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?

Question

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?

Quizplus · Accepted Answer

Mechanical ventilation is required for severe respiratory failure, impaired sensorium, hemodynamic instability, or difficulty clearing secretions. However, prolonged invasive ventilation can lead to ventilator-associated pneumonia (VAP) and increased mortality. Evidence supports that patients with underlying lung disease (eg, chronic obstructive pulmonary disease) and compensated hypercapnia who meet criteria for extubation likely benefit from extubating to noninvasive ventilation (NIV) rather than to no ventilatory support (eg, nasal cannula) (Choice A). In these patients, extubating to NIV may decrease recurrent respiratory failure and reduce invasive ventilation time, leading to shorter intensive care unit (ICU) stays and decreased rates of VAP and ICU mortality. criteria for extubation A randomized trial in high-risk adults (eg, age >65, moderate to severe chronic obstructive pulmonary disease) showed that extubation to high-flow conditioned oxygen therapy is noninferior to NIV in preventing reintubation; high-flow conditioned oxygen therapy is also associated with decreased rates of postextubation respiratory failure compared with conventional oxygen therapy. (Choice C) This patient is ready for extubation as he demonstrates clinical improvement, hemodynamic stability, and ability to follow commands. In addition, his rapid shallow breathing index (respiratory rate divided by tidal volume in liters [18/0.3]) is 60, predictive of successful extubation, and arterial blood gas is consistent with mostly chronic (rather than acute) hypercapnic respiratory failure. (Choice D) Tracheotomy performed <14 days following intubation and initiation of invasive mechanical ventilation has not been shown to decrease VAP or mortality. This patient appears ready to discontinue invasive mechanical ventilation and does not need to be considered for tracheotomy. (Choice E) There is no difference in the rate of extubation for patients who undergo breathing trials once daily compared to those who undergo multiple daily trials. Therefore, a repeat trial is not indicated. Educational objective: Extubating to noninvasive ventilation may decrease recurrent respiratory failure, invasive ventilation time, and mortality in patients with underlying lung disease (eg, chronic obstructive pulmonary disease) and compensated hypercapnia who are recovering from acute respiratory failure. __________ References: Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease. A randomized, controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/9556465) Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/19460803)

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