A 75-Year-Old Man Is Admitted to the Intensive Care Unit

A 75-year-old man is admitted to the intensive care unit due to septic shock and acute respiratory distress syndrome.  The patient's medical history is significant for relapsed refractory multiple myeloma and malignant bone pain requiring long-term opioid therapy.  Despite a prolonged course of mechanical ventilation, his condition deteriorates; he is transitioned to comfort-oriented care in accordance with his advance directive.  The patient is extubated to a simple oxygen face mask.  Morphine is administered intravenously to ease air hunger, and glycopyrrolate is given to reduce heavy secretions.  Thirty minutes later, he is gurgling loudly.  Pulse is 118/min and respirations are 8/min.  Oxygen saturation is 90%.  Examination reveals a cachectic, obtunded man with irregular, rattling respirations.  Pupils are pinpoint bilaterally.  Skin is diaphoretic.  In addition to suctioning the oropharynx, what is the most appropriate next step in management at this time?

A) Administer additional morphine
B) Administer naloxone
C) Initiate noninvasive ventilation
D) Insert oropharyngeal airway
E) Obtain portable chest x-ray

Correct Answer:

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