Case Studies Case study: Bill Bill, a 40‐year‐old, has had asthma since childhood. He has experienced many hospitalisations and required long‐term oral steroids. He presents to the emergency department (ED) with acute exacerbation of his asthma that he believes has been triggered by a known allergen. At home he increased his salbutamol with little effect. He is now anxious and agitated. On presentation to the ED his clinical assessment reveals: Noted use of accessory muscles RR 36 breaths/minute HR 150 beats/minute BP 142/88 mmHg Temperature 36.2oC SpO2 88% Height 170 cm Weight 80 kg Management in the ED includes: Oxygen via a non‐rebreather mask at 15 L/min Salbutamol, ipratropium bromide via nebuliser First ABG Suggested normal values pH 7.25 7.35‐7.45PaO2 60mmHg 80‐100mmHg PaCO2 55mmHg 35‐45mmHg ‐ HCO3 22mmol/L 22‐26mmol/L Base excess ‐2 ‐2 to +2 No improvement so further management of: IV hydrocortisone Adrenaline via a nebuliser Salbutamol as an intravenous infusion IV normal saline at 100 mL/hour Arterial blood gas analysis