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Category: Critical Care Medicine-Pulmonary Disorders--->Respiratory Failure
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Question 1#Print Question

A 40-year-old previously healthy 90-kg man (ideal body weight of 80 kg) walks into the Emergency Department (ED) complaining of 5 days of myalgias, fevers, rhinorrhea, and dry cough. Over the last day, he has become short of breath walking across the room. In the ED, he is febrile, hypotensive requiring vasopressors, with a respiratory rate of 30 and SpO2 88% on a non-rebreather face mask. He receives 30 mL/kg crystalloid and develops worsening work of breathing requiring endotracheal intubation 2 hours after arrival in ED. Endotracheal tube placement is confirmed by end-tidal CO2 and bilateral breath sounds. His SpO2 nadir is 75% but despite 5 minutes of bagging his SpO2 remains in the mid-80s. His chest X-ray is shown below:

Which of the following statements is true?

a. Following ARDSnet ventilation at 6 mL/kg, if his Plateau airway pressure is 35 cm H2O on PEEP of 14, his goal tidal volume should be 480 mL
b. Given hypotension and severe respiratory failure, a PA catheter should be placed to optimize cardiac filling pressures and improve his chances of survival
c. A strategy of doing a recruitment maneuver followed by lowering PEEP until lung compliance is maximal will improve his chances of survival
d. Inhaled nitric oxide is likely to improve his PaO2 /FiO2 ratio
e. Proning this early in ARDS has not been shown to favorably affect survival


Question 2#Print Question

A 52-year-old woman with a history of DVT on warfarin and active smoker develops several days of epigastric pain and melena and presents to the ED with a hemoglobin of 5.5 and tachycardia without hypotension, INR of 3.9, and a platelet count of 215,000/ µL. Following transfusion of 2 units PRBCs and 2 units FFP, she develops rapidly progressive acute hypoxemic respiratory failure and increased work of breathing requiring intubation, with CXR new confirming bilateral infiltrates.

Which of the following statements is true of the most likely etiology for her respiratory decompensation?

a. Risk factors include smoking and chronic alcohol use
b. PRBCs, FFP, and platelets all confer equal risk of this process
c. The incidence of this process has decreased dramatically in the last decade
d. Neutrophils are not thought to play an important role in this process
e. A diagnosis of transfusion-related acute lung injury (TRALI) can be made in patients with multiple risk factors for ARDS (eg, aspiration, shock, pneumonia)


Question 3#Print Question

A 53-year-old man with a history of mild asthma and alcoholic cirrhosis complicated by ascites (controlled with diuretics) presents to the ED with shoulder pain after a mechanical fall. Musculoskeletal examination and plain films yield a diagnosis of an acute acromioclavicular joint injury. Vitals obtained in the ED are notable for SpO2 of 91% on RA. He uses albuterol MDI about once a week, denies dyspnea, and has no new pulmonary symptom. His lung examination is notable for subtle prolongation of the expiratory phase without wheezes and chest X-ray is clear.

Which is true of the likely etiology for hypoxemia?

a. Spider nevi are infrequently seen
b. SpO2 tends to drop further in the supine position
c. Contrast echocardiography is the test of choice
d. Asthma is a major contributor
e. It is never an indication for liver transplantation


Question 4#Print Question

A 65-year-old man diagnosed with idiopathic pulmonary fibrosis a year ago not on supplemental oxygen therapy presents to the ED with a week and a half of worsening exercise tolerance, increased dry cough, myalgias, and subjective fevers. Over the last day he has been unable to walk across the room without resting. Physical examination is remarkable for SpO2 of 85% on 6 L NC with tachypnea and increased work of breathing, bibasilar crackles. Laboratory test results reveal WBC 10,000/ µL (slightly increased absolute neutrophil count), normal metabolic panel and liver function tests, troponin of 0.1 ng/mL, and BNP of 120 pg/mL. Rapid flu is negative, and PCR panel is pending. CXR shows worsening bilateral opacities, and results of CT scan are shown in the figure below:

The patient is admitted to the ICU and placed on high flow nasal cannula at 40 LPM flow. Overnight FiO2 has ranged between 0.7 and 0.9 to maintain SpO2 in the low 90s, and he was unable to sleep because of dyspnea. On examination he appears to be tiring.

Which of the following statements is true?

a. Intubation and mechanical ventilation in this setting are associated with in-hospital mortality approaching 90%
b. The use of corticosteroids is supported by moderate- to high-quality trial data
c. If metapneumovirus nucleic acid is detected in respiratory secretions, then it is not appropriate to diagnose “Acute exacerbation of IPF” (AE-IPF)
d. Risk factors for AE-IPF include low BMI
e. Lung biopsy would be most likely to show organizing pneumonia


Question 5#Print Question

A 60-year-old thin female smoker presents to the ED with several days of worsening dyspnea, productive cough, and high fevers. She remains hypotensive despite fluid resuscitation and develops worsening hypoxemia/ARDS requiring intubation and mechanical ventilation. A central line is placed in the right internal jugular vein for vasopressor administration, and she is admitted to the ICU and placed on low tidal volume ventilation protocol using the high PEEP/FiO2 grid studied in the ALVEOLI trial. Twenty-four hours later admission blood cultures are positive for Streptococcus pneumonia and her respiratory status has continued to deteriorate, now on 6 mL/kg IBW with FIO2 of 0.8 and PEEP of 20 cm H2O with plateau pressure of 29 cm H2O. ScVO2 is 75% while on moderate dose of norepinephrine and ABG is 7.32/40/65. Using volumetric capnography you measure dead space to be 75%. Several hours later she desaturates, and the FiO2 is raised to 1.0 with PEEP 24 cm H2O. Because making the ventilator change she has worsening hypotension and SpO2 remains in the low 90s. SCVO2 is remeasured at 55% and repeat ABG is 7.24/48/59 with no change in minute ventilation from the prior ABG. In another 10 minutes, SpO2 drops to the low 80s and you are adding a second vasopressor.

Which of the following should you do next?

 

a. Increase the PEEP
b. Start inhaled nitric oxide
c. Order urgent echocardiogram
d. PE protocol chest CT
e. Transiently disconnect the patient from the ventilator




Category: Critical Care Medicine-Pulmonary Disorders--->Respiratory Failure
Page: 1 of 2