Pulmonary Edema and ARDS Practice Questions

30 multiple-choice questions on Pulmonary edema and ARDS for paramedic and EMT students, from Chapter 17 (Respiratory Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. Thirty minutes after his choking episode was cleared, a healthy 22-year-old develops pink frothy sputum, crackles, and an SpO2 of 88%. What is the most likely cause?

   1. A. A delayed allergic reaction to the food
   2. B. Acute left heart failure from a heart attack
   3. C. Aspiration pneumonia from the food particles
   4. D. Negative-pressure pulmonary edema
   Show answer

   Answer: D. Negative-pressure pulmonary edema

   Forceful inspiration against an obstructed upper airway creates very negative pressure in the chest that pulls fluid into the alveoli (negative-pressure pulmonary edema), typically within minutes to hours of choking or laryngospasm. Give oxygen, add PEEP or CPAP as needed, and transport. There are no allergic signs such as hives or swelling. A healthy 22-year-old is unlikely to have acute left heart failure from a heart attack. Aspiration pneumonia from food particles develops over a day or more.

2. Two hours after 2 liters were drained from a large pleural effusion, a patient being transferred develops cough, frothy sputum, and crackles on the drained side. What is the likely cause?

   1. A. A new pneumonia on that side
   2. B. A heart attack brought on by the procedure
   3. C. Pulmonary edema in the re-expanded lung
   4. D. Normal clearing of leftover fluid
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   Answer: C. Pulmonary edema in the re-expanded lung

   Rapidly re-expanding a lung that has been collapsed, especially after draining more than about 1.5 L, can cause re-expansion pulmonary edema on that side within hours; give oxygen and support breathing. Pneumonia does not develop within 2 hours. An MI is possible but would not explain one-sided frothy edema. Frothy sputum with hypoxemia is not normal clearing.

3. During an open-water triathlon swim, a fit 38-year-old develops cough, dyspnea, and pink frothy sputum. What is the most likely cause?

   1. A. Swimming-induced pulmonary edema
   2. B. An asthma attack from cold water
   3. C. A heart attack from a blocked artery
   4. D. Drowning after a long submersion
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   Answer: A. Swimming-induced pulmonary edema

   Swimming-induced pulmonary edema occurs in fit swimmers and divers, especially in cold water, from raised pulmonary capillary pressure during immersion and exertion. It usually improves within a day with oxygen and rest out of the water. Asthma causes wheezing without frothy sputum. An MI is possible but less likely in a fit athlete with these findings. He was not submerged.

4. An 82-year-old with known severe aortic stenosis is in pulmonary edema with a BP of 118/70. Why is nitroglycerin used with great caution here?

   1. A. Nitroglycerin narrows the aortic valve further
   2. B. Aortic stenosis makes nitroglycerin ineffective here
   3. C. Nitroglycerin causes the valve to leak
   4. D. Her heart depends on preload to push past the valve
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   Answer: D. Her heart depends on preload to push past the valve

   In severe aortic stenosis, cardiac output depends on filling pressure, and a sudden drop in preload from nitrates can cause profound hypotension; use CPAP and small, cautious doses only with medical direction. Nitroglycerin does not change the valve opening or cause regurgitation. It still lowers preload, which is exactly what makes it risky.

5. A week after a viral illness, a 14-year-old has dyspnea, fatigue, a heart rate of 140, crackles, and an enlarged liver. What best explains these findings?

   1. A. Dehydration from the recent viral illness
   2. B. Exercise-induced asthma
   3. C. Heart failure from viral myocarditis
   4. D. An anxiety reaction
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   Answer: C. Heart failure from viral myocarditis

   Myocarditis after a viral illness weakens the heart and causes heart failure: tachycardia out of proportion, crackles, and hepatomegaly. Large fluid boluses can worsen it. Dehydration does not cause crackles or an enlarged liver. Asthma causes wheezing, not hepatomegaly. Anxiety does not cause crackles or hepatomegaly.

6. A dyspneic 78-year-old has crackles. Which finding most favors pneumonia over heart failure as the cause?

   1. A. Orthopnea and distended jugular veins
   2. B. Swelling of both ankles
   3. C. Fever with crackles on one side only
   4. D. Crackles at both bases
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   Answer: C. Fever with crackles on one side only

   Fever, a productive cough, and focal (one-sided) crackles point toward pneumonia. Orthopnea, JVD, ankle edema, and crackles at both bases are typical of heart failure. The two can coexist, so assess the whole picture.

