ACUTE RESPIRATORY

DISTRESS SYNDROME
MEGAN DAVIS, COLIN JACK & ASHLEY CAMARGO
PATHOPHYSIOLOGY
SEVERE ACUTE LUNG INJURY CAUSES INFLAMMATORY
RESPONSE
INFLAMMATION RELEASES MEDIATORS THAT AFFECT
CAPILLARY MEMBRANE PERMEABILITY, AIRWAY
DIAMETER, AND PULMONARY VASCULATURE

PATHOPHYSIOLOGY
INCREASED CAPILLARY PERMEABILITY
FLUID INFILTRATE INTO LUNGS
LOSS OF SURFACTANT
ALVEOLAR COLLAPSE
PATHOPHYSIOLOGY
DECREASED AIRWAY DIAMETER
INCREASED AIRWAY RESISTANCE & DECREASED
LUNG COMPLIANCE
INCREASED WORK OF BREATHING
ALVEOLAR HYPOVENTILATION
REFRACTORY HYPOXEMIA
PATHOPHYSIOLOGY
INJURY TO PULMONARY VASCULATURE
PULMONARY VASOCONSTRICTION
MICROEMBOLI FORMATION
PULMONARY HYPERTENSION
INCREASED ALVEOLAR DEAD SPACE & DECREASED
CARDIAC OUTPUT
ETIOLOGY/RISK FACTORS
ASPIRATION (GASTRIC SECRETIONS,
DROWNING, HYDROCARBONS)
INHALATION OF HIGH
CONCENTRATIONS OF OXYGEN,
SMOKE OR CORROSIVE
SUBSTANCES OVER A LONG PERIOD
OF TIME
DIRECT LUNG INJURY (SMOKE
INHALATION)
DRUG OVERDOSE
HEMATOLOGIC ISSUES (DIC,
MASSIVE TRANSFUSION,
CARDIOPULMONARY BYPASS)
LUNG INFECTION
SHOCK
SYSTEMIC SEPSIS
METABOLIC DISORDERS
(PANCREATITIS, UREMIA)
TRAUMA (PULMONARY
CONTUSION, MULTIPLE
FRACTURES, HEAD INJURY)
MAJOR SURGERY
FAT OR AIR EMBOLISM
SEVERE ACUTE LUNG INJURY/ALVEOLAR DAMAGE
LAB TESTS/DIAGNOSTICS

CHEST X-RAY
BNP LEVELS-BNP LEVELS INDICATE ARDS OVER CARDIOGENIC EDEMA
TRANSTHORACIC ECHOCARDIOGRAPHY-USED IF BNP IS DOES NOT LEAD TO
CLEAR DIAGNOSIS. AORTIC AND MITRAL VALVE DYSFUNCTION, OR LOW LEFT
VENTRICULAR EJECTION FRACTION SUGGEST CARDIOGENIC PULMONARY
EDEMA.
PULMONARY ARTERY CATHETERIZATION-DEFINITIVE DIAGNOSTIC PROCEDURE
TO DETERMINE WHETHER PATIENT HAS HEART FAILURE OR ARDS. ALSO USED
TO EVALUATE FLUID STATUS AND PULMONARY HYPERTENSION.
ARTERIAL BLOOD GAS ANALYSIS

LAB TESTS/DIAGNOSTICS
PULSE OXIMETRY
PULMONARY FUNCTION TESTING
BLOOD TESTS SUCH AS CBC AND BLOOD CHEMISTRIES
URINALYSIS
SPUTUM CULTURES
BRONCHOSCOPY


MEDICATIONS
MEDICATIONS TO SUPPORT PATIENT
INOTROPIC MEDICATIONS/VASOPRESSORS TO TREAT SYSTEMIC
HYPOTENSION
PULMONARY ANTIHYPERTENSIVE AGENTS
ANTISEPSIS AGENTS

MEDICATIONS
SEDATIVES TO REDUCE OXYGEN USE AND FACILITATE EFFECTIVE MECHANICAL
VENTILATION: LORAZEPAM (ATIVAN), MIDAZOLAM (VERSED), DEXMEDETOMIDINE
(PRECEDEX), PROPOFAL (DIPRIVAN), AND SHORT-ACTING BARBITUATES
PARALYTICS MAY ALSO BE USED: PANCURONIUM (PAVULON), VECURONIUM
(NORCURON), ATRACURIUM (TRACRIUM), AND ROCURONIUM (ZEMURON)
MEDICATIONS TO LOWER CHANCES OF DEEP VEIN THROMBOSIS AND GI BLEED

