A 65-year-old man with moderate chronic obstructive pulmonary disease comes to the physician complaining of a dry cough over the past week. He has no fever, chills, night sweats, or weight loss, but the cough has kept him awake at night. The patient has been using his rescue albuterol 3 times a day. Pulmonary function testing a month ago showed a forced expiratory volume in 1 second of 53% of predicted, a forced vital capacity of 64% of predicted, and FEV₁/FVC ratio of 0.56. His past medical history also includes hypertension and hyperlipidemia. His other medications include budesonide/formoterol, tiotropium, long-acting nifedipine, and simvastatin.
His temperature is 37 C (98.6 F) , blood pressure is 120/80 mm Hg, pulse is 89/min, and respirations are 18/min. Pulse oximetry is 97% on room air. Examination shows a thin, elderly man in no significant respiratory distress but with frequent cough. There is good air entry with diffuse bilateral wheezes in all lung fields and scattered coarse breath sounds that clear with cough.
Posteroanterior and lateral chest x-rays reveal no infiltrates. His white blood cell count is 6,700/µL with normal differential.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_98df_e44e_853d_5b8fd1be48a5_MD0002_00 This patient's acute worsening of underlying dyspnea and cough is consistent with exacerbation of chronic obstructive pulmonary disease (COPD). COPD exacerbation is most commonly due to respiratory infections (viral or bacterial). Patients typically have the cardinal symptoms of increased sputum volume, sputum purulence, and/or dyspnea. Mild COPD exacerbation is defined as having 1 of the 3 cardinal symptoms and not requiring hospitalization or ventilator support. Moderate-to-severe COPD exacerbation is defined as having at least 2 of the 3 symptoms or requiring hospitalization or ventilator support. Drug therapy for COPD exacerbation includes glucocorticoids, bronchodilators, and antibiotics. Systemic glucocorticoids shorten recovery time, improve lung function and arterial hypoxemia, reduce the risk of early-relapse treatment failure, and decrease length of hospital stay. This patient has a mild COPD exacerbation and a cardinal symptom (cough) and would benefit from oral glucocorticoids. (Choice A) The addition of inhaled ipratropium will not likely add much benefit as the patient is already on a long-acting anticholinergic inhaler. (Choice B) Clinical factors to support an inpatient hospital stay for COPD include unstable vital signs (eg, tachycardia, tachypnea), hypoxemia or acidosis, severe or resting dyspnea, failure of outpatient management, high-risk comorbidity (eg, congestive heart failure, chronic kidney disease), or inadequate social support at home. This patient is clinically stable and does not require hospitalization. (Choice D) Antibiotics are useful for moderate-to-severe exacerbations of COPD, especially those with increased cough and purulent sputum or requiring intensive care unit admission. Current evidence indicates that antibiotics in these patients can reduce short-term mortality by 77% and treatment failure by 53%. However, evidence for antibiotics in mild exacerbation is inconsistent, especially for patients treated on an outpatient basis. Educational objective: Drug therapy for chronic obstructive pulmonary disease (COPD) exacerbation includes glucocorticoids, bronchodilators, and antibiotics. Antibiotics have proven benefit in severe COPD exacerbation, especially for patients requiring intensive care unit admission, but they are less likely to be of benefit for mild exacerbation. __________ References: Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/11845001) Antibiotics for exacerbations of chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/23235687)

A 65-Year-Old Man with Moderate Chronic Obstructive Pulmonary Disease Comes