A 65-year-old man with chronic obstructive pulmonary disease comes to the emergency department with increased dyspnea and worsening cough for the last 2 days. He has been unable to rest due to increased symptoms. The patient has increased sputum production compared to his baseline. He tried 3 nebulizer treatments with albuterol and ipratropium bromide at home with no relief. His most recent spirometry during an office visit a month ago showed FEV1 of 60% of predicted. His temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 23/min. The patient's oxygen saturation is 87% on room air. He appears to be in mild respiratory distress. Lung examination shows bilateral wheezing and prolonged expiration. ECG shows sinus tachycardia. Chest x-ray reveals a flattened diaphragm and no infiltrates. Initial laboratory studies show a white blood cell count of 11,000/mm³. He is started on supplemental oxygen, bronchodilators, and glucocorticoids. Which of the following additional therapies would also benefit this patient in the acute setting?

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Explanation: 11ec25c8_d1f2_cd03_bc81_4b62a978084a_MD0003_00 This patient has an acute exacerbation of chronic obstructive pulmonary disease (COPD), with an increase in dyspnea, cough, and sputum production. All patients with acute COPD exacerbation should receive bronchodilators and systemic glucocorticoids. In addition, antibiotics are indicated for patients with the following: Moderate to severe COPD exacerbation (defined as >2 cardinal symptoms), especially with increased sputum purulence or Mechanical ventilation requirement (endotracheal intubation or noninvasive positive pressure) In such patients, antibiotic therapy has demonstrated increased likelihood of clinical improvement, reduced risk of subsequent exacerbation, and decreased in-hospital mortality in cases requiring mechanical ventilation. Up to 50% of COPD exacerbations are likely caused by acquisition of a bacterial respiratory pathogen, but identifying such a trigger can be clinically challenging. Collection of sputum cultures is not recommended (except in patients with risk factors for Pseudomonas aeruginosa infection) due to difficulty in isolating a single bacterial pathogen. Therefore, empiric antibiotic therapy is directed at common upper respiratory bacterial pathogens (Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae) and includes macrolides (eg, azithromycin), respiratory fluoroquinolones (eg, levofloxacin, moxifloxacin), or penicillin/beta-lactamase inhibitors (eg, amoxicillin-clavulanate). Typical duration of antibiotic therapy is 3-7 days. (Choice B) Chest physiotherapy with percussion and vibration and other mechanical techniques to aid sputum clearance have not been shown to improve clinical outcomes in acute COPD exacerbations. Chest physiotherapy is used in patients with bronchiectasis. (Choice C) Inhaled glucocorticoid therapy is used in long-term management of asthma. In patients with COPD who have relatively advanced disease, these agents reduce exacerbation frequency and improve symptoms but do not appear to affect lung function or mortality. Unlike systemic glucocorticoids, inhaled glucocorticoids do not play a role in the management of acute COPD exacerbation. (Choice D) Intravenous magnesium sulfate causes bronchodilation and is used for severe, life-threatening asthma exacerbations. However, studies have failed to demonstrate any benefit from magnesium sulfate for acute COPD exacerbation. (Choice F) Roflumilast is a phosphodiesterase inhibitor with anti-inflammatory properties that helps decrease mucociliary malfunction and pulmonary remodeling. It is useful as maintenance therapy to reduce future exacerbations in patients with severe COPD and history of exacerbations, but it is not indicated during an acute exacerbation. Educational objective: Antibiotics are indicated for treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) in patients with moderate to severe exacerbation and those needing mechanical ventilation. Antibiotics are not indicated in patients with mild COPD exacerbation. References: Antibiotics for acute and chronic respiratory infection in patients with chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/23924286) Treatment of stable chronic obstructive pulmonary disease: the GOLD guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/24364481)

A 65-Year-Old Man with Chronic Obstructive Pulmonary Disease Comes to the Emergency