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Category: Critical Care Medicine-Pulmonary Disorders--->Acute Respiratory Distress Syndrome
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Question 1#Print Question

A 65-year-old woman with history of COPD, congestive heart failure with ejection fraction of 35%, Hepatitis C cirrhosis without ascites, and body mass index of 35 is intubated for hypoxemic respiratory failure after an aspiration event and transferred to the ICU for further management. A chest radiograph demonstrates bilateral patchy infiltrates, and initial PaO2 is 145 on FiO2 100%. The patient remains hypoxemic on standard ventilation with tidal volumes 6 mL/kg and PEEP titrated to 12 cm H2O on FiO2 100%.

Which clinical factor suggests this patient may benefit from esophageal pressure measurements to titrate ventilation parameters?

A. COPD
B. CHF with reduced EF
C. HCV cirrhosis
D. BMI 35


Question 2#Print Question

A 36-year-old man is admitted to the ICU intubated status post polytrauma, with trauma burden including multiple lacerations over the ventral chest wall and an uncleared c-spine. He develops progressive hypoxemia over the first 12 hours of admission, with PaO2 :FiO2 ratios decreasing to <150 on FiO2 100%. Mechanical ventilation with tidal volumes 6 mL/kg and PEEP titrated to 12 cm H2O is initiated; however, arterial blood gas persistently shows pH 7.25 with PaCO2 68 and PaO2 67 on FiO2 100% over the subsequent 6 hours. The patient is adequately sedated, paralyzed, and demonstrates no ventilator asynchrony.

What is the next best step?

A. Use esophageal pressure measurements to titrate PEEP
B. Initiate venovenous ECMO
C. Prone the patient
D. Initiate inhaled nitric oxide


Question 3#Print Question

A 29-year-old woman is admitted to the floor with a productive cough and fevers; her influenza swab is positive, and chest radiograph demonstrates bilateral patchy pulmonary opacities. She develops progressive hypoxemic respiratory failure requiring intubation on the first day of admission. On transfer to the ICU, her initial arterial blood gas shows:

  • pH 7.35
  • PaO2 86
  • PaCO2 33 on FiO2 100%

What is the next best step?

A. Ventilation with tidal volumes 4 to 6 mL/kg and PEEP >5
B. Initiate venovenous ECMO
C. Obtain a chest CT
D. Blood cultures and broad spectrum antibiotics


Question 4#Print Question

A 66-year-old woman with Haemophilus influenzae pneumonia is intubated on the floor for hypoxemic respiratory failure and transferred to the ICU. Chest radiograph demonstrates bilateral patchy infiltrates; ABG is:

  • PH 7.34
  • PaCO2 47
  • PaO2 105 on FiO2 100%

Mechanical ventilation is titrated to tidal volumes 6 mL/kg with PEEP 8 cm H2O, and plateau pressures remain <30 cm H2O. The patient is paralyzed and sedated with no ventilator asynchrony noted.

What is the next best step?

A. Initiate venovenous ECMO
B. Prone the patient
C. Initiate inhaled nitric oxide
D. Esophageal pressure monitoring to titrate PEEP


Question 5#Print Question

A 54-year-old man with a history of moderate COPD is transferred from the floor to the ICU one day after a witnessed aspiration event for increased work of breathing. On examination, pulmonary auscultation reveals bilateral rhonchi but no wheezing, and chest radiograph shows new bilateral, patchy pulmonary opacities. Respiratory rate is 36, and the patient communicates in one to three word sentences between breaths. Initial arterial blood gas analysis shows:

  • pH 7.34
  • PaCO2 65
  • PaO2 135 on 15L non-rebreather face mask

What is the next best step?

A. Trial of noninvasive ventilation (NIV)
B. Ipratropium/albuterol nebulizer
C. Intubation and mechanical ventilation
D. Furosemide IV bolus




Category: Critical Care Medicine-Pulmonary Disorders--->Acute Respiratory Distress Syndrome
Page: 1 of 2