If an alveolar waveform is not present after intubation, what is the next step?

• A. Reattempt intubation immediately.
• B. Increase oxygen flow.
• C. Remove ETT or SGA and proceed to next step.
• D. Administer epinephrine.

Answer: (C)

When you’ve just placed an airway device, the presence of an alveolar (end-tidal) CO2 waveform confirms that ventilation is happening through the trachea. If that waveform isn’t present after intubation, it raises concern that the tube or supraglottic airway isn’t delivering ventilation as intended—most commonly it could be in the esophagus or otherwise not providing gas exchange.

The best next move is to remove the airway device and proceed to the next step of airway management. This allows you to reassess the airway, reattempt intubation with improved technique or positioning, or switch to an alternative airway strategy while ensuring you don’t stay with a device that isn’t providing effective ventilation.

Increasing oxygen flow won’t address the lack of CO2 signal, since the issue is whether ventilation is actually occurring through the airway. Reattempting intubation immediately without addressing the uncertain placement can waste time and increase risk, and epinephrine won’t fix a ventilation problem related to misplacement or poor gas exchange.