Mr. Whaley is a 65-year-old man with a history of COPD who presents to his primary care provider’s (PCP) office complaining of a productive cough off and on for 2 years and shortness of breath for the last 3 days. He reports that he has had several chest colds in the last few years, but this time it won’t go away.  His wife says he has been feverish for a few days, but doesn’t have a specific temperature to report. He reports smoking a pack of cigarettes a day for 25 years plus the occasional cigar.

Upon further assessment, Mr. Whaley has crackles throughout the lower lobes of his lungs, with occasional expiratory wheezes throughout the lung fields. His vital signs are as follows:

BP 142/86 mmHg HR 102 bpm

RR 32 bpm Temp 38.8°C

SpO2 86% on room air

The nurse locates a portable oxygen tank and places the patient on 2 lpm oxygen via nasal cannula.  Based on these findings, Mr. Whaley’s PCP decides to call an ambulance to send Mr. Whaley to the Emergency Department (ED).  While waiting for the ambulance, the nurse repeats the SpO2 and finds Mr. Whaley’s SpO2 is only 89%. She increases his oxygen to 4 lpm, rechecks and notes an SpO2 of 95%.  The ambulance crew arrives, the nurse reports to them that the patient was short of breath and hypoxic, but sats are now 95% and he is resting. Per EMS, he is alert and oriented x 3. 

Upon arrival to the ED, the RN finds Mr. Whaley is somnolent and difficult to arouse. He takes a set of vital signs and finds the following:

BP 138/78 mmHg HR 96 bpm

RR 16 bpm Temp 38.4°C

SpO2 96% on 4 lpm nasal cannula

The provider writes the following orders:

Keep sats 88-92%

CXR

Labs: ABG, CBC, BMP

Insert peripheral IV

Albuterol nebulizer 2.5mg

Budesonide-formoterol 160/4.5 mcg

The nurse immediately removes the supplemental oxygen from Mr. Whaley and attempts to stimulate him awake. Mr. Whaley is still quite drowsy, but is able to awake long enough to state his full name. The nurse inserts a peripheral IV and draws the CBC and BMP, while the Respiratory Therapist (RT) draws an arterial blood gas (ABG).  Blood gas results are as follows:

pH 7.30 

pCO2 58 mmHg

HCO3– 30 mEq/L

pO2 50 mmHg

SaO2 92%

Mr. Whaley’s chest x-ray shows consolidation in bilateral lower lobes.

Mr. Whaley’s condition improves after a bronchodilator and corticosteroid breathing treatment. His SpO2 remains 90% on room air and his shortness of breath has significantly decreased. He is still running a fever of 38.3°C.  The ED provider orders broad spectrum antibiotics for a likely pneumonia, which may have caused this COPD exacerbation. The provider also orders two inhalers for Mr. Whaley, one bronchodilator and one corticosteroid. Satisfied with his quick improvement, the provider decides it is safe for Mr. Whaley to recover at home with proper instructions for his medications and follow up from his PCP.