7. A ventilated patient being transferred has a PaO2 of 90 mmHg on an FiO2 of 0.6 with PEEP of 10. Using the Berlin definition, how severe is her ARDS?

   1. A. Mild, P/F ratio of about 250
   2. B. Moderate, P/F ratio of 150
   3. C. Severe, P/F ratio of 90
   4. D. Moderate, P/F ratio of 54
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   Answer: B. Moderate, P/F ratio of 150

   The P/F ratio is PaO2 divided by FiO2: 90 / 0.6 = 150. Berlin grades ARDS as mild (200 to 300), moderate (100 to 200), or severe (100 or less), so 150 is moderate. 250 does not follow from the numbers. 90 uses the PaO2 alone. 54 multiplies instead of divides.

8. Minutes after a generalized seizure, a 30-year-old with no heart disease has frothy sputum, crackles, and an SpO2 of 86%. What is the likely cause?

   1. A. Neurogenic pulmonary edema
   2. B. Aspiration of a large meal
   3. C. Left heart failure from valve disease
   4. D. Asthma triggered by the seizure
   Show answer

   Answer: A. Neurogenic pulmonary edema

   A massive sympathetic surge after a seizure or brain injury can cause rapid-onset noncardiogenic (neurogenic) pulmonary edema, usually resolving in a day or two with supportive care. Aspiration can follow a seizure but causes coughing and a later pneumonia, typically on one side. He has no heart disease. Asthma causes wheezing, not frothy sputum.

9. A hallmark of ARDS is hypoxemia that:

   1. A. Occurs only during sleep
   2. B. Improves with hyperventilation
   3. C. Resolves with nasal cannula
   4. D. Resists oxygen alone
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   Answer: D. Resists oxygen alone

   Fluid-filled, collapsed alveoli create shunt physiology, so hypoxemia persists despite high oxygen concentrations. PEEP helps recruit alveoli.

10. Why is PEEP helpful for patients with ARDS?

    1. A. It removes carbon dioxide
    2. B. It dries out the airways
    3. C. It keeps alveoli open
    4. D. It lowers the heart rate
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    Answer: C. It keeps alveoli open

    Positive end-expiratory pressure prevents alveolar collapse at end-exhalation, improves oxygenation, and reduces shunting.

11. Ventilated ARDS patients are typically managed with which lung-protective strategy?

    1. A. Zero PEEP
    2. B. Low tidal volumes
    3. C. Very slow rates
    4. D. High tidal volumes
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    Answer: B. Low tidal volumes

    Low tidal volumes of about 6 mL/kg of ideal body weight reduce ventilator-induced lung injury in ARDS.

12. A 66-year-old with heart failure reports gaining 8 lb in 4 days and now cannot lie flat. What do these findings suggest?

    1. A. Pneumonia
    2. B. Fluid overload
    3. C. Pulmonary embolism
    4. D. Dehydration
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    Answer: B. Fluid overload

    Rapid weight gain and orthopnea indicate fluid retention and worsening heart failure. Pneumonia and PE cause dyspnea but not rapid weight gain, and dehydration causes weight loss.

13. A septic patient has bilateral crackles and an SpO2 of 86% on a nonrebreather. Which finding most favors ARDS over cardiogenic pulmonary edema?

    1. A. Distended neck veins and a new S3 sound
    2. B. A long history of heart failure
    3. C. Recent weight gain and ankle swelling
    4. D. No JVD and no history of heart disease
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    Answer: D. No JVD and no history of heart disease

    ARDS is noncardiogenic: it follows a trigger such as sepsis, and the patient typically has no JVD, no S3, and no history of heart disease or fluid overload. Distended neck veins with a new S3, a long history of heart failure, and recent weight gain with ankle swelling all point to a cardiogenic cause.

14. Why might a patient with acute pulmonary edema also have wheezing?

    1. A. Bronchiolar edema
    2. B. Upper airway swelling
    3. C. Foreign body
    4. D. Allergic reaction
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    Answer: A. Bronchiolar edema

    Fluid in the bronchial walls can narrow small airways and cause wheezing, sometimes called 'cardiac asthma.'

15. A patient with pulmonary edema has a BP of 210/120. Per many protocols, which approach to nitroglycerin is appropriate?

