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Category: Critical Care Medicine-Pulmonary Disorders--->Lung Transplantation, Complications, and VV ECMO
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Question 1# Print Question

A 45-year-old female with history of idiopathic pulmonary fibrosis is admitted to the intensive care unit (ICU) after compatible bilateral lung transplantation. The surgery required the use of intraoperative cardiopulmonary bypass (CPB). Postoperatively, she is on lung protective ventilation with low tidal volumes. She has progressive increase in oxygen requirements and is requiring an FiO2 of 0.7 with a PEEP of 10 to maintain saturations of 92%. At 24 hours, her PaO2 /FiO2 ratio is 175 and chest radiography reveals bilateral diffuse infiltrates. She has a HR of 90/min, BP of 105/76 mm Hg, and a CVP of 7 mm Hg. A bronchoscopy is performed which is unremarkable except for mild erythema in the bronchi.

Which of the following is the MOST appropriate next step in managing this patient?

A. Initiation of veno-venous (VV) ECMO
B. Administration of inhaled nitric oxide
C. Therapeutic plasma exchange
D. Systemic anticoagulation

Question 2# Print Question

Which of the following patients on mechanical lung support in ICU is best suited for lung transplantation?

A. A 40-year-old male on “awake” VV ECMO for worsening idiopathic pulmonary fibrosis
B. A 25-year-old female on VV ECMO for ARDS due to sepsis and dialysis for AKI
C. A 47-year-old morbidly obese female (BMI-42) with severe restrictive lung disease on mechanical ventilation
D. A 76-year-old male with a recent history of bladder cancer resection on mechanical ventilation for acute exacerbation of end-stage COPD

Question 3# Print Question

A 58-year-old male patient is admitted to the hospital 6 months after receiving bilateral lung transplantation. He complains of increasing shortness of breath with a “barking” cough and inability to clear secretions over the past 2 months. He mentions that he has been sleeping in his recliner chair due to dyspnea when lying flat. He is afebrile with a HR of 88/min, BP of 140/80 mm Hg, SpO2 of 94% on room air, and a respiratory rate of 30/min. He is using his accessory neck muscles, and right-sided rhonchi are noted during the chest examination. Administration of bronchodilators fails to improve his symptoms. He is started on noninvasive positive pressure ventilation, which leads to a marked improvement.

Which of the following is the gold standard test to diagnose his condition?

A. Pulmonary function testing with spirometry
B. Standard CT scan of the chest
C. Flexible fiber-optic bronchoscopy
D. Sputum for microbiological analysis

Question 4# Print Question

Three months after bilateral lung transplantation, a 50-year-old female patient is admitted to the ICU with complaints of worsening shortness of breath, low grade fever, and cough. She is compliant with her drug regimen consisting of prednisone, tacrolimus, azathioprine, valganciclovir, and trimethoprim-sulfamethoxazole. Examination reveals bilateral crackles and decreased breath sounds over the left lower chest wall. She has:

  •  temperature of 38 °C
  • HR of 90/min
  • BP of 105/65 mm Hg
  • RR of 25/min
  • SpO2 of 91% on room air

She is started on oxygen therapy, and a chest CT is obtained, which reveals bilateral ground glass opacities with a leftsided pleural effusion. Laboratory testing is unremarkable except for slight eosinophilia. Bronchioalveolar lavage reveals lymphocytic predominance and transbronchial biopsy is significant for dense perivascular and bronchial mononuclear infiltrates with a negative C4d staining.

Which of the following is the best next step in management?

A. Intravenous methyl prednisone
B. Intravenous ganciclovir and piperacillin-tazobactam
C. Intravenous immunoglobulins (IvIg) and rituximab
D. Therapeutic plasma exchange

Question 5# Print Question

A 62-year-old male patient with end-stage emphysema undergoes left-sided single-lung transplantation. He arrives at the ICU after his surgery and is mechanically ventilated on volume assist control mode. The initial ventilator settings are FiO2 of 0.4, PEEP of 10 cm H2O, tidal volume of 380 mL, and respiratory rate of 20 breaths/minute. A few hours later, arterial blood gas reveals hypoxia with hypercapnia. In response, his ventilator settings are changed to FiO2 of 0.5, PEEP of 12 cm H2O, and respiratory rate of 26 breaths/min. One hour later, he has a HR of 120/min, BP of 80/60 mm Hg and SpO2 of 89%. Chest examination reveals bilateral air entry with coarse breath sounds on the left. Arterial blood gas shows worsening hypoxia and hypercapnia. He is started on norepinephrine, and FiO2 is further increased to 0.6.

What is the next best step in management of this patient?

A. Chest tube insertion on the right side
B. Increase PEEP and respiratory rate
C. Decrease PEEP and respiratory rate
D. Obtain a CT scan of the thorax

Category: Critical Care Medicine-Pulmonary Disorders--->Lung Transplantation, Complications, and VV ECMO
Page: 1 of 2