The most appropriate management is to extubate the patient now and initiate bilevel noninvasive positive pressure ventilation (NPPV). This patient's condition is improving after intubation for a COPD exacerbation with hypercapnic respiratory failure. For most patients on invasive ventilatory support, the use of NPPV after extubation to facilitate weaning has not been shown to have improved outcomes. However, patients such as this one, with COPD and hypercapnia who can be extubated and started on NPPV, are an exception to this general rule. This strategy has been shown in some studies to decrease the ICU length of stay and improve survival, and would be a reasonable next step in this patient who has been steadily improving, is otherwise stable, and has a normal mental status. These patients require careful follow-up and observation for reintubation if they do not remain stable on NPPV.

Extubating this patient without immediate NPPV support could be considered, but there are indications that he may not be ready for unsupported breathing yet.

Tracheostomy is a good option for patients who have been intubated for an extended period of time and likely require continued mechanical ventilation to avoid damage to the vocal cords and subglottic airway. However, this patient's condition is improving and he is unlikely to need mechanical ventilation for an extended period of time; therefore, placing a tracheostomy tube is unnecessary.

Continuing spontaneous breathing trials on invasive ventilation would probably lead to gradual improvement and eventual extubation, but the risk of complications from mechanical ventilation increases with longer use, and the opportunity to extubate sooner should be pursued if available.