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A 45-year-old male with morbid obesity (BMI 55) presents to the ED at 6 AM with right leg pain, and cellulitis that has kept him awake all night. He is admitted to the ward and his fevers and skin examination are improved with antibiotics during the first 16 hours of hospitalization. At 2 AM you are called to evaluate the patient for ICU admission because of somnolence and hypoxemia (SpO2 falling to high 70s on 2LNC). The rapid response team had difficulty waking the patient and ABG was performed before your arrival in the patient’s room: 7.29/74/52. Following arterial puncture, the patient woke up and by your arrival he is able to converse but remains sleepy with eyes closed, denying dyspnea, with SpO2 now 92% on 2LNC, and normal work of breathing. Medication history was reviewed, and no opiates have been administered. The ward team is requesting ICU transfer because of acute hypercarbic respiratory failure and initiation of BiPAP. You review recent laboratory test results and note that serum bicarbonate has been 38 to 40 over the last 6 months.Which of the following statements is true?

A 40-year-old female is admitted to the intensive care unit with worsening shortness of breath. She states that she had a clot in her lung “a long time ago” for which she “took blood thinners for a few months.” Her initial transthoracic echocardiogram reveals enlarged right-sided chambers with severe tricuspid regurgitation and a large thrombus in the pulmonary artery with severe pulmonary hypertension. This patient is MOST likely to belong to which of the groups of the World Health Organization clinical classification of pulmonary hypertension.

A 62-year-old male patient with a history of COPD presents to the office with a complaint of cough and “body aches” for 3 days. He tests positive for influenza A.For this patient, the current CDC recommendation to treat influenza is to begin therapy with:

A 72-year-old female with history of Parkinson disease and diabetes presents to the emergency department (ED) complaining of nausea, vomiting, and abdominal pain. A CT scan revealed a small bowel obstruction secondary to a twist in the mesentery. She subsequently was intubated for exploratory laparotomy and lysis of adhesions. She continued to fail daily spontaneous breathing trials for the last 3 days. The chest radiograph below is the morning post breathing trial failure: CXR2.jpg What is the next step?

A 67-year-old-male with bullous emphysema is scheduled for a bullectomy to prevent air-leak syndrome. The AG-ACNP knows which of the following patients would not be suited for a bullectomy:

A 48-year-old male with no prior medical history is admitted with community-acquired pneumonia and severe acute respiratory distress syndrome (ARDS). On day 1 of his illness, he is admitted to your ICU on volume control-assist control ventilation with a VT of 4 mL/kg IBW, respiratory rate 32 breaths per minute, PEEP 14 cm H2O, and FiO2 1.0. On those settings, he is found to be hypoxemic with a SaO2 of 86% with an ABG that demonstrates pH 7.28 PCO2 65 mm Hg and PaO2 55 mm Hg. Which of the following interventions is most likely to improve his survival?

An 84-year-old male with severe chronic obstructive pulmonary disease (FEV1 20% predicted, on 4 L/min home O2) is admitted with severe hypoxemic respiratory failure due to a Streptococcus pneumoniae infection. He is intubated and placed on volume control-assist control ventilation with a set TV of 400 mL (6.5 mL/kg IBW), PEEP of 8 cm H2O and a respiratory rate of 30 breaths per minute. When the paralytic used for intubation wears off, the patient is noted to be triggering additional spontaneous breaths with a total respiratory rate of 36 breaths per minute, and his exhaled TVs vary from 100 to 800 mL. During an end-expiratory pause, his airway pressure is 18 cm H2O. Which of the following is the MOST accurate statement regarding his ventilator settings?

A 42-year-old obese female with OSA, diabetes mellitus, and hypertension is admitted for community-acquired pneumonia. After multiple attempts, she is emergently intubated with ET tube size 8.5. She has been intubated for 7 days and today she has tolerated the spontaneous breathing trial. What is the next step?

A 90-year-old female with a history of atrial fibrillation on Eliquis presents with right rib pain and dyspnea after a mechanical fall from standing. She is hemodynamically stable, but her chest CT reveals right rib fractures 3 to 5 with associated hemothorax. The next best step in management includes:

A 79-year-old male with a history of hypertension, dyslipidemia, and type-2 diabetes mellitus presents to the emergency department complaining of increasing shortness of breath, over the past 4 hours. Arterial blood gas (ABG) analysis at room air shows: PaO2 54 mm Hg, PaCO2 28 mm Hg, pH 7.48, HCO3 22 mEq/L. Upon admission, the patient is administered oxygen via a face mask with oxygen reservoir at 15 L/min. The SpO2 raises from 87% to 99%. Thirty minutes later, the patient is still dyspneic (respiratory rate: 32 breaths/min). Noninvasive blood pressure is 180/85 mm Hg, heart rate is 100 bpm. ABG now shows: PaO2 249 mm Hg, PaCO2 27 mm Hg. Chest auscultation reveals mild bilateral crackles at the bases of the lungs and mild wheezing. Body temperature is 36.2°C, WBC 6500/mL, creatinine 1.8 mg/dL, lactate 1.4 mmol/L. What is the MOST likely diagnosis?