Soru

A $71$-year-old man is evaluated in the intensive care unit (ICU) for management of acute respiratory failure. He was intubated and mechanically ventilated yesterday for a severe chronic obstructive pulmonary disease (COPD) exacerbation triggered by community-acquired pneumonia. His medical history includes COPD, heart failure with reduced ejection fraction (LVEF $30\%$), and chronic kidney disease.

Current ventilator settings (Volume Control):
Fraction of inspired oxygen ($\text{FiO}_2$): $0.40$
Tidal volume: $450\text{ mL}$ ($6\text{ mL/kg}$ predicted body weight)
Respiratory rate: $10\text{/min}$
Positive end-expiratory pressure (PEEP): $5\text{ cm H}_2\text{O}$

Vital signs:
Temperature: $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)
Blood pressure: $110/70\text{ mm Hg}$
Heart rate: $98\text{/min}$

Physical examination shows coarse breath sounds and prolonged expiration. There is no jugular venous distention. Bedside echocardiography demonstrates a collapsible inferior vena cava with no B-lines.

Arterial blood gas (ABG) on current settings:
pH: $7.25$
$\text{PaCO}_2$: $70\text{ mm Hg}$
$\text{PaO}_2$: $75\text{ mm Hg}$
$\text{HCO}_3^-$: $30\text{ mEq/L}$

The patient's sputum culture from admission has finalized, growing *Streptococcus pneumoniae* susceptible to ceftriaxone. He is currently receiving intravenous vancomycin, piperacillin-tazobactam, and azithromycin.

Concurrently, the patient's estranged son arrives from out of state and demands immediate extubation, stating his father "would not want to live on a machine." The patient's wife, who is his legally designated healthcare proxy, is present and strongly desires to continue full medical support.

Which of the following interventions are appropriate in the management of this patient? (Select all that apply)