A 68-Year-Old Man Was Admitted to the Intensive Care Unit

A 68-year-old man was admitted to the intensive care unit 5 days ago due to septic shock and respiratory failure from pneumonia.  The patient has been treated with intravenous fluids, vasopressors, broad-spectrum antibiotics, and intubation with mechanical ventilation.  Blood cultures have resulted with Streptococcus pneumoniae, and the antibiotics have been tailored based on the sensitivity.  Vasopressors have been weaned off and the sedation has been held.  Current ventilator settings are assist-control mode with tidal volume 480 mL (8 mL/kg body weight) , fraction of inspired oxygen (FiO₂) 35%, and positive end-expiratory pressure (PEEP) 5 cm H₂O.  Temperature is 37.2 C (99 F) , blood pressure is 118/74 mm Hg, pulse is 86/min, and respirations are 18/min.  On physical examination, the patient is awake with the endotracheal tube in adequate position.  He answers questions with head nods and follows simple commands such as to lift his head off the pillow.  Lung auscultation reveals right-sided crackles.  Heart sounds are normal.  The extremities are warm without edema and the distal pulses are normal.  Leukocyte count is 10,800/mm³, and arterial blood gas testing reveals pH 7.45, pCO₂ 35 mm Hg, and PaO₂ 82 mm Hg.  Which of the following is the most appropriate next step in management of this patient?

A) Decrease tidal volume
B) Extubate to room air
C) Maintain current ventilator settings
D) Perform spontaneous breathing trial
E) Schedule tracheostomy

Correct Answer:

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