A 71-year-old man is evaluated in the emergency department for a 3-day history of progress… — USMLE Step 2 CK

A 71-year-old man is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath, increased cough, and a change in sputum color from clear to yellow-green. He has a 45-pack-year smoking history and severe chronic obstructive pulmonary disease (COPD). Temperature is $37.4^\circ\text{C}$ ( $99.3^\circ\text{F}$ ), heart rate is $105/\text{min}$ , respiratory rate is $24/\text{min}$ , and blood pressure is $135/85\text{ mmHg}$ . Pulse oximetry shows an $SpO_2$ of $88\%$ on room air.

Physical examination shows a patient sitting forward and using accessory muscles of respiration. Jugular venous pulsation is visible at $10\text{ cm H}_2\text{O}$ . Chest examination reveals a barrel-shaped chest, hyperresonance to percussion, and diffuse expiratory wheezing with a prolonged expiratory phase. Cardiac examination reveals distant heart sounds with a prominent $P_2$ , but no $S_3$ gallop. There is $2+$ bilateral pitting edema of the lower extremities.

Arterial blood gas on room air shows:
pH: $7.30$
$pCO_2$ : $62\text{ mmHg}$
$pO_2$ : $55\text{ mmHg}$
$HCO_3^-$ : $30\text{ mEq/L}$

Chest radiograph demonstrates hyperinflated lung fields, flattened diaphragms, enlarged central pulmonary arteries, and a narrow cardiac silhouette, with no focal consolidations or pleural effusions.

Based on the clinical presentation and diagnostic findings, which of the following are the most appropriate immediate interventions for this patient? (Select all that apply)

Systemic glucocorticoidsAnswer
Inhaled short-acting bronchodilatorsAnswer
C
Intravenous furosemide
D
Intravenous piperacillin-tazobactam
E
Intravenous sodium bicarbonate

Answer

The correct interventions are systemic glucocorticoids and inhaled short-acting bronchodilators.

This patient is experiencing a severe acute exacerbation of COPD (AECOPD), characterized by the three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. Immediate management consists of supplemental oxygen (targeting saturations of 88-92% to avoid worsening hypercapnia), inhaled short-acting bronchodilators (such as albuterol and ipratropium) to reverse acute bronchoconstriction, and systemic glucocorticoids (oral or intravenous) to reduce airway inflammation and speed recovery. Antibiotics are also indicated due to the presence of purulent sputum, but they should generally be narrow-spectrum.

Step-by-Step Solution

Analyze the clinical presentation and vital signs.

The patient has cardinal symptoms of an acute exacerbation of COPD (AECOPD): worsening dyspnea, increased cough, and increased sputum purulence.

Identifying the primary clinical syndrome drives immediate management priorities.

Interpret the physical exam and imaging findings.

The elevated JVP, prominent P2, and peripheral edema in the setting of hyperinflated, clear lungs indicate chronic right heart failure (cor pulmonale) secondary to COPD, rather than acute decompensated left heart failure.

Differentiating cor pulmonale from left-sided heart failure prevents inappropriate administration of diuretics.

Evaluate the arterial blood gas.

The ABG shows an acute-on-chronic respiratory acidosis (low pH, high pCO2, and elevated HCO3- indicating chronic metabolic compensation) alongside hypoxemia.

Understanding the acid-base derangement confirms the etiology of respiratory failure and guides oxygen/ventilatory therapy.

Select evidence-based therapies for AECOPD.

Initial management includes supplemental oxygen (target 88-92%), short-acting inhaled bronchodilators, systemic glucocorticoids, and targeted oral antibiotics.

These interventions are proven to decrease mortality, reduce length of stay, and improve lung function in severe exacerbations.

Key Concept

Management of Acute Exacerbations of COPD (AECOPD) and differentiation from acute decompensated heart failure.

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