04-11-2011, 11:16 AM
ANSWER IS D
This patient is the ideal candidate for noninvasive positive pressure ventilation (NPPV). Numerous controlled trials as well as meta-analyses have demonstrated significant benefits of NPPV compared to standard therapy in such patients, including more rapid improvements in respiratory and heart rate, gas exchange, avoidance of intubation, reduced rates of morbidity and mortality, and shorter hospital lengths of stay. The patient has the usual features of patients benefiting from NPPV in the studies, including moderate respiratory distress, use of accessory muscles, tachypnea, and acute on chronic carbon dioxide retention. She also has none of the contraindications, such as excessive secretions, uncooperativeness, or acute ischemic changes on electrocardiography (the multifocal atrial tachycardia is not a problem as long as the patient is hemodynamically stable).
Close observation, is not the most appropriate next step because, although she has roughly a 50% of responding to medical therapy, waiting to see if she worsens increases the likelihood of NPPV failure. CPAP alone has been shown to reduce work of breathing by counterbalancing auto-PEEP in patients with COPD, but is less effective at doing so than the combination of pressure support plus positive end-expiratory pressure. Intubation should be avoided in patients with COPD because of the increased morbidity and mortality associated with its use.
This patient is the ideal candidate for noninvasive positive pressure ventilation (NPPV). Numerous controlled trials as well as meta-analyses have demonstrated significant benefits of NPPV compared to standard therapy in such patients, including more rapid improvements in respiratory and heart rate, gas exchange, avoidance of intubation, reduced rates of morbidity and mortality, and shorter hospital lengths of stay. The patient has the usual features of patients benefiting from NPPV in the studies, including moderate respiratory distress, use of accessory muscles, tachypnea, and acute on chronic carbon dioxide retention. She also has none of the contraindications, such as excessive secretions, uncooperativeness, or acute ischemic changes on electrocardiography (the multifocal atrial tachycardia is not a problem as long as the patient is hemodynamically stable).
Close observation, is not the most appropriate next step because, although she has roughly a 50% of responding to medical therapy, waiting to see if she worsens increases the likelihood of NPPV failure. CPAP alone has been shown to reduce work of breathing by counterbalancing auto-PEEP in patients with COPD, but is less effective at doing so than the combination of pressure support plus positive end-expiratory pressure. Intubation should be avoided in patients with COPD because of the increased morbidity and mortality associated with its use.