A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis. For the past several days, he has had increasing cough with greenish-yellow sputum. He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit. The patient has mild dyspnea but no fever or chest pain. His other medical problems are peripheral vascular disease and osteoarthritis. His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium. He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally. The patient had a screening CT scan 2 years ago that was negative for lung mass. His father died of lung cancer. Blood pressure is 140/95 mm Hg and heart rate is 100/min. The patient's pulse oximetry shows 95% on room air. Lung auscultation reveals bilateral expiratory wheezing. The initial workup reveals no significant abnormality. The patient is started on glucocorticoid therapy and additional inhaled albuterol. Which of the following is the best next step in management?

Question

A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient's pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing. The initial workup reveals no significant abnormality.  The patient is started on glucocorticoid therapy and additional inhaled albuterol.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: This patient's presentation (cough productive of greenish-yellow sputum, dyspnea, and wheezing) and history of chronic obstructive pulmonary disease (COPD) are suggestive of acute COPD exacerbation. Antibiotics are generally not recommended for management of acute bronchitis in otherwise healthy individuals as most exacerbations are of viral etiology. However, guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend antibiotic therapy for patients who have a COPD exacerbation with any two of the following features: increased sputum purulence, increased sputum volume, or increased dyspnea. Antibiotics are also recommended for those requiring mechanical ventilation (noninvasive or invasive). (Choice A) Inpatient management of COPD exacerbation is indicated only for those who fail outpatient therapy or have severe symptoms (eg, rapidly worsening dyspnea, worsening hypoxia/hypoxemia, altered mental status, forced expiratory volume in 1 second <50% predicted). (Choices B and E) No clear benefit has been seen with expectorant agents (eg, N-acetylcysteine) or systemic bronchodilators (eg, theophylline) over inhaled bronchodilators. (Choice C) Supportive care should include adequate hydration, glucocorticoids, and bronchodilation. Educational objective: Acute bronchitis is the most common cause of hemoptysis. A trial of antibiotic therapy is warranted in patients with increased dyspnea, increased sputum volume, or increased sputum purulence.

A 60-Year-Old Man with a History of Chronic Obstructive Pulmonary