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Self-Assessment Questions

Critical Care Medicine

Acute Respiratory Distress Syndrome/Acute Lung Injury: Review Questions

Nuala J. Meyer, MD

Dr. Meyer is a pulmonary and critical care fellow, University of Chicago, Chicago, IL.

Choose the single best answer for each question.

Figure 1

1. A 28-year-old woman is admitted to the intensive care unit (ICU) for severe hypoxemia following an emergency caesarean section for placental abruption. She received general endotracheal anesthesia, and although no aspiration was noted, it was a difficult intubation. The patient had not fasted prior to coming to the hospital. The anesthesiologist used Fio2 of 1.0 to keep the patient’s arterial saturation above 93%. Chest radiography was performed (Figure 1). In the ICU, the patient’s blood pressure is 115/72 mm Hg, heart rate is 124 bpm, respiratory rate is 36 breaths/min, temperature is 100.6°F, and Sao2 is 92% on Fio2 of 1.0. She is intubated and sedated but making active respiratory efforts. Cardiovascular examination reveals tachycardia with a regular rhythm, no murmurs, and a hyperdynamic precordium. Capillary refill is normal. Lung examination discloses diffuse crackles in both lungs without wheezing. Neurologic examination is limited by sedation but is grossly nonfocal. Arterial blood gas (ABG) is as follows: pH, 7.29; Pco2, 55 mm Hg; and Po2, 62 mm Hg. The ventilator settings are volume-cycled assist-control (A/C) mode; respiratory rate, 26 breaths/min; tidal volume, 500 mL; positive end-expiratory pressure (PEEP), 10 cm H2O; and Fio2, 0.7. The patient’s height is 5 ft 5 in, and she weighs 70 kg (postpartum; ideal body weight [IBW], 57 kg). Her plateau (pause) pressure measured on passive breaths is 37 cm H2O. Which of the following ventilator adjustments should be made?

  1. Increase the tidal volume to 600 mL and respiratory rate to 30 breaths/min in an attempt to normalize the pH to 7.40
  2. Decrease PEEP to 5 cm H2O to avoid barotrauma
  3. Increase Fio2 to 0.8 and PEEP to 15 cm H2O to raise the Pao2 above 70 mm Hg
  4. Decrease the tidal volume to 342 mL (6 mL/kg IBW) and increase the respiratory rate to 34 breaths/min
  5. Decrease the tidal volume to 420 mL (6 mL/kg actual weight) and increase the respiratory rate to 30 breaths/min
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2. Which of the following is not a frequent cause of acute respiratory distress syndrome (ARDS) in a peripartum patient?

  1. Amniotic fluid embolus
  2. Aspiration
  3. Pneumonia
  4. Retained products of conception/disseminated intravascular coagulopathy
  5. Unsuspected mitral valve disease (MVD)
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3. A 54-year-old man with non-Hodgkin’s lymphoma who underwent allogeneic stem cell transplant 4 months ago is admitted to the hospital for neutropenic fever. The initial chest radiograph is clear, but over the first 2 hospital days the patient develops bilateral dense airspace opacification. The patient continues to have low-grade fevers despite broad-spectrum antibiotics. On hospital day 3, his breathing is labored and he has a new oxygen requirement; he remains only 92% saturated on 6 L by nasal cannula. Physical examination reveals a tachypneic man in respiratory distress who appears fatigued. Blood pressure is 130/72 mm Hg, heart rate is 118 bpm, respiratory rate is 32 breaths/min, temperature is 101.3°F, and Sao2 is 94% on 40% oxygen by face mask. Neurologic examination is normal. Crackles are heard in both lungs with egophony. Cardiovascular examination is normal except for tachycardia. He has no rash. On 40% oxygen, ABG values are: pH, 7.36; Pco2, 45 mm Hg; and Pao2, 61 mm Hg. In this patient, which of the following is true about noninvasive positive pressure ventilation (NIPPV)?

Figure 2

  1. Immunosuppressed patients have a greater risk for aspiration with NIPPV; thus, it should not be used
  2. Immunosuppressed patients with acute respiratory failure benefit from NIPPV
  3. NIPPV may be used at inspiratory positive airway pressure (IPAP) 35 cm H2O and expiratory positive airway pressure 10 cm H2O for less than 1 hour while closely monitoring the patient
  4. NIPPV should not be attempted in a patient with acute lung injury (ALI)
  5. The maximum noninvasive inspiratory pressure is 12 cm H2O IPAP to avoid the possibility of skin breakdown
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Questions 4 and 5 refer to the following case:

A 24-year-old man sustains several pelvic and long bone fractures in a motor vehicle accident and requires 9 U of packed red blood cells (RBCs). He has no obvious chest wall trauma or rib fractures. His FAST examination discloses no intra-abdominal or pericardial fluid collections. The fractures are reduced and externally fixed in the operating room, and all vascular injuries are repaired. On day 2 in the trauma unit, the patient demonstrates an increasing oxygen requirement and is intubated. He is afebrile and hemodynamically stable; urine output is adequate (< 50 mL/hr). Breath sounds are coarse bilaterally. Chest radiography is performed (Figure 2). Initial ventilator settings are volume-cycled A/C mode; respiratory rate, 20 breaths/min; tidal volume, 420 mL; PEEP, 10 cm H2O; and Fio2, 1.0. On these settings, ABG is pH, 7.39; Pco2, 39 mm Hg, and Pao2, 62 mm Hg.

4. Which of the following is the most appropriate volume management strategy for this patient?

  1. Bolus with isotonic intravenous solution using a central venous catheter (CVC) to maintain the right atrial pressure at or above 10 cm H2O
  2. Diuresis guided by a CVC to obtain the lowest right atrial pressure while maintaining adequate perfusion
  3. Insert a pulmonary arterial catheter (PAC) and maintain the pulmonary artery occlusion pressure (PAOP) at or above 12 cm H2O
  4. Insert a PAC and use the PAOP to guide diuresis to the lowest PAOP while maintaining adequate perfusion
  5. Transfuse packed RBCs to increase the hemoglobin level to 14 g/dL
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5. Despite careful ventilator and volume management, the patient remains extremely hypoxemic on Fio2 of 1.0. Which of the following statements is true regarding salvage therapy for ARDS?

  1. High-frequency oscillatory ventilation decreases mortality
  2. Inhaled nitric oxide (NO) increases the number of ventilator-free days but does not decrease mortality
  3. Inhaled NO, prone positioning, and high- frequency oscillatory ventilation have been shown to improve oxygenation but not mortality
  4. Intratracheal surfactant (recombinant surfactant protein-C-based surfactant) given for 24 hours increases the number of ventilator-free days and survival
  5. Prone positioning has been shown to increase morbidity and is therefore not recommended
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