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.