BCCCP: ARDS Critical Care Questions

Question 1 of 10

1. Question

A 58-year-old man with acute respiratory distress syndrome (ARDS) is admitted to the ICU. He is mechanically ventilated and immobilized. On hospital day 3, he develops active gastrointestinal bleeding, confirmed by endoscopy. Prior to bleeding, he was receiving low molecular weight heparin for venous thromboembolism (VTE) prophylaxis. Given his high risk for VTE due to immobility and critical illness, but current contraindication to pharmacologic anticoagulation, which of the following is the MOST appropriate VTE prophylaxis strategy?

Initiate intermittent pneumatic compression (IPC) devices.
Resume unfractionated heparin at a lower dose.
Switch to enoxaparin 40 mg subcutaneously daily.
Discontinue all VTE prophylaxis temporarily until bleeding resolves.

Question 2 of 10

2. Question

A 45-year-old man with severe ARDS from aspiration pneumonia is on mechanical ventilation and norepinephrine, and has developed acute kidney injury requiring intermittent continuous renal replacement therapy (CRRT). Considering the increased volume of distribution in ARDS and enhanced meropenem clearance with CRRT, which dosing regimen is most appropriate to achieve and maintain effective plasma concentrations against Pseudomonas aeruginosa?

Administer a 2 g IV loading dose over 30 minutes, then 1 g IV every 8 hours (each dose infused over 3 hours) with subsequent adjustments guided by CRRT settings and therapeutic drug monitoring.
Start with standard meropenem 1 g IV every 8 hours as a 3-hour extended infusion without a loading dose, adjusting solely based on later therapeutic drug monitoring.
Give a reduced loading dose of 1 g IV over 30 minutes, then 500 mg IV every 24 hours, assuming CRRT and mild hepatic dysfunction will significantly prolong drug exposure.
Administer meropenem 1 g IV every 6 hours as a short infusion without any loading dose or CRRT-based adjustment, relying on CRRT to clear excess drug.

Question 3 of 10

3. Question

A 65-year-old male with acute respiratory distress syndrome (ARDS) is mechanically ventilated in the ICU. Despite optimal ventilator settings, he exhibits persistent hypercapnia and has impaired airway protective reflexes, placing him at high risk for aspiration. His current enteral nutrition is delivered via a gastric feeding tube with a standard high-carbohydrate formula. According to current evidence-based guidelines, which of the following modifications to his enteral nutrition plan is MOST appropriate to support his metabolic needs while minimizing aspiration risk and CO₂ production?

Increase the feeding rate to meet full caloric needs immediately and switch to a high-carbohydrate formula to provide quick energy.
Transition to a post-pyloric feeding tube, elevate the head of the bed to 30–45°, and initiate early trophic enteral feeding with a standard polymeric formula, advancing to goal rate as tolerated while avoiding overfeeding.
Initiate parenteral nutrition to bypass the gastrointestinal tract and reduce CO₂ production, noting this approach is reserved for contraindications to enteral feeding.
Reduce the enteral feeding rate to 25 mL/hr and administer a prokinetic agent to manage gastric residual volumes.

Question 4 of 10

4. Question

A 58-year-old man is admitted to the ICU with severe acute respiratory distress syndrome (ARDS) secondary to pneumonia. The critical care team is evaluating adjunctive therapies to improve outcomes. In this cost‐conscious healthcare system, which of the following adjunctive therapies is least justifiable for broad, initial implementation based on current evidence and pharmacoeconomic considerations?

Early low-dose corticosteroids
Mesenchymal stromal cell therapy
Vibrating mesh nebulizers for aerosolized medications
Inhaled nitric oxide

Question 5 of 10

5. Question

A 65-year-old man with severe ARDS is receiving mechanical ventilation and has been started on inhaled nitric oxide (INOmax) and aerosolized epoprostenol (Flolan) for refractory hypoxemia. Which of the following is the most important practice for optimizing inhaled pulmonary vasodilator delivery and ensuring patient safety?

Place a vibrating mesh nebulizer proximal to the humidifier in the inspiratory limb of the ventilator circuit to maximize lung deposition.
Synchronize nitric oxide delivery to the expiratory phase of ventilation to reduce drug wastage and environmental contamination.
Maintain heat-and-moisture exchangers (HMEs) during aerosolization to preserve circuit humidification and prevent airway drying.
Monitor methemoglobin levels and systemic blood pressure during inhaled nitric oxide therapy to detect toxicity and rebound pulmonary hypertension.

