Case 1

A 78-year-old lady, still smoking 20 cigarettes per day despite home salbutamol and ipratropium nebulisers, presents with worsening shortness of breath, more marked in the previous few hours. She has been coughing up more green sputum than normal and feels generally unwell. On arrival at her house, the paramedics found she had saturations below 70%. 8 litres O₂ is needed to maintain saturations above 90%. On arrival she is a little drowsy.

Her initial observations show the following:

What type of picture does this show?

List 6 steps in your management of this patient