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
ARDS BILATERAL PATCHY INFILTRATES NO SIGNS OR SYMPTOMS OF HF NO IMPROVEMENT IN PA02 DESPITE INCREASING O2 THERAPY MOST COMMON CAUSE? NSG AND COLLABORATIVE CARE?
ARDS 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
(1) injury or exudative (2) reparative or proliferative (3) fibrotic. PATHOPHYSIOLOGY CHANGES
CLINICAL MANIFESTATIONS: EARLY DYSPNEA TACHYPNEA COUGH RESTLESSNESS CHEST AUSCULTATION NORMAL OR MAY REVEAL FINE, SCATTERED CRACKLES ABGS MILD HYPOXEMIA AND RESPIRATORY ALKALOSIS CAUSED BY HYPERVENTILATION CHEST X-RAY NORMAL OR REVEAL MINIMAL SCATTERED INTERSTITIAL INFILTRATES EDEMA MAY NOT SHOW UNTIL 30% INCREASE IN FLUID CONTENT IN THE LUNGS
CASE STUDY ( istockphoto/thinkstock) 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 O 2 IS 88% ON 6 L VIA A FACE MASK.
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, O 2 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 FIO 2 *HALLMARK FINDING INCREASING WOB DESPITE INITIAL FINDINGS OF NORMAL PAO 2 OR SAO 2
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 DAILY ORAL CARE WITH CHLORHEXIDINE
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 PACO 2 - 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 O 2 CAUSES: HYPOTENSION HYPOXIA HYPERCAPNIA NEPHROTOXIC 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 NOW.
CASE STUDY J.P. IS NOW ON MECHANICAL VENTILATION, SEDATED TO ALLOW HER TO REST, AND BEGINNING TO IMPROVE SLOWLY. HER O 2 SATURATION IS NOW 92% AND HER BLOOD GASES ARE SLOWLY RETURNING TO NORMAL.
RESPIRATORY THERAPY POSITIVE PRESSURE VENTILATION PEEP AT 5 CM H 2 O COMPENSATES FOR LOSS OF GLOTTIC FUNCTION OPENS COLLAPSED ALVEOLI APPLY PEEP AT 3 TO 5 CM H 2 O INCREMENTS HIGHER LEVELS OF PEEP FOR ARDS (E.G., 10 TO 20 CM H 2 O) 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 CO 2 REMOVAL (ECCO 2 R) 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
Audience Response Question A PATIENT S ABG RESULTS INCLUDE PH 7.31, PACO 2 50 MM HG, PAO 2 51 MM HG, AND HCO 3 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, PACO 2 40 MM HG, PAO 2 60 MM HG, AND HCO 3 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.
WHEN ASSESSING A PATIENT WITH SEPSIS, WHICH FINDING WOULD ALERT THE NURSE TO THE ONSET OF ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)? a. SPO 2 OF 80% Audience Response Question b. USE OF ACCESSORY MUSCLES OF RESPIRATION c. FINE, SCATTERED CRACKLES ON AUSCULTATION OF THE CHEST d. ABGS OF PH 7.33, PACO 2 48 MM HG, AND PAO 2 80 MM HG
Audience Response Question 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 SPO 2 OF 86% b. A BLOOD PH OF 7.33 c. AGITATION OR CONFUSION d. PACO 2 INCREASES FROM 48 TO 55 MM HG