Rhinovirus-associated severe acute respiratory distress syndrome (ARDS) managed with airway pressure release ventilation (APRV)

A 60-year-old woman presented for elective percutaneous nephrolithotomy for a right-sided staghorn calculus. Her medical history was significant for pre-diabetes, chronic obstructive pulmonary disease, morbid obesity (body mass index (BMI)=42), obstructive sleep apnea and heart failure with preserved ejection fraction. On the day after her procedure, she was febrile (39.2°C), tachycardic (120–140？s beats per minute) and developed leukocytosis (17.6 x 10∧9/L). She was started empirically on vancomycin and piperacillin/tazobactam, and ultimately meropenem, for presumed urosepsis. Within 24？hours, she developed respiratory distress with hypoxemia refractory to non-invasive positive pressure ventilation (figure 1). Her respiratory status further deteriorated, requiring endotracheal intubation with lung protective ventilation (LPV). Postoperative day 2 (POD2) chest X-ray and CT angiogram revealed bilateral pulmonary ground glass opacities concerning for infectious process, acute respiratory distress syndrome (ARDS) or pulmonary edema without evidence of pulmonary embolism (figure 2). Transthoracic echocardiogram revealed normal ejection fraction and ventricular size