Extubated and jaws wired shut

The case A 16-year-old male patient is under the care of the pediatric intensive care unit (PICU). He was a pedestrian struck by a motor vehicle and has suffered a traumatic brain injury (TBI) and mandible fracture. He has been stabilized over the past week after endotracheal intubation, intracranial pressure (ICP) monitor placement, ventriculostomy, and decompressive craniectomy. He has required high levels of sedation and paralytics for ICP control. He undergoes open reduction and internal fixation of the mandible with the oral-maxillary facial surgery (OMFS) service. Preoperative, his oral-tracheal tube is exchanged to a nasal-tracheal tube. The operation proceeds uneventfully. His jaws are wired at the end of the procedure. He returns to the PICU nasally intubated. Overnight, the patient's pulmonary status is favorable. He has maintained normal oxygen saturation with a fractional inspired oxygen (FiO₂) of 35% and is spontaneously breathing with 5 mm of pressure support and 5 mm of PEEP. The patient is following some, but not all, commands. He is evaluated by the PICU staff and the decision is made to extubate. After extubation, he quickly becomes hypoxic, with a SpO₂in the 80s. Chest auscultation reveals clear lungs with course upper airway sounds. The PICU staff is unable to properly suction the oropharynx because of the jaw wires. Anesthesia is called to the bedside. He continues to be hypoxic and in respiratory distress. As the anesthesia resident on call, you look at the PICU staff, who are searching for answers.