Pulmonary Disorders I

Answer: D

The patient has early severe ARDS (for less than

48 hours and Pao2/Fio2 less than 150 mm Hg) and

hemodynamic stability (post-resuscitation MAP greater

than 65 mm Hg). According to the findings of an

ARDSNet-sponsored multicenter trial, he would qualify

for conservative fluid management (CVP less than 4 mm

Hg). In addition, vasopressors should be discontinued

and diuresis initiated to achieve a target CVP less than

4 mm Hg (Answer A is incorrect). Given the timing and

the severity of the patient’s ARDS, he should be placed

in the prone position (Answers B and C are incorrect). In

addition, this patient would qualify for a cisatracurium

infusion. Given the timing and severity of his ARDS, he

qualifies to receive a lung-protective ventilation strategy

(tidal volume 4–6 mL/kg of ideal body weight) and

diuresis to a CVP less than 4 mm Hg (hemodynamically

stable if weaned off vasopressors) while placed in the

prone position and administered a cisatracurium infusion

(Answer D is correct).

The patient presents to your ICU after 3 days of care.

Therefore, she does not currently meet the criteria for

being administered cisatracurium or placed in the

prone position (Answers B–D are incorrect). Currently,

the applicable therapy to apply is a lung-protective

ventilation strategy (tidal volume 4–6 mL/kg of ideal

body weight) (Answer A is correct).

Answer: C

The patient was appropriately started on corticosteroids

for COVID-19 pneumonia during the same hospital

admission prior to developing ARDS and subsequently

transferred to the ICU. Dexamethasone was associated

with favorable results among COVID-19 hospitalized

patient requiring oxygen support (both noninvasive and

invasive mechanical ventilation) as well as critically

ill patients with moderate to severe ARDS; therefore,

continuing dexamethasone is appropriate (Answer

A is incorrect). Methylprednisolone has not been

associated with favorable clinical outcomes among

COVID-19 or moderate to severe ARDS patients

(Answer B is incorrect). Although the DEXA-ARDS

trial found improved clinical outcomes associated

with the dexamethasone 20 mg daily (followed by 10

mg daily) regimen in ARDS patients, it is important

to recognize this patient population did not consist of

COVID-19. Furthermore, a meta-analysis evaluating

various corticosteroid regimens failed to find any benefit

of higher dexamethasone dosing strategies (i.e., 20 mg

daily) compared with lower doses (6 mg daily) (Answer

C is correct; Answer D is incorrect).

Answer: B

Although selective pulmonary vasodilating agents may

modestly improve oxygenation parameters at best,

they have not shown to improve clinical outcomes.

Their role in therapy is uncertain, but it may be mostly

considered salvage therapy after failing more proven

strategies (Answers A and C are incorrect). The role

of neuromuscular blocking agents in ARDS remain

controversial. However, the ROSE clinical trial failed to

corroborate any improved clinical outcomes previously

demonstrated (ACURASYS trial). Cisatracurium may

not be appropriate at this time since plateau pressures

remain acceptable despite using high PEEP (Answer

D is incorrect). ECMO use in ARDS also remains

controversial. However, severe ARDS may be a

compelling reason to initiate ECMO compared with

alternative supportive therapies (Answer B is correct).

Answer: C

ECMO may not be the most appropriate strategy at this

time considering the patient has moderate to severe

ARDS with corresponding Pao2 of 110 mm Hg on lung

protective mechanical ventilation alone (Answers B

and D are incorrect). Furosemide may not be the most

appropriate strategy because the patient is currently

requiring vasoactive support (Answers A and B and

incorrect). Cisatracurium may be indicated for this

patient considering the plateau pressure is elevated as

well as prone positioning to help improve oxygenation

with suboptimal parameters on mechanical ventilation

along; furthermore, corticosteroids may also be indicated

given ARDS severity and timing (Answer C is correct).

Answer: C

Propofol, ketamine, and etomidate can all be used

for induction. Propofol may worsen hypotension;

therefore, because this patient is already receiving

vasoactive medications to maintain his blood pressure,