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NSCC 7520 Critical Care Theory 4 > ARDS > Flashcards

ARDS Flashcards

1
Q

What is ARDS

A

systemic process - lung MODS

non-cardiogenic pulmonary edema

severe hypoxemia resistant to oxygen

decreased lung compliance

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2
Q

T or F ARDS can be caused directly or by indirect injury

A

true

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3
Q

what are 6 direct ways ARDS can be caused

A 
aspiration
near drowning
toxic inhalation
pulmonary contusion
pneumonia
oxygen toxicity
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4
Q

what are 6 indirect injury causes of ARDS

A 
sepsis
non-thoracic trauma
hypertransfusion
severe pancreatitis 
shock states
drug overdose: ASA, opioids, cocaine
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5
Q

What is the major precipitating event for ARDS

A

Sepsis

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6
Q

What are the ABCCs of infection/inflammation

A

arachdonic
bradykinin
coagulation
complement

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7
Q

what is the end result of the arachadonic pathway in the ABCCs of infection/inflammation

A

vasodilation
vasoconstriction
increased permeability

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8
Q

what is the end result of the bradykinin pathway in the ABCCs of infection/inflammation

A

potent vasodilation

increased permeability

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9
Q

what is the end result of the coagulation pathyway of ABCCs of infection/inflammation

A

micro-emboli formation

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10
Q

what is the end result of the complement pathway of ABCCs of infection/inflammation

A

intensify inflammation
damage endothelium
cell adhesion and death

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11
Q

What 3 things that occur in sepsis can lead to the cause of ARDs

A

vasodilation
capillary permeability
maldistribution of blood flow

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12
Q

what do the ABCCs of infection/inflammation do to cause ARDs

A

alveolar epithelial changes
airway changes
endothelial changes

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13
Q

what are the 4 stages of ARDs

A

exudative
proliferative
fibrous
resolution

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14
Q

when does the exudative phase occur

A

w/in 24-72 hours

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15
Q

when does the proliferative stage occur

A

day 2-10

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16
Q

when does the fibrous stage occur

A

> 10 days

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17
Q

when does resolution occur

A

several weeks

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18
Q

What happens in the exudative phase (5)

A

inflammatory mediators increase permeability of capillary membrane

fluid rich with protein, blood cells and fibrin leaks into pulmonary interstitium

alveolar cells type 1 - wall integrity becomes compromised
alveolar cells type 2 - damage causes loss of surfactant

microemboli cause pulmonary artery pressure to rise

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19
Q

What occurs in the fibroproliferative phase (4)

A

disordered healing

cellular granulation and collagen deposition occur within the alveolar-capillary membrane

alveoli become enlarged and irregular shaped (fibrotic)

further stiffening and decreased compliance increasing pulmonary HTN and hypoxemia

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20
Q

What occurs in the resolution phase (2)

A

recovery occurs over several weeks

structural and vascular remodeling takes place to re-establish alveolar-capillary membrane

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21
Q

What imaging is done to support a diagnosis of ARDs what does it look like

A

bilateral opacities - not fully explained by effusions, lobar/lung collapse nodules
‘white out’

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22
Q

What do we look at to quantify intrapulmonary shunting

A

PaO2/FiO2 ratio

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23
Q

what is a normal PaO2/FiO2 ratio

A

> 300 mmHg

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24
Q

what is the numeric value for normal intrapulmonary shunt

A

3-5%

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25
Q

What defines mild ARDs

A

PaO2/FiO2 200-<300 w PEEP or CPAP > or = 5

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26
Q

What defines moderate ARDs

A

100 -200 < PaO2/FiO2 with peep >/= 5

Shunt 15-20%

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27
Q

what defines severe

A

= 100 PaO2/FiO2 with Peep >/= 5

> 20% shunt

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28
Q

what will initial ABGs show for ARDs

A

hypoxemia
respiratory alkalosis from breathing off CO2
increased RR

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29
Q

What happens to a patients RR as ARDS progresses

A

decreases d/t fatigue

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30
Q

If you have a PA line in an ARDs pt what will you see

A

increased PADP while PCWP is unaffected

increase in difference >1-4 mmHg

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31
Q

What type of history would lead us to suspect ARDs

A

direct pulmonary insult or systemic inflammation

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32
Q

what timing would lead us to suspect ARDs

A

within a week of worsening symptoms

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33
Q

what types of assessment findings would lead you to suspect ARDs

A

coarse crackles in lung fields

High PIP and/or plateau pressures indicating worsening compliance

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34
Q

what are two ventilator findings that would indicate ARDs

A

increased PIP and Plateau pressures indicating worsening compliance

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35
Q

What diagnostic findings would indicate ARDs (3)

