CEN Respiratory Emergencies 2 — Questions and Answers
Question 1: A patient is intubated and the ventilator alarms for high peak airway pressure. Breath sounds are absent on the left. What is the most likely cause?
- Pulmonary edema
- Right mainstem intubation (Correct answer)
- Mucus plug in the right bronchus
- Ventilator malfunction
Correct answer: Right mainstem intubation
Right mainstem intubation is common because the right bronchus is less angled; it causes absent breath sounds on the left and increased peak airway pressures.
Question 2: Which clinical criterion is NOT part of the Berlin Definition of ARDS?
- Bilateral opacities on imaging
- PaO2/FiO2 ratio below 300 mmHg
- Respiratory failure not fully explained by cardiac failure
- A high BNP level confirming cardiac cause (Correct answer)
Correct answer: A high BNP level confirming cardiac cause
The Berlin Definition requires bilateral opacities, P/F ratio < 300, respiratory failure within 1 week of insult, and exclusion of cardiac cause—it does not require a high BNP.
Question 3: A 65-year-old patient post-knee replacement develops sudden dyspnea, tachycardia, and hypoxia. ECG shows sinus tachycardia with an S1Q3T3 pattern. What is the most appropriate initial diagnostic test?
- Chest X-ray
- D-dimer assay
- CT pulmonary angiography (CTPA) (Correct answer)
- V/Q scan
Correct answer: CT pulmonary angiography (CTPA)
CTPA is the gold-standard imaging test for diagnosing pulmonary embolism in a high-probability patient with the clinical and ECG findings described.
Question 4: What is the appropriate size (French) for a chest tube inserted for a hemothorax?
- 12–14 Fr pigtail catheter
- 20–22 Fr small-bore tube
- 28–32 Fr or larger tube (Correct answer)
- Needle thoracostomy only
Correct answer: 28–32 Fr or larger tube
A large-bore chest tube (28–32 Fr or larger) is required for hemothorax to allow adequate drainage of blood and prevent clotting of the tube.
Question 5: Which ventilator strategy is recommended to reduce lung injury in ARDS patients?
- Tidal volume of 10–12 mL/kg ideal body weight
- Tidal volume of 6 mL/kg ideal body weight with permissive hypercapnia (Correct answer)
- High PEEP with tidal volume 8 mL/kg
- Low PEEP to minimize barotrauma
Correct answer: Tidal volume of 6 mL/kg ideal body weight with permissive hypercapnia
Lung-protective ventilation in ARDS uses low tidal volumes of 6 mL/kg IBW to reduce volutrauma, allowing permissive hypercapnia as tolerated.
Question 6: A patient with epiglottitis is in the ER. She is drooling, sitting upright, and has inspiratory stridor. What is the most important initial action?
- Attempt immediate oral intubation in the ER
- Keep the patient calm and upright; prepare for definitive airway in the OR (Correct answer)
- Administer racemic epinephrine via nebulizer
- Perform lateral neck X-ray immediately
Correct answer: Keep the patient calm and upright; prepare for definitive airway in the OR
Epiglottitis can cause complete airway obstruction if agitated; keeping the patient calm and moving to the OR for controlled intubation or tracheotomy is the safest approach.
CEN Respiratory Emergencies 2
A patient is intubated and the ventilator alarms for high peak airway pressure.
Breath sounds are absent on the left.
What is the most likely cause?