A 55-year-old man is in the intensive care unit on non-invasive positive pressure ventilation (NIPPV) via a full-face mask for acute respiratory failure. He has a central venous catheter in place for vasopressor support (norepinephrine 0.1 mcg/kg/min). Over the past hour he has become increasingly lethargic, disoriented, and has intermittent gasping respirations. Vital signs are: HR 115 bpm, BP 88/52 mmHg, RR 38 breaths/min, SpO₂ 85% on NIPPV (FiO₂ 100%), and GCS 7 (E2V2M3). Arterial blood gas shows pH 7.18, PaCO₂ 65 mmHg, and PaO₂ 55 mmHg. Despite maximizing NIPPV settings, his mental status and gas exchange continue to deteriorate. Which of the following is the most appropriate immediate intervention?

A 45-year-old man is 30 days post–allogeneic hematopoietic stem cell transplant for acute myeloid leukemia. His graft-versus-host disease (GVHD) prophylaxis consists of tacrolimus and methotrexate. Over the past 48 hours, he has developed a diffuse maculopapular rash covering >50% of his body surface area, 8–10 watery stools per day, and his total bilirubin has risen to 4.5 mg/dL. Which of the following is the most appropriate initial pharmacotherapy for this patient’s acute GVHD?

A 45-year-old man is 60 days post–allogeneic hematopoietic stem cell transplant and is in the ICU for worsening acute graft-versus-host disease (GVHD) of the skin (grade III) and gastrointestinal tract (grade IV). He is mechanically ventilated for respiratory compromise from severe abdominal distension and is receiving a continuous norepinephrine infusion. Despite 7 days of methylprednisolone 2 mg/kg/day, his skin rash has progressed and he continues to have profuse diarrhea (>2 L/day). Liver function tests are stable and there are no signs of infection. Given his steroid-refractory acute GVHD and critical illness, which of the following is the most appropriate next pharmacologic intervention?

A 58-year-old man with a history of allogeneic stem cell transplant complicated by chronic graft-versus-host disease (GVHD) affecting his lungs and heart is admitted to the ICU. He is on assist-control ventilation with a tidal volume of 6 mL/kg ideal body weight, respiratory rate 18 breaths/min, PEEP 12 cm H₂O, FiO₂ 1.0, and sedation with propofol infusion (20 µg/kg/min) targeting a RASS of −2 plus fentanyl at 50 µg/hr. He also receives a norepinephrine infusion through a central line titrated to maintain a MAP of 65 mmHg. During evening rounds, he acutely decompensates with increased dyspnea, ventilator dyssynchrony, hypotension, tachycardia, and SpO₂ 88%. Vital signs: BP 75/40 mmHg, HR 120 bpm, RR 30 breaths/min (ventilator rate 18). Arterial blood gas: pH 7.20, PaCO₂ 60 mmHg, PaO₂ 55 mmHg. Lactate is 4.5 mmol/L. Transthoracic echocardiography shows severe left ventricular dysfunction. Given his acute hypercapnic respiratory failure and cardiogenic shock, which of the following is the MOST appropriate immediate adjustment?

A 45-year-old man with an ideal body weight (IBW) of 70 kg is in the intensive care unit for severe acute graft-versus-host disease with pulmonary involvement, resulting in refractory hypoxemia. He is intubated and on assist-control ventilation with these settings: tidal volume 9.5 mL/kg IBW, FiO₂ 0.60, PEEP 8 cm H₂O, and respiratory rate 20 breaths/min. A norepinephrine infusion at 0.1 mcg/kg/min via a central line maintains a mean arterial pressure of 68 mm Hg. His arterial oxygen saturation (SaO₂) is 95%. Given this patient’s status, which ventilator adjustment most appropriately minimizes complications?

A 45-year-old man with severe acute graft-versus-host disease (GVHD) is in the intensive care unit. He is on assist-control ventilation for progressive respiratory failure and requires a norepinephrine infusion at 0.1 mcg/kg/min via a central line to maintain a mean arterial pressure >65 mmHg. His mental status is diminished, he is unable to clear respiratory secretions, and there is evidence of worsening liver and gut GVHD. A systemic immunosuppressive agent is being initiated. Given this patient’s clinical status, which of the following is the most appropriate route of administration for this agent?

A 48-year-old man is in the intensive care unit on assist-control ventilation with a tidal volume of 560 mL (8 mL/kg ideal body weight; IBW 70 kg) and a PEEP of 8 cm H2O. A norepinephrine infusion at 0.1 mcg/kg/min is used to maintain mean arterial pressure (MAP) above 65 mmHg. During nursing rounds, he develops worsening dyspnea with accessory muscle use and new hypotension (MAP 55 mmHg) despite the current vasopressor dose. Arterial blood gas analysis shows pH 7.28, PaCO2 58 mmHg, and PaO2 65 mmHg on an FiO2 of 0.8. Hemodynamic monitoring reveals a cardiac index that has decreased from 2.5 to 1.8 L/min/m² and a central venous pressure (CVP) that has increased from 14 to 22 cm H2O. Which of the following is the most appropriate next intervention?

A 62-year-old man is in the intensive care unit for acute respiratory failure. He is receiving assist-control mechanical ventilation and a continuous norepinephrine infusion via a central venous catheter. During nursing rounds, his blood pressure acutely drops to 78/45 mmHg with a heart rate of 125 bpm and a respiratory rate of 30 breaths/min. Ventilator settings are: tidal volume 500 mL, set respiratory rate 20 breaths/min, PEEP 10 cmH₂O, and plateau pressures consistently >30 cmH₂O. The patient appears agitated and is triggering additional breaths above the set ventilator rate. What is the most appropriate immediate intervention to correct his hemodynamic instability?

A 45-year-old man, 60 days after allogeneic hematopoietic stem cell transplantation, is in the ICU with acute respiratory failure and cardiogenic shock. He is on assist-control ventilation with a PEEP of 8 cm H₂O and FiO₂ of 60%, maintaining an SpO₂ of 90%. A central line is infusing norepinephrine at 0.1 mcg/kg/min, but his mean arterial pressure (MAP) remains 55 mmHg. Hemodynamic monitoring shows a cardiac index of 1.8 L/min/m² and a pulmonary capillary wedge pressure of 22 mmHg. He is somnolent and unable to follow commands. What is the most appropriate immediate intervention?

A 48-year-old man, 60 days post–allogeneic hematopoietic stem cell transplant, is in the ICU with severe pulmonary graft-versus-host disease. He is on high-flow nasal cannula at 60 L/min, FiO₂ 0.8. Over the past hour, he has become increasingly somnolent, disoriented, and agitated. His respiratory rate is 32 breaths/min, SpO₂ is 88%, and he has shallow, gasping respirations. His blood pressure is 85/45 mmHg despite a 1-L normal saline bolus, and his heart rate is 110 bpm. He is also unable to clear copious respiratory secretions. Considering his rapidly deteriorating status, which finding most strongly indicates the need for immediate invasive mechanical ventilation?