Intravenous and intramuscular therapy in near fatal asthma. A response to Al-Shamrani

The invited review by Al-Shamrani et al. (2020) [1] failed to address the management of a patient having an asthma attack who arrives in the Emergency Department with respiratory failure or in a moribund condition. The only route available for drug therapy in these patients is intravenously (IV) or intramuscularly in a final attempt to reduce bronchoconstriction. This could avoid tracheal intubation and lung ventilation, or make these procedures safer (Sellers, 2013; Williams et al., 1992) [2,3] for the patient if some bronchodilation occurs. Intubation and ventilation prevent coughing but tenacious mucus remains which blocks the bronchi. There are no randomised controlled trials or national asthma guidelines to inform practice at this stage of the disease, especially in under 18 year olds, so case report evidence, experience, common sense, and pharmacological principles must be engaged to save the patient’s life.