Approach to respiratory acidosis Quiz: Ace Your Exams

A 33-year-old man presents to the emergency department for evaluation of shortness of breath and wheezing that began while the patient was eating dinner. The patient reports that he has been experiencing increased coughing and wheezing over the past week and recently ran out of his albuterol inhaler. The patient has a history of asthma treated with an as-needed albuterol inhaler and opiate use disorder treated with daily buprenorphine. The patient smokes 2-3 cigarettes daily and does not use alcohol. Temperature is 37°C (98.6°F), heart rate 123/min, blood pressure 100/68 mmHg, respiratory rate 26/min, and O₂ saturation 95% on room air. The patient appears short of breath with auditory wheezing and use of supraclavicular accessory muscles. He is alert and oriented. He is able to talk in 5–7-word sentences. Pupils are equal and reactive bilaterally. Pulmonary exam reveals minimal air movement and faint expiratory wheezes bilaterally. Cardiac examination is normal. The patient is placed on the cardiac monitor and initial stat blood gas results are obtained, which show pH 7.25 and a pCO₂ 48. Which of the following is the next best step in management?