A

patchy infiltrates or opacities on CXR
non-cardiac pulmonary edema
worsening PaO2/FiO2 ratio

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36
Q

What part of cardiac output does ARDs affect

A

increased rt ventricular afterload causes decreased CO

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37
Q

what type of V/Q mismatch occurs in ARDs

A

both!
Shunting - thickened A-C membrane and inc. airway resitance

deadspace - micro-emboli form pulmonary HTN

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38
Q

what are early systemic findings in ARDs by system

A

CNS - restlessness
CVS - tachycardia
GI/GU - no appetite decreased UO

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39
Q

what Lab values would you see in early ARDs

A

low pO2
low CO2
alkalotic pH
SvO2 low

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40
Q

What systemic findings would you see later in ARDs

A

CNS - agitation, fatigue
CVS - tachycardia, full blow s/s of decreased afterload generalized edema
multiorgan involvement

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41
Q

what lab values would you see later in ARDs

A

resp acidosis
inc lactate
low SvO2
OER inc

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42
Q

what is the 2 pronged approach to treatment of ARDs

A
  1. treat causative factor if able - i.e pneumonia abx

2. support physiological fn and cellular oxygenation until the effects of ARDs/SIRS subside

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43
Q

what are the 4 areas of treatment to support ARDS pts

A

MV
hemodynamic support
positioning
pharmacology

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44
Q

What are 3 MV protective lung strategies for pts with ARDs

A

maintain plateau pressures < 30 cm H20

use low tidal volumes

permissive hypercapnia

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45
Q

What does PIP reflect

A

lung compliance and airway resistnace

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46
Q

is PIP representitive of static or dynamic compliance

A

dynamic

47
Q

what is normal PIP

A

< 40 cm H20

48
Q

When is a plateau pressure measured

A

end of inspiration when the lung is fully inflated but no air is moving in or out

49
Q

what is plateau pressure representive of

A

lung compliance

50
Q

is plateau pressure dynamic or static

A

static

51
Q

what value is most accurate in determining lung compliance

A

plateau pressure

52
Q

what is normal PP

A

25-30 cm H2O

53
Q

what button is pressed to determine PP

A

end-inspiratory hold button

54
Q

What ventilator settings have a decreased mortality and ventilator days in ARDS

A

TV <6 cc/kg and PP <30

55
Q

What is regional over-distension in ARDS

A

preset volume modes
air flows into most complaint alveoli
causes some alveoli to be over distended and others to be underinflated

56
Q

What is the problem with AC ventilation in ARDS

A

regional over-distension in ARDS

57
Q

what can happen with regional overdistension in ARDS

A

alveolar wall trauma and cellular injury
can increase atelectasis
can cause pneumothorax

58
Q

What should you keep tidal volumes in ARDS pts

A

btwn 4-8 ml/Kg

59
Q

What is permissive hypercapnia? why is it a protective lung strategy

A

allowing pCO2 to rise with low tidal volumes
preferable not to drop pH below 7.2
avoids volume and barotrauma that might come from increasing PCV to increase ventilation

60
Q

why do we not increase RR to blow off rising pCO2

A

decreased time for resp cycle
cases increased flow rate d/t dec. in inspiration time
lung tissue has less time to stretch and accommodate incoming volume
increases airway and alveolar pressure

61
Q

If your TV is decreaseing what are 4 things this could mean

A

decreased lung compliance
worsening ARDS
secretions need suctioning
leak in circuit

62
Q

T or F volume-cycled ventilation decreases the risk of volutrama and barotrauma

A

false - PC reduces risk of barotrauma and volutrauma

63
Q

3 benefits of PC

A

improve ventilation d/t decelerating inspiratory flow pattern

laminar flow opens smaller collapsed airways

improve oxygenation by decreasing V/Q mismatch

64
Q

what can we do with MV to improve refractory hypoxemia

A

increase PEEP sometimes as high as 15-18

keep FiO2 levels as low to prevent alveolar damage from O2 toxicity

65
Q

What are the two types of ECMO

A

VA

VV

66
Q

what type of ECMO provides cardiac support to assist systemic circulation

A

VA

67
Q

What type of cannulation does VA require? VV?

A

VA - arterial and venous

VV - venous only

68
Q

What type of ECMO bypasses pulmonary circulation

A

VA

69
Q

what type of ECMO maintains pulmonary blood flow

A

VV

70
Q

What type of ECMO would you use for RV failure

A

VA

71
Q

Which type of ecmo acheives a higher PaO2

A

VA

72
Q

What type of ECMO is connected in series to heart and lungs? parallel to heart and lungs?

