Pulmonary Disorders II

Answer: D

It is imperative to recognize that this patient has acute

respiratory distress syndrome (ARDS) caused by a

CF exacerbation. Therefore, an inclusive therapy plan

should include appropriate treatments for ARDS and CF.

For ARDS, a lung-protective ventilation strategy (tidal

volume 4–6 mL/kg) and a fluid-conservative strategy

(CVP less than 4 mm Hg, if not in shock) are of utmost

importance (Answers A and C are incorrect because of

the CVP goal; Answer D is correct). Appropriate treat-

ment of the CF exacerbation includes empiric therapy for

P. aeruginosa in the form of optimal doses of a β-lactam

and aminoglycoside (Answer B is incorrect because

of the inappropriate tobramycin dose and CVP goal of

10–14 mm Hg).

The highest quality of evidence for improved out-

comes with CF exacerbations is with adjunctive

therapy for mucous clearance. The guidelines recom-

mend airway clearance options such as aggressive chest

physical therapy, nebulized dornase alfa, and hyper-

tonic saline as a grade B recommendation (Answer D

is correct). Hypertonic saline would be appropriate, but

nebulization of normal saline is not included in any of

the recommendations (Answer A is incorrect). Both

corticosteroid administration and concurrent admin-

istration of intravenous and inhaled antibiotics have a

grade I recommendation, meaning evidence is insuffi-

cient to support them (Answers B and C are incorrect).

Answer: D

This patient presents with severe right heart failure. The

primary goal is to optimize RV preload by maintain-

ing a net negative fluid balance using gentle diuresis

and blood pressure monitoring (Answer D is correct).

Dopamine would increase blood pressure; however, it

might worsen the patient’s tachycardia, thereby wors-

ening her already tenuous clinical status (Answer

A is incorrect). Epoprostenol would help decrease

pulmonary pressures; however, epoprostenol would

potentially worsen the patient’s blood pressure because

of its peripheral vasodilating effects (Answer B is incor-

rect). Phenylephrine would not be optimal because this

vasopressor might worsen RV function, further ele-

vate pulmonary artery pressure by α1-receptors in the

pulmonary vasculature, and potentially induce a reflex

bradycardia (Answer C is incorrect).

Answer: C

Treatment goals for PAH include, but are not limited

to, achieving and maintaining WHO FC I or II (Answer

A is incorrect), preserving 6MWD to greater than 440

m (Answer B is incorrect), and preserving RV size and

function (right atrial pressure less than 8 mm Hg and

cardiac index 2.5 L/minute/m2 or greater) (Answer C

is correct). The clinician should normalize BNP to less

than 50 ng/L (Answer D is incorrect).

Answer: C

This patient has shortness of breath at rest that is inter-

fering with his conversational ability, and his FEV1

is less than 50% of predicted; therefore, his asthma

exacerbation would be classified as severe (Answer C

is correct). FEV1 would be greater than 50% in mild/

moderate asthma exacerbation (Answers A and B are

incorrect). In a life-threatening asthma exacerbation,

the patient would have symptoms such as drowsiness,

confusion, or silent chest. This patient could progress to

life threatening but currently would not be classified as

such (Answer D is incorrect).

Answer: B

This patient presents with near-fatal asthma that is

unresponsive to initial therapy. Magnesium sulfate (2 g

intravenously administered over 20–30 minutes) can be

considered in patients who have life-threatening exacer-

bations and are unresponsive to conventional therapies

after 1 hour (Answer B is correct). Antimicrobials are

not routinely recommended for asthma exacerbations

if the patient has no evidence of concurrent infec-

tion (Answer A is incorrect). Because of the lack of

improved outcomes, risk of adverse effects, and supe-

rior bronchodilation with SABAs, methylxanthines

(theophylline and aminophylline) are not recommended

for acute asthma exacerbations (Answer C is incorrect).

Mucolytic agents are irritating and may worsen cough

and airflow obstruction (Answer D is incorrect).

Answer: B

The recommended corticosteroid dose for an ECOPD

is prednisone 40 mg orally once daily (Answer D is