2. INTRODUCTION
Acute respiratory distress syndrome (ARDS) is a severe form of acute
lung injury. This clinical syndrome is characterized by a sudden and
progressive pulmonary edema, increasing bilateral infiltrates on chest x-
ray, hypoxemia unresponsive to oxygen supplementation, and the
absence of an elevated left atrial pressure. Patients often demonstrate
reduced lung compliance.
3. RISKFACTORS
age over 65 years
chronic lung disease
a history of alcohol misuse or cigarette smoking
ARDS can be a more serious condition for people who:
have toxic shock
are older
have liver failure
have a history of alcohol misuse
4. ETIOLOGY
• direct lung injury include:
• gastric aspiration
• bacterial, fungal, or viral pneumonia
• pulmonary contusion
• near drowning
• prolonged inhalation of high concentrations of oxygen, smoke,
or toxic substances
5. indirect injury include:
• sepsis • shock (any cause)
• drug overdose • fat embolism
• prolonged hypotension • nonthoracic trauma
• cardiopulmonary bypass • head injury
• acute pancreatitis • uremia
• hematologic disorders, such as disseminated intravascular
coagulation, or multiple blood transfusions
6. Three Main Phases
• In the exudative phase, an injury to the lungs, whether direct or
indirect, leads to an acute inflammatory response, lasting up to
1 week
• In the proliferative phase (sometimes called the
fibroproliferative phase), the inflammatory process in the lungs
occurs systemically throughout all tissues, leading to increased
capillary permeability and movement of fluid out of the vascular
space and into the tissue; this phase can last up to 1 week
• In the fibrotic phase (sometimes called the resolution or
recovery phase), the lungs begin to recover; lung function may
continue to improve over a period of 6 to 12 months
7. Signs and Symptoms
• The acute phase of ARDS is marked by rapid onset of severe
dyspnea, usually occurring12 to 48 hours after the initial injury
• Other signs of ARDS include:
• rapid, shallow breathing
• intercostal retractions • pulmonary crackles
• rhonchi • altered mental status
• tachycardia • hypotension
• decreased urine output
• respiratory alkalosis
• cyanosis
8. DIAGNOSTIC EVALUATION
blood tests and urine cultures
chest X-ray and CT scan
throat and nose swabs
an electrocardiogram
an echocardiogram
Arterial blood gas
Bronchoscopy
Sputum cultures and analysis
lung biopsy
9. PREVENTION
Seek prompt medical assistance for any trauma, infection, or illness.
Stop smoking cigarettes, and stay away from second-hand smoke.
Give up alcohol. Chronic alcohol use may increase mortality risk
and prevent proper lung function.
Get flu vaccine annually and pneumonia vaccine every five years.
This decreases risk of lung infections.
10. MEDICAL MANAGEMENT
• Monitor arterial blood gas values, pulse symmetry, and pulmonary
function testing.
• Provide circulatory support; treat hypovolemia carefully; avoid
overload
• Provide adequate fluid management; administer intravenous solutions
• Provide nutritional support
• Pharmacologic therapy may include human recombinant interleukin-1
receptor antagonist, neutrophil inhibitors, pulmonary- specific
vasodilators, surfactant replacement therapy, antisepsis agents,
antioxidant therapy, and corticosteroids
11. 5 P’s of ARDS therapy
The five P’s of supportive therapy include
perfusion,
positioning,
protective lung ventilation,
protocol weaning,
preventing complications.
12. 1.Perfusion
The goal of care for ARDS patients is to maximize perfusion in the
pulmonary capillary system by increasing oxygen transport between the
alveoli and pulmonary capillaries.
To achieve the goal, need to increase fluid volume without overloading
the patient.
Give either crystalloids or colloids to replace the fluids that have leaked
from the capillaries into the alveolar spaces.
Blood transfusions can improve oxygen delivery but remember they can
also cause an increased inflammatory response and increase the risk of
infection and death.
13. • Evaluate the patient’s volume status by measuring blood pressure,
respiratory variations of pulmonary and systemic arterial pulse
pressure, central venous pressure, and urine output.
