Medicine>>>>>Hospital-Based Medicine
Question 3#

A 64-year-old man presents with acute exacerbation of chronic obstructive pulmonary disease. The patient had a long smoking history before quitting 2 years ago. In spite of his poor baseline lung function, he has been able to maintain an independent lifestyle. The patient is in obvious respiratory distress and appears tired. He has difficulty greeting you secondary to shortness of breath. Respiratory rate is 32/minute. Auscultation of the lungs reveals minimal air movement. ABGs show:

One dose of IV methylprednisolone has already been administered.

What is the best next step in the management of this patient’s disease? 

A) Urgent institution of BiPAP (bilevel positive airway pressure)
B) Urgent endotracheal intubation
C) Administration of 100% FiO2 by face mask
D) Start inhaled tiotropium immediately
E) IV levofloxacin

Correct Answer is A


Bilevel positive airway pressure (BiPAP) ventilation has found increased favor in acute lung or heart disease, especially in those with acute CO2 retention. The use of BiPAP may prevent the need for endotracheal intubation with its concomitant risks. BiPAP is contraindicated in patients with severe respiratory acidosis, decreased level of consciousness, bradypnea, or hemodynamic instability, for whom endotracheal intubation is the best treatment. Although oxygen should never be withheld from a hypoxic patient, caution must be exercised in patients with chronic CO2 retention. Overly aggressive oxygen therapy may actually increase PaCO2 . In patients with chronic CO2 retention, a targeted oxygen saturation of 88% to 92% is appropriate. Although effective in the chronic management of COPD, inhaled tiotropium will not help acutely. Nebulized albuterol and ipratiotropium are beneficial in COPD exacerbation but in the absence of wheezing would be less effective than BiPAP. Antibiotics are given for severe COPD exacerbations (especially if the patient is producing purulent sputum) but will not affect the immediate outcome of his respiratory failure.