Massive aspiration during induction — FFICM MCQ

Correct answer: E — Continue lung-protective ventilation and treat evolving ARDS supportively

The correct answer is E, continue lung protective ventilation and treat evolving ARDS supportively. This man has aspirated gastric contents and now meets Berlin criteria for evolving ARDS: acute onset, PaO2/FiO2 ratio of 8.9/0.7 = 12.7 kPa (moderate ARDS), and a clear precipitant. Current UK critical care guidance recommends low tidal volume ventilation (6 ml/kg predicted body weight, as already used here) with plateau pressure kept below 30 cmH2O and PEEP titrated to oxygenation, which describes exactly this patient's settings. Particulate matter localised to one lobe without large airway obstruction does not require further mechanical clearance; the priority is protecting the lung from ventilator induced injury while the chemical pneumonitis evolves and secondary infection is monitored for, not treated blindly. Why the other options are wrong: A. Perform repeated saline lavage until clear: repeated lavage disperses particulate material more distally, worsens surfactant washout and hypoxaemia, and is not indicated once large airway obstruction has been excluded on bronchoscopy. B. Increase tidal volume to recruit dependent lung: higher tidal volumes raise plateau pressure and stroke volume delivered to already injured alveoli, increasing barotrauma and volutrauma risk in ARDS rather than improving recruitment. D. Start prophylactic broad-spectrum antifungal therapy: aspiration pneumonitis is a chemical injury; antimicrobials (let alone antifungals) are only indicated if secondary bacterial infection is confirmed or strongly suspected, not empirically at two hours. C. Extubate to CPAP after suctioning: with FiO2 0.7, PEEP 10 and PaO2 8.9 kPa the patient has moderate ARDS and remains unsafe to extubate; premature extubation risks re-aspiration and acute decompensation. Key point: Evolving ARDS after aspiration is managed by maintaining lung protective ventilation (tidal volume 6 ml/kg, plateau pressure under 30 cmH2O) and supportive care, not by mechanical lavage, volume escalation, empirical antimicrobials, or early extubation.

Reference: Intensive Care Society and Faculty of Intensive Care Medicine, Guidelines on the Management of Acute Respiratory Distress Syndrome, 2018 (https://ics.ac.uk/resource/ards-guideline.html)