MEDICATIONS
MAY HELP, BUT ARDS NETWORK DOES NOT RECOMMEND USING THEM ON A
REGULAR BASIS:
CORTICOSTEROIDS
SMALL DOSES MAY INCREASE SURVIVAL RATE.
WHEN GIVEN DURING THE BEGINNING PHASES OF ARDS CAN HELP KEEP CONDITION
FROM PROGRESSING
CORTICOSTEROIDS MUST BE USED CAREFULLY BECAUSE THEY SUPPRESS THE IMMUNE
RESPONSE
INHALED NITRIC OXIDE
CAUSES VASCULAR DILATION IN THE LUNGS
CAN INCREASE GAS-EXCHANGE FOR A SMALL PERIOD OF TIME
DOES NOT DECREASE DEATH RATE.
SCIENTISTS ARE RESEARCHING THE USE OF IV ALBUTEROL,
PROSTAGLANDINS, ACETYLCYSTEINE, AND DROTRECOGEN ALFA AS
TREATMENTS.

TREATMENTS
SUPPLEMENTAL OXYGEN
NEBULIZER THERAPY
CHEST PHYSIOTHERAPY
SUCTIONING
BRONCHOSCOPY
INTUBATION & MECHANICAL
VENTILATION WITH PEEP



ENTERAL OR PARENTERAL NUTRITION
35-45 kCAL/kg/day

REPOSITIONING TO PROMOTE SECRETION DRAINAGE &
GAS EXCHANGE

DECREASE O2 CONSUMPTION
MINIMIZE ANXIETY
PROMOTE REST

PEEP
POSITIVE END-EXPIRATORY PRESSURE
RELATIVELY LOW FIO2 WHILE STILL MAINTAINING PAO2>60 MM HG
OR O2 SATURATION >90%
ASSISTS IN KEEPING ALVEOLI OPEN
INCREASES ARTERIAL O2 LEVELS
BETTER VENTILATION-PERFUSION RATIO

TEACHING PLAN
ASSESS PATIENTS ABILITY TO COMMUNICATE
ESTABLISH COMMUNICATION METHOD WITH PATIENT
OFFER SIMPLE EXPLANATIONS TO PATIENT & FAMILY
BASIC PATHOPHYSIOLOGY
PURPOSE OF DIAGNOSTIC TESTS
PROVIDE OPPORTUNITIES FOR QUESTIONS
INFECTION CONTROL
MEDICATIONS
PURPOSE OF SEDATION/PARALYSIS
PARALYSIS IS TEMPORARY
PURPOSE OF PICC LINE
TEACHING PLAN
INTUBATION AND MECHANICAL VENTILATION
PURPOSE
BASIC PROCESS
ALARMS
PURPOSE OF SUCTIONING, REPOSITIONING, AND OTHER INTERVENTIONS
IMPORTANCE OF PROMOTING REST
ANY MEDICATIONS PATIENT WILL GO HOME ON
FOLLOW UP
HOW TO REDUCE RISK FOR RECURRENCE OF ARDS
SCENARIO
36 YEARS OLD
MVA-PINNED BEHIND STEERING
WHEEL
INTUBATED IMMEDIATELY
BILATERAL FLAIL CHEST
TORN INNOMINATE ARTERY
RIGHT HEMOTHORAX
&PNEUMOTHORAX
FRACTURED SPLEEN
SMALL LIVER LACERATIONS
COMPOUND FRACTURES OF
BOTH LEGS
PROBABLE CARDIAC CONTUSION
SCENARIO
36 UNITS OF PACKED RBCS
20 UNITS PLATELETS
20 UNITS CRYOPRECIPITATE
12 UNITS FRESH FROZEN PLASMA
18 L RINGERS SOLUTION
DEVELOPED ARDS

NURSING PROCESS
NURSING DIAGNOSIS: IMPAIRED GAS EXCHANGE R/T FLUID IN THE ALVEOLI AEB
DYSPNEA, REFRACTORY HYPOXEMIA, AND TACHYPNEA.
GOAL: PATIENT WILL SHOW SIGNS OF ADEQUATE OXYGENATION INCLUDING O2 SAT
>90 AND PAO2 >80 MM HG.
INTERVENTIONS
PREPARE THE PATIENT FOR INTUBATION. ONCE INTUBATED, MONITOR VENTILATOR
SETTINGS.
SUCTION SECRETIONS AS NEEDED
ELEVATE THE HEAD OF THE BED 45 DEGREES
PROMOTE REST
MONITOR BREATH SOUNDS, VITAL SIGNS, AND 02 SAT
MONITOR ABGS
ASSESS SKIN COLOR AND CAPILLARY REFILL

