ACUTE RESPIRATORY DISTRESS SYNDROME ARDS_

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ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)_

• Presented and Modified by
• Christopher W. Blackwell, ARNP, MSN, PhD(c)
• Based on
• Materials Prepared by
• Lucy Baccus Stella, RN, MN
• and
• Introduction to Critical Care Nursing (3rd
  Edition) Sole, Lamborn, Hartshorn (2001)

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Definition

• Noncardiac pulmonary edema
• A form of respiratory failure
• Complication of hospitalized patients
• Serious med-surg problem
• May not be lung related
• Mortality remains 50-60

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Pathophysiology

• Frequently associated
• Low perfusion
• Single organ
• Multi-organ (MODS)
• Total body system (shock)
• Etiology Severe CNS Disorder, Trauma, CVA, Inc.
  CSF.
• Hallmark of ARDS
• Hypoxia

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Pathophysiology

• Other characteristics
• Severe dyspnea
• Diffuse bilateral infiltrates

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Pathophysiology

• Injury to lungs (Scoring)
• Abnormal gas exchange
• Intrapulmonary shunting
• Reduced lung compliance
• Decreased surfactant activity
• Amt. of Infiltrates on CXR.
• Degree of Hypoxemia.
• Amount of PEEP.
• Static Lung Compliance.

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Pathophysiology

• Physiologic alterations
• Injury to pulmonary endothelium and alveolar
  epithelium causes increase in lung permeability.
• Fluid leaks into interstitial spaces causing
  pulmonary edema.
• INCIDENCE AND PREVALENCE

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Pathophysiology

• Physiologic alterations
• Injury to Type II pneumocytes, causes increase in
  surface tension and atelectasis
• Alveolar-capillary membrane damage, inflammation
  occurs, substances gather at site of injury
  decreasing gas exchange

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Pathophysiology

• American-European Consensus Conference (1994)
  Defines ARDS as
• PaO2/FiO2 lt200
• Bilat. Infiltrates
• PCWP lt18mm Hg (or more easily understood, no
  clinical evidence of L Atrial HTN).

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Pathophysiology

• Results of physiologic alterations
• Ventilation-perfusion anomalies
• Decreased lung compliance
• Increase work of breathing

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Etiology

• No single exogenous or endogenous precipitating
  factor? Multiple causes.
• Exact causative mechanism is unknown
• Direct and Indirect Causes

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Etiology

• Many conditions associated
• Most common
• Non pulmonary
• Gram (-) sepsis
• Trauma
• Pulmonary related
• Aspiration
• AIDS/PCP
• Near drowning
• Pulmonary embolism

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Etiology

• Other conditions
• Amniotic fluid embolism
• Bowel infarction
• Drug abuse
• Multiple fractures
• Heat stroke
• Peritonitis
• Multiple blood transfusions

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Clinical manifestations

• Acute respiratory failure
• Change in Personality, disorientation, dec. LOC.
• Initial Dyspnea w/ Hyperventilation (Tachypnea)
• Grunting respirations
• Cyanosis
• Pallor
• Retractions

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Clinical manifestations

• Dry cough
• Diaphoresis
• Crackles, Rhonchi, and Bronchial Sounds.
• Vitals Signs
• Fever
• Hypotension
• Tachycardia (dysrhythmias)
• Altered sensorium
• PaCO2 dec.? Resp. Alkalosis (initial)
• Lactic Acid? Met. Acidosis (later)

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Diagnostic studies

• Radiologic
• CXR
• Diffuse, bilateral infiltrates
• Laboratory
• ABGs
• Hypoxemia
• Respiratory alkalosis

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Phases of ARDS

• Phase I
• Client exhibits dyspnea and tachypnea
• Support client with oxygenation
• Phase 2
• Increasing pulmonary edema
• Mechanical ventilation support

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Phases of ARDS

• Phase 3
• Progressive refractory hypoxemia
• Maintain oxygenation
• Prevent complications
• Phase 4
• Pulmonary fibrosis pneumonia
• Chronic problem
• Maybe ventilator dependent

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Management

• Vent. Settings should be Lung-Protective.
• Unconventional Modes (High Frequency Ventilation,
  Pressure-Controlled Ventilation, and
  Inverse-Ratio Ventilation) have failed to
  demonstrate efficacy and are not standard
  acceptable Tx.

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Nursing diagnosis

• Anxiety
• Impaired gas exchange
• Altered nutrition
• Depression
• Decreased cardiac output
• Knowledge deficit

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Interventions

• Assess
• Sputum production
• Oxygenation
• Heart sounds
• Lung sounds
• Urinary output
• Cardiac rhythm

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Interventions

• Monitor
• ABGs
• Pulse oximetry
• Ventilator settings
• Fluid maintenance
• Teach
• Ventilator
• Lines

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Medical management

• Ventilator
• IMV
• PEEP
• Fluid control
• Swan Ganz line

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Medical management

• Medications
• Diuretics
• Anti anxiety
• Neuromuscular blocking agents
• Analgesics
• Antibiotics
• Dopamine
• Corticosteroids

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Nursing Management

• Possible Prone Positioning (Vollman, 1997).
• F/E Balancing Monitor R Arterial Pressure (RAP)
  and Pulmonary Artery Diastolic (PAD) Pressure.
• Nutrition ARDS increases nutritional
  requirements by 1.5 to 2 times.

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Nursing Management

• Psychosocial Support
• Complications of ARDS
• 1. Heart failure
• 2. Acidosis
• 3. Hyper- hypo- kalemia
• 4. De- over- hydration
• 5. Pulmonary embolism

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Nursing Management

• Cardiac arrest
• DIC
• GI bleed
• Renal failure

• Prognosis
• Pts. Who recover typically return to
  relatively normal lung function. Studies of ARDS
  survivors from 9 months- 4 years after lung
  injury show a mild restrictive pulmonary function.