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Complex Care > ARDS > Flashcards

ARDS Flashcards

1
Q

RF is

A

a failure in gas exchange (oxygenation or ventilation)

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2
Q

ARDS is

A

direct or indirect lung injury from progressive hypoxemia, infiltration, and fibrosis of lung tissue

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3
Q

Hypoxemic RF is..

A

PaO2 less than 60 and normal PaCO2

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4
Q

Hypercapnia RF is..

A

respiratory acidosis, PacO2 is above 50, and pH less than 7.35

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5
Q

Risk factors for respiratory failure (10)

A
  1. Airway obstruction
  2. chest wall injury
  3. Opioid excess/OD
  4. VQ mismatch (COPD, atelectasis, PE, pneumothorax, ARDS, restrictive lung disease/fibrosis)
  5. Impaired diffusion (pulmonary edema, ARDS)
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6
Q

What are the hypercapnia clinical manifestations?

A

HA, confusion, decreased LOC, tachycardia, flushed skin

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7
Q

What are the hypoxemia clinical manifestations?

A

increased HR, RR, BP

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8
Q

What are the early signs of RF?

A 
tachycardia
increased BP
dyspnea 
restlessness
anxiety 
fatigue
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9
Q

What are the late signs for RF?

A

cyanosis
decreased BP
agonal respiration
coma

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10
Q

How do you diagnose RF?

A

ABG, chemistry, CBC, coats, chest x ray, chest CT, sputum culture, history and physical

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11
Q

What should the pulse ox be kept at for respiratory failure?

A

above 94

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12
Q

What is the hemoglobin threshold for transfusing RBCs?

A

7

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13
Q

What is a sudden and progressive form of RF? and how long is the onset?

A

ARDS

less than 7 days

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14
Q

What are the hallmark signs of ARDS?

A
  1. Refractory hypoxemia (hypoxemia that does not improve no matter if you increase the O2)
  2. Bilateral (must be in both lungs) opacities
  3. Widespread inflammation
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15
Q

What is ARDS?

A

diffuse alveolar capillary membrane damage from a direct or indirect injury

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16
Q

What is the most common cause of ARDS?

A

sepsis

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17
Q

What is a predisposing condition of ARDS?

A

SIRS: systemic inflammatory response, trauma, gut ischemia, lung injury, consequence of MODS

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18
Q

What is a mild, moderate and severe P/F ratio for ARDS?

A

Mild: less than 300
Moderate: less than 200
Severe: less than 100

ALL with PEEP or CPAP more than 5 cmH2O

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19
Q

What is the timing of ARDS?

A

one week of clinical insult or worsening respiratory symptoms

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20
Q

What are direct injury to the lungs that can lead to ARDS? (9)

A
  1. Aspiration
  2. Pneumonia
  3. Sepsis
  4. Gastric aspiration, chest trauma, embolism, inhalation injury, near drowning. O2 toxicity
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21
Q

What are indirect injury to the lungs that can lead to ARDS? (11)

A
  1. Sepsis: gram -
  2. Severe trauma
  3. Acute pancreatitis, cardiopulmonary bypass, shock, DIC, gut ischemia, OD, burns, TBI, TRALI
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22
Q

What are the three phases of ARDS?

A
  1. Injury phase or exudative phase
  2. Proliferation phase
  3. Fibrotic phase
23
Q

What is the pathology of alveolar damage in ARDS?

A
  1. r/t inflammation and immune systems
  2. Diffuse membrane damages
  3. Increased capillary permeability
  4. destruction of elastin and collagen
  5. Formation of microemboli
  6. PA vasoconstriction
24
Q

When does the exudative phase occur?

A

24-48 hours after injury

25
Q

What happens in the exudative phase?

A
  1. Damage to the capillary membranes –> protein risk fluid in sac –> intrapulmonary shunt –> draws more fluid in
  2. Damage to type 1 ad 2 cells (surfactant cells) –> unstable sac that collapses with exhale –> atelectasis –> unable to being in O2 –> decreased O2
  3. Hyaline membrane –> decreases lung elastic –> stiff non compliant lungs –> VQ mismatch and increases shunting
26
Q

When does the proliferation phase occur after injury?

A

1-2 weeks after

27
Q

What happens in the proliferation phase?

A
  1. Inflammation coninues and there is an influx of neutrophils, monocytes, fibroblasts, and lymphocytes that proliferate
  2. Lung tissue is being reproduced as dense and fibrous –> decreased lung compliance and increased hypoxemia
  3. If you can stop this process –> lesions will resolve
28
Q

When does the fibrotic phase occur?

A

2-3 weeks after injury

29
Q

What happens in the fibrotic phase?

A
  1. lung tissues remodeled–> scarring and fibrous –> decreased lung compliance –> hypoxemia and hypercapnia
  2. Systemic dysfunction d/t decreased gas exchange
  3. Pulmonary hypertension
  4. Prognosis is poor
30
Q

What are the early clinical manifestations of ARDS?