A

VV series to heart and lungs

VA parallel to heart and lungs

73
Q

what are our two hemodynamic goals in ARDS

A

maintain preload

avoid excessive fluid

74
Q

what type of fluid management do we do with ARDS pt

A

biphasic
hemodynamic instability - early fluid administration

once initial phase of instability has passed then restrictive fluid strategies

75
Q

what type of fluid do we use with ARDS

A

remains isotonic crystalloid

76
Q

what is normal PAS/PAD

A

20-30/10-15

77
Q

what is normal PCWP

A

8-12

78
Q

what is normal SVR

A

800-1500

79
Q

What is normal PVR

A

155-255

80
Q

what is normal CO

A

4-8

81
Q

What should the difference btween PCWP and PAD be

A

1-4 mmHg

82
Q

if there is difference >4mmHg btw PCWP and PAD what does this indicate

A

lung pathology

83
Q

what is something we can get for our ARDS pts that maximizes ventilation and perfusion

A

kientic bed

84
Q

what does a kinetic bed do

A

constant repositioning maximizes ventilation and perfusion improving gas exchange

85
Q

What position is beneficial in ARDS pts? why?

A

proning

improves lung persusion in dependent lung zones

86
Q

how long should ARDS pts be placed in the prone position

A

12-16 horus

87
Q

how many people does it take to prone a pt

A

3-4 RNS and one RT

88
Q

what are 3 side effects of proning a pt

A

potential tube or line dislodgement
pressure wounds, pressure neuropathy
facial edema

89
Q

What RASS goal do we typically aim for with ARDS pts

A

-3 to -5

90
Q

why do we want ARDS pts sedated

A

decrease demand
easier to ventilate
promote patient comfort while on ventilator

91
Q

What type of drugs do we expect to use with ARDS pts

A

bronchodilators

mucolytics

92
Q

have surfactant replacement drugs shown benefit in ARDS pts

A

no

93
Q

what mediaction might be used as a last effort to imrpove oxygenation for ARDS pts

A

nitric oxide

94
Q

what does nitric oxide do

A 
vasodilation of capillary bed
reduces PVR
improves blood flow
reduces V/Q mismatch
decreases O2 toxicity
decrease high PEEP requirements
95
Q

What are 2 side effects of nitric oxide

A

interacts with Hgb to form methemoglobin

can cause renal dysfunction

96
Q

late stage blood gas for ARDS will show what

A

mixed acidosis

97
Q

What PA values will be abnormal in ARDS

A 
decreased SVR d/t to ABCCs of inflammation
increased PVR (increased RT sided afterload)
increased PAD (left sided preload)
98
Q

if you have high PCWP and PADP greater than 4 what does this indicate

A

HF

99
Q

will PCWP be affected in ARDS

A

no

100
Q

if you hear bronchial breath sounds in the lower and mid lung fields what does this mean

A

consolidation happening in the lungs

101
Q

what happens during alveolar epithelial changes

A

type 1 cells wall integrity compromised causing shift in fluid and protein

type 2 cell damage causes loss of surfactant

102
Q

What happens to O2 supply and demand during alveolar epithelial changes

A

decreased SA
thickened membrane
decreased diffusion and decreased alveolar oxygenation

103
Q

what TV do you expect to see for decreased mortality in ARDS pts? PP?

A

<6 cc/Kg

<30 cm

104
Q

What type of pt must you be mindful of with permissive hypercapnia

A

TBI

high CO2 causes cerebral vasodilation which can cause increased ICP

105
Q

what vent settings places a pt at risk for regional overdistention

A

volume cycled, AC

106
Q

why do you want to avoid excessive fluid resuscitation in ARDS pts

A

dont want to overload them and cause more fluid to back up into the lungs

107
Q

what type of blood gas will you see in a patient who is being diuresed with lasxi

A

metabolic alkalosis

108
Q

how should you be giving fluids in patients

A

slowly and carefully as pt already has fluid in the lungs

109
Q

What is the main thing positioning addresses

A

V/Q mismatch

110
Q

what are benefits to proning

A

expands alveoli as heart is not pushing down on them as seen in supine

allows for better oxygenation of dependent side of lung as the fluid will move via gravity

111
Q

what are the two types of patients you will never do a sedation vacation on

A

ARDS

TBI

112
Q

what is another drug that can be used aside from nitric oxide in ARDS pts

A

flolan (prostacylcin)

113
Q

how do flolan work

A

used in pulmonary htn to vasodilate pulmonary arteries

cheaper than nitric oxide

NSCC 7520 Critical Care Theory 4 (5 decks)

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