Post-intubation deterioration

Tube-in/patient-worse differential and immediate rescue.

No EtCO₂ Waveform After IntubationNo waveform EtCO₂ after intubation is a crisis until proven otherwise. Assume the tube or the circulation is the problem and act immediately.Hypoxia After IntubationTube-in, patient-worse hypoxia demands immediate oxygenation while the team searches for displacement, obstruction, pneumothorax/patient factors, equipment failure, and stacked breaths.Hypotension After IntubationPost-intubation hypotension is often physiology plus medications plus positive pressure. Treat it as an airway-adjacent shock problem.High Airway Pressure After IntubationHigh pressure is not a diagnosis. The key move is to classify resistance, compliance, equipment, tube, and patient-ventilator interaction.DOPES Algorithm for Post-Intubation DeteriorationDOPES is a simple shared mental model for tube-in/patient-worse deterioration. It should trigger oxygenation and a systematic search for reversible causes.Ventilator Dyssynchrony / Biting TubeDyssynchrony can be pain, anxiety, hypoxia, hypercarbia, bronchospasm, tube discomfort, or ventilator mismatch.Post-Intubation HypotensionAfter the tube, hypotension may be medication-related, preload/PPV-related, obstructive, or underlying shock.

About this resource

Created by: Andrew Pirotte, MD; Kyle Brown, MD; Reba Hodge, MD; Amanda Vanderwerf, PharmD, BCEMP; Morgan Kimball, PharmD, BCEMP; Joshua Mohess Clinical review: Clinical review pending: local ED, ICU, EMS, anesthesia, pharmacy, and pediatric protocol review recommended before bedside teaching rollout. Last reviewed: 2026-07-23 Next scheduled review: 2027-01-23 Designed for: EM residents, emergency physicians, EMS clinicians, airway educators, and simulation faculty Important: Educational resource and cognitive-aid guide only; not a bedside order set or substitute for local protocol, medical direction, or clinical judgment. Website contact: kybrown@kumc.edu