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Difficulty: MediumPulmonary and Critical Care

A 6868-year-old woman with a history of chronic obstructive pulmonary disease (COPD) and hypertension is brought to the emergency department due to progressively worsening shortness of breath over the past 33 days. She reports orthopnea, paroxysmal nocturnal dyspnea, and bilateral leg swelling. Her blood pressure is 165/95165/95 mm Hg, pulse is 115115/min, and respirations are 2828/min. Pulse oximetry shows an oxygen saturation of 85%85\% on room air. Physical examination reveals jugular venous distention, bilateral crackles extending to the mid-lung fields, and scattered expiratory wheezes. Arterial blood gas analysis on room air shows:

pH: 7.287.28
pCO 2_2: 6262 mm Hg
pO 2_2: 5656 mm Hg
HCO 3−_3^-: 2828 mEq/L

Chest radiography reveals cardiomegaly, bilateral perihilar alveolar opacities, and blunting of the costophrenic angles. Which of the following are the most appropriate next steps in the management of this patient? (Select exactly 2 answers)

  1. Initiate noninvasive positive pressure ventilationAnswer
  2. Administer intravenous furosemideAnswer
  3. C
    Administer intravenous methylprednisolone
  4. D
    Administer intravenous piperacillin-tazobactam
  5. E
    Administer intravenous sodium bicarbonate

Answer

The most appropriate next steps are to initiate noninvasive positive pressure ventilation and administer intravenous furosemide.
The patient is experiencing acute decompensated heart failure presenting with acute hypoxemic and hypercapnic respiratory failure. The correct initial management steps include noninvasive positive pressure ventilation (NIPPV) and intravenous loop diuretics. NIPPV improves oxygenation, decreases the work of breathing, and crucially reduces both left ventricular preload and afterload by increasing intrathoracic pressure. Intravenous furosemide rapidly reduces volume overload, alleviating pulmonary edema.

Step-by-Step Solution

1
Analyze the clinical presentation and physical exam findings.
The patient has orthopnea, jugular venous distention, basilar crackles, and bilateral perihilar alveolar opacities on chest radiography.
These findings strongly indicate acute decompensated heart failure (ADHF) rather than a primary COPD exacerbation, despite the patient's history and presence of wheezing (cardiac asthma).
2
Evaluate the arterial blood gas (ABG) results.
The ABG shows acute-on-chronic respiratory acidosis with severe hypoxemia.
The pulmonary edema from ADHF has led to impaired gas exchange, resulting in acute hypercapnic and hypoxemic respiratory failure.
3
Select the appropriate targeted interventions.
Noninvasive positive pressure ventilation and intravenous furosemide are selected.
NIPPV reduces the work of breathing, improves oxygenation, and beneficially decreases both left ventricular preload and afterload. IV furosemide provides rapid diuresis to relieve pulmonary congestion.

Key Concept

Patients with a history of COPD can present with wheezing due to acute decompensated heart failure (cardiac asthma). The initial management of ADHF with acute respiratory failure includes NIPPV and intravenous loop diuretics.
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Topics

Pulmonary and Critical Care

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