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Zorluk: KolayPulmonary and Critical Care

A 68-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. He has a history of severe chronic obstructive pulmonary disease and primary hypothyroidism. His current medications include an albuterol inhaler as needed and daily levothyroxine. Temperature is 37.7°C (99.9°F), pulse is 105/min, respirations are 24/min, and blood pressure is 140/90 mm Hg. Pulse oximetry shows 89% on room air. Examination shows a prolonged expiratory phase with diffuse expiratory wheezing. Jugular venous pressure is normal, and there is no lower extremity edema. Laboratory studies show a leukocyte count of 9,000/mm³ and a thyroid-stimulating hormone level of 2.5 µU/mL (normal: 0.4–4.0 µU/mL). Arterial blood gas analysis on room air shows a pH of 7.36, PaCO₂ of 52 mm Hg, and HCO₃⁻ of 29 mEq/L. A chest radiograph reveals hyperinflation without focal consolidation or pulmonary vascular congestion. In addition to supplemental oxygen and inhaled short-acting bronchodilators, which of the following is the most appropriate next step in management?

  1. Administration of systemic glucocorticoids and an oral macrolideCevap
  2. B
    Administration of intravenous furosemide
  3. C
    Administration of intravenous vancomycin and cefepime
  4. D
    Administration of intravenous sodium bicarbonate
  5. E
    Increasing the dose of oral levothyroxine

Cevap

Administration of systemic glucocorticoids and an oral macrolide
The correct answer is the administration of systemic glucocorticoids and an oral macrolide. This patient is experiencing an acute exacerbation of chronic obstructive pulmonary disease, defined by an acute worsening of respiratory symptoms that necessitates a change in medication. He exhibits all three cardinal symptoms: worsening dyspnea, increased cough, and increased sputum purulence (indicated by the change to a yellow color). The standard of care for an acute exacerbation includes supplemental oxygen (target saturation 88-92%), inhaled short-acting bronchodilators, systemic glucocorticoids (which shorten recovery time and improve lung function), and antibiotics. Antibiotics are specifically indicated in patients who have increased sputum purulence along with one other cardinal symptom, or those who require mechanical ventilation. A macrolide (e.g., azithromycin) is a highly appropriate choice for targeted coverage.

Adım Adım Çözüm

1
Identify the primary clinical syndrome.
The patient is experiencing an acute exacerbation of chronic obstructive pulmonary disease.
He has a known history of chronic obstructive pulmonary disease and presents with the cardinal symptoms of an exacerbation: increased dyspnea, increased cough, and increased sputum purulence (yellow sputum).
2
Rule out alternative causes of acute respiratory distress based on the physical exam and diagnostic data.
Heart failure and pneumonia are unlikely causes for his presentation.
The absence of jugular venous distention, lower extremity edema, and pulmonary vascular congestion on the chest radiograph rules out decompensated heart failure. The absence of focal consolidation on the radiograph makes pneumonia unlikely.
3
Determine the appropriate pharmacologic management for the exacerbation.
The correct management includes short-acting bronchodilators, systemic glucocorticoids, and targeted antibiotics.
Systemic glucocorticoids reduce recovery time and improve lung function. Antibiotics (such as a macrolide) are specifically indicated because the patient has increased sputum purulence.

Anahtar Kavram

The management of an acute exacerbation of chronic obstructive pulmonary disease includes supplemental oxygen, inhaled short-acting bronchodilators, systemic glucocorticoids, and antibiotics (when cardinal symptoms like increased sputum purulence are present).
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Pulmonary and Critical Care

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