Rachel Criddle Lara Kim Kirstin Vorhes
An Introduction to ARDS ht p:/ www.youtube.com/watch?v=SPWAR0bqMkM
What do you know about ARDS?
Key Points About ARDS Noncardiac pulmonary edemaRefractory hypoxemia PO <50, PCO >50, pH < 7.25 2 2 Mortality rate is greater than 50%
Causes of ARDS Direct Lung Injury Indirect Lung Injury
Causes of ARDS Direct Lung Injury Indirect Lung Injury *Aspiration *Sepsis *Pneumonia *Massive trauma Chest trauma Acute pancreatitis Embolism Anaphylaxis Toxic inhalation Cardiopulmonary bypass Neardrowning Severe head injury O2 Toxicity Vascular: DIC, Massive Radiation pneumonitis transfusions *M ost com m on Opioid drug overdose
Pathophysiology Systemic response, can occur within 24 hr Increased capil ary permeability Due to damage from activated neutrophilsCauses severe pulmonary edema Alveoli fil with fluid surfactant production Causes decreased compliance Causes atelectasis Hyaline membranes form Causes decreased gas exchange and compliance Fibrotic lung changes Leads to widespread fibrosis and scarring
Stages of ARDS 1. Injury or Exudative stage 2. Reparative or Proliferative stage 3. Fibrotic stage
Stages of ARDS 1. Injury or Exudative stage (17 days) Accumulation of fluid/protein lead to endothelial damageInflammatory cel s in response to the initial injury 1. Reparative or Proliferative stage (12 weeks) Continued inflammatory responseComplete when lung composed of dense, fibrous tissue 1. Fibrotic stage (23 weeks) Lung completely remodeled by fibrous tissueAlso cal ed chronic or late phase
Trivia Question 1 Your patient is a 32 yo female hospitalized as a result of a neardrowning. Upon assessment, you suspect ARDS when you observe al of the fol owing except: A. TachypneaB. RetractionsC. ClubbingD. Cyanosis
Answer Your patient is a 32 yo female hospitalized as a result of a neardrowning. Upon assessment, you suspect ARDS when you observe al of the fol owing except: A. TachypneaB. RetractionsC . C lubbingD. Cyanosis
Trivia Question 2 Which of the fol owing is NOT an appropriate method for managing ARDS? A. ADH replacement therapyB. Aggressive respiratory support w/PEEPC. Surfactant replacement therapyD. Sedation & positioning
Answer Which of the fol owing is NOT a way to manage ARDS? A . A D H replacem ent therapyB. Aggressive respiratory support w/PEEPC. Surfactant replacement therapyD. Sedation & positioning
Trivia TimeOut: Journal #1 • Title – The Effects of Early and Repeated Prone Positioning in Pediatric Patients W ith Acute Lung Injury • Objective – Evaluate the safety of placing pediatric patients with ALI/ARDS prone for 20h/d during the acute phase of their il ness • Conclusions – Patients showed improvements in oxygenation without serious injury after prone positioning
Trivia Question 3 Case Study Q uestion You note SOB, crackles throughout al lung fields posteriorly and in both lower lobes anteriorly, and rhonchi over the large airways. What is the significance of crackles in G.S.’s case?
Answer C rackles indicate fluid in the lungsR honchi indicate m ucus in the large airw ays
Trivia Question 4 Case Study Q uestion The nurse from the previous shift charted the fol owing statement, “Crackles and rhonchi clear with vigorous coughing.” Based on your knowledge of pathophysiology, is this statement accurate? Why or why not?
Answer N o, it’s not accurate as w ritten. R honchi clears w ith coughing, but crackles do not.
Pictionary Challenge 1
Pictionary Challenge 2
Trivia Question 5 Which complication affects 68% of patients with ARDS? A. BarotraumaB. Volume pressure traumaC. PneumoniaD. Stress ulcers
Answer Which complication affects 68% of patients with ARDS? A. BarotraumaB. Volume pressure traumaC . Pneum oniaD. Stress ulcers
Trivia TimeOut: Journal #2 • Title: The Effect of Interm ittent Nasogastric Feeding on Preventing Aspiration Pneum onia in Ventilated C riticaly Il Patients • O bjective: Study conducted based on fol owing hypotheses: – Critical y il ventilated patients receiving intermit ent feeding: • Have less gastric residue volume than those with continuous feeding• Will take in more calories from enteral feeding than those receiving continuous feeding • Will have a lower risk of aspiration than those receiving continuous feeding • Will have higher rates of extubation than those receiving continuous feedings • Conclusion: Patients in the intermit ent feeding group: – Had a higher total intake volume (at day 7) than the control group– Had been extubated earlier (at Day 21) than the control group– Had a lower risk of aspiration pneumonia than the control group *The gastric residue volum e m easurem ents were not significantly changed in either groups
Video Challenge What symptom of respiratory distress is this baby exhibiting? ht p:/ www.youtube.com/watch?v=I6WvSY_pqi8&feature=relatedFacilitators: M UTE!
Audio Challenge What adventitious lung sound are you hearing?
Trivia Question 7 Case Study Q uestion You are about to administer 40mg furosemide (Lasix) IVP. What effect, if any, wil furosemide have on G.S.’s breath sounds?
Answer Lasix is a diuretic, w hich w ill cause her to excrete excess fluids and thereby dim inish the crackles.
Trivia Question 8 Case Study Q uestion Name at least two actions you should take before you give furosemide to G.S.
Answer A ssess the lab values Electrolyte levels and kidney function A ssess BP and pulseTrack output Empty catheter drainage bag and use urimeter for increased accuracy
Trivia Question 6 Case Study Q uestion While you administer the furosemide, G.S. says, “This is so weird. A couple times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.” Prioritize your actions from the fol owing: A. Cal a Rapid Response Team code B. Stop the infusion C. Gather equipment for the code responders D. Assess G.S.’s heart (rate, rhythm, etc.)
Answer: B, D, A, C While you administer the furosemide, G.S. says, “This is so weird. A couple times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.” Prioritize your actions from the fol owing: A. Cal a Rapid Response Team codeB. Stop the infusionC. Gather equipment for the code respondersD. Assess G.S.’s heart (rate, rhythm, etc.)
Trivia TimeOut: Journal #3 • Title: Reducing Hospital Standardized M ortality Rate W ith Early Interventions • O bjective: – Successful y implement a working RRT at Henry Ford Hospital, a large teaching hospital – Contribute to a 25% reduction in the hospital standardized mortality rate in conjunction with other 100,000 lives campaign initiatives • Sam ple: 1,335 RRT consults and 207 medical ICU discharge fol owups • Conclusions – Greatest number of occurrences were respiratory triggers • 30% low pulse oximetry • 30% respiratory distress • 20% respiratory rate issues – Number of no pulse blue alert rates fel by 30% – Length of hospital stay decreased by half a day, opening 70 more beds/day – Overal unadjusted hospital mortality rates dropped from 2.8% to 2.4% – Achieved goal of 25% reduction in hospital standardized mortality rate
Trivia Question 9 Case Study Q uestion Which of these values are outside of the normal range? A. Na: 129 mmol/LB. K: 3.3 mmol/LC. pH: 7.38D. PaCO : 49 mm Hg 2 E. HCO : 36 mmol/L 3
Answer: Which of these values are outside of the normal range? A . N a: 129 m m ol/L LO W (136145) B. K : 3.3 m m ol/L LO W (3.55) C. pH: 7.38 OK (7.357.45) D . PaC O : 49 m m H g H IG H (3545) 2 E. H C O : 36 m m ol/L H IG H (2226) 3
Trivia Question 10 Case Study Q uestion Analyze G.S.’s ABGs: pH: 7.38PaO : 82 mm Hg 2 PaCO : 49 mm Hg 2 HCO : 36 mmol/L 3 BE: +2.2SaO : 91% 2
Answer: R espiratory A cidosis w ith Full C om pensation
Trivia Question 11 Case Study Q uestion You open G.S.’s medication drawer to draw the furosemide into a syringe. You find one 20 mg ampule. The pharmacist tel s you that it wil be at least an hour before he can send the drug to you. What should you do?
Answer: G ive 20 m g now Priority is to help G.S. reduce the fluid in her lungs to reduce breathing difficulty Note in G.S.’ s chart that only 20 mg was given and the remaining dose is to be given upon its arrival from pharmacy
Pictionary Challenge 3
Pictionary Challenge 4
Trivia Question 12 The major cause of death in ARDS is ___, often accompanied by ___. A. SIRS (Systemic Inflammatory Response Syndrome); shock B. SIRS; sepsisC. MODS (Multiple Organ Dysfunction Syndrom); shock D. MODS; sepsis
Answer The major cause of death in ARDS is ___, often accompanied by ___. A. SIRS (Systemic Inflammatory Response Syndrome); shock B. SIRS; sepsisC. MODS (Multiple Organ Dysfunction Syndrom); shock D . M O D S; sepsis
Injury to alveolar-capillary membrane Damaged type II alveolar cel Vascular narrowing & obstruction Bronchoconstriction Hyaline membrane formation ARDS
Injury to alveolar-capillary membrane Damaged type II alveolar cel Release of inflammatory mediators ↓Surfactant ↑Alveolar-capillary production Vascular membrane permeability narrowing & ↓Alveolar Outward migration obstruction compliance & recoil of blood cel s & Bronchoconstriction fluids from capil aries Atelectasis Pulmonary edema Hyaline membrane formation Impairment in ↓Lung gas exchange compliance Pulmonary ARDS hypertension
References Chen, Y., Chou, S., Lin, L. & Wu, L. (2006). The effect of intermit ent nasogastric feeding on prevention aspiration pneumonia in ventilated critical y il patients. Journal of Nursing Research, 14 (3), 167180. Curley, M. A. Q., Thompson, J. E., & Arnold, J. H. (2000). The Effects of Early and Repeated Prone Positioning in Pediatric Patients With Acute Lung Injury. Chest Journal, 118 (1), 156163. Deglin, J. H. & Val erand, A. H. (2009). Davis’s Drug Guide for Nurses. Philadelphia, PA: F. A. Davis Company. Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). M edicalSurgical Nursing. St. Louis, MO: Elsevier. Mailey, J., Digiovine, B., Bailod, D., Gnam, G., Jordan, J., & Rubinfeld, I. (2006). Reducing Hospital Standardized Mortality Rate With Early Interventions. Journal of Trauma Nursing, 13 (4), 178182. Pagana, K. D., & Pagana, T. J. (2007). M osby’s Diagnostic and Laboratory Test Reference. St. Louis, MO: Elsevier. Schaffler, R. (2009). [ARDS lecture notes for Adult Health II]. Unpublished. Websites: www.medicinenet.com www.ards.org www.emedicinehealth.com/acute_respiratory_distress_syndrome/article_em.htm