{"id":7350,"date":"2025-08-25T00:01:00","date_gmt":"2025-08-25T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=7350"},"modified":"2026-07-16T11:21:53","modified_gmt":"2026-07-16T19:21:53","slug":"pance-question-of-the-day-ards","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards","title":{"rendered":"PANCE\u00ae Question of the Day: ARDS"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-ards\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this challenging clinical scenario involving a 58-year-old patient with hypertension in the ICU to manage pneumonia and ARDS. Examine the clinical details to make an informed decision about their care.<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 58-year-old man with a history of hypertension is admitted to the intensive care unit for management of pneumonia and subsequent acute respiratory distress syndrome (ARDS). He was intubated and mechanically ventilated due to worsening hypoxemia. His initial ventilator settings were set to a tidal volume of 6 mL\/kg of predicted body weight, with a positive end-expiratory pressure (PEEP) of 5 cm H<sub>2<\/sub>O. Temperature is 38.3\u00b0C (100.9\u00b0F), heart rate is 102\/min, respiratory rate is set at 12 breaths\/min on the ventilator, blood pressure is 135\/85 mmHg, and oxygen saturation is 88% on FiO<sub>2<\/sub> of 50%. The patient is put in a prone position. Lung auscultation reveals bilateral crackles. Arterial blood gas (ABG) analysis shows pH 7.3, PaCO<sub>2<\/sub> 40 mm Hg, PaO<sub>2<\/sub> 55 mm Hg, and HCO<sub>3<\/sub><sup>&#8211;<\/sup> 24 mEq\/L. PaO2\/FiO2 ratio=110. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the best next step in management?&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Increase positive end-expiratory pressure (PEEP) to 8 cm H2O<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Increase FiO2 to 80%<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Increase tidal volume to 8 mL\/kg<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Increase respiratory rate to 16 breaths\/min<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Switch the patient to a supine position<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Increase positive end-expiratory pressure (PEEP) to 8 cm H2O<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Increase FiO2 to 80%<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Escalating FiO2 to 80% is not the first-line approach for moderate hypoxemia in ARDS. High FiO2 levels can increase the risk of oxygen toxicity. The primary strategy should be to optimize PEEP to improve oxygenation while minimizing potential oxygen-related lung injury.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Increase tidal volume to 8 mL\/kg<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Increasing tidal volume to 8 mL\/kg is generally avoided in ARDS due to the risk of volutrauma and should only be considered as a last resort for severe refractory hypercapnia, which this patient does not currently exhibit.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Increase respiratory rate to 16 breaths\/min<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Adjusting the respiratory rate is not the first step in addressing hypoxemia in patients with moderate ARDS. It is considered when addressing ventilation issues, particularly hypercapnia. In this patient with ARDS and acceptable PaCO2 levels, the priority is to optimize oxygenation through PEEP adjustments rather than altering respiratory rate.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Switch the patient to a supine position<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Prone positioning is recommended in moderate ARDS to improve oxygenation as it decreases the amount of weight and compression on the lungs, allowing more air to get to the alveoli, which has already been implemented for this patient. Reverting to supine positioning is contrary to the recommended practice for severe hypoxemia in ARDS and could potentially worsen V\/Q mismatch and oxygenation.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with clinical findings suggestive of <strong>acute respiratory distress syndrome (ARDS) secondary to pneumonia.<\/strong> Based on PaO2\/FiO2 ratio=110 he can be diagnosed with <strong>moderate disease<\/strong>. The best step to improve oxygenation in this patient is to <strong>increase the positive end-expiratory pressure (PEEP) to 8 cm H<\/strong><strong><sub>2<\/sub><\/strong><strong>O<\/strong>. The patient&#8217;s current oxygen saturation (88%) and PaO<sub>2<\/sub> (55 mm Hg) indicate inadequate oxygenation, necessitating adjustments in ventilator settings.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Increasing PEEP is a key strategy to improve oxygenation in ARDS<\/strong>. It helps to recruit collapsed alveoli, improve functional residual capacity, and reduce intrapulmonary shunting, thereby enhancing oxygenation. A careful increase in PEEP can improve gas exchange without significantly raising the risk of barotrauma.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For <strong>hypoxemia <\/strong>(PaO<sub>2<\/sub> &lt; 60 mm Hg), <strong>increasing PEEP<\/strong> is recommended to <strong>improve oxygenation before escalating FiO<\/strong><strong><sub>2<\/sub><\/strong>, due to the risks associated with oxygen toxicity. <strong>Hyperoxia<\/strong> (PaO<sub>2<\/sub> &gt; 90 mm Hg) warrants <strong>decreasing FiO<\/strong><strong><sub>2<\/sub><\/strong><strong> to avoid similar toxicities.<\/strong> On the ventilation side, if the patient is acidotic (PaCO<sub>2 <\/sub>high and pH &lt; 7.25), increasing the respiratory rate (RR) is advised, and as a last resort, increasing tidal volume (Vt) may be considered. Conversely, if <strong>PaCO<\/strong><strong><sub>2<\/sub><\/strong><strong> is low and pH &gt; 7.45<\/strong>, reducing Vt or RR is recommended, and sedation may be deepened to decrease metabolic demand and respiratory drive. Throughout the management, ensuring lung-protective ventilation to prevent alveolar overdistension is critical. This is assessed by measuring <strong>plateau pressure (Pplat) with an inspiratory hold, aiming for a goal Pplat \u2264 30 cm H<\/strong><strong><sub>2<\/sub><\/strong><strong>O<\/strong>.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For patients with moderate severity, ARDS-prone positioning and increased levels of PEEP may be used. In addition to ventilator management, all patients with ARDS should receive supportive care, potentially medications like diuretics, and severity should be assessed regularly to determine the need for other measures like neuromuscular agents to induce paralysis and ECMO for severe disease.&nbsp;&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">In ARDS management, optimizing PEEP is a key initial step for improving oxygenation in patients with moderate disease, with careful monitoring to balance oxygen needs against the risk of ventilator-induced lung injury. Lung-protective ventilation strategies, including low tidal volumes and optimal PEEP, are central to managing ARDS effectively.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch this Osmosis video:&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Acute_respiratory_distress_syndrome\">Acute respiratory distress syndrome<\/a><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?w=700\" alt=\"\" class=\"wp-image-4433\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong><em>Get your\u00a0<a href=\"http:\/\/osmosis.org\/plans\/pa\" target=\"_blank\" rel=\"noreferrer noopener\">f<\/a><a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\">ree trial<\/a> now\u00a0to discover why millions of current and future clinicians and caregivers love learning with us.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Today&#8217;s PANCE\u00ae Question of the Day: ARDS involves a clinical case of moderate ARDS in a patient with pneumonia. What&#8217;s the best ventilator adjustment to improve oxygenation and patient outcomes?<\/p>\n","protected":false},"author":204,"featured_media":7352,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[1336,1344,1341,1337,1338,280,1342,1340,1343,1339],"class_list":["post-7350","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-ards","tag-critical-care","tag-lung-protective-ventilation","tag-mechanical-ventilation","tag-oxygenation","tag-pance","tag-peep","tag-pneumonia","tag-prone-positioning","tag-respiratory-failure"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PANCE\u00ae Question of the Day: ARDS - Osmosis Blog<\/title>\n<meta name=\"description\" content=\"Prepare for the PANCE\u00ae with this ARDS case. 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