Soru

A 74-year-old woman arrives at the emergency department accompanied by her daughter. She complains of rapidly worsening shortness of breath and a cough producing pink, frothy sputum over the past 12 hours. She has a medical history significant for essential hypertension, diet-controlled type 2 diabetes mellitus, and a 45-pack-year smoking history. Her current daily medications are amlodipine and metformin.

Vital signs are as follows:
- Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
- Blood pressure: $210/115 \text{ mmHg}$
- Pulse: $118/\text{min}$
- Respiratory rate: $30/\text{min}$
- Oxygen saturation: $84\%$ on room air

Physical examination reveals a somnolent patient in severe respiratory distress, using accessory muscles of respiration. Jugular venous distention is prominent when the patient is seated upright. Lung auscultation reveals diffuse expiratory wheezes and coarse crackles extending from the bases to the mid-lung fields bilaterally. Cardiac auscultation demonstrates tachycardia, a regular rhythm, and a loud third heart sound (S3). Bilateral 2+ pitting edema is noted in the lower extremities.

Laboratory and arterial blood gas studies on room air reveal the following:
- Leukocyte count: $8,200/\text{mm}^3$
- Serum creatinine: $1.3 \text{ mg/dL}$
- Thyroid-stimulating hormone (TSH): $1.2 \,\mu\text{U/mL}$ (Normal: $0.5 - 5.0 \,\mu\text{U/mL}$)
- Free T4: $0.7 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)
- pH: $7.22$
- PaCO $_2$: $70 \text{ mmHg}$
- PaO $_2$: $50 \text{ mmHg}$
- HCO $_3^-$: $27 \text{ mEq/L}$

Which of the following is the most appropriate next step in the management of this patient?