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Category: Critical Care Medicine-Pulmonary Disorders--->Airway Diseases
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Question 1#Print Question

A 70-year-old female with a history of diabetes, coronary artery disease, and hypothyroidism was admitted to the intensive care unit (ICU) for pneumonia complicated by acute respiratory distress syndrome (ARDS). She was intubated on the day of admission. Her ICU course was complicated by shock, delirium, and recurrent aspiration. She was successfully extubated on ICU day 14. Following extubation, she was noted to have significant coughing that seemed worse with the consumption of liquids. A barium swallow demonstrated a spillage of contrast from the esophagus into the trachea.

Which of the following is a risk factor for this complication?

a. Delirium
b. Hypothryoidism
c. ARDS
d. Hypotension
e. Advanced age


Question 2#Print Question

A 30-year-old female with a past medical history of moderate persistent asthma, substance abuse disorder, and allergic rhinitis was brought to the emergency department (ED) by paramedics after being found down in a subway station surrounded by empty medication bottles and was noted to have needle tracks on her arms. In the ED, she was intubated for airway protection with a 7.0 endotracheal tube. She was then admitted to the ICU where her toxicology panel was positive for cocaine, oxycodone, and methadone. Her mental status improved over the next 72 hours, and she was converted from volume control ventilation to pressure support. She was able to tolerate pressure support 5/5 with an FiO2 of 0.30, a respiratory rate of 18, and tidal volume of 600 mL. Given her clinical improvement, the team contemplated extubation. Prior to extubation, her endotracheal cuff is deflated. The discrepancy between her inspiratory and expiratory volumes is less than 110 mL, but no audible cuff leak is appreciated.

What is the next most appropriate step?

a. Extubate the patient as she was intubated for less than 72 hours
b. Extubate the patient as cuff leaks are not predictive of extubation success
c. Retest for a cuff leak and, if absent, give 60 mg IV methylprednisolone and extubate tomorrow
d. Retest for a cuff leak and, if absent, give 60 mg IV methylprednisolone and extubate in 6 hours.


Question 3#Print Question

A 60-year-old male with a history of type 2 diabetes and prior alcohol use presents to the emergency room with complaints of shortness of breath and mouth pain. His initial temperature is 102°F; he has a heart rate of 110, a blood pressure of 120/60, and a respiratory rate of 30. He states he recently had dental work performed. On examination, he appears uncomfortable with increased work of breathing. He is noted to have a swollen submandibular gland with surrounding erythema at the base of his face extending onto the proximal portion of his neck. His oropharyngeal examination is notable for poor dentition and one tooth with increased erythema along the gum line. There is a high-pitch wheeze with inspiration. The rest of his pulmonary examination is clear. His cardiac examination is notable for sinus tachycardia without murmurs. His labs were notable for an elevated white cell count of 16 000 and an elevated ESR and CRP.

What is the next best step in management?

a. Nasotracheal intubation
b. CT neck and chest
c. Endotracheal intubation
d. Antibiotics and close monitoring in the ICU


Question 4#Print Question

A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD), requiring prior intubation, and active tobacco use presents to the emergency department with shortness of breath. He states that over the last 24 hours, he has had increasing difficulty breathing. He denies fevers or chills at home and is not aware of any sick contacts. His initial vitals are:

  • temperature of 99.4 F
  • heart rate 90/min
  • blood pressure 130/80 mm Hg
  • respiratory rate 22/min
  • SpO2 95%

 On examination, he appears to have a mild increase in work of breathing. He is noted to have scattered wheezing throughout both lung fields. He is started on albuterol nebulizers and IV steroids. Three hours into his emergency room stay you are called to the bedside as the patient appears to be in more distress. His vitals demonstrate:

  • temperature of 99.8
  • HR 125
  • BP 120/70 with an RR of 35
  • SpO2 90%

On examination, the patient is using accessory muscles, and his lung examination is notable for poor air movement with no wheezing. An arterial blood gas is performed:

  • pH 7.28
  • PCO2 50
  • PaO2 65

A chest x-ray is performed and demonstrates hyperinflation of both lung fields with no infiltrate. He is intubated for hypoxemic respiratory failure and is subsequently paralyzed with a neuromuscular blocker secondary to ventilator dyssynchrony. He arrives to the ICU ventilated, with an FiO2 of 0.8, PEEP 10, RR 30, and TV 420 mL/kg (the patient weighs 70 kg). His arterial blood gas demonstrates a pH 7.29/PCO2 50/PaO2 200. His blood pressure upon arrival to the ICU is 80/50 mm Hg.

His flow/time wave form is noted in the following figure:

What would be the next step in management?

a. Increase his tidal volumes
b. Increase his PEEP from 10 to 15
c. Decrease the respiratory rate
d. Increase the inspiratory time


Question 5#Print Question

A 65-year-old male with a history of COPD and active tobacco use with no prior intubations presented to the emergency department with increased work of breathing and increased wheezing. In the emergency department, he was given stacked nebulizers and IV steroids and initiated on BIPAP. His initial blood gas demonstrated:

  • pH 7.2
  • pCO2 75
  • pO2 65

Following intubation, he was placed on volume control ventilation. His initial peak pressure (peak inspiratory pressure [PIP]) was 45 cm H2O, and his plateau pressure (Pplat) was 35 cm H2O. He was placed on a respiratory rate of 30, PEEP 15, FiO2 0.40 and his SpO2 was 90%. Two hours after arrival to the ICU, his ventilator starts to alarm for high pressures. His peak pressures have increased to 65 cm H2O, and his plateau pressure has increased to 55 cm H2O. His heart rate increases from 80 beats per minutes to 110, and his blood pressure drops from 110/70 to 80/50 mm Hg. His SpO2 drops to 75%. His examination is notable for continual wheezing and slight deviation of the trachea toward the left. 

What is the most likely cause for this acute change?

a. Worsening bronchoconstriction
b. Unilateral pneumothorax
c. Biting down on the tube
d. Abdominal distention




Category: Critical Care Medicine-Pulmonary Disorders--->Airway Diseases
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