A
  1. SOB, dyspnea, increase RR, cough
  2. restlessness
  3. Clear to mild crackles
  4. Mild infiltrate on chest x ray
  5. Respiratory alkalosis
31
Q

how long does it take for chest infiltrates to show up on a chest X-ray?

A

24 hours, there is a lag

32
Q

What are the clinical manifestations as ARD progressed? (14)

A
  1. Increased WOB, retractions, productive cough
  2. Course crackle on expiration, rhonchi
  3. Non-cariogenic pulmonary edema
  4. Bilateral infiltrates/opacities on cxray
  5. Respiratory acidosis –> metabolic acidosis
  6. Refractory hypoxemia
  7. pleural effusion
  8. Severe hypoxemia
  9. Organ dysfunction d/t decreased CO and decreased MAP
  10. Intrapulmonary shunt
  11. Extreme V/Q mismatch
  12. Hemodynamic changes (BP)
33
Q

Diagnostics for ARD?

A
  1. ABG
  2. increased lactate d/t anaerobic metabolism
  3. Blood, sputum, and urine cultures
  4. Coags
  5. Electrolytes
  6. Renal/liver function test to determine progression from ARDS –> MODS
34
Q

Cardiac complications of ARDS

A

decreased CO, decreased MAP, dysrhythmias

35
Q

Neuro complications of ARDS

A

confusion, agitation, delirium, PICS

36
Q

Infection complications with ARDS

A

CAUTI, CLABSI, sepsis

37
Q

Renal complications with ARDS

A

AKI

38
Q

Heme complications with ARDS

A

VTE, anemia, DIC, thrombocytopenia

39
Q

GI complications with ARDS

A

stress ulcers, hemorrhage, ileus, pneumonperitoneum

40
Q

Respiratory complications with ARDS (8)

A

abnormal lung function, VAP, barotrauma, volutrauma, O2 toxicity, PE, tracheal injury, laryngeal ulcers

41
Q

Death complications with ARDS

A

usually d/t MODS with sepsis

42
Q

Care of patients with ARDS (3 short ones)

A
  1. Underlying cause and treat it (sepsis –>antibiotics)
  2. ECMO or ECCO
  3. PRBC transfusion if Hbg below 7
43
Q

Care of patients with ARDS: Maintain adequate oxygenation

A
  1. SpO2 > 90, FiO2 < 60, PaO2: 60
  2. Supplemental oxygen
  3. Mechanical ventilation with high PEEP, low vT, and permissive hypercapnia
44
Q

Care of patients with ARDS: maintain perfusion pressure

A

BP, MAP, CO, SV

45
Q

Care of patients with ARDS: Monitor fluids

A

UOP, I&Os, daily weight

46
Q

Care of patients with ARDS: IV fluids

A

Maintaining fluid balance is difficult d/t leaky pulmonary capillaries and third spacing

  1. Crystalloid
  2. Colloids - controversial d/t leakage into pulmonary interstitium
  3. Blood products
47
Q

Care of patients with ARDS: Medication (8)

A
  1. Inotropic meds: dopamine, dobutamine, NE, vasopressin, Milrinone
  2. Corticosteroids –> decrease imflammation
  3. Vitamin C to decrease oxidative stress
  4. Nitric oxide
  5. Surfactant
  6. Neuromuscular blocking agent (NMDA)
  7. High does steroid therapy
  8. Diuretics if needed
48
Q

Care of patients with ARDS: Nutrition

A

Start within 24-72 hours of ventilation
maintain protein and energy stores because muscle mass loss can happen when on ventilator with decrease mobility
Enteral or parenteral feedings

49
Q

Care of patients with ARDS: Positioning

A
  1. Proning –> decrease FiO2 needed, increases airflow and move secretions
  2. Early mobility
50
Q

Care of patients with ARDS: Mechanical vent

A

Goal: correct hypoxemia and maintain ventilation with PVV

  1. Non-invasive PPV (NIVPP) - partial support
  2. Invasive endotracheal intubation PPV - full support
  3. High frequency oscillatory vent (HFOV)
51
Q

Care of patients with ARDS: Prevent DVT, pressure ulcers and stress ulcers

A
  1. DVT: compression stockings
  2. Pressure ulcers: move patient every 2 hours
  3. Stress ulcers: H2 blocker or PPI
52
Q

What are the mechanical ventilation indications for ARDS

A
  1. Respiratory or ventilation failure
  2. Increased CO2
  3. Decreased pH
  4. Decreased O2
  5. Increased or decreased RR
  6. Decreased or absent breath sounds
  7. Unprotected airway
53
Q

Pulmonary artery pressure wedge

A

Measure the pressure in the left pulmonary artery
< 18 –> ARDS
> 18 –> cardiac issue

54
Q

What is permissive hypercapnia?

A

retaining CO2

Complex Care (22 decks)

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