A 70-year-old woman is brought to the hospital for worsening shortness of breath and a cough productive of mucoid sputum. She has no fever or chest pain. The patient has a history of moderate chronic obstructive pulmonary disease (COPD) and has had 2 previous hospitalizations for acute COPD exacerbation over the past year. Her other medical problems include right nephrectomy for renal cell carcinoma 7 years ago, hypertension, chronic low back pain, and degenerative arthritis. Her current medications include tiotropium, albuterol, amlodipine, hydrochlorothiazide, fentanyl patch, and acetaminophen. She has a 48-pack-year smoking history.
The patient is alert and in moderate respiratory distress. Her temperature is 37 C (98.6 F) , blood pressure is 140/90 mm Hg, pulse is 98/min, and respirations are 20/min. Oxygen saturation is 86% on room air and 96% on 3 L oxygen. Her BMI is 28 kg/m². Cardiopulmonary examination shows decreased breath sounds, wheezes with prolonged expiration, and distant heart sounds. There is no jugular venous distension or peripheral edema.
Chest x-ray shows hyperinflation without infiltrates. The patient is started on systemic corticosteroids, bronchodilators, and antibiotics. Four hours later, she appears mildly lethargic but is able to follow commands and cough up secretions. Respirations are 28/min and oxygen saturation is 96% on 3 L oxygen. Her arterial blood gas shows a pH of 7.20, PaCO₂ of 70 mm Hg, and PaO₂ of 74 mm Hg.
Which of the following is the most appropriate next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_9713_fdb8_853d_1dcca5efe8c5_MD0002_00 This patient has a moderate to severe chronic obstructive pulmonary disease (COPD) exacerbation with hypercapnic acidosis. In such patients, noninvasive positive-pressure ventilation (NPPV) decreases respiratory acidosis, treatment failure, intubation rate, mortality, and length of hospital stay. Contraindications to NPPV include impending cardiac or respiratory failure, excessive somnolence, severe acidosis (pH <7.10), inability to protect the airway or clear secretions, and high aspiration risk. This patient's mild lethargy (due to hypercapnic acidosis) is not a contraindication to NPPV, particularly given that she is able to clear secretions and follow commands. She also has moderate hypercarbia (PaCO₂ 45-92 mm Hg) and acidemia (pH 7.10-7.35), which are potential predictors of success for NPPV. An NPPV trial is appropriate and may help avoid mechanical ventilation and its possible complications, including difficulty with extubation in this patient with moderate COPD. If her condition deteriorates or does not improve within 2 hours of NPPV, intubation and mechanical ventilation should be considered (Choice B). (Choice A) Continuous nebulized beta agonists (eg, albuterol) provide no significant advantage over intermittent nebulized administration in acute COPD exacerbation. (Choice C) Supplemental oxygen should be titrated to maintain an oxygen saturation of 88%-92% or an arterial oxygen tension of 60-70 mm Hg, but excessive oxygen can worsen CO₂ retention. Reducing oxygen supplementation alone will not improve this patient's hypercapnic acidosis, dyspnea, or tachypnea. She needs immediate NPPV. (Choice E) This patient's fentanyl patch is likely for her chronic low back pain and may have aggravated her respiratory depression. However, removing the patch will not have an immediate impact on her acute situation and may aggravate her back pain. Educational objective: Management of moderate to severe exacerbations of chronic obstructive pulmonary disease includes standard therapy (eg, inhaled β-agonists, inhaled anticholinergics, steroids, and possibly antibiotics) and a trial of noninvasive positive-pressure ventilation unless contraindicated. __________ References: Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/18321904) Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting (http://www.ncbi.nlm.nih.gov/pubmed/21324867)

A 70-Year-Old Woman Is Brought to the Hospital for Worsening