Chapter 294 - Acute Respiratory Distress Syndrome

Question 1

How many percent of all ICU admission involve patients with ARDS?

Answer 1

10%

Question 2

Most common cause of ARDS

Answer 2

Pneumonia and Sepsis

40-60%

Question 3

Most frequently reported surgical conditions in ARDS

Answer 3

pulmonary contusion
multiple bone fractures
chest wall trauma/flail chest

Question 4

Trauma patients with an APACHE score of ≥16 has how much risk in developing ARDS

Answer 4

2.5 time increased risk

Question 5

Phases of ARDS

Answer 5

Exudative
Proliferative
Fibrotic

Question 6

Identify which phase:

alveolar capillary endothelial cells and type I pneumocytes are injured with consequent loss of a normally tight alveolar barrier

Answer 6

Exudative

Question 7

Identify which phase:

interleukin 1, interleukin 8, TNF and Leukotriene B are increased leading to leukocyte recruitment

Answer 7

Exudative

Question 8

Identify which phase:

Formation of hyaline membrane whorls

Answer 8

Exudative

Question 9

Identify which phase:

Vascular obliteration by microthrombi and fibrocellular proliferation

Answer 9

Exudative

Question 10

Identify which phase:

Reduction in arterial blood flow resulting to increased dead space and pulmonary hypertension

Answer 10

Exudative

Question 11

Hypercapnia in early ARDS results from?

Answer 11

increased pulmonary dead space

Question 12

Where does alveolar edema predominantly involve?

Answer 12

dependent portions of the lung

Question 13

Exudative phase usually present within how many hours? and can be delayed by how many days?

Answer 13

present w/in 12-36h

delayed by 5-7 days

Question 14

Duration of the proliferative phase

Answer 14

from day 7 to day 21

Question 15

Identify which phase:

most patients recover and are liberated from mechanical ventilation

Answer 15

Proliferative

Question 16

Identify which phase:

Some patients may develop early changes of pulmonary fibrosis

Answer 16

Proliferative

Question 17

Identify which phase:

First sign of resolution histologically

Answer 17

Proliferative

Question 18

Identify which phase:

Initiation of lung repair

Answer 18

Proliferative

Question 19

Identify which phase:

organization of alveolar exudates

Answer 19

Proliferative

Question 20

Identify which phase:

shift from neutrophil to lymphocyte predominant pulmonary infiltrates

Answer 20

Proliferative

Question 21

Which type cells proliferate along the alveolar basement membranes during the proliferative phase?

Answer 21

Type II Pneumocytes

Question 22

Identify which phase:

Requires long term support on Mechanical Ventilation

Answer 22

Fibrotic

Question 23

What causes progressive vascular occlusion and pulmonary hypertension in the Fibrotic phase?

Answer 23

Intimal fibroproliferation in the pulmonary microcirculation

Question 24

General Principles

Answer 24

(1) recognition and treatment of underlying disorders
(2) minimization of unnecessary procedures
(3) standardized ICU “bundled care” approaches (4) prompt recognition of nosocomial infections
(5) provision of adequate nutrition

Question 25

Two principal mechanisms of ventilator induced lung injury

Answer 25

Volutrauma | Atelectrauma

Question 26

Benefit of prone positioning

Answer 26

28-day mortality

Question 27

Fluid restriction and diuretics benefit

Answer 27

shortens ICU stay and duration of mech vent

Question 28

In controlled trials, which agent was used for neuromuscular blockade

Answer 28

cisatracurium besylate for 48h

Question 29

Benefit of neuromuscular blockade

Answer 29

increased survival and ventilator free days

Question 30

Low tidal volume

Answer 30

6 ml/kg of predicted body weight

Question 31

Only Grade A recommendation

Answer 31

Low tidal volume

Question 32

Which treatment strategy demonstrated mortality benefit in RCTs

Answer 32

Prone position | Early neuromuscular blockade

Question 33

Grade B recommendations

Answer 33

- Minimized Left atrial filling pressures - High PEEP or Open Lung - Prone Position - Extracorporeal membrane oxygenation - Early neuromuscular blockade

Question 34

Grade C recommendation

Answer 34

- Recruitment maneuvers | - Inhaled NO, Inhaled epoprostenol

Question 35

Grade D recommendation

Answer 35

``` Glucocorticoid High frequency ventilation Surfactant replacement Ketoconazole PGE1 NSAIDs ```

Question 36

Mortality rate of ARDS from the LUNG SAFE trial

Answer 36

Mild 34.9% Moderate 40.3% Severe 46.1%

Question 37

mortality in ARDS is largely attributable to NONPULMONARY causes

Answer 37

True

Question 38

sepsis and nonpulmonary organ failure accounts for how many percent of deaths of ARDS patients

Answer 38

>80%

Question 39

Important risk factors of ARDS mortality are non pulmonary which includes

Answer 39

Advanced Age | Preexisting organ dysfunction

Question 40

Patients with ARDS arising from direct lung injury (including pneumonia, pulmonary contusion, and aspiration) are nearly twice as likely to die as those with indirect causes

Answer 40

True

Question 41

surgical and trauma patients with ARDS—especially those without direct lung injury—generally have a higher survival rate than other ARDS patients.

Answer 41

True

Question 42

there is LITTLE additional value in predicting ARDS mortality from other parameters of lung injury, including the level of PEEP (≥10 cm H2O), respiratory system compliance (≤40 mL/cm H2O), the extent of alveolar infiltrates on chest radiography, and the corrected expired volume per minute (≥10 L/min)

Answer 42

True

Question 43

After how many months will the patient regain a maximal lung function

Answer 43

within 6 months

Question 44

Diagnostic Criteria

Answer 44

A - Absence of left atrial hypertension R - radiograph showing Bilateral opacities at least 3/4 of the lung fields D - Duration within 1 week of clinical insult S - Severity by Berlin criteria

Question 45

Berlin criteria for ARDS severity

Answer 45

Mild: PFR 201 - 300 Mod: PFR 101 - 200 Sev: PFR ≤ 100

Question 46

Initial management of ARDS

Answer 46

1. Initiate volume/pressure limited ventilation 2. Oxygenate 3. Minimize acidosis 4. Diuresis

Question 47

Goal tidal volume

Answer 47

≤ 6 ml/kg PBW

Question 48

Goal plateau pressure

Answer 48

≤ 30 cmH2O

Question 49

Goal RR

Answer 49

≤ 35 bpm

Question 50

Goal FiO2

Answer 50

≤ 0.6

Question 51

Goal SpO2

Answer 51

88 – 95%

Question 52

Goal pH

Answer 52

≥ 7.30

Question 53

Goal MAP

Answer 53

≥ 65 mmHg

Question 54

Direct causes of lung injury

Answer 54

``` Pneumonia Aspiration of gastric contents Pulmonary contusion Near drowning Toxic inhalation injury ```