A 74-year-old man is brought back to the hospital due to fever, shortness of breath, and cough productive of copious yellow sputum. He was hospitalized 2 weeks ago after an ischemic stroke that caused right-sided weakness, dysarthria, and dysphagia necessitating feeding tube placement. The patient has chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus.
The patient's temperature is 39.2 C (102.6 F) , blood pressure is 140/90 mm Hg, pulse is 106/min, and respirations are 30/min. Oxygen saturation is 86% on room air and 92% on 2 L oxygen via nasal cannula. He is alert and can follow commands. Physical examination shows respiratory accessory muscle use with suprasternal and subcostal retractions, upper airway gurgling sounds, and drooling. Diffuse wheezes with prolonged expiration and crackles over the right lower lung are heard on chest auscultation.
Laboratory studies show a white blood cell count of 17,500/µL. Chest x-ray reveals right middle lobe air space opacities. Arterial blood gas on 2 L oxygen shows pH of 7.23, PaCO₂ of 64 mm Hg, and PaO₂ of 65 mm Hg.
Broad-spectrum antibiotics, systemic corticosteroids, and nebulized bronchodilators are administered.
Which of the following is the most appropriate next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_9714_99f9_853d_6300ff454cf2_MD0002_00 This patient's presentation is consistent with a severe chronic obstructive pulmonary disease (COPD) exacerbation due to underlying aspiration pneumonia. Noninvasive positive-pressure ventilation (NPPV) is indicated in the majority of patients with COPD exacerbation who do not require emergency intubation and have no contraindications to NPPV (Table). Upper airway gurgling sounds and drooling indicate this patient's inability to clear secretions and high aspiration risk (from the recent dysphagic stroke). Patients who cannot tolerate or fail to respond to NPPV within 2 hours or with any NPPV contraindication (Choice E) should be intubated and undergo invasive mechanical ventilation. (Choice A) Nebulized acetylcysteine is a mucoactive agent that liquefies mucus shortly after inhalation; however, it can worsen bronchospasm and is not routinely used in COPD exacerbation. (Choices B and C) The patient's respirations are labored (use of accessory muscles, tachypnea) and he needs ventilatory support to prevent acute respiratory failure. Oxygen should be titrated to maintain an oxyhemoglobin saturation of 90%-94% or arterial oxygen tension (PaO₂) of 60-70 mm Hg as excessive oxygen supplementation can worsen CO₂ retention during a COPD exacerbation. Educational objective: Patients with moderate to severe chronic obstructive pulmonary disease exacerbations should undergo a trial of noninvasive positive-pressure ventilation (NPPV). However, patients with any NPPV contraindication or who cannot tolerate or fail to respond to NPPV within 2 hours should be intubated and undergo invasive mechanical ventilation. __________ 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 74-Year-Old Man Is Brought Back to the Hospital Due