I have intubated about six or seven asthmatics in my career and all of them
have been either been either
a) at a point where their dyspnea/ hypoxia/ hypercapnea was inducing a panic
and they were trying to pull off their mask and get out of bed
b) apnea was imminent and they were gasping and frankly cyanotic on high
Interestingly, I have had two other patients where the child arrived in
clear cut CO2 narcosis (eyes closed, but arousable to pain and with
a gag reflex), where I decided to not intubate. I threw the kitchen sink at
them and they improved and avoided intubation.
So my sense is that the indications for intubation are really the patient's
response to their dyspnea. Some patients panic- it is a sensation
they cannot tolerate, while others appear not be bothered by it as their CO2
rises to 100.
Their was a nice review on the pathophysiology of dyspnea in the NEJM many
years ago that I believe alluded to this notion that dyspnea is
a sensation, much like pain, that each individual responds to differently;
Manning et al. NEJM 1995;333:1547.
Jay D. Fisher MD FAAP
Director of Pediatric Emergency Services
Emergency Physicians Medical Group
University Medical Center, Las Vegas NV
St. Rose Sienna Hospital, Henderson NV
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