acute respiratory distress syndrome (ards)...alert the nurse to the onset of acute respiratory...

Acute Respiratory Distress Syndrome

(ARDS)

Rv.8.18.18

Acute Respiratory Distress Syndrome (ARDS)

• Sudden progressive form of acute respiratory failure• Alveolar capillary membrane becomes damaged and

more permeable to intravascular fluid• Alveoli fill with fluid

• Bilateral patchy infiltrates –• No signs or symptoms of HF • No improvement in Pa02 despite increasing O2 therapy

• Most common cause? • Nsg and Collaborative care?

• Results• Severe dyspnea• Hypoxia • Decreased lung compliance• Diffuse pulmonary infiltrates

• 150,000 cases annually• 50% mortality rate

Case Study

• J.P., an 82-year-old woman, is brought to the ED from a long-term care facility.

• 4 days ago she aspirated her lunch. • The physician on call for the facility diagnosed her with

aspiration pneumonia.• She was started on antibiotic therapy of azithromycin

(Zithromax).

Case Study

• During the past 24 hours, J.P. has developed progressive dyspnea and restlessness.

• On admission to the ED, she is confused and agitated. • At times she is gasping for air.• Chest x-ray shows diffuse infiltrates.

Case Study

• What was the cause of J.P.’s respiratory distress?

• What are her risks for ARDS?

• What is her priority of care?

Etiology and Pathophysiology•• direct or indirect lung injuries

• Most common cause is sepsis

• Exact cause for Unknown

• stimulation of inflammatory and immune systems

Pathophysiology Changes

(1) injury or exudative (2) reparative or

proliferative(3) fibrotic .

Clinical Manifestations: Early

• Dyspnea

• Tachypnea

• cough

• restlessness

•Chest auscultationvnormal or may reveal fine,

scattered crackles•ABGs

vMild hypoxemia and respiratory alkalosis caused by hyperventilation

•Chest x-rayvnormal or reveal minimal

scattered interstitial infiltrates •Edema

vmay not show until 30% increase in fluid content in the lungs

Case Study

• J.P. has been in the hospital for 1 week.• She has been diagnosed with ARDS.• She is on IV antibiotics and oxygen therapy, but continues

to struggle to breath. • Her O2 is 88% on 6 L via a face mask.

(©iStockphoto/Thinkstock)

Case Study

• What is she experiencing clinically?

• What is she at risk for in terms of ARDS progression?

Case Study

• As J.P.’s symptoms worsen……..

• she works hard to breathe.• develops diffuse crackles throughout her lungs.• pale and diaphoretic.• Vital signs: BP 158/98, HR 114, RR 32, O2 sat 84%.

Case Study

• What diagnostic tests would be indicated for J.P?

• What is the next step in treatment for her?

Clinical Manifestations: Late

• WOB INCREASES• increased fluid accumulation • decreased lung compliance• Pulmonary function tests reveal decreased compliance, lung

volumes, and functional residual capacity (FRC)

Clinical Manifestations: Late

• Tachycardia• Diaphoresis• changes in mental status• Cyanosis• pallor • Diffuse crackles and coarse crackles• Hypoxemia despite increased FIO2 *HALLMARK FINDING

• Increasing WOB despite initial findings of normal PaO2 or SaO2

Chest x-ray findings : whiteout or white lung

R/T consolidation and widespread infiltrates throughout lung few recognizable air spaces

Tx Complications

•Ventilator-associated pneumonia •Barotrauma•Volutrauma• stress ulcers •Renal failure

Complications

• Ventilator-associated pneumonia (VAP)• Strategies for prevention of VAP

• Strict infection control measures• Ventilation protocol bundle

• Elevate HOB 30 to 45 degrees• Daily “sedation holidays”• Venous thromboembolism prophylaxis• oral care with chlorhexidine 2x /DAY

Complications

• Barotrauma• Rupture of overdistended alveoli during mechanical ventilation

Tx Protocol: AcUTE Respiratory Distress Syndrome Clinical Network (ARDSNet)

• Ventilate with smaller tidal volumes (6ml/kg)• Higher PaCO2 - permissive hypercapnia

Complications

• Volutrauma• large tidal volumes are used to ventilate non-compliant lungs

• Alveolar fracture and movement of fluids and proteins into alveolar spaces

Management strategy:• Smaller tidal volumes or pressure-control

Complications

• Stress ulcers• Bleeding 30% of patients with ARDS on mechanical ventilation

• Management strategies• Correction of predisposing conditions• Prophylactic anti-ulcer drugs• Early initiation of enteral nutrition

Complications

• Renal failure • renal perfusion and subsequent delivery of O2

Causes: hypotensionHypoxiahypercapnianephrotoxic drugs (tx ARDS-related infections ) ex….??

