A 35-year-old male with a history of moderate persistent asthma presents to the emergency department

A 35-year-old male with a history of moderate persistent asthma presents to the emergency department with complaints of shortness of breath and increased wheezing. His initial vitals were notable for a temperature of 100.4F, blood pressure of 130/80 mm Hg, heart rate of 105, respiratory rate of 25, and oxygen saturation of 88%. On examination, the patient was noted to be in moderate distress with increased respiratory muscle use. He did not have evidence of stridor; his pulmonary examination was notable for bilaterally wheezing and cardiac examinmation notable for sinus tachycardia. His

A 35-year-old male with a history of moderate persistent asthma presents to the emergency department with complaints of shortness of breath and increased wheezing. His initial vitals were notable for a temperature of 100.4F, blood pressure of 130/80 mm Hg, heart rate of 105, respiratory rate of 25, and oxygen saturation of 88%. On examination, the patient was noted to be in moderate distress with increased respiratory muscle use. He did not have evidence of stridor; his pulmonary examination was notable for bilaterally wheezing and cardiac examinmation notable for sinus tachycardia. His chest x-ray demonstrated hyperinflation with flattening of the diaphragms bilaterally with no clear infiltrate. In the emergency department, he was started on IV steroids and continuous albuterol nebulizers and placed on 3 L/min of oxygen via nasal cannula. His initial basic metabolic panel was unremarkable with an anion gap of 10. An arterial blood gas showed a pH 7.41, pCO2 34 mm Hg, and PaO2 90 mm Hg on supplemental oxygen. On arrival to the ICU, he continues to be in respiratory distress with accessory muscle use. A repeat basic metabolic panel is performed with labs notable for a creatinine of 0.80 and an anion gap of 24; lactate level was 8. A repeat arterial gas was performed and showed a pH 7.26, PCO2 46 mm Hg, and PaO2 80. What would be the next step in management? A. Stop the albuterol nebulizers B. Administer high-dose magnesium C. Intubate the patient given persistent work of breathing D. Provide patient with IV fluid bolus

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