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Airway situation
Severe Asthma / COPD Crash Airway
Obstructive physiology is an oxygenation and ventilation problem before it is a tube problem. The dangerous post-tube complications are air trapping, dynamic hyperinflation, hypotension, and dyssynchrony.
asthmaCOPDobstructive physiologyauto-PEEP
Clinical-use limit: Educational resource and cognitive-aid guide only; not a bedside order set or substitute for local protocol, medical direction, or clinical judgment.
Before intubation
- Maximize bronchodilators, steroids, magnesium/adjuncts, NIV when appropriate, and hemodynamic preparation before paralysis.
- Pre-brief the ventilator strategy before tube passage: low rate, long expiratory time, permissive hypercapnia when appropriate, and auto-PEEP vigilance.
- Stage suction, BVM/PEEP, waveform capnography, and a rescue plan for deterioration after positive-pressure ventilation.
During intubation
- Avoid rapid aggressive bagging that worsens breath stacking.
- Use the most skilled first attempt; minimize apnea while preserving first-pass success.
- After a failed attempt, oxygenate and change a meaningful variable rather than repeating the same plan.
After intubation
- Set obstructive-physiology ventilator priorities: lower RR, adequate flow, long expiratory time, and waveform review.
- If hypotension occurs with high pressures, disconnect briefly and hand-ventilate while evaluating auto-PEEP, pneumothorax, tube obstruction, and shock.
- Continue sedation/analgesia and bronchodilator therapy; call RT/ICU early.
Common pitfalls
- Ventilating like a normal lung.
- Treating high pressures only by increasing sedation without evaluating auto-PEEP or pneumothorax.
- Paralyzing without a plan for post-intubation sedation and obstructive ventilation.