Synopsis
Recognise failing respiratory support early, escalate without avoidable delay, and understand the first priorities of safe intubation and physiology-led invasive ventilation.
- Escalate on clinical trajectory, work of breathing, consciousness, haemodynamics, gas exchange and response to treatment rather than one numerical threshold in isolation.
- Call critical care early when NIV or high-flow support is being considered in a patient who could require intubation; rescue referral after collapse is preventable harm.
- Common indications include threatened airway, respiratory arrest, refractory oxygenation failure, progressive hypercapnic acidosis, severe fatigue, secretion failure and need for deep sedation or controlled ventilation.
- NIV failure is a diagnosis made actively: mask leak, synchrony, settings and reversible disease must be corrected, but prolonged ineffective NIV must not postpone intubation in an escalation candidate.
- Agree and document treatment ceilings before deterioration where possible; a decision against intubation should trigger an explicit alternative symptom and NIV plan, not therapeutic abandonment.
- Tracheal intubation in critical illness is a high-risk team procedure requiring pre-oxygenation, checklist, haemodynamic preparation, backup airway plans and waveform capnography.
- After intubation, immediately confirm ventilation, secure tube depth, institute analgesia and sedation, and treat hypotension and the precipitating disease.
- Use lung-protective ventilation where lung injury is present, then individualise PEEP, oxygen, respiratory rate and inspiratory flow to mechanics and gas-exchange goals.
- In obstructive disease, allow enough expiratory time and look for dynamic hyperinflation; worsening hypotension after ventilation may be caused by excessive intrinsic PEEP.
- Reassess every intervention through waveforms, pressures, blood gases and the patient; the ventilator supports physiology while sepsis, bronchospasm, oedema, weakness or another cause is treated.
Key red flags
Progressive upper-airway obstruction, recurrent aspiration, copious bleeding, seizures or reduced consciousness with inadequate airway reflexes requires expert airway control before oxygenation and access become impossible.
Persistent hypoxaemia despite appropriately delivered oxygen and non-invasive support, especially with increasing work, diffuse lung injury or haemodynamic compromise, requires immediate critical-care evaluation for invasive support and adjuncts.
Rising PaCO2 with worsening pH, somnolence, fatigue or reduced chest movement despite optimised cause-specific care and NIV signals inadequate alveolar ventilation and possible need for intubation.
Deteriorating pH, respiratory rate, consciousness or oxygenation after competent interface and setting optimisation means NIV is not achieving its goal; escalation status determines urgent intubation versus revised ceiling care.
Hypotension, rising airway pressures and incomplete expiratory flow return in severe asthma or COPD suggests breath stacking and intrinsic PEEP; disconnecting briefly and correcting expiratory time may be lifesaving.
Investigation priorities
Identify immediate danger and response to respiratory support.
Management branches
Respiratory distress, gas-exchange failure or reduced consciousness is worsening despite initial treatment.
- Call senior respiratory, anaesthetic and critical-care help while continuing ABCDE, target oxygen, monitoring and cause-specific emergency treatment.
- Assess airway protection, work and fatigue, consciousness, haemodynamics, secretions and serial gas trajectory; state what current support is failing to achieve.
- Correct quickly reversible NIV problems such as interface leak, synchrony and settings only while an intubation-capable team prepares if escalation is appropriate.
- Confirm the treatment ceiling and communicate it to the patient or surrogate where feasible; document the plan for deterioration and symptom care.