A 68 year old male who is know to have
chronic obstructive pulmonary disease presents with a history of cough
productive of purulent sputum and breathlessness. He has been on salbutamol
and ipratropium inhalers and his GP has recently treated him with a course of
steroids and antibiotics. He continues to smoke 20 cigarettes a day,
On examination he looks cyanosed and
breathless, he has a flapping tremor, his pulse rate is 120 beats per minute
irregularly irregular, he has a loud P2 on auscultation and over his lung
fields there are scattered rhonchi and crepitations.
There is bilateral ankle oedema.
Chest X-ray does not show a
Hb 16.5 g/dL
WBC 18 x109
Urea 9 mmol/L
Sodium 138 mmol/L
Potassium 3.8 mmol/L
Blood gases pH 7.2, PaCO2 8.4 kPa,
PaO2 6.3 kPa
ECG shows atrial fibrillation
In this patient which one of the
following interventions would be of greatest benefit to the patient?
Bi-level Positive Airway Pressure