Internal Medicine and Subspecialties

ARDS and Ventilator Management for #COVID19 Case Study 63-year-old woman with #COVID-19 is admitted to the hospital for septic shock secondary to CAP. After receiving hydroxychloroquine, antibiotics (which include azithromycin), fluids, and vasopressors, her condition stabilizes. However, she subsequently develops ARDS and is intubated. Her oxygen requirement increases until she is receiving 100% oxygen. Ventilator settings are in the volume-controlled continuous mandatory ventilation mode with RR 22, TV 330 mL (6 mL/kg of ideal body weight), FIO₂ 100%, and PEEP 5. Peak pressure of 25 cm H₂O, and a plateau pressure of 22 cm H₂O. On exam, temp 100.4, BP 115/60, HR 105/min and RR 15. The skin is cool. There is no JVD. Heart sounds are rapid and regular but otherwise unremarkable. Diffuse crackles are heard on pulmonary exam. There is no edema. The remainder of the physical exam is noncontributory. ABG show a pH 7.31, PaCO2 50 and PaO2 of 54. CXR shows extensive patchy areas of opacification of the lung fields Which of the following is the most appropriate management? A) Decrease the TV B) Implement a prone positioning maneuver C) Start inhaled NO or prostacyclin analogs D) Decrease the RR E) Increase the PEEP F) V-V ECMO