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