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CMAJ. 2010 April 6; 182(6): 593.
PMCID: PMC2845696

Intubation in acute asthma

Dr. Hodder and coauthors have written a detailed review describing the management of the severe asthmatic with respiratory failure requiring mechanical ventilator support.1 I have a concern about their suggested approach to endotracheal intubation. Although they appropriately recommend that this procedure should be carried out by a skilled expert, they suggest rapid-sequence intubation if such help is not available. Rapid-sequence intubation in unskilled hands can have catastrophic consequences.2 I would strongly advocate a near-awake intubation with maintenance of spontaneous respiratory efforts, as an initial intervention. This can be effectively achieved in most patients, with rapid-sequence intubation used as a backup approach. Once an artificial airway has been established, sedation can be given to facilitate ventilation. It is important to bear in mind that the combination of pre-existing volume depletion, air trapping and sedative administration can cause marked hypotension and even cardiac arrest.


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1. Hodder R, Lougheed MD, Fitzgerald JM, et al. Management of acute asthma in adults in the emergency department: assisted ventilation. CMAJ. 2010;182:265–72. [PMC free article] [PubMed]
2. Mace SE. Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am. 2008;26:1043–68. [PubMed]

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