A 79-Year-Old Man on Mechanical Ventilation Is Evaluated Following a Spontaneous

question 20

Multiple Choice

A 79-year-old man on mechanical ventilation is evaluated following a spontaneous breathing trial.  The patient has a history of chronic obstructive pulmonary disease with an extensive prior smoking history.  He was admitted 3 days ago due to fever, shortness of breath, wheezing, and productive cough.  The patient's respiratory distress failed to improve after a trial of noninvasive ventilation, and endotracheal intubation was performed.  Treatment with inhaled bronchodilators, systemic glucocorticoids, and empiric antibiotics was begun.  His sputum cultures grew methicillin-resistant Staphylococcus aureus and the antibiotics were adjusted.  His suctioning requirement decreased significantly to 2 or 3 times daily.
The patient undergoes a spontaneous breathing trial.  After 2 hours of continuous positive airway pressure of 5 cm H₂O, his temperature is 37.2 C (99 F) , blood pressure is 153/76 mm Hg, pulse is 98/min, and respirations are 18/min.  His average tidal volume is 300 mL.  Pulse oximetry is 98% on 40% FiO₂.  Examination shows left-sided crackles and normal S1 and S2.  The patient is able to follow commands and lift his head off the bed.
Laboratory results are as follows:
Chest-x ray reveals an infiltrate at the left base that is unchanged from a prior x-ray.
Which of the following is the most appropriate next step in management of this patient?

• A)Extubate to nasal cannula
• B)Extubate to noninvasive ventilation
• C)Place the patient back on mechanical ventilation
• D)Refer the patient for tracheotomy
• E)Repeat weaning trial in 2 hours

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Definitions:

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