[Questions concerning an endotracheal intubation or a tracheotomy in amyotrophic lateral sclerosis]

Amyotrophic lateral sclerosis (ALS) is an illness in which respiratory complications often determine the terminal prognosis. Emergency situations lead one to pose questions concerning an endotracheal intubation or a tracheotomy. A tracheotomy should not be performed during an emergency situation. A tracheotomy necessitates a stable condition and prior reflection. Orotrachael intubation is the method of choice during emergency situations requiring invasive ventilation or airway protection. Intubation during an emergency situation presents specific problems: the lack of knowledge concerning the person and their pre-established desires, the impossibility of evaluating the potential reversibility of an acute pathology, the risk of not being able to wean the patient off the ventilator and the lack of time to gather all the elements necessary for a well-thought out decision. It may be appropriate for emergency personnel to introduce mechanical ventilation and leave the reflection for a later moment, but this approach is not suitable for people in end of life situations in which the person and the family wish to avoid all unreasonable therapeutics. One solution may be to develop among emergency care teams the practice of using non-invasive ventilation and airway clearance techniques as well as developing palliative care knowledge. Orotracheal intubation in an emergency situation presents certain practical difficulties, notably regarding the choice of anesthetics. Preventings situations where emergency intubation may be necessary is probably best obtained by anticipating acute problems, by preparing the ill person, the family and the care givers, by coordinating the potential care providers and by educating emergency personnel in palliative care.