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Pulmonary Disorders I Grace E. Benanti, Pharm.D., BCCCP Loyola University Medical Center Maywood, Illinois…

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Pulmonary Disorders I Pulmonary Disorders I Grace E. Benanti, Pharm.D., BCCCP Loyola University Medical Center Maywood, Illinois…

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Learning Objectives 3 min

Pulmonary Disorders I Learning Objectives 1. Recommend an evidence-based therapeutic plan to manage critically ill patients with acute respiratory distress syndrome. 2. Assess appropriateness of…

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Content 3 min

Pulmonary Disorders I C. Empiric antibiotic therapy, aggressive diuresis (goal central venous pressure less than 4 mm Hg), and vasopressors for shock; low tidal vol- ume (4–8 mL/kg) ventilation str…

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Exam Content Outline 1 min

Pulmonary Disorders I BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1: Critica…

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Data Tables 3 min

Pulmonary Disorders I I.  ACUTE RESPIRATORY DISTRESS SYNDROME A. Definition and Epidemiology 1. First described in 1967; several definitions have evolved over the years 2. The Berlin ARDS definitio…

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Pulmonary Disorders I C. Management Strategies 1. MV a. Lung-protective strategies using low tidal volume ventilation are considered the standard of care and cornerstone in managing ARDS. b. The…

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Pulmonary Disorders I e. Recently published clinical practice guidelines strongly recommend prone positioning in moderate to severe ARDS (Table 2) (Am J Respir Crit Care Med 2017;195:1253-63; BMJ Op…

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Pulmonary Disorders I d. The 2019 clinical practice guidelines state that ECMO should be considered in patients with severe ARDS or more specifically with Pao2/Fio2 ratios less than 80 mm Hg and/or…

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Pulmonary Disorders I d. The RADAR-2 trial also evaluated the conservative and standard of care fluid strategies in critically ill patients (n=180) (Intensive Care Med 2022;48:190-200). Although thi…

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Pulmonary Disorders I 6. Corticosteroids a. Proposed rationale for corticosteroid use in ARDS was to prevent fibroproliferation with subsequent alveolar fibrosis from a proinflammatory response. b.…

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Pulmonary Disorders I 7. Corticosteroids in COVID-19 (see the Infectious Diseases I chapter for further information) a. Currently, clinical practice guidelines strongly recommend the use of dexameth…

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Pulmonary Disorders I d. The WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group conducted a meta-analysis of seven randomized clinical trials involving 1703 critically ill pat…

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Pulmonary Disorders I d. Despite the paucity of data for inhaled epoprostenol, it is commonly used in the ICU for ARDS as a bridge to more invasive management strategies (i.e., ECMO) and/or as salva…

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Pulmonary Disorders I Patient Cases (continued) 2. A 70-year-old woman (height 63 inches, weight 65 kg) is transferred to your ICU from an outside hospital after outside hospital admission for hypox…

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Pulmonary Disorders I II.  INTUBATION A. Endotracheal Intubation 1. Provides access for suctioning of tracheobronchial secretions, maintains a patent airway, and allows administration of medication…

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Pulmonary Disorders I D. Pretreatment or Preintubation Optimization 1. Occurs before an induction agent or NMBA is administered 2. Pretreatment attenuates the sympathetic and parasympathetic respon…

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Pulmonary Disorders I i. No convincing or consistent evidence suggests that etomidate is associated with an increased risk of death (Intensive Care Med 2011;37:901-10; Chest 2015;147:335-46). ii. L…

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Pulmonary Disorders I 7. Reversal of nondepolarizing NMBAs with a failed airway a. An acetylcholinesterase inhibitor (neostigmine or pyridostigmine) in combination with an anticholinergic (atropine…

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Pulmonary Disorders I Patient Cases 6. A 55-year-old man (weight 75 kg) is admitted to the burn ICU after a 65% total body surface area burn to the abdomen, back, and lower extremities from a hou…

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Data Tables 2 min

Pulmonary Disorders I 2. Synchronized intermittent mandatory ventilation (SIMV): Patients will receive a predetermined respiratory rate and tidal volume plus additional spontaneous, self-generated b…

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Pulmonary Disorders I Patient Case 8. A 74-year-old woman (height 63 inches, weight 65 kg) is transferred to your ICU from an outside hospital after admission for hypoxic respiratory failure. She…

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Pulmonary Disorders I REFERENCES Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as comp…

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Pulmonary Disorders I for the acute respiratory distress syndrome*. Crit Care Med. 2015;43(2):288-295. https://doi.org/10.1097/ ccm.0000000000000715 Guérin C, Reignier J, Richard JC, et al. Prone p…

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Pulmonary Disorders I illness: the role of active deresuscitation after resuscita- tion-2 (RADAR-2) randomised clinical trial. Intensive Care Med. 2022;48(2):190-200. https://doi.org/10.1007/ s00134-…

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Answers & Explanations 4 min

Pulmonary Disorders I ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: D The patient has early severe ARDS (for less than 48 hours and Pao2/Fio2 less than 150 mm Hg) and hemodynamic stability (…

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Pulmonary Disorders I propofol would not be ideal (Answer A is incorrect). Succinylcholine causes the up-regulation of acetylcholine receptors, predisposing the muscle fibers to release excess pota…

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Self-Assessment 4 min

Pulmonary Disorders I ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: B According to the Berlin ARDS definition, the category of acute lung injury was removed in favor of categoriz-…

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Pulmonary Disorders I 6. Answer: A The DEXA-ARDS clinical trial has been the only contem- porary trial evaluating corticosteroids (dexamethasone) among ARDS patients already receiving lung-protectiv…

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