ARDS

acute repiratory distress syndrome for adult

1. ACUTE RESPIRATORY DISTRESS SYNDROME PREPARED BY: RN Arpana B husal BNS

2. Contents Introduction Definition Risk factor Etiology Pathophysiology Phases Clinical manifestation

3. Content cnt … Diagnostic evaluation Management Medical Pharmacological Nursing Complication References

4. Introduction Acute respiratory distress syndrome (ARDS ) is a sudden, progressive form of respiratory failure characterized by severe dyspnea , refractory hypoxemia, and diffuse bilateral infiltrates.

5. Introduction It follows acute and massive lung injury that results from a variety of clinical states , often occurring in previously healthy people.

6. ARDS definition is based upon 5 key clinical features: a risk factor for the development of acute respiratory distress (e.g ., sepsis, trauma, pneumonia, aspiration, pancreatitis ) severe hypoxemia despite a relatively high fraction of inspired oxygen ( FIO2). decreased lung compliance. bilateral pulmonary infiltrates. lack of clinical evidence of cardiogenic pulmonary edema. Within one week of known clinical insult or new or worsening respiratory symptoms.

7. The syndrome was first described in 1967, and has been referred to by several terms, including shock lung, wet lung, posttraumatic lung, congestive atelectasis, capillary leak syndrome, and adult hyaline membrane disease

8. RISK FACTORS A ge over 65 years C hronic lung disease A history of alcohol misuse or cigarette smoking ARDS can be a more serious condition for people who : H ave toxic shock A re older H ave liver failure H ave a history of alcohol misuse

9. 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 .

10. I ndirect injury include: Sepsis Shock (any cause) Drug overdose Fat embolism Prolonged hypotension Non-thoracic trauma Cardiopulmonary bypass

11. Indirect injury cnt … Head injury Acute pancreatitis Uremia Hematologic disorders, such as disseminated intravascular coagulation, or multiple blood transfusions

12. PATHOPHYSIOLOGY

13. Phases Three distinct stages (or phases) of the syndrome including : 1. Exudative stage 2. Proliferative (or fibro-proliferative ) stage 3. Fibrotic stage

14. Exudative Stage (0-6 Days) Characterized by : Accumulation of excessive fluid in the lungs due to exudation (leaking of fluids) and acute injury. Hypoxemia is usually most severe during this phase of acute injury, as is injury to the endothelium (lining membrane) and epithelium (surface layer of cells ). Some individuals quickly recover from this first stage; many others progress after about a week into the second stage.

15. Proliferative Stage (7-10 Days) Connective tissue and other structural elements in the lungs proliferate in response to the initial injury, including development of fibroblasts. The terms "stiff lung" and "shock lung" frequently used to characterize this stage. Abnormally enlarged air spaces and fibrotic tissue (scarring ) are increasingly apparent.

16. Fibrotic Stage ( >10-14 Days) Inflammation resolves. Oxygenation improves and extubation becomes possible. Lung function may continue to improve for as long as 6 to 12 months after onset of respiratory failure, depending on the precipitating condition and severity of the initial injury. Varying levels of pulmonary fibrotic changes are possible.

17. EARLY SYMPTOMS Restlessness Severe dyspnea Confusion Low blood pressure Extreme tiredness Change in patient behaviour Mood swing Disorientation Change in LOC

18. LATE SYMPTOMS Severe difficulty in breathing i.e., labored, rapid and shallow breathing. Shortness of breath. Tachycardia Thick frothy sputum Metabolic acidosis Cyanosis (blue skin, lips and nails) Abnormal breath sounds, like crackles, rhonchi Decreased PaCo2 with respiratory alkalosis. Decreased PaO2 urine output  

19. Diagnostic evaluation Complete history On physical examination-Auscultation reveals abnormal breath sounds- wheezing, crackles . The first tests done are : Arterial blood gas analysis Blood tests Urine test and culture Chest x-ray Sputum cultures and analysis

20. Diagnosis cnt .. Other tests are : Chest CT Scan Echocardiogram lung biopsy Bronchoscopy

21. MANAGEMENT

22. Persons with ARDS are hospitalized and require treatment in an intensive care unit . No specific therapy for ARDS exists. 1. Medical management Supportive measures : Supplemental oxygen Mechanical VENTILATION

23. Positioning strategies Fluid therapy Respiratory therapy 2. Pharmacological management 3. Nursing management

24. 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 and believe to reduce the mortality.

25. Positioning strategies Prone positioning About two-thirds of patients with ARDS improve their oxygenation after being placed in a prone position. Mechanisms that may explain the improvement include : increased functional residual capacity; change in regional diaphragmatic motion perfusion redistribution; improved clearance of secretions. (PaO2 level is more in prone than supine position.

26. Lateral rotation therapy To stimulate postural drainage and help mobilized the secretion. The lateral movement of bed is done for 18-24 hours slowly.

