Pseudo bulbar palsy: A rare cause of extubation failure
The present case has been published in the Indian Journal of Critical Care Medicine. Here the authors report an unusual presentation of lacunar stroke with pseudobulbar palsy presenting with Extubation Failure (EF).

An 80-year-old woman a known case of hypertension and Type 2 diabetes mellitus with good premorbid functional status, presented with 10 days history of intermittent fever associated with chills and rigor, nausea, and episodes of loose stools. History also included increased urinary urgency and frequency and urinary incontinence. Four days after the illness, she developed shortness of breath. She was referred to ICU on the 8th day of her illness.

She had dysphonia at presentation. She had distressed breathing, bilateral basal crepts on auscultation, shock with cold peripheries, and ongoing noradrenaline dose of 0.2 mics/kg/min. She was managed as per the ICU protocols. She was weaned off the ventilator, and after a successful spontaneous breathing trial, she was extubated. Within 2 h of extubation, she had stridor, drooling of saliva, and dysphagia. Airway edema was suspected.

Measures taken to reduce edema included adrenaline nebulizations and systemic steroid, to which she did not show any improvement. She was re-intubated and subsequently tracheostomized. Upper airway bronchoscopy was done which was suggestive of hypotonic pharyngeal muscle with no vocal cord movements. Indirect laryngoscopy (IDL) performed by ears, nose, and throat surgeon validated the above findings.

Further neurological examination revealed a brisk jaw jerk reflex with bulbar weakness clinically evident as swallowing dysfunction. Her laboratory parameters including sodium were within normal limits throughout her stay in ICU. Magnetic resonance imaging (MRI) brain was done which was suggestive of multiple foci of confluent long hyperintensities in bilateral cortical and subcortical areas.

After 2 weeks of ICU stay, she was discharged with a tracheostomy tube in situ, and routine tracheostomy care was taught to the relatives. She has been advised for a 2 weekly follow-up.

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