Acute Respiratory Distress Syndrome (ARDS) PDF

Acute Respiratory Distress Syndrome (ARDS) Dr. Yasser Abu Jaish PhD in Emergency and critical Care PhD in Community Health Asrar 🧃  What it’s Hypercapnic respiratory failure? - Inadequa...

Acute Respiratory Distress Syndrome (ARDS) Dr. Yasser Abu Jaish PhD in Emergency and critical Care PhD in Community Health Asrar 🧃  What it’s Hypercapnic respiratory failure? - Inadequate CO2 removed. The most important changes in ABG gas in relation to LEARNING OBJECTIVES Hypercapnic respiratory failure? - PaCO2 above normal ( >45 mm Hg) + Acidemia (pH 18mmHg. 4 the balloon can be in ated for measurement of the pulmonary capillary wedge pressure. Normal between 4 to 12 mmHg. If it rises to 18 or more, it indicates excess or uid retention. ▪ Occurrence of an acute lung injury or a history of systemic or pulmonary risk factors 5 6▪ Acute onset of respiratory distress i w i.mil dawns ▪ Diffuse, bilateral infiltrates on chest X-ray y  Management Strategies oTreatment for ARDS primarily involves supportive care in the ICU, including: 1 Providing adequate oxygenation with avoidance of complications 2 Drug therapy 3 Nutritional support Prone positioning 4 Permissive hypercapnia 5 oSupportive therapy almost always includes endotracheal intubation and mechanical 2 ventilation with a low tidal 1volume, pressure-limited approach and low 3 to Inhalation volume moderately high PEEP (lung protective strategies) (positive end-expiratory pressure) to prevent the collapse  Lung Protective Strategies 7 Ventilator therapy for ARDS consisted of high tidal volumes (10 to 12 mL/kg) with high PEEP (20 to 25 cm H2O) to improve oxygen delivery 2 High airway pressures commonly caused patients to develop pneumothorax a collection of air outside the lung but within the pleural (barotrauma) se cavity. 3 High tidal volumes and PEEP levels significantly overdistended the alveoli (volutrauma) y The current ventilation strategy is to deliver a low tidal volume (titrate to 6 mL/kg) themaingoal and low to moderately high PEEP (5 to 20 cm H2O) to keep the alveoli open and diminish the negative effects of high-pressure settings  1. Ventilation 450 500ml normal02Volume Low tidal volume: 6 ml/kg to limit barotrauma (is extra-alveolar air and includes pneumothorax), volutrauma (is lung injury secondary to overdistention of alveoli. Volutrauma occurs when individual alveolar units are overstretched) and rate increased to 20-30 breaths/mt thoria alias Permissive hypercapnia: Low tidal volume with normal respiratory rate. PaCo2 should not exceed 80-100 mm of Hg. Simultaneously arterial PH should be maintained at 7.2 or greater. This is done by giving intravenous sodium bicarbonate. Pressure control ventilation: Each breath is delivered with preset amount of inspiratory pressure  2. Oxygen therapy Goal is to maintain arterial hemoglobin oxygen saturation of 90% or greater using the lowest level of oxygen Positive end expiratory pressure(PEEP) : Opens collapsed alveoli and increases lung compliance. Usually 10-15 cm of H2O normal 5 15 cm  3. Tissue perfusion Adequate hemoglobin & cardiac output are essential for oxygen transport. Cardiac output depends on the heart rate, preload, afterload and contractility. Current approach is maintaining low intravascular volume with fluid resuscitation and diuretics & supporting cardiac output with vasoactive and inotropic medications  4. Drug therapy A gold standard medication regimen for ARDS has yet to be developed. Antibiotics to treatment sepsis-related ARDS or to treat confirmed or suspected underlying infection A diuretic may be used to increase renal excretion of water, which decreases pulmonary interstitial and alveolar edema A mechanically ventilated patient may need to be sedated The administration of fluids in patients with ARDS remains somewhat controversial  5. Nutritional Support Nutritional support is critical for the patient with ARDS Because metabolic demand is high, his caloric needs will be increased; enteral nutrition is preferred  6. Prone Positioning Prone positioning is a treatment modality that can be used for mechanically ventilated patients with ARDS who require high FiO2 levels sb I.sk i.IN Prone positioning may potentially trigger complications, such as pressure ulcers, corneal abrasions, and brachial nerve injury  7. Permissive Hypercapnia A newer management strategy for ARDS The allowance of high levels of carbon dioxide in the bloodstream, achieved by setting low tidal volumes on the ventilator The patient’s pH is allowed to reach levels as low as 7.2 Has been shown to reduce lung injury and is thought to provide a protective mechanism against injury from inflammation  Nursing Management 1 Nursing diagnosis ✓Impaired gas exchange R/T ventilation perfusion mismatching. ✓Decreased cardiac output R/T alterations in preload. ✓Imbalanced nutrition less than body requirements R/T increased metabolic demand ✓Risk for aspiration ✓Risk for infection ✓Anxiety R/T threat to biological, psychological and social integrity  2 Planning oTo keep the maintenance of airway patency. 7 oTo improve or maintain clear airway. 2 oTo Identification of potential complications 3  3 Nursing Interventions 1✓Because patient’s condition could quickly become life-threatening, frequent assessment of his status, including arterial blood gas values and hemodynamic parameters, and evaluation of the effectiveness of treatment are necessary ✓Encourage frequent coughing if the patient can cough, which will help loosen excessive airway mucus and maintain open alveoli ✓If patient can’t cough, you can suction the airway if your assessment 3 determines it’s needed  3 Nursing Interventions ✓Frequent turning and repositioning has been found to improve ventilation and 4 perfusion in the lungs and enhance secretion drainage ✓If prone positioning is being used for your patient, closely monitor his response 5 and for deterioration in oxygenation: Moving patient from the supine position to the prone position can lead to changes in hemodynamic stability ✓Be alert to areas of pressure while your patient is in the prone position, including the knees, face, and abdomen, and take care not to overextend his shoulders to reduce the chance of brachial plexus injury  3 Nursing Interventions 7✓Monitor patient for signs and symptoms of cardiovascular compromise, particularly a decreased cardiac output, which may be caused by decreased venous return or because of positive pressure ventilation 8✓Be alert for changes in BP; decreased pulse intensity, oxygen saturation, or urinary output; and mental status changes 9✓Monitor lab values, especially the hemoglobin level because an adequate amount of hemoglobin is needed to carry oxygen to the tissues  3 Nursing Interventions ✓Administer analgesia and sedation as indicated to optimize patient comfort and reduce anxiety CDC 1✓Follow the Center for Disease Control’s guidelines for proper hand hygiene to help prevent infection VAP 2✓To help prevent Ventilator Associated Pneumonia, implement the Institute for Healthcare Improvement’ ventilator bundle Thank you