TheAnswerPage/Hospital & Critical Care Medicine Sunday 02/07/2010 This week: Weaning

Our patient subsequently received once daily spontaneous breathing trials with assist-control ventilation in between trials. On hospital day #8 he successfully completed a 2 hour spontaneous breathing trial and was extubated. Although he initially appeared well, over the course of the first several hours post extubation he was noted to become progressively more tachypneic with increasing use of his accessory muscles and a decline in his oxygen saturation (to 85% on a 40% face mask). His examination was notable for diffuse expiratory wheezes without obvious stridor. He was also noted to have dependent sacral and lower extremity edema, which was new since admission but unchanged over the past several days. A CXR was obtained and showed new perihilar infiltrates and pulmonary vascular redistribution consistent with pulmonary edema, in addition to his previously noted right middle and lobe lobe airspace disease.

1. Why might this patient have developed pulmonary edema following extubation?
2. What steps might be taken to avoid reintubation in this patient?
3. What are some common obstacles to effective use of noninvasive ventilation?

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