Question

A 75-year-old man with a long history of COPD and a past smoking history of 114 pack-years presents to the ED with shortness of breath, productive cough with green purulent sputum, and cyanosis. He has had two prior hospitalizations for acute infective exacerbations of his COPD within the past year. He has no comorbidities or occupational exposure. Physical examination reveals the following: pulse 105 beats/min and regular, blood pressure 140/85 mm Hg, respirations 30 breaths/min with prolonged expiration and use of accessory muscles, percussion is hyper-resonant, breath sounds are reduced bilaterally with prolonged expiratory wheezes. Laboratory work shows white blood cells (WBCs) 11,500 cells/mm3 and room air ABG pH 7.30, PaCO2 55 mm Hg, PaO2 53 mm Hg, and HCO3 2 32 mEq/L.

1. Analyze this situation and identify and explain five presenting problems.

2. What treatment recommendations should be suggested for this patient at this time? A repeat ABG following appropriate therapy reveals the following: pH 7.19, PaCO2 67 mm Hg, PaO2 60 mm Hg.

3. What is the most appropriate treatment option at this time

Answer 1

1.An intermittant cough ,which is the earliest symptom ,usually occurs in the morning with the expectoration of small amounts of sticky mucus resulting from bouts of coughing.The coug initially maybe intermittent .Later it is present every day,but is seldom present during the night.

Dyspnea is often progressive ,and usually occurs with exertion .However ,patients may dismiss the importance of this symptom as they rationalize.In the late stages of COPD,dyspnea maybe present at rest .As more alveoli become overdistended ,increasing amounts of air are trapped.

Wheezing may be present,but may vary by time of day or from day to day ,especially in patients with more severe disease.

Hypoxaemia may develop with hypercapnia later in the disease.The bluish-red discolouration of the skin results from polycythemia and cyanosis. Cyanosis develop when there is atleast 5g/dl or more of circulating unoxygenated hemoglobin.

2 Exacerbrations of COPD should be treatedas soon as possible,especially if the patient is in severe stages of COPD.Often the best indication of the presence of a bacterial infection is the increasing quantity ,viscosity or purulence of sputum.Patients are given a prescription for a 7-10 day supply of antibiotics and are instructed to begin taking them at the first signs of changes of sputum.Oxygen therapy is frequently used in the treatment of COPD and other problems associated with hypoxaemia.Respiratory therapy and Physical therapy rehabilitation activities are performed by respiratory therapists depending on the institution.

3 Cessation of cigarette smoking in all stages of COPD is the single most effective and cost-effective intervention to reduce the risk of developing COPD and stop the progression of disease.After discontinuation of smoking ,the accelerated decline in pulmonary function slows and pulmonary function usually improves.Normally individuals after age 35 lose aproximately 20 to 25 ml of lung function per year as measured by spirometry.Persons with COPD who continues to smoke lose approximately 50ml per year.With the cessation of smoking ,the loss can fall to almost nonsmoking levels at 35ml per year.Thus the sooner the smoker stops ,the less pulmonary function is lost and sooner the symptoms decrease,especially cough and sputum production

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