October 16, 2007
Internal Medicine World Report, October 2007, Volume 0, Issue 0

Q. A 56-year-old man presents with a 3-day history of increasing shortness of breath, cough, and sputum production. He has not had fever or chills. He has been using his beta2-agonist metered-dose inhaler every 2 to 3 hours. He quit smoking 2 years ago. Pulse oximetry reveals an oxygen saturation of 89%. He is audibly wheezing, using accessory muscles of respiration. He is also tachypneic. You diagnose an exacerbation of chronic obstructive pulmonary disease (COPD). All the following statements are true, except:

A. Supplemental oxygen should be used to correct the hypoxia

B. Corticosteroids can reduce the risk of treatment failure

C. Antibiotics should be withheld, since the patient has been afebrile

D. Inhaled beta2-agonists or anticholinergics are a mainstay of treatment

See the Answer.

C. Antibiotics should be started, because they reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. Supplemental oxygen should be used to correct the hypoxia. There has been concern about decreasing respiratory drive, hypercapnia, and subsequent respiratory acidosis; however, most cases of CO2 retention are thought to be the result of V/Q mismatch rather than depression of the respiratory center. Inhaled bronchodilators are used routinely to treat COPD. Corticosteroids improve symptoms and can reduce the risk of treatment nonresponse.

Source:

Cochrane Database Syst Rev.

Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. 2006;(2):CD004403.