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.
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.
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.
Key medicines
Rapid-sequence induction agent selected for physiologyUse the anaesthetist-selected intravenous, weight-based dose from the current local critical-care intubation protocol, reducing it when shock or frailty requires.
Rocuronium for rapid neuromuscular blockadeGive the protocol-specified rapid-sequence intravenous dose based on appropriate body-weight calculation, with immediate post-intubation sedation already prepared.