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Pulmonology 2 > Clin Med - ARDS > Flashcards

Clin Med - ARDS Flashcards

1
Q

ARDS is also known as

A
  • non-cardiogenic pulmonary edema
  • adult hyaline membrane dz
  • capillary leak syndrome
  • shock lung
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2
Q

ALI (acute lung injury)

A

a syndrome of inflammation and increased permeability that is associated w/ a constellation of clinical, radiographic and physiologic abnormalities that cannot be explained, but may co-exist w/ left arterial or pulmonary htn

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3
Q

ARDS relation to ALI

A
  • ARDS is a severe form of ALI

- more hypoxic

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4
Q

ARDS classification

A
  • acute
  • bilateral
  • no left sided heart failure
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5
Q

Epidemiology of ARDS

A
  • annual incidence 60/10k
  • 20% of pts in ICU meet criteria for ARDS
  • moridity and mortality:
  • 26-48% (over 80% of deaths attributed to non-pulm organ failure
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6
Q

risk factors for ARDS

A
  • extrems of age, pre-existing organ dysfunction, chronic medical illnesses
  • pts w/ ARDS from a direct lung injury have a higher incidence of death
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7
Q

Causes of ARDS (in order of most common to least)

A
  • pneumonia
  • severe sepsis
  • aspiration
  • other (drowning, smoke/chemical inhalation)
  • trauma
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8
Q

Pathophys of ARDS

A
  1. direct/indirect injury to alveolus causes macrophages to release pro-inflammatory cytokines
  2. cytokines attract neutrophils into alveolus and interstitum where they damage the alveolar-capillary membrane
  3. ACM integrity is lost, alveolus fills w/ fluid, surfactant can no longer support alveolus
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9
Q

Consequences of lung injury include? (3)

A
  • impaired gas exchange (reduced perfusion and diffusion)
  • decreased compliance (decreased ventilation)
  • increased pulmonary arterial pressure
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10
Q

impaired gas exchange caused by ARDS

A
  • V/Q mismatch
  • shunting: mixed blood = hypoxemia
  • increased dead space: impairs CO2 elimination; higher minute vent needs
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11
Q

decreased compliance caused by ARDS

A
  • hallmark of ARDS
  • consequence of stiff, non or poorly aerated lung
  • fluid filled lung becomes stiff and boggy
  • requires increasing pressure to deliver Vt
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12
Q

increased pulmonary arterial pressure caused by ARDS

A
  • about 25% of patients
  • result of hypoxic vasoconstriction
  • can result in right ventricular failure
  • not routinely measured
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13
Q

treatment of ARDS

A
  • treat the underlying cause!
  • low tidal volume ventilation
  • use PEEP
  • monitor airway pressures
  • conservative fluid management
  • reduce potential complications
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14
Q

tidal volume hypothesis in tx of ARDS

A

-ventilation w/ smaller tidal volumes (6mL/kg) will result in better clinical outcomes than traditional tidal volumes ventilation

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15
Q

when compared to larger tidal volumes, Vt of 6ml/kg of ideal body weight:

A
  • decreased mortality
  • increased number of ventilator free days
  • decreased extrapulmonary organ failure
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16
Q

mortality is decrease in low tidal volumes despite the patients having:

A
  • worse oxygenation
  • increased pCO2
  • lower pH
17
Q

Explain how ARDS effects the lungs differently

A
  • normal alveoli
  • injured alveoli: can potentially participate in gas exchange, susceptible to damage from opening and closing
  • damaged alveoli: filled w/ fluid, do not participate in gas exchange
18
Q

protective measures to avoid over distention of normal alveoli:

A
  • use low (normal) tidal volumes
  • minimize airway pressures
  • use PEEP (positive end expiratory pressure)
19
Q

PEEP hypothesis in ARDS treatment

A

pts ventilated w/ 6ml/kg, higher levels of PEEP will result in better clinical outcomes than lower levels of PEEP

20
Q

PEEP

A
  • every ARDS pt needs it

- goal is to maximize alveolar recruitment and prevent cycles of recruitment/derecruitment

21
Q

what is most predictive of lung injury?

A

-plateau pressure

22
Q

plateau pressure

A
  • goal is <30, the lower the better
  • decreases alveolar over-distension and reduces risk of lung strain
  • refer to graph if needed
23
Q

fluid management in ARDS

A

-conservative fluid management improved lung function and shortened mechanical ventilation times and ICU days w/o increasing nonpulmonary organ

24
Q

things to remember w/ fluid managment in ARDS

A
  • increased lung water is the underlying cause of many of the clinical abnormalitites in ARDS
  • after shock is resolved, effort should be made to diuresis
  • shortens time on vent and ICU length
25
Q

prone positioning in ARDS

A

-early application of prolonged prone positioning significantly decreased 28 day and 90 (day?) mortality in pts w/ severe ARDS

26
Q

to summarize:

A
  • recognize ALI early
  • intervene in the dz process early
  • limit fluids to physiologic necessity, diurese as able
  • ventilate w/ low tidal volumes (6cc per ideal body weight) and high PEEP (keep O2 sat > 88%)

Pulmonology 2 (17 decks)

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