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Difficulty: EasyPulmonary and Critical Care

A 67-year-old male is brought to the emergency department by his daughter due to a three-day history of progressively worsening shortness of breath. The patient reports that his typical morning cough has worsened, producing a larger volume of thick, yellowish-green sputum. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. Current vital signs reveal a temperature of 37.3°C (99.1°F), blood pressure of 138/86 mm Hg, heart rate of 98/min, and a respiratory rate of 22/min. Pulse oximetry shows an oxygen saturation of 91% on ambient air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention, and the lower extremities are free of edema. Which of the following interventions are indicated in the initial management of this patient's current condition? (Select all that apply.)

  1. Nebulized albuterol and ipratropiumAnswer
  2. Oral prednisoneAnswer
  3. C
    Intravenous furosemide
  4. D
    Intravenous piperacillin-tazobactam
  5. E
    Intravenous sodium bicarbonate

Answer

The correct interventions are nebulized albuterol and ipratropium, and oral prednisone.
The patient is experiencing an acute exacerbation of chronic obstructive pulmonary disease, characterized by an acute worsening of respiratory symptoms including increased dyspnea, sputum volume, and sputum purulence. The standard initial management for this condition includes the administration of short-acting bronchodilators (such as albuterol and ipratropium) to relieve acute bronchospasm and systemic corticosteroids (such as oral prednisone) to decrease airway inflammation and improve recovery time. Although this patient also requires antibiotics due to having all three cardinal symptoms, a standard macrolide or aminopenicillin is indicated rather than broad-spectrum intravenous coverage.

Step-by-Step Solution

1
Evaluate the patient's clinical presentation.
The patient has worsening dyspnea, increased sputum volume, and increased sputum purulence.
These are the cardinal symptoms of an acute exacerbation of chronic obstructive pulmonary disease.
2
Determine the appropriate initial pharmacological therapy.
Short-acting bronchodilators and systemic corticosteroids should be administered.
These medications reduce airway resistance, decrease inflammation, and improve lung function in acute exacerbations.

Key Concept

The initial management of an acute exacerbation of chronic obstructive pulmonary disease requires short-acting bronchodilators and systemic corticosteroids.
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Pulmonary and Critical Care

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