NURSING PROCESS
NURSING DIAGNOSIS: RISK FOR INFECTION R/T INTUBATION, URINARY CATHETER,
CHEST TUBE, AND PICC LINE.
GOAL: PATIENT WILL REMAIN FREE FROM INFECTION, AND IF INFECTION BEGINS TO
DEVELOP IT WILL BE QUICKLY RECOGNIZED AND REPORTED TO DOCTOR.
INTERVENTIONS:
NURSING INTERVENTIONS:
FREQUENT AND PROPER ORAL CARE
SUCTIONING
CATHETER CARE & MONITOR URINE OUTPUT
MONITOR CHARACTERISTICS OF FLUID OUTPUT FROM CHEST TUBE
MONITOR TEMPERATURE AND VITAL SIGNS
PROPER PICC LINE CARE WITH ASEPTIC TECHNIQUE
FIRST DRESSING CHANGE-24 HOURS POST-PLACEMENT
THEN DRESSING CHANGES EVER 5-7 DAYS AND ADDITIONALLY PRN

NURSING PROCESS
NURSING DIAGNOSIS: ANXIETY R/T TRAUMA AND NEAR DEATH AEB PATIENT
LOOKS FRIGHTENED.
GOAL: PATIENTS ANXIETY WILL BE REDUCED TO THE MINIMUM POSSIBLE
INTERVENTIONS:
EXPLAIN PROCEDURES TO PATIENT AS THEY ARE PERFORMED
WATCH FOR NON-VERBAL SIGNS OF ANXIETY
PROVIDE QUIET ENVIRONMENT
ALLOW PATIENTS FAMILY TO VISIT PATIENT
ADMINISTER SEDATIVES IF INDICATED
EXPLAIN THAT EFFECT OF PARALYTICS IS TEMPORARY

G.S.S RISK FACTORS FOR ARDS
LUNG INJURY
MULTIPLE BLOOD
TRANSFUSIONS
TRAUMA
MAJOR SURGERY
PROGRESS NOTES
AWAKE, ALERT, ORIENTED TO PERSON
& PLACE
MOVES BOTH ARMS, WIGGLES TOES ON
BOTH FEET
CLEAR HEART TONES
BILATERAL RADIAL PULSE 3+
FOOT PULSES BY DOPPLER ONLY
VS: BP 138/90, 02 88, RR 26, T 99.3
DEGREES F
HEALED INCISIONS/LACERATIONS
BILATERAL CHEST TUBE TO WATER SUCTION
WITH CLOSED DRAINAGE; BOTH DRESSINGS
DRY AND INTACT
DUODENAL FEEDING TUBE
FOLEY CATHETER TO DOWN DRAIN
DOUBLE LUMEN PICC LINE
SIX WEEKS LATER ARDS IS ALMOST RESOLVED AND G.S. IS TRANSFERRED
FROM ICU:
WHAT ADDITIONAL INFORMATION WILL YOU REQUIRE DURING THIS
REPORT?
BREATHE SOUNDS
02 SAT
ABGS
URINE OUTPUT
AMOUNT/QUALITY OF CHEST TUBE DRAINAGE
COLOR, TEMPERATURE, & SENSTATION IN PATIENTS FEET
CASE STUDY PROGRESS NOTES
YOU COMPLETE YOUR ASSESSMENT OF G.S. AND FIND:
SOB
FINE CRACKLES THROUGHOUT ALL LUNG FIELDS POSTERIORLY & IN BOTH LOWER
LOBES
COURSE CRACKLES OVER LARGE AIRWAYS
WHAT IS THE SIGNIFICANCE OF THE FINE AND COURSE CRACKLES?
FINE CRACKLES INDICATE FLUID IN ALVEOLI
COURSE CRACKLES INDICATE FLUID AND SECRETIONS IN LARGE AIRWAYS
THE NURSE FROM THE PREVIOUS SHIFT CHARTED: FINE AND COURSE
CRACKLES THAT CLEAR WITH VIGOROUS COUGHING. IS THIS STATEMENT
ACCURATE?
NO, IN ARDS THE CRACKLES DO NOT CLEAR AFTER COUGHING



CASE STUDY PROGRESS NOTES
FUROSEMIDE (LASIX) 40 MG IV PUSH IS ORDERED. WHAT AFFECT
WILL THIS HAVE ON G.S.S BREATH SOUNDS?
REDUCE CRACKLES (PULLS EXTRA FLUID FROM LUNGS)
WHAT ACTIONS SHOULD YOU TAKE BEFORE ADMINISTERING THE
FUROSEMIDE?
CHECK RENAL AND LIVER FUNCTION
CHECK ELECTROLYTE LEVELS

