A 65-year-old male diagnosed with idiopathic pulmonary fibrosis a year ago not on supplemental oxygen therapy presents to the ED with a week and a half of worsening exercise tolerance, increased dry cough, myalgias, and subjective fevers. Over the last day he has been unable to walk across the room without resting. Physical examination is remarkable for SpO2 of 85% on 6 L NC with tachypnea and increased work of breathing, bibasilar crackles. Laboratory test results reveal WBC 10,000/ μL (slightly increased absolute neutrophil count), normal metabolic panel and liver function tests, troponin of 0.1 ng/mL, and BNP of 120 pg/mL. Rapid flu is negative, and PCR panel is pending. CXR shows worsening bilateral opacities, and results of CT scan are shown in the figure that follows. CT1.jpgThe patient is admitted to the ICU and placed on high flow nasal cannula at 40 LPM flow. Overnight FiO2 has ranged between 0.7 and 0.9 to maintain SpO2 in the low 90s, and he was unable to sleep because of dyspnea. On examination he appears to be tiring. Which of the following statements is true?

Which of the following chronic medical therapies are shown to improve survival in patients with COPD? Smoking cessation in combination with:

A 56-year-old male with a 30-pack-year smoking history, COPD, and peripheral vascular disease is admitted for right femoral popliteal bypass. Anesthesia has attempted to extubate him but he subsequently developed shortness of breath and hypoxia. Nebulizers, corticosteroids, and NIPPV are applied. Two hours later, the patient has increased work of breathing, and his oxygen saturation would intermittently drop to the 70s. His chest radiograph has shown a persistent infiltrate on the right lower lobe. On the second day, the chest radiograph shows no acute pulmonary disease. The patient is being liberated from the mechanical ventilator. What should be considered?

You assess a 55-year-old male patient who is a candidate for bariatric surgery. He is 175 cm, 120 kg and has arterial hypertension for which he takes ramipril. His wife tells you the patient snores during the night. His blood pressure (BP) is 125/75 mm Hg and pulse oximetry is 89% on room air. What is the MOST appropriate management of this patient?

A 65-year-old male with a history of COPD and active tobacco use with no prior intubations presented to the emergency department with increased work of breathing and increased wheezing. In the emergency department, he was given stacked nebulizers and IV steroids and initiated on BIPAP. His initial blood gas demonstrated pH 7.2/ pCO2 75/ pO2 65. Following intubation, he was placed on volume control ventilation. His initial peak pressure (peak inspiratory pressure [PIP]) was 45 cm H2O, and his plateau pressure (Pplat) was 35 cm H2O. He was placed on a respiratory rate of 30, PEEP 15, FiO2 0.40 and his SpO2 was 90%. Two hours after arrival to the ICU, his ventilator starts to alarm for high pressures. His peak pressures have increased to 65 cm H2O, and his plateau pressure has increased to 55 cm H2O. His heart rate increases from 80 beats per minutes to 110, and his blood pressure drops from 110/70 to 80/50 mm Hg. His SpO2 drops to 75%. His examination is notable for continual wheezing and slight deviation of the trachea toward the left.What is the most likely cause for this acute change?

A 68-year-old woman with HIV is admitted to the ICU with respiratory failure secondary to pneumocystis pneumonia, requiring intubation and mechanical ventilation. A chest CT scan was performed before intubation and demonstrated cystic changes throughout the lungs, thought to be a sequela of past pneumocystis infection, with superimposed diffuse ground glass opacities. Her ventilator is set on volume assist-control, TV 6 mL/kg, respiratory rate 16 breaths per minute, FiO2 0.8, and PEEP of 10 cm H2O. On day 2 of her critical illness, her ventilator suddenly alarms for elevated peak pressures. She is observed to be deeply sedated and breathing passively on the ventilator. The peak pressure has risen from 25 cm H2O several hours before 50 cm H2O. The patient has simultaneously experienced oxygen desaturation from 95% to 90%. She is otherwise hemodynamically stable. A chest radiograph is ordered. An inspiratory hold maneuver is performed and her plateau pressure is 20 cm H2O. Which of the following is the MOST LIKELY explanation for this acute event?

A 26-year-old male presents to the ED with complaints of shortness of breath and right-sided chest pain that began after a 2-mile run. The symptoms have been persistent for the past 3 hours. Pain is increased with inspiration. He denies any constitutional symptoms of fever, cough, chills, or sick contacts. He is an avid runner on a daily basis, but does smoke ½-pack of cigarettes per day. On physical exam he is tachypneic, with respiratory rate 30, 94% saturation on room air. Breath sounds are decreased in the left lung fields, and there is hyperresonance to percussion. The AG-ACNP obtains the following chest x-ray: CXR1.jpg What is the diagnosis?

An 80-year-old male patient presents to the hospital on supplemental oxygen with the following arterial blood gas: pH of 7.24, Paco2 of 70 mmHg, and Pao2 of 63 mmHg. He shows evidence of which of the following?

1. Which of the following nutrients provides the most energy per gram?

An 84-year-old male with severe chronic obstructive pulmonary disease (FEV1 20% predicted, on 4 L/min home O2) is admitted with severe hypoxemic respiratory failure due to a Streptococcus pneumoniae infection. He is intubated and placed on volume control-assist control ventilation with a set TV of 400 mL (6.5 mL/kg IBW), PEEP of 8 cm H2O and a respiratory rate of 30 breaths per minute. When the paralytic used for intubation wears off, the patient is noted to be triggering additional spontaneous breaths with a total respiratory rate of 36 breaths per minute, and his exhaled TVs vary from 100 to 800 mL. During an end-expiratory pause, his airway pressure is 18 cm H2O. Which of the following is the MOST accurate statement regarding his ventilator settings?