A 47-year-old woman with wheezing and respiratory failure unresponsive to conventional ventilatory modalities.

A 47-year-old woman presented to the emergency department complaining of 2 days of increasing shortness of breath despite escalating use of albuterol by metered-dose inhaler (MDI). She had a long history of bronchial asthma, including one hospital admission for status asthmaticus with respiratory failure requiring intubation and ventilatory support. That hospitalization had been complicated by a slowly resolving myopathy from paralytic agents and corticosteroids prompting tracheotomy and a prolonged period of ventilatory support. She denied fever, facial pain, nasal discharge, or other symptoms of sinusitis, and her cough was nonproductive. Medications included albuterol MDI, fluticasone MDI, and diltiazem for mild hypertension.