ARDS Flashcards
What is acute respiratory distress syndrome ?
its a sudden progressive form of acute respiratory failure
what does acute respiratory distress syndrome allow to happen to our alveolis ?
alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
( alveoli fill with fluid )
patients with ARDS, usually end having clinical manifestations like ?
severe dyspnea
hypoxia
decreased lung compliance
what is the biggest predisposition or cause of patients contracting acute respiratory distress syndrome ?
sepsis
what is sepsis ?
systemic infection
how do we treat sepsis ?
antibiotics
if the antibiotics are working what happens ?
if the antibiotics are not working ?
they get better
fever, low blood pressure, increase heart rate
dr brooks says, if your patients come into the unit with pneumonia, are they at risk of developing sepsis ?
if they get sepsis, they are at risk for ?
yes
ARDS
ards is something that happens quickly, and can you explain the patho to me on how this happens quickly?
you get a bunch of fluids in your lungs and scarring in your lungs all at the same time
fluids decrease the gas exchange
scarring decrease lung compliance, in other words allow you to take a deep breath
Ards can happen 2 ways, can you name both ways?
direct lung injury
indirect lung injury
what is the direct lung injury for ards?
something that directly hurts the lung
aspiration
pneumonia
pulmonary embolism
near drowning
what is the indirect lung injury for ards?
problem from elsewhere in the body that move towards favorable lung enviroemtn and proliferate ( something that alerts lung function, not directly to the lung )
examples
sepsis and massive trauma
shock
acute pancreatitis
what is the pathophysiology behind acute respiratory distress syndrome ?
neutrophils are attracted to the lungs, either from a direct cause like pulmonary embolism or an indirect cause like sepsis throughout the body and activate inflammatory and immune responses
what are the 4 pathophysiology examples and or conditions that are going on in the body when you develop acute respiratory distress syndrome ?
increase pulmonary capillary membrane permeability
destruction of elastin and collagen
formation of pulmonary micro emboli
pulmonary artery vasoconstriction
we understand that the following 4 are the things that are going on inside the body when we develop acute respiratory distress syndrome, but can you elaborate on each one more in depth
- increase pulmonary capillary membrane permeability
- destruction of elastin and collagen
- formation of pulmonary micro emboli
- pulmonary artery vasoconstriction
explain to me what is going on and in detail
leaky capillaries
- ( fluid around your alveoli )
less lung compliance
- ( not as stretchy or good )
decreased perfusion
- ( small clots = gas exchange goes down )
increased pulmonary pressures
- ( pulmonary hypertension )
the pathophysiology changes in ARDs goes through 3 phases, what are they ?
Injury or exudative phase
reparative or proliferative phase
fibrotic or fibroproliferative phase
when does the injury or exudative phase occurs ?
24-72 hours after initial injury to the lung ( directly or indirectly ) and can last up to 7 days
what are the 2 things that are going on in the injury or exudative phase ?
hypoxemia causes increase work of breathing
cardiac output increase then to decrease
so this injury or exudative phase will cause hypoxemia in patients, resulting in them to have increase work of breathing, what are some things we see on a patient with ards?
increase WOB
increase RR
why does cardiac output increase then decrease when you are in the injury or exudative phase with ards?
because it’ll increase intitallty to try to compensate, however as condition worsens the blood pressure and heart will fall and hypoventilation occurs leading to decreased perfusion throughout the body
something important to note with ARDS, you are going to want to send the patient off to do a chest x-ray, however what are you going to see when they are in this injury/ early phase of ards?
nothing, it takes time to be shown on chest x-ray, most of the time you’ll see symptoms of it before hand
when does reparative or proliferative phase happen ?
1-2 weeks after initial lung injury
what is the x-ray going to look like in the reparative or proliferative phase ?
filled with fluid
what is going inside with the reparative or proliferative phase ?
lung becomes dense and fibrous and lung compliance continues to drop heavily
scarring and inflammation are still going on
when does the fibrotic or fibroproliferative phase happen ?
2-3 weeks after initial lung injury
what is going on inside the body when we are in the fibrotic or firboproliferativu phase?
everything is literally just 100x worse, the likeliness of them surviving is like zero to none, everything is hard, lung compliance just keeps getting worse, area for gas exchange is just near to nothing and pulmonary hypertension is at its all high time cause if the lack of perfusion in the body
clinical progression
some patients are able to survive the acute phase of lung injury and their pulmonary edema resolves and make a complete recovery within a week or so, however how likely are patients who enter the fibrotic phase able to survive?
usually they also end up requiring what ?
not for long, long term mechanical ventilation
do you think their are factors that determine patients recovery ? if so can you name some?
nature of initial injury, comorbidities, complications and genetic predisposition
how are patients in the early phase of ards going to look like ? like clinical manifestations wise
24-72 hours
mild dyspnea
tachypnea
cough
restlessness
how are patients ABGs and chest x-ray going to be looking like when they are in the early phase of ards?
