A 51-year-old woman with antibody-positive myasthenia gravis, on immunosuppressive therapy with…

A 51-year-old woman with antibody-positive myasthenia gravis, on immunosuppressive therapy with azathioprine, is admitted to the intensive care unit for increased work of breathing. Two weeks prior she had an upper respiratory tract infection, and when it did not improve, she was prescribed a course of levofloxacin, which she started 3 days ago. Since that time she has had a progressive dyspnea and was unable to walk up a flight of stairs. Her initial vital signs in the emergency department (ED) were normal and her oxygen saturation was 98% on room air with a respiratory rate of 24. She

A 51-year-old woman with antibody-positive myasthenia gravis, on immunosuppressive therapy with azathioprine, is admitted to the intensive care unit for increased work of breathing. Two weeks prior she had an upper respiratory tract infection, and when it did not improve, she was prescribed a course of levofloxacin, which she started 3 days ago. Since that time she has had a progressive dyspnea and was unable to walk up a flight of stairs. Her initial vital signs in the emergency department (ED) were normal and her oxygen saturation was 98% on room air with a respiratory rate of 24. She appeared comfortable, and although tachypneic she did not have accessory muscle use. She underwent bedside spirometry testing and was found to have a negative inspiratory force of -40 mm Hg and forced vital capacity of 0.75 L (weight 79.6 kg). An arterial blood gas was obtained in the intensive care unit and was pH 7.32, pCO2 32, and pO2 171. Should this patient be intubated? A. Yes, given her tachypnea, low-forced vital capacity, and respiratory alkalosis, she should be intubated. Intubation should be completed using a depolarizing neuromuscular blocker. B. Yes, given her tachypnea, low-forced vital capacity, and respiratory alkalosis, she should be intubated. Intubation should be completed using a nondepolarizing neuromuscular blocker. C. No, given her comfortable appearance, appropriate negative inspiratory force, and respiratory alkalosis, she should not be intubated and continue with close neurologic and respiratory monitoring. D. No, given her comfortable appearance, appropriate negative inspiratory force, and respiratory alkalosis, she should not be intubated, however, bilevel positive airway pressure support (BiPAP) should be initiated.

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