Medical

Severe asthma / COPD crash airway

Before / During / After / Pitfalls

Before

• Treat before tube when possible: bronchodilators, steroids, magnesium/epinephrine as appropriate, NIV if safe, and call RT early.
• Plan the ventilator before induction: low RR, high inspiratory flow/short Ti, long expiratory time, permissive hypercapnia when clinically acceptable.
• Have sedation/paralysis strategy ready to avoid severe dyssynchrony and breath stacking.

During

• Avoid prolonged apnea; maintain oxygenation but do not over-bag.
• After tube, bag slowly and feel for air trapping; disconnect briefly if peri-intubation auto-PEEP shock is suspected.
• Confirm with waveform EtCO2 and assess peak/plateau if high pressures occur.

After

• Low RR, long expiratory time, monitor flow-time waveform, evaluate auto-PEEP.
• Deep sedation ± paralysis for dangerous dyssynchrony per local protocol.
• Reassess BP; dynamic hyperinflation can cause hypotension.

Pitfalls

• High RR after intubation causing breath stacking.
• Treating high peak pressure as tube obstruction without checking bronchospasm/auto-PEEP.
• Forgetting that hypotension may improve after disconnecting the ventilator.