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Difficulty: MediumGeneral Internal Medicine

A 74-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening shortness of breath and increased sputum production. She has a medical history of chronic obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction, and type 2 diabetes mellitus. Her current medications include lisinopril, amlodipine, metformin, and a daily tiotropium inhaler. She has a 40-pack-year smoking history. Her temperature is 37.3 °C (99.1 °F), blood pressure is 138/86 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 89% on room air. The patient is sitting upright and using accessory muscles of respiration. The jugular venous pressure is 6 cm H2O. Chest auscultation reveals a prolonged expiratory phase with diffuse expiratory wheezing bilaterally. Cardiac examination shows a regular rate and rhythm with a normal S1 and S2; there are no murmurs or gallops. There is no peripheral edema. Laboratory studies show:

Leukocyte count: 9,500/mm³
Serum Na+Na^+: 139 mEq/L
Serum K+K^+: 4.1 mEq/L
Serum Cl−Cl^-: 96 mEq/L
Serum HCO3−HCO_3^-: 33 mEq/L
BUN: 18 mg/dL
Creatinine: 0.9 mg/dL
Thyroid-stimulating hormone (TSH): 0.15 µU/mL (Normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 1.1 ng/dL (Normal: 0.9–2.4 ng/dL)

An arterial blood gas on room air shows:
pH: 7.35
PaCO2PaCO_2: 60 mm Hg
PaO2PaO_2: 58 mm Hg

A chest radiograph shows hyperinflated lungs and flattened diaphragms, with no focal consolidation, pleural effusion, or pulmonary vascular congestion. Which of the following is the most appropriate next step in management of this patient's current condition?

  1. Administer nebulized albuterol-ipratropium and systemic glucocorticoidsAnswer
  2. B
    Administer intravenous furosemide and restrict oral fluid intake
  3. C
    Administer intravenous piperacillin-tazobactam and vancomycin
  4. D
    Administer a continuous intravenous infusion of sodium bicarbonate
  5. E
    Initiate therapy with oral methimazole

Answer

The most appropriate next step is to administer nebulized albuterol-ipratropium and systemic glucocorticoids.
The patient presents with cardinal symptoms of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), including worsened dyspnea, increased sputum production, and wheezing. The physical examination showing accessory muscle use and a prolonged expiratory phase, along with a chest radiograph demonstrating hyperinflation without infiltrates or pulmonary congestion, strongly supports this diagnosis. The most appropriate initial management for AECOPD includes short-acting bronchodilators (such as albuterol and ipratropium), systemic glucocorticoids (e.g., prednisone), and supplemental oxygen to maintain saturations between 88% and 92%. The arterial blood gas confirms a baseline chronic CO2 retention that is well compensated (pH 7.35, elevated PaCO2PaCO_2, and elevated HCO3−HCO_3^-), which is typical for a patient with severe, chronic COPD.

Step-by-Step Solution

1
Analyze the clinical presentation and physical examination findings.
The patient presents with worsened dyspnea, increased sputum, accessory muscle use, and diffuse wheezing, with a normal JVP and no peripheral edema.
To distinguish between a primary pulmonary etiology (like a COPD exacerbation) and a primary cardiac etiology (like acute decompensated heart failure).
2
Interpret the laboratory data, arterial blood gas, and imaging.
Chest X-ray shows hyperinflation without congestion. ABG shows a fully compensated respiratory acidosis (pH 7.35, high PaCO2PaCO_2, high HCO3−HCO_3^-). Thyroid panel reveals euthyroid sick syndrome.
To confirm the diagnosis of COPD exacerbation and rule out co-occurring acid-base, infectious, or endocrine derangements.
3
Select the appropriate evidence-based intervention.
The standard of care for an acute COPD exacerbation is selected: short-acting bronchodilators, systemic glucocorticoids, and targeted oxygen therapy.
To alleviate bronchospasm, reduce airway inflammation, and improve oxygenation safely.

Key Concept

Diagnosis and initial management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
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Topics

General Internal Medicine

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