acute respiratory distress syndrome (ards)
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08/12/14 LBS 1
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 (3
rd
Edition) Sole, Lamborn, Hartshorn (2001)
08/12/14 LBS 2
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%
08/12/14 LBS 3
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
08/12/14 LBS 4
Pathophysiology
•
Other characteristics
–
Severe dyspnea
–
Diffuse bilateral
infiltrates
08/12/14 LBS 5
Pathophysiology
•
Injury to lungs (Scoring)
–
Abnormal gas exchange
–
Intrapulmonary shunting
–
Reduced lung compliance
•
Decreased surfactant activity
1. Amt. of Infiltrates on CXR.
2. Degree of Hypoxemia.
3. Amount of PEEP.
4. Static Lung Compliance.
08/12/14 LBS 6
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
08/12/14 LBS 7
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
08/12/14 LBS 8
Pathophysiology
•
American-European Consensus
Conference (1994) Defines ARDS as:
1. PaO
2
/FiO
2
<200;
2. Bilat. Infiltrates;
3. PCWP <18mm Hg (or more easily
understood, no clinical evidence of L
Atrial HTN).
08/12/14 LBS 9
Pathophysiology
•
Results of physiologic alterations
–
Ventilation-perfusion anomalies
–
Decreased lung compliance
–
Increase work of breathing
08/12/14 LBS 10
Etiology
•
No single exogenous or endogenous
precipitating factor Multiple causes.
•
Exact causative mechanism is unknown
•
Direct and Indirect Causes
08/12/14 LBS 11
Etiology
•
Many conditions associated
–
Most common
•
Non pulmonary
–
Gram (-) sepsis
–
Trauma
•
Pulmonary related
–
Aspiration
–
AIDS/PCP
–
Near drowning
–
Pulmonary embolism
08/12/14 LBS 12
Etiology
•
Other conditions
–
Amniotic fluid embolism
–
Bowel infarction
–
Drug abuse
–
Multiple fractures
–
Heat stroke
–
Peritonitis
–
Multiple blood transfusions
08/12/14 LBS 13
Clinical manifestations
•
Acute respiratory failure
–
Change in Personality, disorientation, dec.
LOC.
–
Initial Dyspnea w/ Hyperventilation
(Tachypnea)
–
Grunting respirations
–
Cyanosis
–
Pallor
–
Retractions
08/12/14 LBS 14
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)
08/12/14 LBS 15
Diagnostic studies
•
Radiologic
–
CXR
•
Diffuse, bilateral
infiltrates
•
Laboratory
–
ABGs
•
Hypoxemia
•
Respiratory alkalosis
08/12/14 LBS 16
Phases of ARDS
•
Phase I
–
Client exhibits dyspnea and tachypnea
•
Support client with oxygenation
•
Phase 2
–
Increasing pulmonary edema
•
Mechanical ventilation support
08/12/14 LBS 17
Phases of ARDS
•
Phase 3
–
Progressive refractory hypoxemia
•
Maintain oxygenation
•
Prevent complications
•
Phase 4
–
Pulmonary fibrosis pneumonia
•
Chronic problem
•
Maybe ventilator dependent
08/12/14 LBS 18
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.
08/12/14 LBS 19
Nursing diagnosis
•
Anxiety
•
Impaired gas exchange
•
Altered nutrition
•
Depression
•
Decreased cardiac output
•
Knowledge deficit
08/12/14 LBS 20
Interventions
•
Assess
–
Sputum production
–
Oxygenation
–
Heart sounds
–
Lung sounds
–
Urinary output
–
Cardiac rhythm
08/12/14 LBS 21
Interventions
•
Monitor
–
ABGs
–
Pulse oximetry
–
Ventilator settings
–
Fluid maintenance
•
Teach
–
Ventilator
–
Lines
08/12/14 LBS 22
Medical management
•
Ventilator
–
IMV
–
PEEP
•
Fluid control
–
Swan Ganz line
08/12/14 LBS 23
Medical management
•
Medications
–
Diuretics
–
Anti anxiety
–
Neuromuscular blocking agents
–
Analgesics
–
Antibiotics
–
Dopamine
–
Corticosteroids
08/12/14 LBS 24
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.
08/12/14 LBS 25
Nursing Management
•
Psychosocial Support
•
Complications of ARDS:
1. Heart failure
2. Acidosis
3. Hyper- hypo- kalemia
4. De- over- hydration
5. Pulmonary embolism
