Viva 6

A previously well 36 year old man was found with a GCS of 6 (E1,V1, M4) having not been seen for some hours previously. There is circumstantial evidence of a drug overdose. There is a suicide note.
He is intubated and ventilated in the emergency department because of coma, poor oxygen saturations, tachypnoea,  hypotension and is transferred to the ICU.  His chest X- ray reveals extensive bilateral pulmonary infiltrates.
Over the next 12 hours his course is characterised by worsening oxygenation, high airway pressures and slowly rising inotrope requirement. His renal function remains normal.

Why has he developed respiratory failure?

Focus of discussion: - -Ventilatory modes in ARDS, evaluation of recent trials – ARDSnet, Steroids etc, role of therapies- NO, ECMO, HFOV etc.

Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.