Question 6 of 10

6. Question

A 45-year-old male is admitted to the ICU with moderate to severe acute respiratory distress syndrome (ARDS) secondary to pneumonia. He is intubated and mechanically ventilated with lung-protective settings, including a tidal volume of 6 mL/kg predicted body weight and PEEP of 12 cm H₂O. His PaO₂/FiO₂ ratio is 106 mmHg despite optimized ventilation and hemodynamic support. Considering current evidence and guidelines, what is the best approach to the timing and duration of prone positioning for this patient to improve outcomes?

Prone positioning should be initiated early and continued for at least 16 consecutive hours daily to maximize mortality benefit.
Prone positioning should be reserved until the PaO₂/FiO₂ ratio drops below 75 mmHg, indicating more severe refractory hypoxemia.
Prone positioning should only be continued if there is a rapid and significant improvement in oxygenation within the first 6 hours.
Prone positioning should be performed for short, intermittent sessions (e.g., 4–6 hours) to minimize the risk of pressure injuries.

Question 7 of 10

7. Question

A 45-year-old male is admitted to the ICU with severe pneumonia complicated by acute respiratory distress syndrome (ARDS). He is currently on assist-control ventilation with a tidal volume of 6 mL/kg predicted body weight and PEEP of 10 cm H₂O. He requires a norepinephrine infusion for hemodynamic support. His arterial blood gas shows pH 7.28, PaCO₂ 55 mmHg, PaO₂ 80 mmHg on an FiO₂ of 0.8, yielding a PaO₂/FiO₂ ratio of 100. The medical team is considering next steps to improve oxygenation and reduce ventilator-induced lung injury. Given this patient’s presentation and current management, which of the following interventions should be prioritized to optimize respiratory support and improve outcomes?

Initiate prone positioning for at least 16 hours daily.
Increase positive end-expiratory pressure (PEEP) to 18 cm H₂O.
Administer a continuous infusion of a neuromuscular blocking agent.
Initiate inhaled nitric oxide therapy.

Question 8 of 10

8. Question

A 42-year-old man with severe acute respiratory distress syndrome (ARDS) secondary to pneumonia is admitted to the ICU. Despite optimized conventional mechanical ventilation strategies—including low tidal volume ventilation, prone positioning, and neuromuscular blockade—his oxygenation remains critically low with a PaO2/FiO2 ratio of 70 and plateau pressures exceeding 30 cm H2O. The ICU team is considering advanced respiratory support. As the critical care pharmacist reviewing this case, which of the following is the MOST appropriate recommendation regarding initiation of advanced respiratory support and your pharmacotherapy management role?

Recommend a trial of inhaled nitric oxide to improve V/Q matching; the pharmacist will optimize dosing, oversee delivery, and monitor for methemoglobinemia.
Prepare for venovenous (V-V) ECMO initiation; the pharmacist will adjust drug dosing for altered pharmacokinetics and manage anticoagulation.
Prepare for high-frequency oscillatory ventilation (HFOV); the pharmacist will adjust sedation and neuromuscular blockade infusions.
Consider early percutaneous tracheostomy to facilitate prolonged ventilation; the pharmacist will coordinate sedation weaning and monitor for infectious complications.

Question 9 of 10

9. Question

A 58-year-old man is admitted to the intensive care unit with acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation. He is agitated, and the team wants to apply an analgesia-first, nurse-driven sedation protocol with daily sedation interruption, light-sedation targets, and routine delirium monitoring as recommended by the 2018 PADIS guidelines and the ABCDEF bundle. Which of the following is the MOST appropriate initial sedation strategy for this patient?

Initiate a continuous propofol infusion, targeting a RASS of –1 to 0, as part of an analgesia-first, nurse-driven protocol with daily sedation interruption and regular delirium assessments.
Initiate a continuous dexmedetomidine infusion, targeting a RASS of –1 to 0, without scheduled daily sedation interruption or delirium monitoring.
Initiate a continuous midazolam infusion, targeting a RASS of –1 to 0, with daily sedation interruption but no analgesia-first protocol.
Initiate a continuous propofol infusion, targeting a RASS of –3 to –4, with daily sedation interruption.

Question 10 of 10

10. Question

A 58-year-old male with severe acute respiratory distress syndrome (PaO2/FiO2 95) is mechanically ventilated with lung-protective settings (tidal volume 6 mL/kg PBW, PEEP 12 cm H2O) and is deeply sedated. The team aims to prevent ventilator-associated pneumonia (VAP) and ventilator-induced lung injury (VILI) while optimizing oxygenation. Which intervention should the critical care pharmacist prioritize?

Implement daily sedation interruptions and assess readiness for prone positioning.
Transition to airway pressure release ventilation (APRV) to improve alveolar recruitment.
Initiate inhaled nitric oxide at 20 ppm to enhance oxygenation.
Switch to high-frequency oscillatory ventilation (HFOV) to reduce barotrauma.

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