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 βearlyβ 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, βlateβ (greater than 5β7 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
Ξ²-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).