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Difficulty: EasyPulmonary and Critical Care

A 62-year-old woman comes to the urgent care clinic complaining of progressively worsening dyspnea over the last 48 hours. She mentions that her usual morning cough has become more frequent and is now producing a larger amount of thick, yellowish-green mucus. Her medical history is significant for severe chronic obstructive pulmonary disease (COPD) and hypertension. Vital signs include a temperature of 37.3°C (99.1°F), heart rate of 94/min, respiratory rate of 24/min, and blood pressure of 142/88 mmHg. Oxygen saturation is 89% on room air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. There is no jugular venous distention and no lower extremity edema. A chest radiograph reveals hyperinflated lungs and flattened diaphragms, but no focal opacities. Which of the following treatments are indicated for this patient right now? (Select all that apply)

  1. Nebulized albuterol and ipratropiumAnswer
  2. A short course of oral prednisoneAnswer
  3. A 5-day course of oral azithromycinAnswer
  4. D
    Empiric therapy with piperacillin-tazobactam
  5. E
    An intravenous bolus of furosemide

Answer

The indicated treatments for this acute COPD exacerbation are nebulized short-acting bronchodilators, a short course of systemic corticosteroids, and a targeted antibiotic such as oral azithromycin.
The correct answers reflect the standard triad of treatment for an acute COPD exacerbation with cardinal symptoms: short-acting bronchodilators to relieve acute bronchospasm, systemic glucocorticoids to decrease airway inflammation and prevent early relapse, and an antibiotic (such as a macrolide) targeted at common respiratory pathogens since the patient has purulent sputum.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation.
The patient is experiencing an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), characterized by the three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.
Recognizing the triad of cardinal symptoms is necessary to determine the appropriate bundle of interventions, particularly the need for antimicrobial therapy.
2
Select the appropriate pharmacologic interventions for an uncomplicated AECOPD.
The standard management bundle includes short-acting bronchodilators, systemic corticosteroids, and antibiotics.
Bronchodilators open the airways, steroids reduce inflammation, and antibiotics treat the likely bacterial trigger causing the purulent sputum.
3
Differentiate the correct intensity of antibiotic therapy and rule out other causes of dyspnea.
Standard narrow-spectrum antibiotics are appropriate. Broad-spectrum agents and heart failure treatments are not indicated.
Antibiotic stewardship dictates using narrow-spectrum agents unless risk factors for resistant organisms are present. The lack of volume overload signs rules out acute heart failure.

Key Concept

The standard management of an acute COPD exacerbation featuring all three cardinal symptoms includes short-acting bronchodilators, systemic glucocorticoids, and targeted antibiotics.
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Topics

Pulmonary and Critical Care

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