A 69-year-old man comes to the emergency department due to severe shortness of breath for the past 12 hours. He has used his albuterol inhaler many times without relief. He reports one day of low-grade fever that resolved with acetaminophen. The patient quit smoking 2 years ago but has a 40-pack-year history. His temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 22/min. The patient is using accessory muscles of respiration. Lung examination shows prolonged expiration with end-expiratory wheezing bilaterally. Results of arterial blood gas testing performed on room air are as follows: Noninvasive positive-pressure ventilation is initiated. Which of the following additional therapies is most likely to benefit this patient?

Question

A 69-year-old man comes to the emergency department due to severe shortness of breath for the past 12 hours.  He has used his albuterol inhaler many times without relief.  He reports one day of low-grade fever that resolved with acetaminophen.  The patient quit smoking 2 years ago but has a 40-pack-year history.  His temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 22/min.  The patient is using accessory muscles of respiration.  Lung examination shows prolonged expiration with end-expiratory wheezing bilaterally.  Results of arterial blood gas testing performed on room air are as follows:  Noninvasive positive-pressure ventilation is initiated.  Which of the following additional therapies is most likely to benefit this patient?

Quizplus · Accepted Answer

11ec25c8_d4af_ca76_bc81_4fd277cac8e3_MD0003_00 This patient with acute respiratory distress, hypoxemia, and a significant smoking history most likely has an acute exacerbation of chronic obstructive pulmonary disease (COPD). The low-grade fever suggests an upper respiratory infection as the exacerbation trigger. Treatment of an acute COPD exacerbation includes supplemental oxygen (as needed to maintain SpO₂ of 88%-92%), combination short-acting bronchodilators (β2 adrenergic agonist and anticholinergic agents), systemic glucocorticoids, and antibiotics (in select patients). Systemic glucocorticoids decrease inflammation associated with COPD exacerbation, improve lung function and hypoxemia, and have been shown to decrease risk of relapse, treatment failure, and length of hospital stay. They are usually administered for 5 days as oral prednisone or intravenous methylprednisolone. Intravenous administration is more often used in severe exacerbations but has no demonstrated benefit over oral administration. (Choice A) Acetylcysteine is a mucolytic agent useful in patients with abnormal/thick mucous secretions. It has not consistently demonstrated benefit in patients with COPD and may increase the risk of bronchospasm. (Choice B) Methylxanthines (eg, aminophylline, theophylline) are phosphodiesterase inhibitors that cause bronchodilation. Their use in the chronic management of patients with uncontrolled asthma or severe COPD is limited due to their toxicity, and they have no added benefit over inhaled bronchodilators and glucocorticoids in the treatment of acute exacerbation of COPD. (Choices C and H) Inhaled cromolyn is a mast cell stabilizer (prevents release of histamine and leukotrienes) used in the treatment of asthma. Similarly, zafirlukast is a leukotriene-receptor antagonist used in the management of asthma. Neither medication is useful for acute COPD treatment. (Choice D) Inhaled corticosteroids (eg, fluticasone inhaler) are used in the long-term management of persistent asthma. In patients with COPD who have relatively advanced disease, these agents may reduce exacerbation frequency and improve symptoms, but they do not appear to affect mortality or lung function. They do not play a role in the management of acute exacerbation of COPD. (Choice F) Oral furosemide is indicated for patients with decompensated congestive heart failure (CHF), which would be characterized by orthopnea and/or paroxysmal nocturnal dyspnea, prominent S3, elevated jugular venous pressure, and bilateral lower-extremity edema. This patient's presentation does not suggest CHF. (Choice G) Long-acting β2 agonists (eg, salmeterol) are used in the maintenance therapy of COPD. They are not recommended for acute exacerbations. Educational objective: All patients with acute exacerbation of chronic obstructive pulmonary disease should receive inhaled bronchodilators (β2 agonists and anticholinergics) and systemic glucocorticoids. In addition, supplemental oxygen, antibiotics, and ventilatory support should be administered when indicated. References: Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. (http://www.ncbi.nlm.nih.gov/pubmed/23695200) Treatment of stable chronic obstructive pulmonary disease: the GOLD guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/24364481)

A 69-Year-Old Man Comes to the Emergency Department Due to Severe