1. Ensure adequate rehydration.

2. Generous humidification should be given to loosen mucus plugs. Use a heat-moisture exchanger plus either hourly 0.9% saline nebulisers or instillation of 5ml 0.9% saline down the endotracheal tube.

3. Physiotherapy assists mobilisation of secretions and removal of mucus plugs. Hyperventilation should be avoided.

4. With improvement, gradually normalise ventilator settings (VT, rate, I:E ratio) to achieve normocapnia before allowing patient to waken and breathe spontaneously

5. Consider pneumothorax or lung/lobar collapse if acute deterioration occurs.

6. If mucus plugging constitutes a major problem, instillation of a mucolytic (N-acetyl cysteine) may be considered though this may induce further bronchospasm. Bronchoscopic removal of plugs should only be performed by an experienced operator.

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