acute respiratory distress syndrome (ards)...alert the nurse to the onset of acute respiratory...
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Acute Respiratory Distress Syndrome
(ARDS)
Rv.8.18.18
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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
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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?
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ARDS
• Results• Severe dyspnea• Hypoxia • Decreased lung compliance• Diffuse pulmonary infiltrates
• 150,000 cases annually• 50% mortality rate
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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).
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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.
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Case Study
• What was the cause of J.P.’s respiratory distress?
• What are her risks for ARDS?
• What is her priority of care?
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Etiology and Pathophysiology•• direct or indirect lung injuries
• Most common cause is sepsis
• Exact cause for Unknown
• stimulation of inflammatory and immune systems
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Pathophysiology Changes
(1) injury or exudative (2) reparative or
proliferative(3) fibrotic .
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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
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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.
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(©iStockphoto/Thinkstock)
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Case Study
• What is she experiencing clinically?
• What is she at risk for in terms of ARDS progression?
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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%.
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Case Study
• What diagnostic tests would be indicated for J.P?
• What is the next step in treatment for her?
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Clinical Manifestations: Late
• WOB INCREASES• increased fluid accumulation • decreased lung compliance• Pulmonary function tests reveal decreased compliance, lung
volumes, and functional residual capacity (FRC)
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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
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Chest x-ray findings : whiteout or white lung
R/T consolidation and widespread infiltrates throughout lung few recognizable air spaces
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Tx Complications
•Ventilator-associated pneumonia •Barotrauma•Volutrauma• stress ulcers •Renal failure
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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
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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
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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
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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
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Complications
• Renal failure • renal perfusion and subsequent delivery of O2
Causes: hypotensionHypoxiahypercapnianephrotoxic drugs (tx ARDS-related infections ) ex….??
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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.
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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.
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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)
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Respiratory Therapy
• Alternative modes PPV:
• Airway pressure release ventilation• Pressure control inverse ratio ventilation• High-frequency ventilation• Permissive hypercapnia
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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
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Positioning strategies
• PRone• Turn from supine to prone position
•why?
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RotoProne Bed
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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.
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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
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Continuous Lateral Rotation
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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
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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
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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.
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Audience Response Question
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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
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Audience Response Question
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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
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Audience Response Question