A 72-year-old woman is being treated in the intensive care unit for lobar pneumonia, septic shock, and respiratory failure with intravenous fluids, antibiotics, vasopressors, and mechanical ventilation. Her condition is improving and she is extubated on day 5. Within a few minutes of extubation, the patient develops stridor and is given intravenous dexamethasone and nebulized epinephrine. Her current examination shows blood pressure of 148/86 mm Hg, pulse of 102/min, and respirations of 30/min. Pulse oximetry shows 94% on nonrebreather mask. She has audible stridor and labored breathing with use of accessory muscles of respiration. Which of the following is the best next step in management of this patient?

Question

A 72-year-old woman is being treated in the intensive care unit for lobar pneumonia, septic shock, and respiratory failure with intravenous fluids, antibiotics, vasopressors, and mechanical ventilation.  Her condition is improving and she is extubated on day 5.  Within a few minutes of extubation, the patient develops stridor and is given intravenous dexamethasone and nebulized epinephrine.  Her current examination shows blood pressure of 148/86 mm Hg, pulse of 102/min, and respirations of 30/min.  Pulse oximetry shows 94% on nonrebreather mask.  She has audible stridor and labored breathing with use of accessory muscles of respiration.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Intubation causes direct mechanical damage to the laryngeal mucosa, leading to inflammation that may cause significant edema. Laryngeal edema typically presents with post-extubation stridor (PES) and respiratory failure. It occurs in up to 30% of patients, with approximately 5% requiring reintubation. Risk factors for laryngeal edema include female sex, small tracheal diameter or large endotracheal tube size, and prolonged duration of intubation. Administration of a multiple-dose regimen of glucocorticoids prior to extubation can prevent laryngeal edema and extubation failure. Reintubation should be considered early to secure the airway in all patients with signs of impending respiratory failure. This patient has several clinical features of impending respiratory failure and has PES with no improvement with conservative measures. PES and respiratory failure are consistent with extubation failure due to significant laryngeal edema and should be managed aggressively with immediate reintubation and mechanical ventilation. impending respiratory failure (Choice A) Emergency tracheostomy is reserved as a last resort for patients with severe laryngeal edema who fail attempts at endotracheal intubation. (Choice B) A helium and oxygen mixture has a lower density than oxygenated air and reduces airway resistance; however, there is no clinical evidence of its usefulness in patients with laryngeal edema and respiratory failure. (Choice C) The use of non-invasive positive-pressure ventilation in patients with chronic obstructive pulmonary disease has been shown to prevent reintubation and decrease mortality. Its use in patients with respiratory failure due to laryngeal edema leads to delay in reintubation and can be harmful. (Choice E) The efficacy of intravenous corticosteroids and epinephrine nebulization has not been confirmed in any randomized clinical trials. However, case control studies in patients with suspected PES have shown reduced risk of extubation failure when intravenous glucocorticoids are given prior to extubation. Epinephrine and corticosteroids may also be used after extubation to reduce inflammation and edema. However, patients with impending respiratory failure should be reintubated. Educational objective: Laryngeal edema typically presents with post-extubation stridor; reintubation should be considered early to secure the airway in all patients with signs of impending respiratory failure. References: Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. (http://www.ncbi.nlm.nih.gov/pubmed/20017891)

A 72-Year-Old Woman Is Being Treated in the Intensive Care