Respiratory Distress in a Patient with COPD and CHF

A 75-year-old man is admitted to the ICU for exacerbating chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The patient experienced retrosternal chest pain lasting 4 minutes, which was relieved by a sublingual nitroglycerine tablet of 1/150 mg. Initial physical examination Respiratory rate: 35 bpm Heart rate: 123 bpm with a regular rhythm BP: 189/98 mmHg Rales and scattered wheezing in the bilateral lung bases Fixed split second heart sound (S 2 ) and third heart sound (S 3 ) gallop present Lower extremities show 2+ pitting edema Chest X-ray reveals CHF pattern and cardiomegaly as well as hyperinflation and COPD changes, without acute infiltrates.

Arterial blood gas (ABG) shows a pH of 7.45, PaCO 2 of 35 mmHg, and PaO 2 of 100 mmHg on 100% FiO 2 . β-natriuretic peptide (BNP) level: 1000 pg/mL (Normal < 100) Troponin cardiac enzyme level: 5 ng/mL (Normal <…