A 65-Year-Old Man With a Cough and Worsening Dyspnea

Joshua M. Kosowsky, MD


April 09, 2020

The mainstays of therapy for acute exacerbations of COPD, as in this case, are oxygen, bronchodilators, and steroids. Adequate oxygen should be given to relieve the hypoxia. Supplemental oxygen should maintain an oxygen saturation to above 90%. Bronchodilator therapy with both beta-agonist and anticholinergic nebulizer therapy should be administered promptly. The need for intubation should be established and performed if indicated (eg, hypoxia not relieved with supplemental oxygen, severe respiratory distress, CO2 retention with obtundation). If necessary and available, noninvasive continuous positive airway pressure may be used. Other therapies that are indicated in specific situations may include antibiotics, magnesium, and Heliox (a mixture of helium and oxygen that leads to increased oxygen delivery as a result of improved laminar flow).

The patient in this case was given a combination beta-agonist and anticholinergic nebulizer therapy for his respiratory distress and hypoxia. A chest radiograph was performed, which revealed a moderately sized basilar infiltrate. Antibiotics appropriate for community-acquired pneumonia coverage and intravenous steroids were administered, and the patient was admitted to the hospital for continued inpatient therapy and monitoring.

On the morning of hospital day 3, the patient was noted to be breathing easier and was discharged to home with prescriptions for maintenance inhaled steroid therapy, and for beta-agonist and anticholinergic metered-dose inhalers. Appropriate follow-up was arranged for continued outpatient management.


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