Correct!
4. 1 and 3

The basic principles of care for an acute exacerbation of asthma are the following (1):

• Assess the severity of the attack
• Use inhaled short-acting beta agonists early and frequently and consider concomitant use of ipratropium for severe exacerbations
• Start systemic glucocorticoids if there is not an immediate and marked response to the inhaled short-acting beta agonists
• Make frequent (every one to two hours) objective assessments of the response to therapy until definite, sustained improvement is documented
• Admit patients who do not respond well after four to six hours to a setting of high surveillance and care
• Educate patients about the principles of self-management for early recognition and treatment of a recurrent attack and develop an "asthma action plan" for recurrent symptoms

The patient was admitted to a general medical ward but did not do well. Non-invasive positive pressure ventilation (NIPPV) was considered but was not given due to clinical deterioration warranting ICU transfer for initiation of mechanical ventilation. Her initial ventilator settings were: assist/control 18, PEEP 0, FiO2 60%, tidal volume 350 ml. She had peak respiratory pressures of about 51 cm H2O. Her arterial blood gases showed pH 7.15, PaCO2 81 mm Hg, and PaO2 114 mm Hg.

Which of the following should be considered at this time? (Click on the correct answer to proceed to the third of four panels)

1. Begin oseltamivir, zanamivir, or peramivir
2. General anesthesia
3. Switch to pressure controlled ventilation
4. 1 and 3
5. All of the above

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