title: Difficult-to-wean: High index of suspicion.
abstract: METHODS
  Female, 57 FINAL DIAGNOSIS: Syryngomyelia • cervical
  
  
  METHODS
  Acute respiratory insufficiency Medication: - Clinical Procedure: - Specialty: Pulmonology.
  
  
  OBJECTIVE
  Rare disease.
  
  
  BACKGROUND
  Failed planned extubation occurs in a minority of patients with acute respiratory failure requiring invasive mechanical ventilation. In patients presenting with acute respiratory failure with no identifiable cardiopulmonary causes, uncommon conditions, such as cervical spondylotic myelopathy, should be considered. In very rare instances, when cervical spondylotic myelopathy and syringomyelia present concomitantly, they can be devastating.
  
  
  METHODS
  A 57-year-old woman visited the emergency room (ER) after feeling unwell for several days. She was brought to the ER with acute respiratory distress and obtunded state with GCS of 6/15. She was hypotensive and agonally breathing. Her initial neurologic evaluation was unrevealing. Based on these findings, she was intubated. Over the next several days, she was difficult to wean from the ventilator and had persistent respiratory acidosis. After a short-lived extubation, the patient was again re-intubated. This time the neurologic evaluation showed decreased movements of all muscle groups against gravity and forces, with generalized weakness. An MRI of the brain and cervical spine demonstrated moderate degenerative disc disease and syringomyelia extending from C2 to C7 level. The patient underwent de-compression laminectomy. After failing several weaning trials, she underwent bronchoscopically-assisted tracheotomy.
  
  
  CONCLUSIONS
  Acute cardiopulmonary and intensive care unit-acquired neuromuscular conditions have been attributed as a major cause of difficult weaning and extubation. Failure to identify and correct other rare combinations (such as cervical degenerative disc disease and syringomyelia) may cause acute respiratory failure and subsequent failure to wean and extubation, resulting in high rates of mortality and morbidity.
authors.affiliation: Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A.
authors.forename: Alehegn
authors.initials: A
authors.lastname: Gelaye
authors.affiliation: Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A.
authors.forename: Brijesh
authors.initials: B
authors.lastname: Patel
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A.
authors.forename: Wassim
authors.initials: W
authors.lastname: Farra
authors.affiliation: Department of Neurology, Providence Hospital and Medical Center, Southfield, MI, U.S.A.
authors.forename: Bruce
authors.initials: B
authors.lastname: Kole
keywords: Difficult-to-wean; Spinal Cord Compression; Syringomyelia