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E case #5 Eric Liu M.D. January 29-February 2 Patient is a 65 y.o. man with a ninety pack year smoking history who presents to an ER with a five day history of progressive dyspnea and a cough minimally productive of yellow-green mucous. He is found to have severe inspiratory and expiratory wheezing, no rales and minimal use of his accessory muscles. His cardiac exam demonstrates no murmurs or gallops.His chest x-ray is clear. His white count is twelve thousand, and chem 7 is normal including bicarbonate. His initial ABG is 7.27/65/50. He is given an albuterol /atrovent nebulizer, and a repeat albuterol nebulizer 45minutes later. He also receives a solumedrol load of 125mg IV, as well as a dose of cefotetan. His repeat ABG in one hour is 7.31/54/122 on FiO2 50% by face mask. Question What is your management at this point in regards to
Discussion Clearly, the patient needs to be admitted to the ICU for monitoring. Albuterol nebulizers can be given frequently, every 45 - 60 minutes initially. Atro vent nebulizers are maximally dosed every four hours. Solumedrol 60mg q six hours is standard. The causative organisms for bronchitis are Streptococcus pneumonia, Hemophilusinfluenza and Moroxallacatarrhalis, though the majority are viral in etiology. Emperic coverage with his respiratory failure is standard. The literature regarding non-invasive ventilation demonstrates that BIPAP can be supportive inpatients whose pH is greater than 7.3 after one hour of therapy, and may prevent intubation. Those who have a pH less than 7.3 usually will be intubated within 24 hours. BIPAP may not be well tolerated in severe respiratory distress, and is relatively contraindicated with significant mucous production. The main advantage is ventilatory support in obstructive lung disease, or in neuromuscular weakness, such as ALS. It is also indicated for primarily alveolar processes such as pulmonary edema and pneumonia (not for oxygenation, but for respiratory muscle fatigue with high respiratory rates and subsequent hypoventilation). In this case, the patient was admitted to the ICU. Initially, BIPAP was not tolerated well with his tachypnea. He remained alert and minimally anxious. He continued to receive albuterol every 45 minutes. Ninety minutes later,his wheezing and respiratory rate was improving to a minimal degree, though he still had severe wheezing. A repeat ABG demonstrated a value of7.34/47/144 on the same amount of oxygen. BIPAP was reinitiated at an inspiratory pressure of 12, and a expiratory pressure of 8, and toleratedmoderately. Over the ensuing 36 hours, the patient continued to improveslowly. He required his albuterol nebulizer every two to three hours, no longer was retracting, and normalized his ABG to 7.44/35/112 on 4 liters. After continued improvement, he was sent to the floor without non-invasiveventilation. His exam demonstrates significant wheezing on both inspiration and expiration, but there was no neck retraction or a prolonged expiratoryphase.His airflow volumes continued to improve. His solumedrol is tapered to prednisone, his nebulizers are given every four hours, and his antibiotics are converted to oral doxycycline. The patient is discharged to home. 2) What should be his outpatient regimen?
A recent study (Rick Albert/Tom Martin were investigators) looked at the effects of a two-week versus eight-week steroid taper of prednisone and found no benefit with the longer course. Prophylactic steroids are a foundation in COPD treatment, as COPD is an inflammatory disease of the bronchi (chronic cough and mucous production/mucin gland hyperplasia) that results in the wheezing. The introduction of high potency steroid MDI's like budesonide and fluticasone are highly effective and can be prednisone sparing for maintanence. Budesonide and fluticasone (220mcg) have an 8:3greater potency than flunisolide (Aerobid) and triamcinolone (Azmacort) in the same number of puffs. In clinical trials, budesonide is more effective than fluticasone because of delivery. It has a powdered vehicle leading to better delivery to the bronchi. Also, it has a turbo inhaler that injects the medicine with inhalation, eliminating poor timing techniques. Theophylline is regarded as a second line agent, though still effective in refractory cases, both in the ICU and as an outpatient. Leukotriene antagonists have little role in COPD. They are indicated in mild to moderate asthma of varying etiologies. The concern with long acting beta agonists is down regulation of the number of beta-receptors with chronicdosing. It is a theoretical risk, but clinical trials show that they do improve outcome in patients who need around the clock beta agonist therapy for symptom control. REFERENCES
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