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A 34-year-old woman with a history of myasthenia gravis presents to the emergency department with 2 days of worsening generalized weakness, difficulty swallowing, and shortness of breath. She recently had an upper respiratory tract infection. Her medications include pyridostigmine. On examination, she has bilateral ptosis, a weak cough, difficulty handling oral secretions, and shallow respirations. Her respiratory rate is 28/min, oxygen saturation is 96% on room air, and she is alert and oriented. Pulmonary function testing demonstrates a forced vital capacity (FVC) of 14 mL/kg and a negative inspiratory force (NIF) of −18 cm H₂O. Arterial blood gas analysis shows a PaCO₂ of 42 mm Hg. Which of the following is the most appropriate next step in management? A. Administer supplemental oxygen and repeat pulmonary function testing in 4 hours B. Initiate noninvasive positive-pressure ventilation and monitor for clinical improvement C. Perform elective endotracheal intubation and initiate mechanical ventilation D. Administer intravenous immunoglobulin and defer airway intervention until treatment response is assessed E. Administer additional pyridostigmine and reassess respiratory function
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