LAB VALUES
WHICH LABORATORY VALUES CONCERN YOU AND WHY?
LOW POTASSIUM BECAUSE FUROSEMIDE CAN LEAD TO
HYPOKALEMIA
LOW CALCIUM BECAUSE FUROSEMIDE CAN LEAD TO
HYPOCALCEMIA
LOW SODIUM BECAUSE FUROSEMIDE CAN CAUSE
HYPONATREMIA
LOW CHLORIDE BECAUSE FUROSEMIDE CAN CAUSE
HYPOCHLOREMIA
HIGH CREATININE & BUN LEVELS BECAUSE FUROSEMIDE CAN
AFFECT RENAL FUNCTION
CASE STUDY PROGRESS NOTES
PHYSICIANS ORDERS
STAT magnesium (Mg) level
KCl 40 mEq IVPB over 4 hours now
Calcium gluconate 2 g in 100 mL NS IVPB over 3 hours
GIVEN THE LABORATORY VALUES LISTED, WHAT ACTION WOULD YOU TAKE
BEFORE ADMINISTERING THE FUROSEMIDE, AND WHY?
BEGIN ADMINISTERING THE KCl AND THE CALCIUM GLUCONATE BEFORE
ADMINISTERING THE FUROSEMIDE
MEDICATION ADMINISTRATION
G.S. HAS ONE AVAILABLE PORT TO USE ON THE PICC LINE. DESCRIBE YOUR
PLAN FOR ADMINISTERING THE KCl AND THE CALCIUM GLUCONATE.
ADMINISTER THE KCl THROUGH THE PICC LINE AND ADMINISTER THE
CALCIUM GLUCONATE IVPB.
AFTER YOU START THE ELECTROLYTES, PLACE A PERIPHERAL IV TO PUSH
THE FUROSEMIDE THROUGH.

WHEN YOU OPEN G.S.S MEDICATION DRAWER, YOU FIND THAT THERE IS ONLY
ONE 20-mg AMPULE OF FUROSEMIDE. THE PHARMACIST TELLS YOU THAT IT
WILL BE AT LEAST AN HOUR BEFORE HE CAN SEND THE DRUG TO YOU. YOU
REALIZE IT IS ILLEGAL TO TAKE THE MEDICATION DISPENSED BY A
PHARMACIST FOR ONE PATIENT AND USE IT FOR ANOTHER PATIENT. WHAT
SHOULD YOU DO?
GIVE 20-mg NOW AND GIVE THE OTHER 20-mg WHEN IT ARRIVES



CASE STUDY PROGRESS NOTES
WHILE YOU ADMINISTER THE FUROSEMIDE AND HANG THE IVPB MEDICATION,
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 THERES A
BIRD FLOPPING AROUND IN THERE. WHAT ARE THE FIRST ACTIONS YOU
SHOULD TAKE AND WHY?
STOP ADMINISTERING THE LASIX BECAUSE IT COULD BE CAUSING THE SYMPTOMS
TAKE VITALS
START AN ECG AND ASSESS THE PATIENTS HEART RATE AND RHYTHM
ASSESS FOR ADEQUATE PERFUSION

ASSESSMENT
HR 66, IRREGULAR
BP 92/70
RR 26
A LITTLE LIGHTHEADED; DENIES PAIN OR NAUSEA
ECG
WHAT DO YOU THINK IS HAPPENING WITH G.S.?
SINUS RHYTHM WITH FREQUENT PVCS AND RUNS OF
VENTRICULAR TACHYCARDIA
RESPONDING TO PVCS/VENTRICULAR
TACHYCARDIA
WHAT WILL YOUR NEXT ACTIONS BE?
PUT PATIENT ON TELE
GET 02 SAT AND PUT ON 02 IF INDICATED
PREPARE TO CARDIOVERT OR DEFIBRILATE IF IT BECOMES
NECESSARY
CONTINUE TO MONITOR


PVCS/ V-TACH
WHAT ARE THE MOST LIKELY CAUSES OF G.S. HAVING ABNORMAL
HEART BEATS?
HYPOKALEMIA IS MOST LIKELY CAUSE
HYPOCALCEMIA AND OTHER ELECTROLYTE IMBALANCES MAY
CONTRIBUTE
ARTERIAL BLOOD GASES

HOW WOULD YOU INTERPRET G.S.S BLOOD GASES?
pH 7.30
PaCO2 59 mm HG
PaO2 82 mm HG
HCO3 36 mmol/L
SaO2 91%
PARTIALLY COMPENSATED RESPIRATORY ACIDOSIS





CASE STUDY
YOU NOTICE THAT G.S. LOOKS FRIGHTENED AND IS LYING STIFF
AS A BOARD. HOW WOULD YOU RESPOND TO THIS SITUATION?
FIRST ASSESS VITAL SIGNS
IF VITALS ARE TRENDING DOWNWARD RAPIDLY, CALL A CODE
ECG
ASK PATIENT TO DESCRIBE HOW SHE IS FEELING
COMPLETE PHYSICAL ASSESSMENT