27. Fluid management Distinction between primary ARDS due to aspiration, pneumonia, or inhalational injury, which usually can be treated with fluid restriction , from secondary ARDS due to remote infection or inflammation that requires initial fluid and potential vasoactive drug therapy is central in directing initial treatments to stabilize the patient

28. Fluid management cnt … 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.

29. Respiratory therapy Primary goal is o2 therapy is correct hypoxemia. O2 administered by mask. Spo2 continuously monitored . O2 administration give patient the lowest concentration that results in Pao2 of 60 mm hg or greater when the fio2 exceeds 60% for more than 48 hours the risk of o2 toxicity increases. Mechanical ventilation is provide to client

30. Pharmacological management Antibiotics Anti-inflammatory drugs ; such as corticosteroids Diuretics Drugs to raise blood pressure Anti-anxiety Muscle relaxants Inhaled drugs (Bronchodilators)

31. Pharma mgmt cnt … Specific therapy human recombinant interleukin-1 receptor antagonist neutrophil inhibitors pulmonary- specific vasodilators surfactant replacement therapy

32. Nursing management NURSING DIAGNOSIS 1. Ineffective breathing pattern related to decreased lung compliance , decreased energy as characterized by dyspnea, abnormal ABGs, cyanosis & use of accessory muscles . 2. Ineffective tissue perfusion(pulmonary) related to decreased blood circulation .

33. 3. Risk for decreased Cardiac output related to positive pressure ventilation. 4 . Impaired physical mobility related to monitoring devices, mechanical ventilation & medications as characterized by imposed restrictions of movement, decreased muscle strength & limited range of motion .

34. 6. Risk for impaired skin integrity related to prolonged bed rest , prolonged intubation & immobility . 7. Knowledge deficit related to health condition, treatment modalities & hospitalization as characterized by increased frequency of questions posed by patient.

35. Correcting breathing pattern Assess for hypoxia, headache, restlessness, apprehension, cyanosis, behavioral changes. Monitor vital signs, ECG, oximetery , and ABG analysis for oxygenation. Monitor patients response to IV fluids/vasopressors

36. Monitor oxygen therapy used to relieve hypoxemia. Prepare patient for assisted ventilation when hypoxemia. Encourage deep breathing and coughing exercises after chest physiotherapy. Instruct patient to cover nose and mouth while coughing .

37. Improving tissue perfusion Closely monitor for shock decreasing blood pressure, tachycardia, cool, clammy skin. Monitor prescribed medications given to preserve right ventricular filling pressure, increased BP . Patient should be kept in bedrest to reduce oxygen demand and risk of bleeding.

38. Monitor urinary output hourly, because there may be reduced renal perfusion and decreased GFR . Consider physician evaluation when these signs are present, especially if accompanied by cyanotic nail beds, circumoral pallor, and increased respiratory rate .

39. Reducing anxiety Correct dyspnea and relief physical discomfort. Explain diagnostic prcedures and the patients role :correct misconception. Listen to patiet concers ; attentive listening relieves anxiety and reduces emotional distress. Speak calmly and slowly.

40. Evaluate patient for sign of hypoxia thoroughly when anxiety, restlessness, and agitation of new onset are noted, before administering as needed sedatives.

41. Rest and sleep Patient should be kept in bed rest to reduce oxygen demand. Encourage use of relaxation techniques and diversional activities. Position with head of bed should be slightly elevated. Maintain semi-fowler’s position

42. Controlling infection Recognize early manifestations of respiratory infection increased dyspnea, fatigue; change in color, amount, and character of sputum; nervousness; irritability; low-grade fever. Obtain sputum for Gram stain and culture and sensitivity. Administer prescribed antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways.

43. COMPLICATIONS Common complications are ; Nosocomial pneumonia: Barotrauma Renal failure

44. COMPLICATIONS cnt … Other complications are stress ulcers, Tracheal ulceration, Blood clots leading to deep vein thrombosis & pulmonary embolism . Infection – catheter related infection hospital acquired –pneumonia sepsis

45. Respiratory infections- O2 toxicity ventilator - associated pneumonia pulmonary emboli Acute renal failure Endotracheal tube intubation complications laryngeal ulceration tracheal ulceration

46. Psychological complication Delirium Sleep deprivation Post-traumatic stress syndrome

47. Management of complication Hospital acquired pneumonia – it occur in 68% of patient with ARDS in which include Infection Contaminated medical equipment Aspiration Prolonged ventilation Respiratory tract infection Main control on infection, sterile techniques ,elevate the bed to prevent aspiration.

48. References B runner and S uddarth , “Text Book of Medical and S urgical Nursing”, 12th edition, W olter K luwer I ndia Private Limited Lewis, H eitkemper D irksen, “Medical S urgical N ursing” 6th edition, mosby Publications Mandal G.N (2016) “A Textbook of Medical Surgical Nursing”. 5 th edition. Kathmandu.Makalu Publication House.2078/03/11 at 4:30 pm 2019. Mayo Foundation of Medical Foundation and Research . ARDS. https :// www.mayoclinic.org@2021/06/25 at 3pm .

49. 2019. Mayo Foundation of Medical Foundation and Research. ARDS. https://www.mayoclinic.org@2021/06/25 at 3pm. October 23, 2018. ARDS. https:// www.slideshare.net/PINKEERATHEE@2021/06/25 at 11AM