On-shift rescue mode

Post-Intubation Troubleshooting

Use this when the tube is in but the patient is not stable: hypoxia, hypotension, high pressures, no waveform EtCO₂, or ventilator alarms.

Back to checklist Vent calculators Skill decks

First move if unstable: call for help, disconnect from the ventilator, manually ventilate with 100% oxygen, check waveform EtCO₂, and troubleshoot DOPES while RT/ICU support is coming.

Immediate algorithm

Tube in, patient worse

1Oxygenate

Disconnect vent. Bag with 100% O₂. Add PEEP valve if appropriate.

2Confirm tube

Waveform EtCO₂, depth, bilateral chest rise/sounds, cuff/circuit.

3Sort failure mode

Hypoxia, hypotension, high pressure, no EtCO₂, poor compliance, dysynchrony.

4Change something

Fix position, suction/obstruction, vent/circuit, pneumothorax, or auto-PEEP.

DOPES + no waveform EtCO₂

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D: DisplacementTube moved, mainstemmed, or never tracheal.

Check continuous waveform EtCO2.
Check depth at teeth/lips and compare to documented depth.
Listen for bilateral breath sounds and look for symmetric chest rise.
If no waveform or wrong depth: remove/reposition using your local emergency airway pathway.

O: ObstructionTube, circuit, secretions, biting, kink, bronchospasm.

Pass a suction catheter through the ETT.
Look for biting/kinked tube or blocked HME/filter.
Assess peak vs plateau pressure with RT.
Treat bronchospasm and consider tube exchange if catheter will not pass.

P: Pneumothorax / PatientTension physiology, mainstem, collapse, edema, PE, bronchospasm.

If hypoxia + hypotension + high pressures: tension pneumothorax must be considered immediately.
Use bedside exam/ultrasound/chest radiograph when stable enough.
Treat immediately when exam and instability support tension physiology.
Do not wait for imaging in a crashing patient with confirmatory clinical findings.

E: EquipmentVentilator, circuit, gas source, valve, filter, disconnect.

Disconnect from ventilator and bag with 100% oxygen plus PEEP valve when appropriate.
If bagging is easy and oxygenation improves, suspect ventilator/circuit problem.
Check oxygen source, circuit connections, valve function, filters, and ventilator settings.
Call RT early.

S: Stacked breathsAuto-PEEP, dynamic hyperinflation, obstructive shock.

Disconnect briefly to allow full exhalation if severe air-trapping physiology is suspected.
Lower RR and minute ventilation demand when safe.
Increase expiratory time; evaluate flow-time waveform.
Use deep sedation/paralysis when dyssynchrony is driving air trapping.

No EtCO₂ waveformEsophageal tube until proven otherwise, low-flow state, equipment issue.

Reconfirm tube immediately.
Check detector/capnography connection and circuit.
If cardiac arrest/very low perfusion, waveform may be low but should not be ignored.
Use direct visualization/reintubation pathway when placement is uncertain.

Hypotension after intubation

Tube/circuit: confirm placement and oxygenation first.
Obstructive causes: tension pneumothorax, auto-PEEP, high PEEP, RV failure/PE.
Medication/vasodilation: sedative/opioid effect, induction-related sympathetic lysis.
Preload/bleeding/sepsis: reassess volume, vasopressors, source control, and MAP target.
Vent pivot: reduce intrathoracic pressure when air-trapping or excessive PEEP is plausible.

High airway pressure alarm

Bag the patient: feel compliance and bypass equipment.
High peak, normal plateau: resistance problem—tube kink, secretions, bronchospasm, small tube.
High peak and high plateau: compliance/pressure problem—ARDS, edema, pneumothorax, mainstem, auto-PEEP.
Check waveform: flow returning to zero? If not, suspect breath stacking.

Scenario pivots

After the initial vent settings, match the physiology

Severe asthma/COPD

Low RR, long expiratory time, avoid stacking, permissive hypercapnia when clinically acceptable, deep sedation if dyssynchrony.

ARDS/hypoxemia

PBW-based low VT, plateau/driving pressure awareness, deliberate PEEP/FiO₂ escalation, early ICU/RT pathway.

Metabolic acidosis/DKA

Plan before paralysis. Preserve minute ventilation as safely as possible. Avoid sudden apnea and post-intubation hypoventilation.

TBI/neuro

Avoid hypoxia and hypotension. Use EtCO₂ targets and sedation strategy consistent with neurocritical goals.

Shock/RV failure

Preload/pressor plan, avoid excess intrathoracic pressure, consider RV afterload and peri-intubation collapse risk.

Pediatrics

Use measured/length-based weight, staged backup sizes, age-appropriate vent RR, and early pediatric/RT support.

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