Pulmonary Disorders I

Answer: A

The DEXA-ARDS clinical trial has been the only contem-

porary trial evaluating corticosteroids (dexamethasone)

among ARDS patients already receiving lung-protective

mechanical ventilation strategies (Answer A is cor-

rect). Despite the numerous ARDS trials evaluating

methylprednisolone, none have concurrently evaluated

with lung-protective strategies among all study patients

(Answer C is incorrect). Despite the optimal timing of

corticosteroid use in ARDS remains controversial, dexa-

methasone was started “early” after ARDS onset in the

DEXA-ARDS trial (Answer B is incorrect). The LaSRS

clinical trial found increased risk of death in the steroid

group compared with controls among patients enrolled

greater than 14 days after ARDS onset. Unfortunately,

this unadjusted subgroup analysis may have biased these

findings. Subsequent re-evaluation of these results found

no differences in mortality among in this subgroup.

Furthermore, “late” (greater than 5–7 days) corticoste-

roid use in ARDS has not consistently demonstrated

worse outcomes (Answer D is incorrect).

Answer: D

Neuromuscular blocking agents should always be admin-

istered after induction agents (Answers A, B, and C are

incorrect). In addition, atropine is not routinely recom-

mended (Answer C is incorrect) for RSI in adult patients.

Atropine should be kept nearby for patients who are at

an increased risk of bradycardia during RSI (use of

β-blockers, calcium channel blockers, digoxin, or amio-

darone). Induction agents (and pretreatment medications)

should be administered before NMBAs (Answer D is

correct).

Answer: B

The patient has moderate to severe ARDS. The initial

MV strategy is using low tidal volumes (Answers A and

C are incorrect). Considering the patient is hemody-

namically stable without requiring vasoactive support,

conservative fluid management approaches are war-

ranted (Answer B is correct). Hemodynamically unstable

patients may be candidates for liberal fluid management

strategies (Answer D is incorrect).