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

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

Correct Answer:

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