A 19-year-old asthmatic presents to the ED with a chief complaint of wheezing and dyspnea. Upon arrival it is clear that the patient is in respiratory distress with significant tachypnea and increased work of breathing despite duonebs in progress via EMS. You quickly call your respiratory therapist to initiate NIPPV as they are now becoming hypoxic. The RT obtains an ABG and the PaCO2 is normal. What do you do?

A. De-escalate to nasal cannula 

B. Prepare for intubation 

C. Order a CXR

D. Redraw the ABG to confirm that values are accurate 

Answer: B; This is a case of a severe asthma exacerbation. Do not be reassured by a normal PaCO2 level on someone who is this sick! In fact, your alarm bells should be ringing. Your tachypneic patient with significant airway obstruction and air trapping is expected to be hypercarbic. If their PaCO2 is normal or elevated, your patient is beginning to fatigue despite your interventions. You need to prepare for impending respiratory arrest, and therefore, intubation.

https://emcrit.org/ibcc/asthma/

Refresh your status asthmaticus knowledge in this prior EM Daily post: https://emdaily.cooperhealth.org/content/severe-asthma-management