Acute Respiratory Distress Syndrome

Question 1

Annual incidence of ARDS pre-covid

Answer 1

60 cases/100,000 population

Question 2

Clinical syndrome of severe dyspnea of rapid onset, hypoxemia, and diffuse pulmonary infiltrates leading to respiratory failure

Answer 2

Acute Respiratory Distress Syndrome

Question 3

Most frequently reported surgical condition in ARDS (3)

Answer 3

1. Pulmonary contusion
2. Multiple bone fractures
3. Chest wall trauma/flail chest

Question 4

Most common cause of ARDS

Answer 4

Sepsis and Pneumonia (~40-60%)

Question 5

Trauma patients with APACHE score of ____ have a 2.5-fold increased risk of developing ARDS

Answer 5

≥ 16

Question 6

In this phase of ARDS, alveolar capillary endothelial cells and type 1 pneumocytes (alveolar epithelial cells) are injured, with consequent loss of the normally tight alveolar barrier

Answer 6

Exudative Phase (first 7 days of illness)

Question 7

In this phase of ARDS, edema fluid that is rich in protein accumulates in the interstitial and alveolar spaces

Answer 7

Exudative phase

Question 8

In this phase of ARDS, hyaline membrane whorls are seen.

Answer 8

Exudative Phase

Question 9

Xray finding of ARDS

Answer 9

Opacities consistent with pulmonary edema, and often involves 3/4 of the lung field

Question 10

Chest CT scan finding in ARDS

Answer 10

Presence of bilateral pulmonary infiltrates

Question 11

Phase in ARDS where 1st signs of resolution is evident

Answer 11

Proliferative phase (days 7-21)

Question 12

Phase of ARDS, recover rapidly and are liberated from mechanical ventilator

Answer 12

Proliferative phase (days 7-21)

Question 13

Phase of ARDS, shift from neutrophil to lymphocyte-predominant pulmonary infiltrates

Answer 13

Proliferative phase (days 7-21)

Question 14

As part of the reparative process in Proliferative phase, _____ proliferates along the alveolar basement membrane

Answer 14

Type II pneumocytes (synthesizes new surfactant)

Question 15

In ARDS, presence of ____ in lung biopsy, in any phase of the disease, increases risk of mortality

Answer 15

Pulmonary Fibrosis

Question 16

Function of PEEP

Answer 16

Promotes alveolar recruitment

Question 17

This intervention provide significant reduction in 28-day mortality for patients with SEVERE ARDS

Answer 17

Prone positioning

Question 18

Principle of Fluid Management in ARDS

Answer 18

Maintain low left atrial filling pressure
Fluid restriction and Diuretics limited only by hypotension and hypoperfusion

Question 19

Only Category A recommendation in management for ARDS

Answer 19

Low tidal volume

Question 20

Category D recommendation in management of ARDS (3)

Answer 20

Glucocorticoid treatment
Surfactant replacement
High frequency ventilation

Question 21

Category B recommendation in management of ARDS (4)

Answer 21

HELP

Minimize left atrial filling pressure
High PEEP or Open Lung
Prone position
ECMO

Question 22

Category C recommendation in management of ARDS (3)

Answer 22

RNV

Recruitment maneuvers
Early neuromuscular blockade (Routine Use)
Inhaled vasodilators

Question 23

Goals and Limits in Management of ARDS

Answer 23

Tidal Volume ≤ 6 mL/kg
Plateau pressure ≤30 cmH2O
RR ≤35 bpm
FiO2 ≤ 0.6
SpO2 88-95%
pH ≥ 7.30
MAP ≥ 65 mmHg
Avoid Hypoperfursion

Question 24

Patients with ARDS recover maximal lung function within ___

Answer 24

6 months

Question 25

____ after endotracheal extubation, more than 1/3 of ARDS survivor have **normal spirometry** and **normal diffusion capacity**

Answer 25

1 year

Question 26

Many patients with ARDS **recover lung function** ______ after initial pulmonary injury

Answer 26

3-4 weeks

Question 27

Phase of ARDS, alveolar edema and inflammatory exudates of earlier phases convert to extensive alveolar duct and interstitial fibrosis

Answer 27

Fibrotic phase

Question 28

Marked disruption of acinar architecture leads to__________

Answer 28

emphysema-like changes, with large bullae.

Question 29

Intimal fibroproliferation in the pulmonary microcirculation causes ______ (2)

Answer 29

1. Progressive vascular occlusion 2. Pulmonary hypertension

Question 30

Physiologic consequences in Fibrotic Phase (3)

Answer 30

1. Increased risk of pneumothorax 2. Reductions in lung compliance 3. Increased pulmonary dead space

Question 31

General Principles in management of ARDS

Answer 31

1. **Recognition and treatment** of underlying medical and surgical disorders (e.g., pneumonia, sepsis, aspiration, trauma) 2. The minimization of **unnecessary procedures** and their complications 3. **Standardized “bundled care”** approaches for ICU patients, including prophylaxis against venous thromboembolism, gastrointestinal bleeding, aspiration, excessive sedation, prolonged mechanical ventilation, and central venous catheter infections 4. Prompt recognition of **nosocomial infections** 5. Provision of **adequate nutrition** via the enteral route when feasible

Question 32

Repeated **alveolar overdistention** from excess tidal volume

Answer 32

Volutrauma

Question 33

Recurrent **alveolar collapse**

Answer 33

Atelectrauma

Question 34

Trial about use of lung-protective strategy using lower tidal volumes of 6ml/kg of PBW

Answer 34

ARDS Network trial (ARMA Trial)

Question 35

Maintaining a ____________ minimizes pulmonary edema and prevents further decrements in arterial oxygenation and lung compliance; improves pulmonary mechanics; and shortens ICU stay and the duration of mechanical ventilation.

Answer 35

Low left atrial filling pressure

Question 36

Ways to lower left atrial filling pressure

Answer 36

**Fluid restriction Diuretics** limited only by hypotension and hypoperfusion of critical organs

Question 37

Mortality rate for Mild ARDS

Answer 37

34.9%

Question 38

Mortality rate for Moderate ARDS

Answer 38

40.3%

Question 39

Mortality rate for Severe ARDS

Answer 39

46.1%

Question 40

ARDS management that improves survival (3)

Answer 40

**PEL** Low tidal volume Prone prositioning ECMO

Question 41

Major risk factors to ARDS mortality is **non-pulmonary**. The most important risk factor is:

Answer 41

Advance age (>75)

Question 42

**TRUE OR FALSE** Patients with ARDS arising from **direct lung injury** are nearly **twice as likely to die** as those with indirect causes of lung injury

Answer 42

TRUE

Question 43

Factors associated with **LESS recovery of pulmonary function** after ARDS (4)

Answer 43

1. Low static respiratory compliance 2. High levels of required PEEP 3. Longer duration of mechanical ventilation 4. High lung injury scores

Question 44

Early neuromuscular blockade with ___ for 48H in patients with **severe ARDS** had increased survival and ventilator free days **without increasing ICU-acquired paresis**

Answer 44

Cisatracurium besylate

Question 45

Phase of ARDS: pulmonary vascular injury

Answer 45

Exudative Phase

Question 46

Central feature of ARDS

Answer 46

**Increased pulmonary vascular permeability** leading to interstitial and alveolar edema fluid rich protein