ACUTE RESPIRATORY DISTRESS  Decreased Lung Compliance

SYNDROME (ARDS) o Decreased aeration

o Fibrosis
 Acute Lung Injury  Increased  Etiology
Vascular Permeability  Results to
o Sepsis – most common cause,
Edema and Decreased Aeration especially in alcoholics
(decreased glutathione in lungs)
o Pneumonia – most likely
nosocomial
o Aspiration – commonly gastric
contents (assoc. TEF)
o Severe trauma – bilateral lung
contusion, lung bone fractures
(fat emboli, 12-48 hours)
o Massive blood transfusions - >15
units
o Stem cell transplant (Lung/Bone
Marrow) – primary graft failure
(2-3 days post)
o Drug
 Overdose: alcohol, aspirin,
cocaine, opioids,
phenothiazine
 Idiosyncratic: protamine,
nitrofurantoin,
chemotherapy
 Other Causes
o Smoking
o Cardiopulmonary bypass
o Thoracic surgery
o Pneumonectomy
o Acute pancreatitis
o Obesity
o Blood type A
o Near drowning
 Clinical Condition
o Inciting event  6-72 hours
symptomatic  rapidly worsens
 Three Stages
o Exudative Stage
 diffuse alveolar damage 
Effects: fluid accumulation
(usually <7days)
 Decreased Gas Exchange  Manifestations:
o VQ mismatch – ventilation  Dyspnea
perfusion mismatch is a ratio
 Cyanosis
used to assess the efficiency and (hypoxemia)
adequacy of the matching of two
 Diffuse crackles
variables: V – ventilation – the air
(fluid)
that reaches the alveoli. Q –
 RR/HR
perfusion – the blood that
 Diaphoresis
reaches the alveoli via the
 Use of accessory
capillaries
muscles for
o Physiologic Shunting – right to
breathing
left shunting
 Cough
o Hypoxemia – decrease Oxygen in
blood  Chest pain
 o Proliferative Stage
 Resolution of pulmonary
edema (7-10 days)
 Alveolar type II cells –
squamous metaplasia
 Interstitial myofibroblasts
 Symptoms improve,
unless go to Fibrotic stage
o Fibrotic Stage
 Obliteration of normal
lung
 Diffuse fibrosis
 Cysts formation
 Medical Approach
 Long term MV and
O2
 Biopsy
 Diagnostic Investigations
o ABG – decreased O2, Acute
Respiratory Acidosis
o CXR – diffuse bilateral alveolar
infiltrates
o CT Scan – widespread
patchiness, air bronchogram
 Diagnosis
o Respiratory symptoms - <1 week
of inciting event
o CXR/CT Scan – opacities
o Rule out other conditions:
 Cardiogenic pulmo edema
 no murmur (s2/s4)
 no increase in
jugular vein
pressure
 no cardiomegaly
 venous congestion
 Kerley B-lines
 B-type Natriuretic
Peptide (BNP)
 Blood test
 100pg/ml
 echocardiogram –
normal heart
findings
 PCWP <18mmHg
 Interstitial lung disease
(acute exacerbation)
 clinical findings
 CXR
 Diffuse Alveolar
Hemorrhage
 Hemoptysis
 low H/H
 bronchoalveolar
lavage (BAL) –
frothy blood, RBC,
hemosiderin laden
macrophage
 Cancer
 sometimes so rapid
 mimics ARDS
 Severity of ARDS
o Mild – 200-300
o Moderate – 100-200
o Severe - < 100
 Medical Management
1. Supplemental O2
 Intubation and MV
 Low tidal volume ventilation –
prevent ventilator induced lung
injury; alveolar over distention
and collapse
 PEEP: the setting in the MV that
maintains positive pressure
within the lungs at the end of
expiration, which increases the
residual capacity, reducing
hypoxia
2. Supportive
 Sedation – increase tolerance to
MV; decrease O2 consumption
(LORAZEPAM)
 Paralysis – if sedation is
inadequate (NM BLOCKER;
Succinylcholine)
 Opioid – pain relief
(FENTANYL/MORPHINE)
 Fluid Management – decrease
left atrial filling pressure –
decrease PE; CVP <4mmHg while
maintaining adequate organ
perfusion (esp. kidneys) (FLUID
RESTRICTION, DIURETICS)
 Nutritional Support – high
catabolic state, high nutrition
requirements (ENTERAL
FEEDING)
 Glucose Control
 DVT/GIT Prophylaxis
 3. Treat underlying cause
 Most common cause of death
 Not directly from respiratory
failure
4. Other Therapies
 Surfactant/Antioxidants – no
evidence
 Nitric Oxide, Prostacyclin (PGI),
Prostaglandin (PGE) – no
improvement in outcomes
 Glucocorticoids/Corticosteroids -
<2weeks – uncertain; 2 weeks –
harmful
 Human Mesenchymal Stem Cell
– evidence shows optimistic
results
 Nursing Management
o Assist in respirations
 May require MV to
maintain respiration
 May need to be
transferred to ICU
 May need O2 to combat
hypoxia
 Suction PRN
 Monitor ABG
 If not on MV, asses VS
and respiratory status
every 15 minutes
 Cough, deep breath every
hour
 May need: chest
percussion, vibration;
postural drainage,
suction; bronchodilator
medications
o Prevent Complications
 Decrease anxiety and
provide psychological care
 Maintain calm
atmosphere
 Encourage rest to
conserve energy
 Emotional Support
 Obtain Fluid Balance
 Slow IV flow rate
 Diuretics: rapid
acting, low dose
 Monitor
 PAP (N – 10-20
mmHg) and PCWP
(N – 4-12 mmHg)
 CVP, cardiac
output, peripheral
perfusion
 Intake and Output
 Bleeding
tendencies,
potential for DIC
 Protect from Infection
 Strict aseptic
technique
 Antibiotic therapy
 Provide Physiological
Support
 Maintain nutrition
 Skin Care
o Health Teachings
 Briefly explain procedures
as they are happening
(emergency situation can
frighten the patient)
 Give rationale for follow
up care
 Identify risk factors as
appropriate for prevention
of recurrence
o Outcomes
 Maintain adequate gas
exchange
 Communication reduction
in anxiety
 Performs activities without
respiratory distress or
fatigue