This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
1. Patrick Laird, DNP(C), MSN, RN, ACNP-BC, CCRN;
Susan D. Ruppert, PhD, RN, ANP-BC, NP-C, FCCM, FAANP,
2011.
Published on Wolters Kluwer Health
Case Study
2. Pathophysiology of the
disease
ECMO
Summary
First patient encounter
Day 2-4
V/S
P/E
Lab result
CXR
Plan
Outline:
3. 55 y/o male recently diagnosed with influenza A.
Presented to the emergency department (ED)
accompanied by his wife with worsening shortness of
breath, fever, productive cough ( green ) sputum, and
new onset altered mental status.
Primary assessment revealed oxygen saturation of 61% on room air.
Respirations were labored with abdominal accessory muscle use.
BIPAP was used but his respiratory status continued to deteriorate -------
( intubation ) .
Difficult intubation.
4. After intubation the patient became hypotensive.
A Levophed drip was initiated.
Once hemodynamically stable the patient was
admitted to the intensive care unit (ICU) for
continued management.
Continue
5. CHIEF COMPLAINT :
“Shortness of breath and confusion”
PAST MEDICAL AND SURGICAL HISTORY :
• Hypertension — Diagnosed in 2009.
• Hyperlipidemia — Diagnosed in 2009.
• No history of surgical procedures.
• Denied any history of smoking and drinks approximately
2 alcoholic beverages per week.
SOCIAL AND FAMILY HISTORY :
Married for 28 years , Employed with Anadarko petroleum
division. His parents both diagnosed with hypertension
treated with medication.
6. CURRENT HOSPITAL MEDICATIONS :
Levophed infusion at 0.4 μg/kg/min intravenous
(IV).
Propofol infusion at 55 μg/kg/min IV.
Protonix 40 mg IV daily.
Lovenox 40 mg subcutaneous daily.
Azithromycin 500 mg IV daily.
7. REVIEW OF SYSTEMS :
Patient orally intubated at the time of interview and
examination.
Chest :
Complains of increased dyspnea and cough with
increased green sputum production 2 days prior
to admission.
Heart:
Complains of weakness for 10 days prior to arrival.
Urinary system:
decrease in normal urinary output because of
decreased oral intake.
8. Neurological :
His wife reports change in his mental status over
last 2 days. States patient is “not making any
sense and is saying inappropriate things.
12. Overall status:
General: well nourished.
Skin: No skin rashes/lesions observed.
HEENT.
Chest: Symmetrical expansion.
Heart: (S1, S2) are noted. Regular
rhythm. No murmurs, gallops, or rubs
are appreciated.
Abdomen: Soft, nontender and
nondistended.
Day
2
13. Cont.
Extremities: Warm. No edema, clubbing, or
cyanosis was appreciated.
Capillary refill: +2 seconds. Nail beds are
pale.
Neurological: Sedated on mechanical
ventilation.
Spontaneous movement of all 4 extremities is
noted. Does not follow verbal commands.
Day
2
14. CXR:
Endotracheal tube tip located 2 cm above
the carina.
Interval worsening perihilar air space
opacity suggestive of worsening
pulmonary edema or ARDS.
No pneumothorax or pleural effusion.
Day
2
23. Pathophysiology
Consequences of lung injury include:
Impaired gas exchange
V/Q mismatch
Increased dead space
Decreased compliance
24. PLAN
The main goal is to optimize oxygenation and prevent
further inflammation that may lead to multi-organ failure
and that may done by :
Low tidal volume
Low PEEP/high Fio2
Initial ventilator settings
made by ED physician were not compliant
with current therapy recommendations. Ventilator
settings were adjusted in the ICU immediately
following initial evaluation.
Day
2
25. Ventilator management
A/C VC
IBW = 90 Kg
VT= 8mL/Kg = 700mL
PEEP= 10 cm H2O
RR = 18 bpm
Fio2 = 100%
VT= 6mL/kg = 540mL
PEEP= 14 cm H2O
Day
2
26. Community Acquired Pneumonia ..
For the treatment of CAP for patients in the ICU
include a B-lactam, and either azithromycin or a
respiratory fluroquinolone.
Patients with a penicillin allergy should receive a
respiratory fluroquinolone and aztreonam.
27. Neuromuscular blocking agents
(NMBA) Are used :
In the ICU to facilitate and optimize mechanical ventilation.
To improve chest wall compliance, eliminate dysynchrony, and reduce
peak airway pressures.
Muscle paralysis used :
In decreasing the work of breathing and respiratory muscle blood flow
thereby reducing oxygen consumption
28. Cont.
The patient displayed mild ventilator dysynchrony and refractory
hypoxemia.
Paralytics were initiated to gain full control of ventilation and
eliminate ventilator asynchrony.
Once paralytics were initiated, the patient’s ventilator asynchrony
resolved.
30. Subjective data ..
• Remains critically ill.
• Orally intubated on mechanical ventilation.
• Oxygen saturations remain less than 86%.
Day
4
31. Objective data ..
oVital Signs:
• T = 38.4 C
• Pulse = 102 B/min
• RR = 20 B/min
• BP = 101/52
• O2 sat =84 %
Day
4
32. Physical examination ..
No murmurs, gallops, or rubs.CV
Bilateral breath sounds with course crackles; diminished in bilateral bases; no
wheezes noted.
RESP
Warm, 2+ pitting edema to bilateral lower extremities, no cyanosis or clubbing
noted.
EXT
Paralyzed on Nimbex drip at 3 μg/kg/min , Sedated on
propofol infusion at 50 μg/kg/min.