Case Study

• J.P.’s daughter arrives to be with her. • She shares that her mother had smoked for over 30 years, but quit

20 years ago.• She asks you if smoking contributed to her respiratory problems

Case Study

• J.P. is now on mechanical ventilation, sedated to allow her to rest, and beginning to improve slowly.

• Her O2 saturation is now 92% and her blood gases are slowly returning to normal.

Respiratory Therapy

• Positive pressure ventilation• PEEP at 5 cm H2O compensates for loss of glottic function

• Opens collapsed alveoli• Apply PEEP at 3 to 5 cm H2O increments • Higher levels of Peep for ARDS (e.g., 10 to 20 cm H2O)

• caution• Can hyper inflate alveoli• Can result in barotrauma or volutrauma• compromise venous return to right side of heart

(Decreases preload, CO, and BP)

Respiratory Therapy

• Alternative modes PPV:

• Airway pressure release ventilation• Pressure control inverse ratio ventilation• High-frequency ventilation• Permissive hypercapnia

Respiratory Therapy

• External devices:

• Extracorporeal membrane oxygenation (ECMO)• Extracorporeal CO2 removal (ECCO2R)

• Blood passes across gas-exchanging membrane outside the body• Oxygenated blood is returned to the body

Positioning strategies

• PRone• Turn from supine to prone position

•why?

RotoProne Bed

RotoProne bed. (ArjoHuntleigh. Reprinted with permission.) Note: The RotoProne Delta Therapy System allows clinicians to place patients in the prone position, safely and effectively. This product is not specifically indicated for the treatment of ARDS or VAP.

Respiratory Therapy

• Other positioning strategies • Continuous lateral rotation therapy (CLRT)

• Continuous, slow side-to-side turning <40 degrees• 18 of every 24 hours

• Kinetic therapy• Patient rotated side-to-side >40 degrees

Continuous Lateral Rotation

Medical Supportive Therapy

• Maintenance of cardiac output and tissue perfusion• Hemodynamic monitoring via a central venous or pulmonary artery catheter

• Monitor CO and BP• Sample blood for ABGs

Medical Supportive Therapy

• Maintenance of nutrition/fluid balance• Enteral or parenteral feedings are started• Monitor hemodynamic parameters

• (e.g., CVP, stroke volume variation)• Monitor daily weight, intake and output

A patient’s ABG results include pH 7.31, PaCO2 50 mm Hg, PaO2 51 mm Hg, and HCO3 24 mEq/L. Oxygen is administered at 2 L/min, and the patient is placed in high-Fowler’s position. An hour later, the ABGs are repeated with results of pH 7.36, PaCO2 40 mm Hg, PaO2 60 mm Hg, and HCO3 24 mEq/L. What is most important for the nurse to do?a. Increase the oxygen flow rate to 4 L/min.b. Document the findings in the patient’s record.c. Reposition the patient in a semi-Fowler’s position. d. Prepare the patient for endotracheal intubation and mechanical

ventilation.

Audience Response Question

When assessing a patient with sepsis, which finding would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)?a. SpO2 of 80% b. Use of accessory muscles of respirationc. Fine, scattered crackles on auscultation of the chestd. ABGs of pH 7.33, PaCO2 48 mm Hg, and PaO2 80 mm Hg

A patient with severe chronic lung disease is hospitalized with respiratory distress. Which finding would suggest to the nurse that the patient has developed rapid decompensation?a. An SpO2 of 86%b. A blood pH of 7.33c. Agitation or confusiond. PaCO2 increases from 48 to 55 mm Hg

acute respiratory distress syndrome (ards)...alert the nurse to the onset of acute respiratory...

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