A52-28 An Unrepresented Man Reclaiming His Breath: Successful Extubation Without Tracheostomy After Protracted Mechanical Ventilation in a Patient With Multi-System Disease

Abstract Learning Objectives •Emphasize the role of an individualized, patient-centered care model in managing an intubated Patient •Discuss the clinical decision-making process regarding deferral of Tracheostomy Introduction Prolonged mechanical ventilation is associated with increased morbidity and mortality. While transition from endotracheal to tracheostomy tube is often made in hospital around 10-14 days, tracheostomy may correctly be delayed or deferred due to complex anatomical and/or ethical considerations. Case A 70-year-old male with history of emphysema, heart failure, aortic stenosis and schizophrenia presented to the hospital with altered mental status and respiratory distress in concern for mixed septic and cardiogenic shock. He was intubated for hypoxic and hypercapnic respiratory failure. Testings revealed leukocytosis, lactic acidosis, hyperglycemia, and elevated Troponins. The patient was admitted to the intensive care unit (ICU). An extubation attempt on day 2 of his hospital course was unsuccessful, requiring immediate re-intubation. After re-intubation, he repeatedly failed daily spontaneous breathing trials (SBTs) with no improvement in respiratory status. Furthermore, he was initially unable to consent for himself and had no willing decision makers, two-physician consent was used to change code status to do not resuscitate (DNR) based on prior expressed wishes. Given difficult anatomy with palpable thyroid cartilage and sub-optimal neck extension, bedside percutaneous tracheostomy on Day 17 was postponed. On Day 21, he continued to fail daily SBTs, but remained awake and able to follow commands. He was successfully extubated to high-flow nasal cannula. Once extubated, Pt confirmed his code status as DNR and indicated tracheostomy did not align with his goals of care. Clinical picture improved, and he was ultimately discharged from the ICU without any Oxygen needs. Discussion Prolonged mechanical ventilation is associated with increased morbidity and mortality. While Tracheostomy placement within 10-14 days has been associated with improved patient comfort and shorter-length ICU stays, studies have shown no mortality benefit from early tracheostomy. Any decision to transition to tracheostomy tube requires ethical consideration. For this case, both difficulty anatomy and bioethical concerns - a patient deemed unrepresented with no clear evidence of wanting tracheostomy - saw the procedure delayed for an ultimately successful extubation. Once extubated, he confirmed with capacity that he would not have wanted the procedure, thus preserving autonomy. Conclusion Patients with prolonged intubation intervals can be successfully extubated without the intervention of a tracheostomy tube. Albeit uncommon, cases such as these highlight the need for patient-centered, ethically-guided approaches when considering tracheostomy tube placement. This abstract is funded by: None