Post-intubation hypoxia

Reviewed and revised 26 September 2015


Post-intubation hypoxia can be rapidly fatal without early intervention, which requires a structured approach to concurrently identifying and treating the underlying cause


The immediate life threats can be summarized as “DOPES”:

  • Displacement of the endotracheal tube (ETT)
  • Obstruction of the ETT
  • Patient — especially pneumothorax; also: pulmonary embolism, pulmonary edema, collapse, bronchospasm
  • Equipment — ventilator problems
  • Stacked breaths’ — a reminder about bronchospasm and ventilator settings.

Structured approach

  1. Disconnect the ventilator and administer high-flow 100% oxygen (FiO2 1.0) using a bag-valve-mask.
    • Disconnection allows the release of trapped gas in the patient with severe bronchospasm — these patients usually have evidence of bronchospasm and/ or hypotension in addition to hypoxia.
    • Also, if the patient is easy to ventilate and re-oxygenate, then the problem probably lies with the ventilator or the circuit.
    • In a ventilated patient that has a problem always think: man versus machine.
  2. Assess the patient using the MASH approach before attempting to diagnose the problem:
    • Movement of the chest during ventilation —
      is it absent or is movement only on one side? Is the chest hyper-expanded?
    • Arterial saturation (SaO2) and PaO2 —
      obtain an ABG sample
    • Skin colour of the patient (is he turning blue or pinking up?) —
      the SO2 monitor lags behind the true oxygen saturation of the patient.
    • Hemodynamic stability
  3. If the patient is difficult to manually ventilate, determine if the problem lies with the endotracheal tube or with the patient.
  4. If there is little chest movement, a patient problem is still possible, but a problem with the ETT needs to be be ruled out urgently:
    • check ETCO2 to ensure the ETT is not in the esophagus and is patent.
    • pass a suction catheter and/ or a bougie to ensure the ETT is not obstructed.
    • check the placement of the tube visually — preferably by bronchoscopy, or alternative by by laryngoscopy from the top end (although this is far from 100% reliable).
    • consider a CXR to check ETT position if hypoxemia is not critical, especially if endobronchial intubation is suspected
    • If in doubt, and the hypoxia has not been rapidly resolved, take the tube out… and replace it.
  5. If there is reasonable chest movement, a patient problem is most likely. Perform a focused exam and urgently seek and treat the following life-threats:
    • pneumothorax (look for asymmetrical chest movement)
    • lung collapse (look for asymmetrical chest movement)
    • pulmonary edema
    • bronchospasm (chest wall movement may be minimal — look for hyper-expansion)
    • pulmonary embolus
  6. If the bag is easy to compress during manual ventilation, but there is little or no chest movement suspect either:
    • a circuit leak (e.g. cuff leak, disconnection, or a hole in the circuit), OR
    • dislodgement of the endotracheal tube — you may be ventilating the oropharynx or the stomach
  7. If the patient is easy to ventilate with the bag and the hypoxemia rapidly resolves
    • Find out what happened just before the desaturation:
      • had suctioning been performed? (in some settings the loss of PEEP during disconnection of the circuit may lead to derecruitment and atelectasis, result in desaturation)
      • had there been a disconnection of the ventilator/circuit?
    • Otherwise, there may be a problem with the ventilator settings or there was an equipment failure.
      • check ventilator settings
      • trouble-shoot equipment failure

Acute Respiratory distress syndrome (ARDS)

ARDS patients are typically ventilated with a protective lung ventilation strategy +/- an open lung approach. In cases of refractory hypoxaemia there are numerous strategies for improving oxygenation in ARDS. These topics are covered in other sections of the CCC, see the CCC ventilation series below.

CCC Airway Series

CCC Ventilation Series


FOAM and web resources

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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