NEURO
Day
4
33. • Norepinephrine at 0.5 μg/kg/min IV
• Nimbex at 3 μg/kg/min IV
• Propofol at 50 μg/kg/min IV
• Clindamycin 600 mg IV every 8 hours
• Rocephin 2 grams IV every 24 hours
• Albuterol/Atrovent unit dose nebulized every 4 hours .
Day
4
Current medications ..
34. Chest X-ray films ..
• Bilateral infiltrates and pulmonary edema
• Endotracheal tube in adequate position above the
carina.
Day
4
36. ASSESSMENT ..
• ARDS
• Metabolic acidosis
• Septic shock
• Community acquired pneumonia
• Acute renal failure
• Recent influenza A (H1N1)
Day
4
37. PLAN ..
Despite optimal medical therapy, the patient failed conventional
treatment, and without further intervention death was eminent.
Day
4
38. Controversial ( adults )
Common indications for use of ECMO in adults include
postcardiotomy, postcardiac transplant, severe refractory
heart failure, ARDS, pneumonia, trauma, or primary graft
failure following lung transplant.
Consult cardiovascular surgeon for
placement of extracorporeal membrane
oxygenation (ECMO):
39. Use of ECMO results in 1 extra survivor for every 6 patient
treated .
40. A total of 201 adult patients received mechanical ventilation
for confirmed or suspected influenza. 68 of these patients
received ECMO and the remaining 133 received
conventional mechanical ventilation.
48 patients (71%) that received ECMO survived to ICU
discharge and 32 patients survived to hospital discharge.
Overall mortality of the ECMO group was 21%. The
researchers contributed the lower mortality to the age of the
study participants and the cause of ARDS (H1N1).
41. Use of ECMO has a multitude of potential complications
including life-threatening bleeding, coagulopathy, air
embolism, thromboembolism, intracerebral hemorrhage
(in neonates), and limb ischemia.
risks must carefully be weighed against benefit prior to
initiation
42. Despite optimal medical therapy, the patient failed
conventional treatment, and with- out further intervention
death was eminent. After consulting cardiovascular
surgery, available therapy options were discussed with the
patient’s spouse and the decision was made to place the
patient on ECMO as salvage therapy.
In this scenario
45. day 4 : taken to OR , ECMO was
initiated.
ECMO for 6 days
day 10 ,returned to the OR for removal of
ECMO and insertion of a percutaneous
tracheostomy , and percutaneous
endoscopic gastrostomy (PEG) tube
placement
46. continued to make marked
improvements following removal of
ECMO .
Day 18 :was weaned from the ventilator.
Physical therapy, occupational therapy,
and speech therapy were consulted.
Day 21, the patient was discharged from
the ICU.
day 25 transferred to a long-term acute
care (LTAC) facility for continued
physical and occupational therapy
47. On day 25 transferred to a long-term acute care facility for
continued physical and occupational therapy( 2 weeks ).
The patient was discharged to his home with no physical or
cognitive deficits noted.
Since his discharge from LTAC, the patient has returned to
work and has no limitations .
49. 55 y/o male recently diagnosed with influenza A.
Presented to the emergency department (ED)
accompanied by his wife with worsening shortness
of breath, fever, productive cough ( green ) sputum,
and new onset altered mental status.
This case study explores the management of an
unusually complicated case of (ARDS) extending
over 52 days of hospitalization. Despite the
utilization of conventional medical treatments and
optimum respiratory support modalities, the patient’s
condition worsened and death was imminent without
salvage therapy. After cardiovascular surgery
consultation, (ECMO) therapy was initiated for 6
days. The patient recovered and was able to return
to regular employment.
50. Conclusion
Acute respiratory distress syndrome (ARDS) is a life-
threatening medical condition where the lungs can't provide
enough oxygen for the rest of the body.
ARDS can affect people of any age and usually develops as a
complication of a serious existing health condition.
(ARDS) has a mortality rate of 34% to 58% .
Notes de l'éditeur
Flu (influenza) viruses are divided into three broad categories: influenza A, B or C. Influenza A is the most common type. H1N1 flu is a variety of influenza A.
Influenza A viruses are divided into subtypes based on two proteins on the surface of the virus: the hemagglutinin (H) and the neuraminidase
first Intubation ------- without success.
A Combi-tube was placed then replace it with a traditional endotracheal tube.
to keep the mean arterial pressure greater than 70 mm Hg.
Levophed :Treating low blood pressure
Prpofol : sedative
Sodium chloride inhalation can remove certain bacteria in body secretions. / n catheter flush injections or intravenous infusions
Protonix :is a proton pump inhibitor that decreases the amount of acid produced in the stomach.
Levonex :Anticoagulant
Azithromycin : antibiotic.
Information was gath- ered from the spouse and from the patient’s chart.
Interpretation.
Go through each more in details.
Go through each more in details.
Brain-natriuretic peptide: -18 < refer to the lecture for more info.
Indirect – acute systemic inflammation response
Direct or indirect injury to the alveolus causes alveolar macrophages to release pro-inflammatory cytokines
Cytokines attract neutrophils into the alveolus and interstitum, where they damage the alveolar-capillary membrane (ACM).
ACM integrity is lost, interstitial and alveolus fills with proteinaceous fluid, surfactant can no longer support alveolus
V/Q mismatch = shunt
VD = Results in high minute ventilation
Dec.C = Fluid filled lung becomes stiff
height—72 inches
CAP originates outside of the hospital may becaused by Streptococcus pneumoniae, Mycoplasma
pneumoniae, Haemophilus influenzae, and Chlamydophila pneumoniae
Use of ECMO in adults remains controversial. Two early randomized controlled trials utilizing ECMO in adults failed to identify any benefit of therapy.