    1. A. Withhold all nitrates
    2. B. Higher or repeated doses
    3. C. One dose, then stop
    4. D. Give it only orally
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    Answer: B. Higher or repeated doses

    Many protocols allow repeated or higher-dose nitroglycerin for hypertensive pulmonary edema, along with CPAP, to reduce preload and afterload.

16. A patient with pulmonary edema is on CPAP after three sublingual nitroglycerin doses. Her BP has fallen from 176/98 to 96/60, and her breathing is easier. What should you do?

    1. A. Give a fourth nitroglycerin dose right away
    2. B. Remove the CPAP and give a 2-liter bolus
    3. C. Hold further nitroglycerin and keep the CPAP on
    4. D. Lay her flat with her legs raised to support BP
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    Answer: C. Hold further nitroglycerin and keep the CPAP on

    Her breathing has improved, but her BP is now near the usual nitroglycerin cutoff, so hold more nitrates and continue CPAP with close monitoring. Another dose risks hypotension. A large fluid bolus can re-flood the lungs, and removing CPAP lets edema return. Lying flat worsens pulmonary edema.

17. Which patient presentation suggests pulmonary edema from a noncardiac cause?

    1. A. Dyspnea with chest pain
    2. B. Dyspnea after drowning
    3. C. Dyspnea with JVD and edema
    4. D. Dyspnea with a new murmur
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    Answer: B. Dyspnea after drowning

    Near-drowning, inhalation injury, sepsis, and high altitude can cause noncardiogenic pulmonary edema.

18. A 29-year-old climber develops dyspnea, cough, and crackles after rapidly ascending to 4,000 meters. What is the definitive treatment?

    1. A. Fluids
    2. B. Albuterol
    3. C. Descent
    4. D. Antibiotics
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    Answer: C. Descent

    High-altitude pulmonary edema is treated with descent and oxygen. Descending even several hundred meters can bring rapid improvement.

19. A 40-year-old with a history of Graves disease has a temperature of 40 °C (104 °F), agitation, atrial fibrillation at 170/min, and new crackles. What best explains her pulmonary edema?

    1. A. Heart failure from thyroid storm
    2. B. Aspiration pneumonia with sepsis
    3. C. Panic attack with hyperventilation
    4. D. Heatstroke from a hot room
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    Answer: A. Heart failure from thyroid storm

    Thyroid storm drives extreme tachycardia, fever, and agitation, and the heart can fail under the load, causing pulmonary edema; she needs urgent care and rate control per medical direction. Aspiration pneumonia does not explain known Graves disease with extreme tachycardia and agitation. Panic does not cause fever of 40 °C or crackles. There is no heat exposure to suggest heatstroke.

20. Which position is best for a conscious patient in acute pulmonary edema with an adequate BP?

    1. A. Prone with the head turned
    2. B. Supine with legs elevated
    3. C. Trendelenburg position
    4. D. Upright, legs dangling
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    Answer: D. Upright, legs dangling

    Sitting upright with legs down reduces venous return and pulmonary congestion and eases breathing.

21. Which finding suggests that a patient with pulmonary edema is improving on CPAP?

    1. A. Falling respiratory rate
    2. B. Rising heart rate
    3. C. Increasing confusion
    4. D. Rising EtCO2 with fatigue
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    Answer: A. Falling respiratory rate

    Improvement is shown by slower, easier breathing, better SpO2, and the patient's ability to speak more.

22. What is a common precipitating cause of acute cardiogenic pulmonary edema?

    1. A. A low-salt meal
    2. B. Starting a new statin
    3. C. Seasonal pollen exposure
    4. D. Missed medications
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    Answer: D. Missed medications

    Nonadherence to medications or diet, ischemia, dysrhythmias, and uncontrolled hypertension commonly trigger decompensation. A low-salt meal reduces the fluid load, and statins and pollen do not cause decompensation.

23. A 64-year-old with dyspnea and crackles has ST elevation in leads II, III, and aVF. How should this affect your plan?

    1. A. Treat for STEMI and pulmonary edema
    2. B. Treat as COPD with albuterol
    3. C. Treat the crackles as pneumonia only
    4. D. Give CPAP and skip the aspirin
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    Answer: A. Treat for STEMI and pulmonary edema

    Acute MI can cause pulmonary edema. Activate the STEMI system, manage the airway and breathing, and use nitrates cautiously given possible right ventricular involvement. Albuterol treats bronchospasm, not ischemic pulmonary edema, CPAP may help the edema but aspirin is still given for the STEMI, and the crackles here are cardiac rather than pneumonia.

