MEDizzy - A 56-year-old woman is admitted to the ICU with a 4-day

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Disorders of the Respiratory System and Critical Care Illness

A 56-year-old woman is admitted to the ICU with a 4-day history of increasing shortness of breath and cough with copious sputum production. She has known severe COPD with an FEV1 of 42% predicted. On presentation, she has a room air blood gas with a pH of 7.26, PaCO2 of 78 mmHg, and PaO2 of 50 mmHg. She is in obvious respiratory distress with the use of accessory muscles and retractions. Breath sounds are quiet with difuse expiratory wheezing and rhonchi. No infiltrates are present on the chest radiograph. Which of the following therapies has been demonstrated to have the greatest reduction in the mortality rate for this patient?

ExplanationAcute exacerbations of COPD are marked by an increase in dyspnea, an increase in sputum, and a change in sputum color. Acute exacerbations of COPD account for more than $10 billion in healthcare expenditures annually in the United States, with signifcant morbidity and mortality associated with these exacerbations. Prompt treatment can improve symptoms and decrease hospitalizations and mortality in this setting. In patients presenting with hypercarbic respiratory failure in the setting of an acute exacerbation, the treatment that has demonstrated the strongest reduction in mortality, when compared to traditional mechanical ventilation, is noninvasive positive-pressure ventilation (NIPPV). NIPPV also decreases the need for endotracheal intubation, complications, and length of stay in the hospital. Antibiotics, bronchodilators, and glucocorticoids are all cornerstones of therapy in the treatment of acute exacerbations in COPD but have not been demonstrated in clinical trials to have similar mortality benefits in the situation of acute hypercarbia respiratory failure. Specifically, no benefit is demonstrated for intravenous versus oral corticosteroids. Likewise, the choice of antibiotic should be made based on local susceptibility patterns, and the need for broad-spectrum antibiotics that cover Pseudomonas is not typically indicated. Recent studies have demonstrated that high-flow nasal oxygen may be an effective alternative to NIPPV, with improved outcomes (need for mechanical ventilation) and improved patient comfort.