A 23-year-old man attends A&E with a 1-d history of shortness of breath. He reports no cough and no fever. He has a past medical history of asthma and takes a salbutamol and corticosteroid inhaler. On examination, his chest is diffusely wheezy with reduced air entry bilaterally. He ahs increased work of breathing. His vital signs are within normal parameters. He is commenced on back-to-back salbutamol and oral prednisolone. Nebulised ipratropium (500 μg) has also been provided. His arterial blood gases (ABGs) after an hour of medical therapy are shown below:


||||
|--------------|:-------:|------------------|
|pH|7.34|7.35 - 7.45|
|PaO₂|12.2 kPa|11 - 15|
|PaCO₂|6.5 kPa|4.6 - 6.4|
|Bicarbonate|23mmol/L|22 - 30|
|Base Excess|mmol/L|-2 to +2                  
O<sub>2</sub> saturation|99%|94-98%


What is the next step in his management?

Options:
explanation: A nasopharyngeal airway is an airway adjunct that will help maintain an airway at risk of obstruction/obstructed at the nasopharyngeal level. It does not provide definitive airway support and will not enable mechanical ventilation, which this tiring patient with asthma with a near-fatal flare-up requires at this stage.
name: Insert a nasopharyngeal airway
label: b
answer: no
explanation: This patient has raised carbon dioxide levels, indicating that he is tiring. This represents a near-fatal asthma exacerbation. An intensive care review is now required since he will need intubation and ventilation. Practically, a 2222 call may need to be placed to summon the intensive care team immediately.
name: Immediate intensive care review
label: a
answer: yes
explanation: This patient has already had ipratropium bromide at the correct dose. Ipratropium is not provided back to back because it does not provide additional benefit in this manner and has anticholinergic side effects. The next dose would be due in 6-h time (500 μg 4 times a day). Furthermore, no additional time should be spent on medical management as a next step since seeking intensive care review with a view to intubation and ventilation is most important at this stage.
name: Provide a further dose of nebulised ipratropium bromide
label: e
answer: no
explanation: Inhaled corticosteroids will not provide immediate benefit to a patient presenting with an acute asthma flare-up. They have a role in long-term asthma control. They should be continued on the drug chart if a patient is admitted with an asthma flare-up and is already on them in the community; adding them in the acute setting will not provide significant rapid relief. Oral steroids are indicated in the management of acute asthma exacerbations. In the context of a raised PaCO<sub>2</sub>, this patient requires mechanical ventilation without delay.
name: Add high-dose inhaled corticosteroids
label: c
answer: no
explanation: This would be a sensible addition. However, this patient is tiring and so while magnesium may be provided, the next step should be summoning the intensive care team immediately with a view to intubation and ventilation before any further time is spent on medical management.
name: Start a magnesium sulphate infusion
label: d
answer: no

Correct answer: a


Learning point: In severe asthma exacerbations, rising carbon dioxide levels signal potential respiratory failure. Immediate intensive care review is crucial to provide interventions, support breathing, and prevent life-threatening complications from impaired gas exchange.