(1):15-19. [Context Link]


13. Thomas VK, Abraham SV. Adding an "R" in the "DOPE" mnemonic for ventilator troubleshooting. Ind J Crit Care Med. 2018;22(5):388. [Context Link]