mild hypoxemia
normal
how are patients in the late phase of ards going to look like ? like clinical manifestations wise
symptoms are 100x worse with increase fluid accumulation
increase WOB -> respiratory distress
tachypnea, intercostal retraction
tachycardia
cyanosis
pallor
crackles
how is the chest x-ray going to be looking at in the later phases of ards?
showing diffuse and extensive bilateral interstital and alveolar infiltrates
- literally their lungs are filled with fluid
literally completely white or full of scaring
how are the ABGs going to look like in the late presentation ? (2)
refractory hypoxemia
hypercapnia
refractory hypoxemia is a late presentation, but what does that mean ?
usually this is hypoxemia in patients who are in mechanical ventilations, so like not even the machine can help their breathing
the following will be going through every system and how patients with arbs die, so your job Is to name reason why they do due to it.
infection
respiratory
gi
renal
cardiac
hematologic
Endotracheal tube ( ET )
CNS
- Catheter-related
- o2 toxicity, barotrauma, pe, pulmonary fibrosis,vap
- stress ulcers, hemorrhage
- acute kidney injury
- dysrhythmias, decreased cardiac output
- anemia, VTE
- laryngeal ulceration, stenosis
- delirium, PTSD, sleep deprivation
what is the main cause of death with patients who have ards?
MODS
sepsis
vital organs affect - kidneys, lungs, liver, heart
notes
complications for ARDS - ventilator-associated pneumonia ( VAP )
- impaired host defense
- invasive monitoring devices
- aspiration of GI contents
- prolonged mechanical ventilation
strategies for prevention of VAP
- good Hand hygiene
- elevated HOB 30-45 degrees
- oral care
- stress ulcer prophylaxis
- VTE prophylaxis
patients with ards can also get something called barotrauma, what is it ?
high peak pressures cause rupture of over distended alveoli during mechanical ventilation
how can we prevent barotrauma with patients suffering from ards?
patients should be ventilated with smaller tidal volumes and varying amounts of PEEP to reduce the risk
stress ulcers are a common complication with patients suffering with ards, how does this occur with patients with ards?
the diversion of blood from gi tract to respiratory system to try to meet the demand of oxygen
how do we correct stress ulcers and know that its being effective?
proton pump inhibitor & early feeding
no more bleeding in stool -> testing for occult blood
how is VTE a complication for patients who are having ards?
immbolity and venous status leading to increased risk of developing DVT and PE
how do we prevent VTE from happening to patients with ards?
compression stockings
early ambulation
anticoagulants
how does acute kidney injury happen to patients who have ards?
from decreased renal perfusion and subsequent decreased delivery of oxygen to kidneys
remember if you are not getting oxygen, the first thing your body does to try to compensate is to ignore the kidneys = decreased urine output
what is the management for acute kidney injury with patients with ards?
monitor input and output
Daily bun and creatinine levels
dialysis
to recap, what were the big 4 complications for ards?
barotrauma
stress ulcers
VTE
acute kidney injury
notes
patients who end up surviving ards can end up having things like
- anxiety
- memory and attention issues
- inability to focus
- nightmares
- depression
- PTSD ( up to 5 years later )
what are some things we are going to do on assessment with patients on ards?
past health history
medications
surgery or other treatments
tachycardia progressing to bradycardia
extra heart sounds
abnormal heart sounds
hypertension to hypotension
somnolence, confusion, delirium
something I want to mention is that when a patient is having ards, what happens first then progresses into what ?
it starts off with hypertension then into hypotension
nursing diagnoses
- anxiety, ineffective breathing patterns, airway clearance, risk for imbalanced fluid volume, impaired gas exchange
nursing planning
- adequate lung ventilation to maintain normal PH
- clear lungs on auscultation
- resolution of precipitating factors
what are some nursing implementation we are going to do for our patients with ARDS? (7)
oxygen administration
PEEP
prone positioning
ECMO
mechanical ventilation
pain meds
nutrition
when is the best practice to do prone positioning for patients of ards?
for how long ?
early ards
16 hours per day
what is another positioning strategies we can do for patients with ards?
continuous lateral rotation therapy
- side to side turning of the bed Frame less than 40 degrees 18 of every 24 hours
- helps you not have fluid sitting in one place
what is kinetic therapy ?
patient rotated side to side at 40 degrees or greater
sometimes we may want to give pain and sedation pills to do what for patients with ards?
help with pain, discomfort and reduce anxiety
why do we want to promote tissue perfusion with patients with ards?
to help avoid hemodynamic compromise and overall be able to give blood and oxygen to the rest of the body in order to breathe better and avoid other complications
why do we want to maintain fluid balance and nutrition for patients with ards?
because it burns off so much calories trying to breathe and we want to avoid other complications
remember start 24-48 hours
notes ards evaluation
expected outcomes
- independenly maintain a patent airway
- achieve normal or baseline respiratory system and function
- maintain adequate oxygenation as shown by normal or baseline abgs
- have normal hemodyanmic status
- be free of complications
remember we want at the end is adequate breathing!
