Acute Resp. Failure/Acute Lung InjuryARF: sudden deterioration in pulmonary gas exchange = CO2 retention & inadequate oxygenation | paO2 < 60 mmHg | (should be 80-100) | paCO2 60 mmHg | (should be 35-45) | arterial pH < 7.35 | (pts usually acidotic) |
CausesDirect | Indirect | Aspiration | Sepsis | Pneumonia | Burns | Contusions/trauma | Truama | Upper airway obstruction | TRALI | Toxic inhalation | Drug reaction/OD | SARS | Cardiopulm. bypass | | Pancreatitis | | Multiple fractures | | Lung/bone marrow tx |
Stages of ARFStage 1: inc. SOB, RR, few CXR changes... within 24 hr signs of ARDS (CXR changes) - Tachypneic, dyspneic | Stage 2 (Exudative): vent. required - Address underlying issues | Stage 3 (Proliferative): hemodynamically unstable - Can't maintain BP, tachy, compen. mechanisms, inflammation & cascade of events | Stage 4 (Fibrotic): lung fibrosis issues; vent. management issues - Dec. compliance, stiffness |
Types of Respiratory FailureType 1 - Acute Hypoxemic: abnl. transport of O2 w/ resultant inadequate oxygenation | Type 2 - Hypercapnic: inadequate alveolar ventilation; marked elevation in paCO2 | Type 3 - Mixed Hypoxemic-Hypercapnic: inadequate alveolar ventilation & abnormal O2 transport - Often most common type |
Management of ARFWarrants immediate intervention! | GOALS: Correct the cause Alleviate hypoxemia & hypercapnia |
Indications for IntubationAltered mental status or coma | Severe respiratory distress | Extremely low or agonal RR (gasping) - Cerebral issue r/t O2 | Obvious respiratory muscle fatigue - r/t inc. work of breathing = mechanical vent. | Peripheral cyanosis - fingers, lips dusky | Impending cardiopulm. arrest - heart starts to compensate (tachy, arrythmias) cardiac arrest |
Better to intubate electively rather than emergently!
Mechanical vent. - helps to breathe, protects airway
| | Systemic Inflammatory Response Syndrome (SIRS)2+ of... | Temp. > 100.4oF (38oC) or 98.6oF (36oC) | HR > 90 bpm | RR > 20 breaths/min or paCO2 < 32 | WBC > 12,000 or < 4,000 or/ >10% bands |
Older adults - inc. risk for MODS w/ less chance of recovery from ARDS
Acute Respiratory Distress Syndrome (ARDS)Severe end of continuum | Complex syndrome w/ high mortality risk | Precipitated by direct or indirect lung injury | Pathophysiology: Lung injury Dec. blood flow to lungs (inflamm. mediators thin lung lining) Alveolar membrane damage (membranes thicken, gases can't exchange) Inc. membrane protein permeability ("Leak syndrome"; changes osmotic pressure) Interstitial & intra-alveolar edema (alveolar area flooded = pulm. edema) Further impaired oxygenation Pulm. edema Inflamm. changes can lead to fibrosis (may cause permanent lung change) |
Surfactant gets lost & makes process worse...
- Dec. gas exchange
- Dec. lung compliance (resistance, pressure)
ARDS (cont.)Symptoms can develop very quickly after lung insult | Assessment: | - Accessory muscle use | - Tachypneic | - Tachycardia | - Restless, air hunger = change in O2 - Confusion | - New/worsening lung sounds (crackles, wheezes) steroids | - Change in SpO2 | - Lethargy (lose ability to protect airway) | - Dyspnea | - At risk for arrythmias | - Change in renal status |
Bolded are the earliest signs
ARDS Diagnostic CriteriapaO2 -FiO2 ratio < 200 - shunt formula; normally > 300 | B/L infiltrates on CXR - white out | Elevated serum lactate levels - indicates anaerobic metabolism, tissue hypoxia | No cariac etiology for pulm. edema | Deterioration of ABG's despite intervention - resistant to O2 |
ARDS ManagementGOALS: - Correct the cause - Prevent further damage - Supportive care | Care bundles to improve outcomes | 5 P's of ARDS: - Perfusion (max O2 transport) - Position - Protective lung vent. - Protocol weaning - Prevent complications | Mechanical ventilation |
Fluid status: RA/CVP, JVD, BP, urinary output
| | Mechanical VentilationImproves O2 , figures out CO2 , buys time | Lowest FiO2 possible, smallest TV possible | Modes of MV: | - Volume cycled: pushes air in until preset volume delivered | - Time cycled: pushes air in until preset time reached | - Assist modes: pt can assist but vent can take over work of breathing | - Pressure support: weaning mode; depends on pt's breathing (used for weaning) | - Pressure control: preset volume (based on age, sex, height) | - Airway Pressure-Release Ventilation (APRV) | Weaning ASAP! - Infection - Dependent on machine - Muscles dependent - Vent may cause trauma (barotrauma, pressure trauma) | Positive End Expiratory Pressure (PEEP): back pressure prevents alveolar collapse; helps to keep fluid out of alveoli | - Inc. PEEP = inc. intrathoracic pressure dec. perfusion = dec. CO - Affected intrathoracic pressure = organ failure |
Management of Ventilated Patients3 Priorities: | 1) Monitor & evaluate pt response - Vent setting, trach appropriately - Assess s/s of distress (lung sounds, chest expansion, ABC & disynchrony r/t proper setting [change vent settings]) | 2) Manage vent safely - Not alone, daily CXR for placement | 3) Prevent complications - Oral care (dec. bacteria), turn & repo. (changes lung perfusion), VAP protocol (elevate HOB >30o, aspiration precautions), DVT prophylaxis, skin care | Note: - Breath sounds should be equal & symm. - Document safety, measurement | Proning: no shock, inc. ICP, unstable spine | Pharmacotherapy: - Antibiotics (if known microorganism) - Bronchodilators (airway patency) - Surfactant? (not really used, expensive) - Corticosteroids? (immunosuppressed, glycemic control) - Diuretics (dec. lung/general edema, watch electrolytes) - Neuromuscular blocking agents (paralytic agents, sedatives = dec. work of breathing) - Flolan? (new; inc. flow, V/Q mismatch) - Epinephrine - Low dose dopamine | Ex. Neuromuscular Blocking Agents - propophol, Nimbex, + inotropes + Inotropes: dilate vascular bed = inc. CO (dibutamine, watch for dec. BP - r/t dose; vasopressors) | Nutrition: - Dec. mortality, days of not eating prophylactic enzyme release - Avoid inc. carb feeds | Prevent complications - VAP, SIRS, MODS, DVT, infection, skin breakdown |
Nursing DiagnosesARDS | Mechanical Vent | Impaired gas exchange | Risk for infection | Dec. tissue perfusion | Risk for injury - r/t airway | Airway clearance | Risk for injury - r/t immobility |
NO ineffective breathing pattern
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