The Patient is a 59-year-old white male with severe end stage obstructive lung disease with a significant bronchitic component. He has been on a prolonged course of antibiotics and high dose steroids and was slow to recover to his low baseline. He has no worsening of cor pulmonale or change in sleep pattern but his breathing is increasingly difficult and his functional status continues to deteriorate.

PE: T 96.2, P 98, RR 36, O2sat on 4L 95%, BP 150/98

ABG: pH 7.35, PaCO2 44.7, PaO2 84.6 on 4 L O2

Lungs: crackles bilaterally which do not clear with deep inspiration; central rhonchi; and wheezes on forced expiration.

Heart: regular rate and rhythm with epigastric PMI; no S3, S4 or JVD. No peripheral edema.

1. What is your assessment?

2. What issues do you see here?

3. What can you offer this patient?