How to manage a 60-year-old patient with chronic obstructive pulmonary disease (COPD) and ataxia, who developed aspiration pneumonia and was initially treated with meropenem (Merrem) 1g twice daily (BD) and nebulisation, but experienced clinical deterioration with fever, hypoxia, and hypotension after stopping meropenem injections?

Management of COPD Patient with Recurrent Aspiration Pneumonia

The patient should be immediately hospitalized for IV antibiotics, oxygen therapy, and supportive care due to the recurrence of aspiration pneumonia with fever, hypoxia, and hypotension after stopping meropenem. 1

Initial Assessment and Management

• Obtain arterial blood gases immediately to assess oxygenation and acid-base status, noting the inspired oxygen concentration 1
• Perform chest radiograph to rule out progression of pneumonia or other complications 1
• Complete blood count, urea and electrolytes, and ECG within the first 24 hours 1
• Collect blood cultures and sputum samples for culture before restarting antibiotics 2

Oxygen Therapy

• Administer controlled oxygen therapy with target saturation of 88-92% to avoid respiratory acidosis 1
• Use 24-28% Venturi mask or nasal cannulae at 1-2 L/min 3
• Monitor oxygen saturation continuously with pulse oximetry 1
• Repeat arterial blood gas measurements within 60 minutes of starting oxygen therapy and if clinical situation deteriorates 2

Antibiotic Therapy

• Restart intravenous broad-spectrum antibiotics immediately due to clinical deterioration after stopping meropenem 2
• Consider restarting meropenem 1g IV every 8 hours as it has shown efficacy in severe respiratory infections including aspiration pneumonia 4
• Alternatively, consider piperacillin/tazobactam which has shown comparable efficacy to meropenem in healthcare-associated pneumonia 5
• Continue IV antibiotics for at least 7-10 days based on clinical response 2

Bronchodilator Therapy

• Administer nebulized bronchodilators using compressed air (not oxygen) to drive the nebulizer if the patient has hypercapnia and/or respiratory acidosis 6
• Use short-acting beta-2 agonist (salbutamol 2.5-5 mg) via nebulizer every 4-6 hours 2
• Add anticholinergic (ipratropium bromide 0.25-0.5 mg) via nebulizer for severe exacerbations 2
• Provide low-flow supplemental oxygen via nasal prongs at 1-2 L/min during nebulization if the patient is hypoxemic 6

Corticosteroid Therapy

• Administer systemic corticosteroids (prednisolone 30-40 mg daily or equivalent) for 7-14 days 2
• Plan to discontinue corticosteroids after the acute episode unless there is a definite indication for long-term treatment 2

Hemodynamic Support

• For hypotension, administer IV fluid resuscitation with crystalloids (20-30 ml/kg) while monitoring for fluid overload 7
• If hypotension persists despite adequate fluid resuscitation, initiate vasopressor therapy (norepinephrine) to maintain mean arterial pressure ≥65 mmHg 7
• Monitor urine output, targeting >0.5 ml/kg/hour 7

Additional Interventions

• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if patient is not responding to standard therapy 2
• If methylxanthines are used, monitor blood levels daily 2
• Administer diuretics if there is peripheral edema and raised jugular venous pressure 2
• Consider prophylactic subcutaneous heparin for prevention of thromboembolism 2

Ventilatory Support Assessment

• If respiratory acidosis persists (pH < 7.26) despite standard medical management, consider non-invasive ventilation (NIV) 2
• Monitor closely for signs of worsening respiratory failure requiring escalation to invasive mechanical ventilation 2
• Factors favoring use of invasive ventilation include: first episode of respiratory failure, pneumonia as a reversible cause, and previously acceptable quality of life 2

Addressing Aspiration Risk

• Elevate head of bed to 30-45 degrees to reduce risk of aspiration 8
• Consider speech and language therapy evaluation for swallowing assessment once stabilized 8
• Implement aspiration precautions including proper positioning during meals and thickened liquids as needed 8

Monitoring Response to Treatment

• Monitor vital signs, oxygen saturation, and level of consciousness frequently 1
• Repeat arterial blood gases if clinical deterioration occurs 2
• Record peak flow twice daily until clinically stable 2
• Reassess within 24-48 hours for clinical improvement 2

Common Pitfalls to Avoid

• Avoid uncontrolled high-flow oxygen which may worsen hypercapnia 1
• Do not continue corticosteroids beyond 14 days unless specifically indicated 3
• Avoid prolonged courses of antibiotics beyond 7-10 days unless clinically indicated 3
• Do not use chest physiotherapy routinely as it is not recommended in acute COPD exacerbations 2