Discussion Board Example:  Should we intubate? 
Archie: 
initial posting: Our question is should we intubate our patient? I disagree with intubating the patient now. I think we should try another jet nebulizer treatment. We have only tried one so far and another may work.  We had a case like this last semester only it was an adult asthmatic. We didn't intubate that patient. What does everyone think? 

Replies to initial posting by Archie and secondary replies:

Reggie:		   I don’t think we should intubate yet. I don’t think one treatment will do. He needs a continuous jet nebulizer with a higher dose of albuterol. We also need to think about other medications besides albuterol. What do you think about giving him some atrovent or sub q epinephrine? He will also need some steroids. 
Jughead: Give him the atrovent and the steroids. 

Betty:		 I disagree. I think the patient should be intubated. He has a strong history of asthma. He has been to the ER 7 times in the last year and been admitted to the ICU at least once.  Look at his peak flows. They are in the red zone. And his physical exam shows severe respiratory distress. 
Veronica: I agree with you that the patient is in distress, but not severe distress. What about the exam makes you think the patient is in severe distress? 
  Betty: He has supraclavicular and intercostals retractions, he is diaphoretic and he is tachycardiac and tachypnic. He is having shortness of breath. He has high-pitched wheezes. According to our text, that can indicate airway obstruction. He can't speak in full sentences. What really worries me is that he is getting tired and that is not a good sign. 

Reggie:

   He may be tired and in distress, but I don’t think you should intubate someone until all other options have been exhausted and we still have options in this case. According to the NAEEPP guidelines he is having a severe exacerbation of asthma. The guidelines call for continuous or hourly treatments with a beta agonist drug, and IV corticosteroids. He may also need to have his oxygen increased. Hopefully we can buy him some time and he will respond to the treatment and not have to be intubated. 

Betty:

 The guidelines also suggest possible intubation at this time. I am worried he could tire out and respiratory arrest before the medication takes affect. He is lethargic and that makes me nervous. Our patient has been in respiratory distress for over three hours now. I think he is will benefit from intubation. While it may a traumatic and invasive procedure, I would rather do it under controlled circumstances than an emergency situation. When we were performing intubations in the skills lab, we learned that they usually are better handled under controlled circumstances. 

Veronica:

 We don’t know if the lethargy is from the distress. It could it be from something else. Maybe he has a head injury. 

Reggie:

 I don’t think he has a head injury. The lethargy may be from hypoxia. Before I would intubate I would want more tests. Can we order an ABG? It will tell us if the patient is hypoxic. The PCO2 levels should tell us if he is tiring. According to our text, a PCO2 level above 42 would indicate that he would need intubation. 
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Archie:

   I still don’t think the data we have indicates intubation. – At least not yet. I think he will need it if his asthma attack can't be brought under control quickly. 
We seem to have different ideas about when to intubate this patient. The ABG may be the key to determining that. Jughead, what do you think? 
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Jughead:		 I'm not sure. There are pros and cons for both sides of the argument. I don’t think we have to intubate yet.