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Difficulty: EasyPulmonary and Critical Care

A 67-year-old male with a 40-pack-year smoking history and known chronic obstructive pulmonary disease (COPD) presents to the emergency department reporting three days of progressively worsening shortness of breath. He also notes increased cough frequency and a change in his sputum from clear to thick, yellow-green. He denies orthopnea, paroxysmal nocturnal dyspnea, and lower extremity swelling. Vital signs include a temperature of 37.1 C (98.8 F), heart rate of 102/min, respiratory rate of 24/min, blood pressure of 134/82 mmHg, and oxygen saturation of 90% on room air. Chest auscultation reveals diffuse expiratory wheezing with prolonged expiration, but no crackles. A chest radiograph demonstrates hyperinflation without focal consolidation, pleural effusion, or pulmonary edema. Which of the following are appropriate initial pharmacologic interventions for this patient? (Select exactly 3)

  1. Inhaled albuterol and ipratropiumAnswer
  2. Oral prednisoneAnswer
  3. Oral azithromycinAnswer
  4. D
    Intravenous furosemide
  5. E
    Intravenous meropenem

Answer

The appropriate initial interventions include inhaled albuterol and ipratropium, oral prednisone, and oral azithromycin.
The correct combination of therapies for this acute exacerbation of COPD includes short-acting bronchodilators (to relieve acute bronchospasm), systemic corticosteroids (to decrease airway inflammation and improve recovery time), and a targeted antibiotic like azithromycin. Antibiotics are specifically indicated here because the patient has increased sputum purulence along with increased dyspnea.

Step-by-Step Solution

1
Diagnose the primary condition based on the clinical presentation.
The patient is experiencing an acute exacerbation of COPD, evidenced by worsening dyspnea, increased cough, and purulent sputum.
Identifying the classic triad of COPD exacerbation symptoms guides the need for specific therapeutic bundles.
2
Rule out alternative causes of respiratory distress, such as acute decompensated heart failure.
The absence of orthopnea, crackles, and radiographic pulmonary edema makes heart failure highly unlikely.
Differentiating COPD from heart failure is crucial to avoid inappropriate and potentially harmful treatments like aggressive diuresis.
3
Select the appropriate pharmacologic management for an uncomplicated COPD exacerbation.
The standard regimen includes short-acting bronchodilators, systemic corticosteroids, and a targeted antibiotic (since sputum purulence is present).
This combination addresses bronchoconstriction, airway inflammation, and a likely bacterial trigger without promoting unnecessary antibiotic resistance.

Key Concept

Management of acute exacerbations of COPD requires short-acting bronchodilators, systemic corticosteroids, and, if specific cardinal symptoms (like purulent sputum) are present, targeted antibiotics.
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Topics

Pulmonary and Critical Care

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