Author Question: Causes of Respiratory Distress in a Ventilated Patient

Terry Asks:

My question is what would make a person in a drug induced coma go into respiratory distress? My character is having really strange dreams/nightmares in his comatose state and I want to introduce a dark force (ie death), that is trying to take him. At the same time, in the hospital that dark force is actually a respiratory distress, but I can’t find any information on what would cause him to go into distress or how that would be handled by the doctors and nurses.

Image by Simon Orlob from Pixabay

Jordyn Says:

A patient in a medically induced coma will also be intubated (a tube inserted into the trachea to help the person breathe) and will be ventilated by a machine.

There is a pneumonic that most medical people run through when a person on a ventilator develops trouble breathing and it is the D.O.P.E. pneumonic. I first learned it in Pediatric Advanced Life Support (PALS) that is a class taught by the American Heart Association.

I’ll give you what they stand for and the medical treatment the nurse/doctor would take.

D: Dislodgement: Dislodgement means the tube is somewhere it shouldn’t be. The endotracheal tube (ETT) could be out of the patient (termed accidental extubation) or it could have migrated into the right bronchi thereby only ventilating one lung. If the tube is completely out (or sitting in the mouth— no longer in the trachea) then the patient would need to be reintubated. If the tube is in the right bronchi, it simply needs to be pulled back a little bit until there are breath sounds in both lungs and equal chest rise when the machine gives a breath. Often times, after measures are taken to correct the situation, a chest x-ray would be taken to verify the tube is in the right place.

O: Obstruction: Obstruction can mean a lot of things. It more commonly means that there are secretions in the ETT tube that need to be cleared. If that happens, they would be suctioned out. However, obstruction can also mean something like a developing pneumonia that may require increased settings on the ventilator and initiation of antibiotics. Ventilated patients are at high risk for developing pneumonia (if they don’t have it already).

P: Pneumothorax: This indicates that one lung has collapsed. Because the lung is deflated it can no longer be ventilated properly and is causing difficulty breathing. Treatment for a pneumothorax is placement of a chest tube to reinflate the lung. The patient should improve after the chest tube is placed, but it does take time for the lung to fully reinflate. Ventilated patients are also at risk for a collapsed lung, particularly if they are on pretty high ventilator settings.

E: Equipment Failure: This can mean something is wrong with the ventilator itself. It can be as simple as the machine became unplugged. Not all ventilators have battery back-up. If this is causing the patient to have respiratory distress, we simply take the patient off the ventilator and begin to bag the patient manually via the ETT until the problem can be sorted out.

Any of these situations can cause respiratory distress in a ventilated patient. It is your choice as the author which one to use.

Hope this helps and good luck with your story!

Medical Errors in Manuscripts: People on a Vent Cannot Speak

Last post I posed a medical question. Why are there white stripes on IV catheters? Answer: If the catheter is lost in the patient, you can find it on x-ray.

Now for another common medical error seen mostly on television and at times in works of fiction.

Note to writers everywhere: Intubated people (those that are on a breathing machine) cannot talk or even moan.

I’ll start by covering the basics. The sound of talking (and other noises) is made when you pass air through your vocal cords causing them to vibrate. This is what your vocal cords look like.


When a patient is intubated, a large plastic tube called an endotracheal tube (ETT) is passed down the throat, through the vocal cords, and into the trachea. The end of the ETT should sit slightly above the carina. The carina is the bifurcation, or splitting, of your trachea into the right and left lung. The ETT is positioned there so both of the lungs get ventilated or inflated with oxygen.

This is what an endotracheal tube looks like.

Adventures of a Respiratory Care Student/Photobucket

When the ETT is fitted correctly, a person should not be able to make noise because air is not passing through their vocal cords, it’s passing through the tube. In an adult, the balloon at the end of the tube is inflated so that it fits snug inside the trachea. If we hear an intubated person speaking or moaning, we know that air is passing through the vocal cords again and something is wrong with the ETT.

It could be as simple as the balloon or “cuff” needing to be inflated with a little more air so it fits snug again. It could be as complicated as the patient has become extubated—meaning the ETT is no longer in the trachea and you go in the room and find the patient holding the tube in their hand.

Medical question for you: How are intubated patients kept from extubating themselves?