Case Summary:

A 72-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with worsening shortness of breath, increased cough, and greenish sputum production for the past 3 days. He is a smoker with a 50-pack-year history. On examination, his respiratory rate is 28 breaths per minute, oxygen saturation is 88% on room air, and he has bilateral wheezing and decreased breath sounds at the bases.

Key Investigations:

• Chest X-ray: Hyperinflation, no consolidation
• Arterial Blood Gas (ABG): pH 7.34, pCO2 60 mmHg, pO2 55 mmHg, HCO3 34 mEq/L
• CBC: Mild leukocytosis
• Spirometry: FEV1 40% predicted

Questions:

1. What is the most likely diagnosis in this patient, and how does his ABG support your diagnosis?
2. How does his COPD history contribute to the acute exacerbation? Discuss the mechanisms.
3. What are the indications for non-invasive positive pressure ventilation (NIPPV) in patients with COPD exacerbations?
4. Discuss the role of antibiotics in the management of this patient. What are the criteria for their use in COPD exacerbations?
5. What pharmacologic and non-pharmacologic interventions should be included in the management of acute COPD exacerbation?

References:

• Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023.
• Rampulla, J. et al. (2020). "Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease." American Journal of Respiratory and Critical Care Medicine.