24. Which feature distinguishes ARDS from cardiogenic pulmonary edema?

    1. A. Presence of crackles
    2. B. Presence of dyspnea
    3. C. Normal left heart filling
    4. D. Presence of hypoxemia
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    Answer: C. Normal left heart filling

    ARDS occurs without elevated left atrial or capillary wedge pressure. Both conditions cause crackles and hypoxemia.

25. ARDS most often develops how soon after the triggering injury?

    1. A. Only after 1 month
    2. B. Usually after 2 to 3 weeks
    3. C. Usually after 10 days
    4. D. Within about 1 week
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    Answer: D. Within about 1 week

    ARDS typically develops within hours to days, and by definition within 1 week, of a known clinical insult. Onset after 10 days, weeks or a month falls outside the definition.

26. You are transferring an intubated ARDS patient on PEEP. During transport you must ventilate with a BVM. What should you do?

    1. A. Use large tidal volumes
    2. B. Remove all PEEP
    3. C. Ventilate very fast
    4. D. Use a PEEP valve
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    Answer: D. Use a PEEP valve

    Losing PEEP can cause rapid alveolar collapse and desaturation. A PEEP valve on the BVM helps maintain recruitment.

27. A bedbound 80-year-old has fine crackles at both bases, but no dyspnea, JVD, or edema. After several deep breaths and a cough, the crackles disappear. What is the likely cause?

    1. A. Atelectasis from shallow breaths
    2. B. Acute cardiogenic pulmonary edema
    3. C. Early bilateral pneumonia
    4. D. Pulmonary fibrosis
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    Answer: A. Atelectasis from shallow breaths

    Crackles from collapsed basal alveoli (atelectasis) are common in bedbound patients who take shallow breaths, and they often clear after deep breaths and coughing. Crackles from acute cardiogenic pulmonary edema, early bilateral pneumonia, or pulmonary fibrosis do not disappear with a few deep breaths, and edema would bring dyspnea, JVD, and other fluid signs.

28. Inhaling smoke or toxic gases can cause pulmonary edema by:

    1. A. Lowering plasma protein levels
    2. B. Increasing left ventricular pressure
    3. C. Injuring the alveolar membrane
    4. D. Raising pressure in the lung veins
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    Answer: C. Injuring the alveolar membrane

    Toxic inhalation injures the alveolar-capillary membrane, causing fluid leakage. The onset may be delayed for hours. Raised pulmonary venous or left ventricular pressure is the cardiogenic mechanism, and low plasma protein is not the problem; the leak comes from the damaged membrane.

29. Your service carries a device that provides bilevel (BiPAP) noninvasive ventilation but not CPAP alone. Is it acceptable for an alert patient with cardiogenic pulmonary edema?

    1. A. Yes; CPAP and bilevel are both recommended
    2. B. No; bilevel is meant for COPD and asthma
    3. C. No; it raises the pressure in her lungs too much
    4. D. Yes, but just after she is intubated
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    Answer: A. Yes; CPAP and bilevel are both recommended

    ERS/ATS guidelines recommend either CPAP or bilevel NIV for acute cardiogenic pulmonary edema, since both reduce the need for intubation. Bilevel is not limited to COPD and asthma. Appropriate settings do not overpressurize the lungs. Noninvasive ventilation is used instead of intubation, not after it.

30. In saltwater versus freshwater drowning, how should field treatment of pulmonary edema and hypoxemia differ?

    1. A. Saltwater victims need IV fluids to dilute the salt
    2. B. Freshwater victims need diuretics first
    3. C. Saltwater victims alone need positive pressure
    4. D. No difference; treat both the same way
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    Answer: D. No difference; treat both the same way

    Both saltwater and freshwater aspiration damage surfactant and cause pulmonary edema and hypoxemia, so there is no difference in field care: give oxygen, PEEP or CPAP, and ventilation as needed. Electrolyte shifts are rarely significant in survivors, so saltwater victims do not need IV fluids to dilute the salt, and freshwater victims do not need diuretics first. Positive pressure helps both groups, not saltwater victims alone.