From the Guidelines
The patient should be treated with bronchodilator therapy, supplemental oxygen, and empiric antibiotic therapy, while also addressing his reduced kidney function and encouraging smoking cessation. The patient, a 79-year-old male with COPD history who vapes, presents with shortness of breath and laboratory findings suggesting mild urinary tract infection and reduced kidney function.
Treatment Approach
- Bronchodilator therapy with albuterol nebulizer (2.5mg every 4-6 hours) and ipratropium bromide (0.5mg every 6-8 hours) is recommended to address the respiratory symptoms, as suggested by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
- Supplemental oxygen should be provided to maintain oxygen saturation above 88-92%, being cautious of CO2 retention given his COPD, in line with the BTS guidelines for the management of chronic obstructive pulmonary disease 1.
- For the apparent urinary tract infection, empiric antibiotic therapy with ceftriaxone 1g IV is appropriate, followed by oral antibiotics like trimethoprim-sulfamethoxazole DS (1 tablet twice daily for 7 days) upon discharge, with dose adjustment for his reduced kidney function (eGFR 46).
Additional Considerations
- The patient should be hydrated with IV fluids, preferably normal saline at 75-100ml/hr, to support kidney function while monitoring fluid status given his respiratory condition.
- Smoking cessation counseling is essential, with consideration of nicotine replacement therapy and referral to cessation programs, as emphasized by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
- Follow-up should be arranged within 1-2 weeks with both primary care and pulmonology to reassess respiratory status and kidney function, as the elevated creatinine (1.53) and reduced eGFR require monitoring. This comprehensive approach addresses both the acute respiratory symptoms and the underlying conditions contributing to his presentation.
From the Research
Patient Assessment and Treatment
The patient is a 79-year-old male with a history of COPD, complaining of shortness of breath (SOB) and vaping. The urinalysis results show WBC 6-10/hpf, RBC 3-5/hpf, few bacteria, and trace blood and leukocyte esterase. The CBC results are within normal limits, except for a slightly low RBC count. The CMP results show a creatinine level of 1.53 and an eGFR of 46.
Oxygen Therapy
According to the study by 2, oxygen therapy should be initiated when the SpO2 threshold is crossed, and the delivered oxygen fraction should be titrated to maintain SpO2 within a target range. For patients with COPD, oxygen therapy should be started when SpO2 is ≤88% and stopped when it is >92%. The study by 3 also recommends long-term oxygen use in patients with COPD with severe chronic resting hypoxemia.
Urinary Tract Infection Treatment
The study by 4 compares the efficacy of ciprofloxacin, ofloxacin, and trimethoprim/sulfamethoxazole in treating acute urinary tract infections in women. The results show that all three antibiotics have similar efficacy, but ciprofloxacin has a lower frequency of adverse events. The study by 5 also compares ciprofloxacin and trimethoprim/sulfamethoxazole in preventing urinary tract infections in renal transplant recipients and finds that ciprofloxacin is at least as effective as trimethoprim/sulfamethoxazole and better tolerated.
Treatment at the ED
Based on the patient's symptoms and test results, the following treatment options may be considered: