ARDS (Acute respiratory distress syndrome).pptx

Acute respiratory distress syndrome (ARDS) is a life-threatening lung injury that allows fluid to leak into the lungs.
Causes of ARDS include: Sepsis: Sepsis is the most common cause of ARDS. It can happen when you have a serious infection in your lungs (pneumonia) or other organs with widespread inflammation.

1. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) PRESENTED BY PANKAJ SINGH RANA NURSE PRACTITIONER

2. INTRODUCTION ACUTE RESPIRATORY DISTRESS IS A CONDITION WHEN FLUID FILLS IN THE LUNGS ALVEOLI.

3. RISK FACTOR DIRECT CAUSE Aspiration Localize infection Trauma Surgery Toxic inhalation of fumes INDIRECT CAUSE Shock Metabolic acidosis Trauma Sepsis

4. STAGES

5. SYMPTOMS Dyspnea Cough Fever Restlessness Tiredness Hypotension Confusion Cyanosis Respiratory acidosis

6. PHYSICAL EXAMINATION VITAL SIGN Temperature for hyperpyrexia Pulse for tachycardia Respiratory rate for reparatory distress and tachypnea Heart rate for tachycardia SpO2 level for hypoxia

7. LUNGS Dyspnea and tachypnea Decreased breath sound Crackles on both side or one side of lungs Intercostal retraction or wheezing

8. SKIN Cyanosis due to poor oxygenation Pallor due to poor perfusion

9. DIGNOSTIC TEST Arterial blood Gas. (hypoxia) Chest X Ray. ( Bilateral consolidation )

10. CT SCAN Heterogeneous distribution The lung changes are not uniform, with different areas of the lung showing different densities  Ventro -dorsal gradient The lung has a gradient of density from top to bottom, with denser consolidations in the bottom regions  Ground-glass opacification This is a non-specific sign that indicates a reduction in air in the affected lung. It's likely due to protein and edema in the alveoli and interstitium   Normal or hyperinflated parenchyma In the non-dependent regions, the lung may be normal or hyperinflated , especially if the patient is on mechanical ventilation 

11. Pro BNP Levels Low NT- proBNP : Low levels of NT- proBNP (< 200 pg /ml) are generally supportive of ARDS.  High NT- proBNP : High levels of NT- proBNP (> 1200 pg /ml) are generally supportive of cardiogenic pulmonary edema.  Elevated NT- proBNP : Elevated NT- proBNP levels are associated with higher odds of mortality, organ dysfunction, and fewer ventilator-free days

12. COMPLICATION Nosocomial infection Barotrauma Kidney failure Stress Ulcer

13. MANAGMENT

14. Medical Management Antibiotics (broad spectrum) Anti-inflammatory drugs ( hydrocortisone, methylprednisolone   ) Diuretics Inhaled drugs (Inhaled nitric oxide ( iNO ) and salbutamol ) Neuromuscular Blockers ( cisatracurium ) fluid conservative strategies (based on central venous pressure, urine output)

15. 5 P’s of ARDS

16. Mechanical Ventilation Intervention Lung protective ventilation (tidal volume of 4–8 mL/Kg predicted body weight and plateau pleasure of <30 cm H 2 O ) Higher PEEP

17. Recruitment maneuvers Recruitment maneuvers ( A recruitment maneuver is a ventilator intervention to transiently increase airway pressure to open the collapsed alveoli, thereby improving oxygenation and volume distribution ). Sustained inflation involves changing the ventilator to CPAP mode and using pressures of 35–50 cmH 2 O for 20–40 s while ensuring that the pressure support is set to zero to avoid additional pressure increases . A staircase or incremental PEEP strategy uses stepwise increase in PEEP every 2–3 min while maintaining constant driving pressure (plateau pressure – PEEP), followed by stepwise decrease in PEEP to the optimal PEEP level which is determined by compliance and oxygenation.

18. Non-Pharmacological Interventions Prone Positioning  It reduces the ventral to dorsal transpulmonary pressure difference and lung compression . Prone positioning for at least 16 hours/day or to be left in supine position.

19. Prone positioning is contraindicated in patients Facial/neck trauma or spinal instability Recent sternotomy Large ventral surface burn Elevated intracranial pressure Massive haemoptysis Patients at high risk of requiring cardiopulmonary resuscitation (CPR) or defibrillation

20. Potential complications of Prone Position Endotracheal tube dislodgement or kinking Vascular catheter kinking Elevated intra-abdominal pressure Transient increase in oral/tracheal secretions occluding the airway Increased gastric residuals Facial edema Pressure ulcers Lip trauma Brachial plexus injury from arm extension

21. Extracorporeal Membrane Oxygenation (ECMO ) ECMO is an extracorporeal life support modality used to temporarily support patients with respiratory and/or cardiac failure that are refractory to conventional treatment.

22. ECMO consideration Respiratory failure are murray score > 3, Refractory hypoxemia (P/F < 100) despite lung protective ventilation, Neuromuscular blockade and Prone positioning when indicated or persistent respiratory acidosis with ph < 7.2.

23. Absolute contraindication Terminal illness with life expectancy < 6 months, Uncontrolled metastatic cancer, Acute intracranial hemorrhage or infarction Contradiction to systemic anticoagulation.

24. Complications of ECMO Bleeding (29.3%), Neurological complications (7.1%) including intracranial hemorrhage , ischemic stroke, brain death and seizures

25. NURSING MANAGEMENT PHYSICAL ASSESSMENT 1 . Closely monitor the respiratory status. ARDS often presents with dyspnea and hypoxemia within 12-48 hours of the inciting event. 2. Monitor the vital signs. Assess for the following changes in the vital signs: Rapid breathing (tachypnea) Rapid pulse rate ( tachycardia ) Low oxygen saturation (requiring a high fraction of inspired oxygen to maintain oxygen levels) Hyperthermia  or hypothermia 3. Determine the presence of infection or sepsis. Sepsis is the most common cause of ARDS, causing  hypotension  and peripheral vasoconstriction that leads to cold extremities and cyanosis. Assess for potential sites of infection, such as surgical incisions, IV lines, or  pressure ulcers . 4. Auscultate the lung sounds. Bilateral rales may be heard during lung auscultation.

26. 1. Assess for infiltrates and hypoxemia. ARDS is the acute onset of bilateral pulmonary infiltrates and severe hypoxemia. While some lab tests and diagnostic findings may support the diagnosis, it is primarily detected through gas exchange abnormalities and radiographic results of: PaO2/FiO2 ratio of less than 300 mmHg Bilateral lung infiltrates on chest X-ray 2 . Obtain blood for ABG. Respiratory alkalosis is frequently the initial finding on ABGs. However, as the condition progresses, the partial pressure of carbon dioxide (PCO2) rises, and respiratory alkalosis becomes respiratory acidosis. 3. Assess the cardiovascular function. An echocardiography and plasma B-type natriuretic peptide (BNP) level may help rule out cardiogenic  pulmonary edema . B-type natriuretic peptide (BNP)  level of less than 100 pg /mL in a patient with bilateral infiltrates and hypoxemia indicates a diagnosis of ARDS over cardiogenic pulmonary edema. Echocardiogram  reveals details on valvular anomalies, right ventricular function, and left ventricular ejection fraction. 4 . Prepare the patient for an imaging scan. The following imaging scans may help visualize the lungs: Chest radiography (X-ray)  detects lung disease, injury, and fluid in the lungs. Diffuse bilateral lung infiltrates with ground glass appearance indicate ARDS. Computerized tomography (CT scan)  is more sensitive than plain chest radiography in detecting heart and lung conditions. It creates cross-sectional images of internal organs by combining X-ray images captured from several angles. 5 . Assist with bronchoscopy. Bronchoscopy may be considered to evaluate for infection or other causes of pulmonary infiltrates. Fluid specimens are obtained through bronchoscopy to analyze for a differential diagnosis.

27. Supportive Care Manage the underlying condition. It is crucial to address the underlying problem in addition to providing supportive care, noninvasive ventilation, mechanical ventilation, and conservative fluid management . 2. Administer medications as prescribed. Infection is frequently the underlying cause of ARDS. Prompt administration of antibiotic therapy is necessary.  3. Remove the cause of sepsis. It may be necessary to perform the following interventions to manage sepsis-associated ARDS: Remove intravascular lines Drain infected fluid collections Surgically debride an infected area Surgically remove or resect an organ

28. 4. Prevent complications associated with mechanical ventilation and ICU stay. Complications may occur from the interventions required to treat ARDS. Prevent deep vein thrombosis, pressure ulcers, and infections by performing the following actions: Deep vein thrombosis (DVT)  prophylaxis Early mobilization Minimize the use of sedation Frequent turning and skin care Elevate the head of the bed Suction as needed Provide Oxygenation

29. Administer oxygen supplementation as ordered. Patients with ARDS may benefit from noninvasive positive-pressure ventilation (NIPPV), a high-flow nasal cannula, or other alternatives to mechanical ventilation. 2. Consider mechanical ventilation. Maintaining oxygenation while avoiding oxygen toxicity and complications are the main objectives of mechanical ventilation in ARDS. The goal is to lower the fraction of inspired oxygen (FiO2) to less than 65% while maintaining the oxygen saturation at 85-90% within the first 24-48 hours . 3. Consider tracheostomy. If long-term mechanical ventilation is expected, a tracheostomy may be performed to allow for a more stable airway and for the patient to mobilize and eventually wean off the ventilator.

30. 4 . Turn the patient to the prone position. Turning from the supine to the prone position dramatically improved oxygenation in about 60–75% of patients with ARDS.  5 . Administer fluids with caution. While early aggressive resuscitation is essential for circulatory shock, recent evidence suggests conservative fluid strategies may prove beneficial for oxygenation and require less mechanical ventilator support.  6 . Administer nutritional support. Institute enteral nutrition after 48 to 72 hours of mechanical ventilation. 7 . Promote bed rest. While most patients with ARDS are on bed rest, frequent repositioning is necessary, as well as active and passive range-of-motion exercises. Elevate the head of the bed to a 45° angle to decrease the risk of ventilator-associated pneumonia. 8 . Minimize sedation. Sedatives and paralytics are often necessary to limit movement and anxiety when mechanical ventilation is required. If applicable, minimize sedation and increase ambulation. These strategies have been shown to decrease the rate of  post-traumatic stress disorder .