MRCP2-4501

MRCP2-4501

A 49-year-old patient presents with a two-day history of worsening breathlessness and productive cough with purulent sputum. The patient has been smoking 20 cigarettes a day since the age of 18 and was recently diagnosed with chronic obstructive pulmonary disease by their general practitioner. This is the patient’s first hospital admission. On examination, the patient is alert and oriented but cyanosed with a respiratory rate of 26 breaths per minute. The patient’s temperature is 37.8°C, pulse is 100/minute, and blood pressure is 150/100 mmHg. Bilaterally reduced air entry is noted on chest auscultation, and the chest radiograph shows hyperinflated lung fields with a normal heart size and no pneumonic consolidation. Arterial blood gases on admission with 24% oxygen by nasal cannulae reveal a pH of 7.34, pO2 of 6.5 kPa, pCO2 of 6.8 kPa, and standard bicarbonate of 27 mmol/L. Nebulised bronchodilators are administered, and the FIO2 is increased to 28%. Repeat arterial blood gases after 30 minutes show a pH of 7.30, pO2 of 7.0 kPa, pCO2 of 8.5 kPa, and standard bicarbonate of 28 mmol/L. What is the next step in management for this patient?