An 89-year-old man is hospitalized because of upper GI bleeding. He presented two days ago with hematemesis, black stools, and lethargy. His trachea was intubated for airway protection in the emergency department. An endoscopy was performed and showed a deep ulcer with a bleeding vessel in the gastric antrum. Hemostasis was achieved with epinephrine injection, cauterization, and endoclips. He received 8 units of packed red blood cells and has not required additional transfusions for the past 24 hours. His other medical problems include hypertension, chronic kidney disease, hypothyroidism, and colon cancer requiring colectomy and adjuvant chemotherapy 9 years ago.
The patient undergoes a spontaneous breathing trial in the intensive care unit. After two hours of 5 cm H₂O continuous positive airway pressure (CPAP) , his temperature is 36.1 C (97 F) , blood pressure is 110/60 mm Hg, pulse is 94/min, and respirations are 28/min. The patient's pulse oximetry shows 97% on 40% FiO₂. His tidal volumes are 200 mL on average. He follows commands adequately. Examination reveals good air entry on both sides and bibasal crackles. No cardiac murmurs are appreciated. There is 2+ bilateral pretibial edema. Muscle strength is 5/5 in both upper and lower extremities.
Laboratory results are as follows:

His chest-x ray shows bilateral airspace opacities.
Which of the following is the most appropriate next step in management?

Question

An 89-year-old man is hospitalized because of upper GI bleeding. He presented two days ago with hematemesis, black stools, and lethargy. His trachea was intubated for airway protection in the emergency department. An endoscopy was performed and showed a deep ulcer with a bleeding vessel in the gastric antrum. Hemostasis was achieved with epinephrine injection, cauterization, and endoclips. He received 8 units of packed red blood cells and has not required additional transfusions for the past 24 hours. His other medical problems include hypertension, chronic kidney disease, hypothyroidism, and colon cancer requiring colectomy and adjuvant chemotherapy 9 years ago.
The patient undergoes a spontaneous breathing trial in the intensive care unit. After two hours of 5 cm H₂O continuous positive airway pressure (CPAP) , his temperature is 36.1 C (97 F) , blood pressure is 110/60 mm Hg, pulse is 94/min, and respirations are 28/min. The patient's pulse oximetry shows 97% on 40% FiO₂. His tidal volumes are 200 mL on average. He follows commands adequately. Examination reveals good air entry on both sides and bibasal crackles. No cardiac murmurs are appreciated. There is 2+ bilateral pretibial edema. Muscle strength is 5/5 in both upper and lower extremities.
Laboratory results are as follows:

His chest-x ray shows bilateral airspace opacities.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9716_bcdf_853d_418d547cf0ea_MD0002_00 There are several factors that can cause difficulty with ventilator weaning, such as positive fluid balance, infection, and malnutrition. In addition, magnesium and phosphate deficiencies, as well as hypothyroidism, can contribute to ventilator weaning difficulties. Ensuring adequate mental status and the absence of copious secretions and upper airway lesions is also essential for successful weaning. The rapid shallow breathing index (RSBI) has been shown to predict successful extubation. The RSBI is calculated using the respiratory rate divided by the tidal volume in liters. A RSBI < 105 is a predictor of successful extubation. This patient has a RSBI of 140 (i.e., 28/0.2), which indicates probable weaning failure. As a result, this patient should not be extubated to nasal cannula and still requires mechanical ventilation on assist control (Choice B). (Choice A) Spontaneous breathing trial durations of 30 and 120 minutes demonstrate equivalent rates of extubation failure. There is no benefit to prolonging a breathing trial beyond 120 minutes. (Choice C) Studies have shown that chronic obstructive lung disease patients (COPD) who fail spontaneous breathing trials can be extubated to noninvasive ventilation with fewer ventilator days and improved mortality. However, this patient does not have COPD and has a high RSBI. (Choice E) Tracheotomy performed at < 14 days in medical patients has not been shown to decrease ventilator-associated pneumonia or mortality. Educational objective: The rapid shallow breathing index is calculated using the respiratory rate divided by the tidal volume in liters and is a predictor of successful extubation if < 105. __________ References: A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. (http://www.ncbi.nlm.nih.gov/pubmed/2023603) Predictors of successful weaning from prolonged mechanical ventilation in Taiwan. (http://www.ncbi.nlm.nih.gov/pubmed/19359156)

An 89-Year-Old Man Is Hospitalized Because of Upper GI Bleeding