A 71-year-old man is admitted to the intensive care unit due to influenza complicated by bacterial pneumonia and acute respiratory distress syndrome. He has been receiving mechanical ventilation for 8 days. The patient completed a course of intravenous antibiotic therapy, and his clinical status has steadily improved. Ventilator settings have been weaned to minimal levels, and he is tolerating daily spontaneous breathing trials. However, the patient remains intubated due to intermittent somnolence and thick secretions requiring frequent suctioning. At night, he is agitated and pulls at his lines, requiring cloth mittens and soft restraints. During the day, the patient is mostly alert and able to communicate by writing on a personal whiteboard. Vital signs are within normal limits. Cough strength is weak, and he has difficulty raising his head from the pillow. Results of serum chemistry are within normal limits, and complete blood count reveals normocytic anemia with hemoglobin of 9.6 g/dL. Which of the following interventions is most strongly indicated at this time to promote recovery and extubation?

Question

A 71-year-old man is admitted to the intensive care unit due to influenza complicated by bacterial pneumonia and acute respiratory distress syndrome.  He has been receiving mechanical ventilation for 8 days.  The patient completed a course of intravenous antibiotic therapy, and his clinical status has steadily improved.  Ventilator settings have been weaned to minimal levels, and he is tolerating daily spontaneous breathing trials.  However, the patient remains intubated due to intermittent somnolence and thick secretions requiring frequent suctioning.  At night, he is agitated and pulls at his lines, requiring cloth mittens and soft restraints.  During the day, the patient is mostly alert and able to communicate by writing on a personal whiteboard.  Vital signs are within normal limits.  Cough strength is weak, and he has difficulty raising his head from the pillow.  Results of serum chemistry are within normal limits, and complete blood count reveals normocytic anemia with hemoglobin of 9.6 g/dL.  Which of the following interventions is most strongly indicated at this time to promote recovery and extubation?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c071_3ddf_8f63_2535a11e9498_MD0005_00 After the acute phase of critical illness, the focus of care shifts to rehabilitation. For this patient, delirium and ventilator liberation are key issues for recovery. These clinical concerns are often encountered together: Delirium is a barrier to extubation, but invasive ventilation exacerbates delirium. Early physical therapy (PT) is an evidence-based practice that fosters global physical and cognitive recovery in the intensive care unit (ICU). PT should be initiated as soon as patients can participate (eg, daytime lucid interval). It can begin even in patients still intubated on minimal ventilator settings. Early mobility therapy is personalized to patients' level of frailty and can involve assisted walking, sitting upright, or even passive limb stretching to avoid contractures. Immediate benefits of early PT/mobility include the following: Physical/pulmonary: secretion mobilization, atelectasis recruitment, respiratory muscle strengthening, and decreased deep venous thrombosis Cognitive: restoration of normal sleep-wake cycle, improved swallowing These benefits are synergistic: Daytime mobility aids in clearance of delirium, setting the stage for pulmonary recovery and earlier extubation. Long-term benefits include favorable, patient-centered outcomes (eg, discharge home) with decreased symptoms of post-intensive care syndrome. For these reasons, early PT is a cornerstone of ICU recovery bundles established by multiple societies. post-intensive care syndrome (Choice A) Copious respiratory secretions can delay extubation. Anticholinergic agents (eg, scopolamine) are occasionally used to lessen secretions. However, due to their CNS effects, they may worsen delirium, especially in elderly patients. Physical measures (deep suctioning, chest percussion, early mobility) are preferred. (Choice B) Deep sedation should be used only as a last resort when agitation immediately threatens life (eg, self-extubation). Further sedation exacerbates delirium and delays recovery. (Choice D) Tracheostomy (within 14 days) may be considered if prolonged mechanical ventilation (eg, respiratory muscle weakness) or a long-term airway (eg, intractable delirium) is required. This patient is tolerating daily spontaneous breathing trials (SBT) (ie, breathing on his own through a tube), signaling adequate respiratory muscle function. Early PT can facilitate recovery from delirium, making extubation an achievable goal. (Choice E) Severe symptomatic anemia may hinder ventilator weaning (stress on cardiopulmonary system). A hemoglobin target ≥7 g/dL ("restrictive strategy") reduces volume overload and lung inflammation exacerbated by blood products, leading to improved outcomes. This patient has nonsevere (hemoglobin above goal), asymptomatic anemia (eg, tolerating SBT), so transfusion is not indicated. Educational objective: In patients recovering from critical illness, early physical therapy for progressive mobilization should be initiated as soon as possible to facilitate recovery from delirium and liberation from mechanical ventilation.

A 71-Year-Old Man Is Admitted to the Intensive Care Unit