Few patients are more challenging in the ED than the asthmatic in extremis who is recalcitrant to standard therapy.  Asthma is different than other causes of severe respiratory distress.  And there are different forms of asthma as well.

Besides cricoid pressure, magnesium, and slowing down ventilations, how else might the provider try to reduce the consequences of breath stacking is this case?

• Weingart prefers noninvasive positive pressure ventilation to BVM early on in the management.

• In the rare cases of severe asthma with a ‘stone chest’ that is incredibly difficult to bag, you need to proceed to immediate RSI and get the tube in as quickly as possible.  It’s the only way to safely provide the airway pressures you need.

• • Prolonged bagging with high pressures carries the risk of gastric insufflation and aspiration.

  • Failed attempts at intubation are especially risky in these patients.  As their hypoxia worsens, they may get more acidotic, running a very real risk of cardiac arrest peri-intubation.