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Acute respiratory distress syndrome — ABIM Board MCQ

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ModeratePulmonary/Critical CareAcute respiratory distress syndromeABIM Board

A 55-year-old man hospitalized with acute pancreatitis develops acute hypoxemic respiratory failure within 48 hours. Chest radiography shows new bilateral diffuse opacities, and echocardiography shows normal left ventricular systolic function without evidence of elevated left atrial pressure. He is intubated. His PaO2/FIO2 ratio is 110 while receiving an FIO2 of 0.80 and PEEP of 10 cm H2O. Which intervention should form the foundation of his ventilatory management?

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Correct answer: E — Use a tidal volume of approximately 6 mL/kg predicted body weight and limit plateau pressure to less than 30 cm H2O

This patient has ARDS due to acute pancreatitis, supported by acute hypoxemia, bilateral opacities, and absence of cardiogenic pulmonary edema. Lung-protective ventilation using a tidal volume near 6 mL/kg of predicted—not actual—body weight and a plateau pressure below 30 cm H2O reduces ventilator-induced lung injury and mortality. High tidal volumes increase alveolar overdistension and mortality. Inhaled nitric oxide may transiently improve oxygenation but does not improve survival and is not routine therapy. Current guidance conditionally supports corticosteroids in selected patients with ARDS, but not routine pulse-dose treatment regardless of timing or cause. Bronchoscopy is reserved for specific diagnostic or therapeutic indications, such as mucus plugging, and does not treat the diffuse alveolar injury.

Reference: Fan E, et al. An Official ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. 2017. https://pubmed.ncbi.nlm.nih.gov/28459336/