Snapshot A 46-year-old woman is admitted to the ICU with severe pancreatitis. During the first 24 hours of admission, severe hypoxemia that requires ventilatory support with high concentrations of inspired oxygen develop. On exam the patient has rhonchi and crackles bilaterally. An arterial blood gas collected at 60% FiO2 reveals pH 7.42, PCO2 35 mmHg, and PO2 108 mmHg. Introduction Defined asacute diffuse, inflammatory lung injury leading to increased vascular permeability, increased lung weight and loss of aerated lung tissue hyperactivation of coagulation and/or inflammation damages both type I and II pneumocytes ↓ type II pneumocytes results in ↓ surfactant production ↓ surfactant production results in low lung compliance and subsequent atelectasis repair often results in interstitial fibrosis Causes infection pneumonia sepsis typically gram-negative sepsis aspiration acute pancreatitis trauma with shock amniotic fluid embolism (rare) uremia Presentation Symptoms dyspnea Physical exam tachypnea bilateral rales and decreased breath sounds Evaluation Arterial blood gas severe hypoxemia on pulse oximetry and ABG may not be responsive to 100% O2 atelectasis results in intrapulmonary shunting Radiology diffuse, bilateral alveolar infiltrates on CXR ground glass opacities and consolidations on chest CT often with dependent lung predominence Histology diffuse alveolar damage protein-rich leakage (exudate) forming an intra-alveolar hyaline membrane Severity graded on PaO2 / FiO2 ratio and required PEEP (see below) Treatment Respiratory support & treat underlying cause Mechanical ventilation with low tidal volume (4-6 mL/kg ideal body weight) High FiO2 PEEP (positive end-expiratory pressure) prevents airway collapse at end-expiration recruits collapsed alveoli increases FRC and decreases shunting improves oxygenation
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PL.15.96) A 48-year-old female suffers a traumatic brain injury while skiing in a remote area. Upon her arrival to the ER, she is severely hypoxemic and not responsive to O2 therapy. She is started on a mechanical ventilator and 2 days later upon auscultation, you note late inspiratory crackles. Which of the following is most likely normal in this patient? QID: 100899 Type & Select Correct Answer 1 Type I pneumocytes 10% (9/91) 2 Type II pneumocytes 23% (21/91) 3 Chest X-ray 3% (3/91) 4 Alveolar-arterial gradient 16% (15/91) 5 Left atrial pressure 45% (41/91) M 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (M1.PL.14.23) A 45-year-old man arrives by ambulance to the emergency room after being involved in a very severe construction accident. The patient was found unconscious with a large metal spike protruding from his abdomen by a coworker who was unable to estimate the amount of time the patient went without medical aid. Upon arrival to the ER, the patient was unconscious and unresponsive. His vital signs are BP: 80/40, HR: 120 bpm, RR: 25 bpm, Temperature: 97.1 degrees, and SPO2: 99%.He is taken to the operating room to remove the foreign body and control the bleeding. Although both objectives were accomplished, the patient had an acute drop in his blood pressure during the surgery at which time ST elevations were noted in multiple leads. This resolved with adequate fluid resuscitation and numerous blood transfusions. The patient remained sedated after surgery and continued to have relatively stable vital signs until his third day in the intensive care unit, when he experiences an oxygen desaturation of 85% despite being on a respirator with 100% oxygen at 15 breaths/minute. On auscultation air entry is present bilaterally with the presence of crackles. A 2/6 systolic murmur is heard. Readings from a Swan-Ganz catheter display the following: central venous pressure (CVP): 4 mmHg, right ventricular pressure (RVP) 20/5 mmHg, pulmonary artery pressure (PAP): 20/5 mmHg. Pulmonary capillary wedge pressure (PCWP): 5 mm Hg. A chest x-ray is shown as Image A. The patient dies soon after this episode. What is the most likely direct cause of his death? QID: 104029 FIGURES: A Type & Select Correct Answer 1 Diffuse alveolar damage 72% (71/98) 2 Ventricular septal defect 2% (2/98) 3 Myocardial free wall rupture 6% (6/98) 4 Papillary muscle rupture 12% (12/98) 5 Myocardial reinfarction 3% (3/98) M 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M1.PL.13.112) A 58-year-old male is hospitalized after sustaining multiple fractures in a severe automobile accident. Soon after hospitalization, he develops respiratory distress with crackles present bilaterally on physical examination. The patient does not respond to mechanical ventilation and 100% oxygen and quickly dies due to respiratory insufficiency. Autopsy reveals heavy, red lungs and histology is shown in Image A. Which of the following is most likely to have been present in this patient shortly before death: QID: 100915 FIGURES: A Type & Select Correct Answer 1 Diaphragmatic hypertrophy 1% (1/115) 2 Proliferation of bronchiolar mucous glands 9% (10/115) 3 Interstitial edema 54% (62/115) 4 Large pulmonary embolus 34% (39/115) 5 Left apical bronchoalveolar carcinoma 0% (0/115) M 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (2) Login to View Community Videos Login to View Community Videos PaO2:FiO2 ratio Keshav Mudgal Respiratory - Acute Respiratory Distress Syndrome (ARDS) D 11/8/2015 127 views 5.0 (3) Login to View Community Videos Login to View Community Videos ARDS Chris Battista Respiratory - Acute Respiratory Distress Syndrome (ARDS) D 3/27/2013 91 views 4.7 (3) Respiratory | Acute Respiratory Distress Syndrome (ARDS) Respiratory - Acute Respiratory Distress Syndrome (ARDS) Listen Now 10:15 min 11/12/2021 31 plays 5.0 (1)