A 64-year-old man with a history of chronic obstructive pulmonary disease (COPD) is evaluated in the emergency department for increased dyspnea over the past 48 hours. There is no change in his baseline production of white sputum but he has increased nasal congestion and sore throat. His medications include inhaled tiotropium , combination fluticason and salmeterol, and albuterol.
The patient is alert but in mild respiratory distress. Temp 38.6°C (101.5°F), bp 150/90 mm Hg, HR 108/min, and RR 30/min. O2 Sat with the patient breathing ambient air is 90%. Breath sounds are diffusely decreased with bilateral expiratory wheezes; he is using accessory muscles to breathe. He does not have any peripheral edema or elevated jugular venous distension. With the patient breathing O2, 2 L/min by nasal cannula, arterial blood gases (ABGs) are pH 7.27, PCO2 60 mm Hg, and PO2 62 mm Hg; O2 is 91%. His CBC shows leukocytosis of 11,000 and chest x-ray does not show any new infiltrates or pneumothorax.
1) What is your diagnosis?
2. How would you approach this patient?
3) His outpatient record shows that his FEV1/FVC 0.4 and his post bronchodilator FEV1 was 67. What GOLD category he was on?
4)What is the indication for noninvasive mechanical ventilation (NMV)?
5) GOLD2020, Pt with COPD exacerbation is already on LABA/LAMA therapy and which population will get a benefit if adding ICS? (which test will show you that adding ICS might be beneficial?) and why?
6) Would you prescribe antibiotics and why?
