• Do not hesitate. Initiate treatment in cases of respiratory
distress immediately, even if the diagnostic work-up is
This may be demonstrated by the patient's:
c. Failure to protect the airway
If "yes" to any of the above, intubate immediately. If the
patient cannot oxygenate, there will be anoxic injury, espe
cially brain injury, within seconds to minutes. The inability
to perform the act of breathing (failure to ventilate) leads
to carbon dioxide buildup, and the ensuing acidosis can
lead to cardiac dysfunction. Finally, if the patient cannot
maintain an open airway (due to brain injury, mechanical
occlusion, etc.), there will be threat to both oxygenation
and ventilation, warranting immediate intubation.
2. Is the respiratory distress rapidly reversible?
Recognizing and promptly intervening on the rapidly
reversible causes of severe respiratory distress can prevent
the need for intubation. Delays in therapy may cause the
patient to quickly decompensate. Some of these reversible
causes (and their solutions) are as follows:
Bronchospasm (beta -agonists/ steroids/ epinephrine)
Hypertensive pulmonary edema (nitrates/diuresis)
Pneumothorax (needle decompression/chest tube)
Allergic reaction (steroids/ epinephrine/ antihistamine)
Imagine the patient had to run for his or her life (in
many ways, this is what the patient is doing). How
long could the patient go before he or she collapsed?
What is the patient's physiologic reserve? For example,
is the patient young and healthy or elderly with
comorbidities? Consider all of the following in this
The decision to intubate or to wait is based on the
patient's ability to maintain the work of breathing. If
the patient is stable, set time limits and reassess
response to therapy frequently. If the patient has poor
reserve or already has respiratory fatigue, it may be
wiser to intubate electively rather than during a crashing situation.
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