• Inotropics such as dobutamine (Dobutrex) can increase cardiac output
to boost oxygenation. Milrinone lactate (Primacor)
• Vasopressors, such as norepinephrine and dopamine, promote systemic
vasoconstriction, thus increasing blood pressure and perfusion.
14. 2.Positioning
Patient positioning also affects perfusion. If a patient is standing, blood
flow moves to the base of the lung and away from the apex. If a patient
is supine, the posterior area of the lung will be more perfused than the
anterior area. Because the better aerated surfaces of the lungs are the
nondependent areas, the result is a ventilation/perfusion mismatch.
15. • Immobility, a major cause of pulmonary complications, greatly
influences perfusion distribution. Three positioning therapies can
decrease these complications and improve perfusion in ARDS
patients:
• Kinetic Therapy (bilateral turning of a patient 40 degrees or more
per side)
• continuous lateral rotational therapy (bilateral turning of a patient
no more than 40 degrees per side)
• prone positioning.
16. 3.Protective Lung Ventilation
During the early stages of ARDS, use mechanical ventilation to open
collapsed alveoli.
The primary goal of ventilation is to support organ function by
providing adequate ventilation and oxygenation while decreasing the
patient’s work of breathing.
But mechanical ventilation itself can damage the alveoli, making
protective lung ventilation necessary.
17. • Current recommendations for protective lung ventilation include:
↣limiting plateau pressures to less than 30 cm H2O
↣maintaining PEEP
↣reducing FiO2 to 50% to 60%, if doing so doesn’t compromise PaO2
↣providing low VTs (6 ml/kg of ideal body weight).
↣Be sure to monitor the patient for changes in respiratory status—such
as increased respiratory rate, adventitious breath sounds, decreased
oxygenation saturation, and dyspnoea—at least every 4 hours and after
every change in PEEP or VT.
18. 4. Protocol weaning
Weaning protocols can reduce the time and cost of care
while improving outcomes for ARDS patients. The rule of
thumb is: The patient either needs full ventilatory support
or should be weaning.
19. 5. Preventing complications
• Deep vein thrombosis
Treatment for DVT includes these interventions:
• applying warm, moist compresses
• elevating the affected leg
• administering anticoagulants, thrombolytics, and analgesics.
• pressure ulcer
20. • 5.Poor nutrition
ARDS patients have a severely compromised nutritional status, so start
nutritional support as soon as possible—within 24 hours of admission,
if possible. The preferred support method is enteral nutrition because it
causes fewer complications than parenteral nutrition. When caring for
an ARDS patient, be sure to consult with a nutrition expert.
• VAP
As many as 40% of ARDS patients develop VAP, which is nosocomial
pneumonia that develops after 48 hours or more of mechanical
ventilation. Most cases result from aspiration of bacteria from the
mouth and GI tract.
21. Nursing Management
A patient with ARDS is critically ill and requires close monitoring in
the intensive care unit, because the patient’s condition could quickly
become life-threatening. In this situation oxygen administration, chest
physiotherapy, endotracheal intubation or tracheostomy, mechanical
ventilation, suctioning, bronchoscopy. Frequent assessment of the
patients necessary to evaluate the effectiveness of treatment.
22. Nursing Intervention
↣Identify and treat cause of the Acute respiratory distress syndrome
↣Administer oxygen as prescribed.
↣Position client in high fowler’s position.
↣Restrict fluid intake as prescribed.
↣Provide respiratory treatment as prescribed.
↣Administer diuretics, anticoagulants or corticosteroids as prescribed.
• Prepare the client for intubation and mechanical ventilation using
PEEP.
23. Nutritional Support
• Nutritional support is critical for the patient with ARDS
• Because metabolic demand is high, his caloric needs will be
increased; enteral nutrition is preferred
• Adequate calories and protein should be provided, including
polyunsaturated fatty acids such as gamma linolenic acid
• Enteral nutrition formulas have been developed that provide a
large amount of fat calories rather than carbohydrates
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