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Difficulty: EasyPulmonary and Critical Care

A 68-year-old man comes to the emergency department due to a 2-day history of worsening shortness of breath, cough, and increased production of thick, yellow sputum. He has a 40-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) 5 years ago. His temperature is 37.4°C (99.3°F), blood pressure is 140/88 mm Hg, pulse is 95/min, and respiratory rate is 24/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals a barrel-shaped chest, diffuse bilateral wheezing, and a prolonged expiratory phase. There is no jugular venous distention, crackles, or lower extremity edema. Which of the following are appropriate initial management steps for this patient? (Select all that apply)

  1. Administration of inhaled short-acting bronchodilators and systemic glucocorticoidsAnswer
  2. Administration of an oral macrolide antibioticAnswer
  3. C
    Administration of intravenous furosemide
  4. D
    Administration of intravenous vancomycin and cefepime
  5. E
    Administration of intravenous sodium bicarbonate

Answer

The correct interventions are the administration of inhaled short-acting bronchodilators with systemic glucocorticoids, and the administration of an oral macrolide antibiotic.
The correct initial management for an acute COPD exacerbation includes supplemental oxygen (to target saturation of 88-92%), inhaled short-acting bronchodilators, and systemic glucocorticoids to relieve bronchospasm and reduce airway inflammation. Additionally, because this patient presents with all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence), a narrow-spectrum antibiotic such as an oral macrolide is indicated to treat potential bacterial triggers.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical presentation.
The patient has an acute exacerbation of chronic obstructive pulmonary disease (COPD).
The patient has a significant smoking history, known COPD, and presents with worsening dyspnea, cough, increased sputum volume, and purulence, along with wheezing on examination.
2
Determine the necessary core pharmacological interventions for the primary diagnosis.
The standard treatment bundle includes bronchodilators, systemic glucocorticoids, and appropriate antibiotics.
Short-acting bronchodilators and systemic steroids treat acute airway inflammation and bronchospasm. Antibiotics are required because the patient exhibits all three cardinal symptoms of a bacterial exacerbation (dyspnea, sputum volume, sputum purulence).
3
Select the appropriate class of antibiotics.
A narrow-spectrum oral agent, such as a macrolide, is chosen.
Broad-spectrum antibiotics are not indicated without specific risk factors for resistant or hospital-acquired organisms.
4
Exclude treatments for alternative diagnoses.
Exclude diuretics and sodium bicarbonate.
There are no signs of heart failure to warrant furosemide, and bicarbonate is not a treatment for respiratory acidosis.

Key Concept

Management of acute chronic obstructive pulmonary disease (COPD) exacerbations
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Topics

Pulmonary and Critical Care

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