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Case Study

Appropriate responses to the following case study are presented at the end of the course. Responses are based on the material you have studied in this module. There may be other equally correct choices based upon personal preference or experience.

1. A 69 year-old white male came to the hospital emergency department by himself. He said he was severely short of breath (SOB) and had difficulty taking more than a couple steps without feeling dyspnea. He reported coughing up thick, greenish sputum, with some tinges of blood in the last few days. He appeared oriented and coherent, somewhat malnourished, and on interaview he admitted to smoking two packs of cigarettes a day since age 18, but that he'd quit about two years ago. He'd been hospitalized six times in the last two years, and current medications include ipratropium bromide by MDI, 2 puffs, QID, with a beta₂ agonist by MDI as needed. He has been using the beta₂ MDI regularly during the last month, at least four times daily.

On physical exam, he was very SOB, and used accessory muscles with a respiratory rate of 22/minute. There was little discernible chest expansion, his breath sounds were distant in all areas, with expiratory wheezes, and air movement appeared poor. He was afebrile, with a pulse = 1q20/min, BP = 170/112 mm Hg. He was admitted with a diagnosis of "acute exacerbation of COPD."

Lab values on admission showed normal electrolytes, but his WBC was 15.2 x 10³/cc, and his hemoglobin was 10.6 g/dl. Arterial blood gas values on room air were the following:

pH = 7.40

PaCO₂ = 42.4 mm Hg

PaO₂ = 64 mm Hg

BE = +1.9 mEq/L

SaO₂ 90%

And a chest x-ray (PA vuew) shows hyperinflation of lung fields, with flattened diaphragms.

Questions on Case Study:

1. What is the first drug indicated by this individual's blood sample values?

 

2. Would you continue his use of ipratropium bromide, and if so, at what dose?

 

3. What additional bronchodilator therapy could you recommend?

 

4. What is the rationale for use of theophylline in this patient?

 

5. What would you check before initiating therapy with theophylline?

 

6. What serum theophylline level would you target if the patient is started on theophylline?