What is the appropriate acute management for a 69-year-old male with chronic obstructive pulmonary disease (COPD) exacerbation, epigastric burning pain, hypoxemia (SpO₂ 80%), hand tremor, chronic alcohol use, and smoking?

Acute Management of Severe COPD Exacerbation with Hypoxemia and Comorbidities

Immediate Oxygen Therapy – Life-Saving Priority

Target SpO₂ 88–92% immediately using controlled oxygen delivery (24–28% Venturi mask or 1–2 L/min nasal cannula) to correct life-threatening hypoxemia while minimizing CO₂ retention. 1

• With an SpO₂ of 80%, this patient has severe hypoxemia requiring urgent correction, but uncontrolled high-flow oxygen increases mortality by approximately 78% in COPD patients through worsening hypercapnic respiratory failure 1, 2
• Obtain arterial blood gas within 60 minutes of starting oxygen to identify hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35), which signal impending respiratory failure 1, 3, 4
• If pH falls below 7.26 with rising PaCO₂, prepare for immediate non-invasive ventilation 1, 4
• Never administer high-flow oxygen (>28% FiO₂ or >4 L/min) without arterial blood-gas monitoring 1

Combined Nebulized Bronchodilator Therapy

Administer salbutamol 2.5–5 mg plus ipratropium 0.25–0.5 mg via nebulizer every 4–6 hours immediately upon presentation. 1, 3

• This combination provides superior bronchodilation lasting 4–6 hours compared with either agent alone 1
• Power nebulizers with compressed air (not oxygen) when hypercapnia is suspected, delivering supplemental oxygen separately via nasal cannula 1, 4
• Continue nebulized therapy for 24–48 hours or until clinical improvement, then transition to metered-dose inhalers 1
• Avoid intravenous methylxanthines (theophylline/aminophylline) as they increase adverse effects without clinical benefit 1, 3

Systemic Corticosteroid Protocol

Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately. 1, 3, 4

• This short course is as effective as a 14-day regimen while reducing cumulative steroid exposure by >50% 1
• The 5-day regimen improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by >50% 1
• Oral administration is equally effective to intravenous and should be the default route unless oral intake is impossible 1
• Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists 1, 3

Antibiotic Therapy Indication

Prescribe antibiotics for 5–7 days if sputum purulence is present together with either increased dyspnea or increased sputum volume (two of three cardinal symptoms required). 1

• First-line agents include amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or azithromycin 1, 3, 4
• This approach reduces short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44% 1
• Target common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Non-Invasive Ventilation Criteria

Initiate NIV immediately as first-line therapy if acute hypercapnic respiratory failure (PaCO₂ > 45 mmHg) with acidosis (pH < 7.35) persists >30 minutes after standard medical treatment. 1, 3, 4

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospital stay, and improves survival 1, 4
• Success rates in appropriately selected patients are 80–85% 1
• Contraindications include altered mental status with inability to protect airway, large-volume secretions, hemodynamic instability, or recent facial surgery 1

Addressing Hand Tremor & Chronic Alcohol Use

Monitor for alcohol withdrawal syndrome given chronic alcohol use and acute illness stress. [General Medicine Knowledge]

• Hand tremor may represent alcohol withdrawal, beta-agonist side effect, or metabolic derangement (hypomagnesemia, hypocalcemia) 3
• Obtain comprehensive metabolic panel immediately to detect electrolyte disturbances (hypokalemia, hypomagnesemia) and hyperglycemia secondary to steroids 1
• Aggressive electrolyte repletion should be performed as needed 1
• Consider thiamine 100 mg IV and folate supplementation in chronic alcohol users [General Medicine Knowledge]

Epigastric Pain Management

Evaluate for peptic ulcer disease, gastritis, or pancreatitis given chronic alcohol use and impending corticosteroid therapy. [General Medicine Knowledge]

• Consider proton pump inhibitor (omeprazole 40 mg daily) for gastric protection during corticosteroid course [General Medicine Knowledge]
• Obtain lipase if pancreatitis suspected [General Medicine Knowledge]
• Epigastric pain may also represent cardiac ischemia—obtain ECG if cardiac risk factors present 3

Hospitalization Criteria Met

This patient requires hospital admission based on multiple high-risk features: 1, 3, 4

• Severe hypoxemia (SpO₂ 80% on room air)
• Marked increase in dyspnea requiring nebulization
• Chronic alcohol use with potential withdrawal risk
• Age 69 years with multiple comorbidities
• Inability to care for self at home

Monitoring & Safety

• Monitor cardiac rhythm closely during nebulized beta-agonist therapy as high-dose agents may precipitate arrhythmias or tachycardia 1
• Repeat arterial blood gas at 30–60 minutes if clinical deterioration occurs 1, 3
• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention 1, 3
• Avoid chest physiotherapy—no evidence of benefit in acute COPD exacerbations 1

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients 1, 4
• Never delay NIV when criteria for acute hypercapnic respiratory failure are met 1
• Never use methylxanthines in acute exacerbations—they add toxicity without benefit 1, 3
• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation 1
• Never administer high-flow oxygen without arterial blood-gas monitoring 1

Discharge Planning (When Stabilized)

• Arrange pulmonary rehabilitation within 3 weeks after discharge to reduce readmissions and improve quality of life 1
• Optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before discharge 1
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention 1
• Verify correct inhaler technique at discharge 1
• Schedule follow-up within 3–7 days to assess treatment response 1