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Failure of NIV in acute asthma: case report and a word of caution

▸ Noninvasive ventilation (NIV) is the provision of ventilatory support without the need for an invasive airway, and has revolutionised the management of patients with diverse forms of respiratory failure. The advantages of NIV include improved patient comfort, reduced need for sedation, whilst avoiding the complications of endotracheal intubation, including upper airway trauma, sinusitis, otitis, and nosocomial pneumonia. In selected patients NIV has also been shown to improve survival. The role of NIV in acute severe asthma is at best controversial. In this case report we describe a patient with acute severe asthma who was initially managed with NIV, and who failed a trial of NIV, and was successfully managed with invasive ventilation. We also review the pathophysiological mechanisms of benefit of NIV in acute severe asthma, and the current literature on the use of NIV in acute asthma.

In conclusion, a trial of NIV in acute asthma may be justified in carefully selected and monitored patients who do not respond to initial medical therapy. However, since its role is not clear and as the condition of an asthmatic patient may deteriorate abruptly, extreme caution is advisable to recognise failure of NIV as in the case presented here. Facilities for immediate endotracheal intubation and next level of treatment should be readily available.

Do we intervene inappropriately for ST elevation?

▸ Targets for reperfusion have altered drastically the assessment of a patient with chest pain. In our emergency department the standard is 10 minutes from presentation to ECG review for these patients. ST elevation on a 12 lead ECG is one of the cardinal features of acute myocardial infarction (AMI). There are, however, other causes of ST elevation in addition to AMI. Intracerebral bleed, aortic dissection, tension pneumothorax, Brugada syndrome and pericarditis have all been reported to cause these changes.

Three cases are …

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