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Near-Fatal Asthma — RACP Adult Medicine MCQ

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HardRespiratoryNear-Fatal AsthmaRACP Adult Medicine

A 45-year-old man with severe asthma is admitted to ICU with acute severe asthma (unable to speak in sentences, HR 130, RR 35, SpO₂ 88% on 15L O₂, silent chest). He has received salbutamol nebulisers × 3, ipratropium, and IV hydrocortisone. PaCO₂ is 55 mmHg (rising). What is the most appropriate next step?

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Correct answer: E — Intubation and mechanical ventilation

Rising PaCO₂ in acute severe asthma indicates respiratory fatigue and impending respiratory arrest. A normal or rising PaCO₂ is a red flag (should be low due to hyperventilation). With silent chest and hypercapnia despite maximal bronchodilator therapy, intubation and mechanical ventilation is required. IV magnesium should have been given already. Ketamine is the preferred induction agent.

Reference: Australian Asthma Handbook – 2024 – Acute Severe Asthma; eTG Respiratory 2024