An Introduction to ARDShttp://www.youtube.com/watch?v

=SPWAR0bqMkM

What do you know about ARDS?

Key Points About ARDSNon-cardiac pulmonary edemaRefractory hypoxemia

PO2 <50, PCO2 >50, pH < 7.25Mortality rate is greater than 50%

Causes of ARDSDirect Lung Injury Indirect Lung Injury

PathophysiologySystemic response, can occur within 24 hr Increased capillary permeability

Due to damage from activated neutrophilsCauses severe pulmonary edema

Alveoli fill with fluid surfactant production

Causes decreased compliance Causes atelectasis

Hyaline membranes formCauses decreased gas exchange and compliance

Fibrotic lung changesLeads to widespread fibrosis and scarring

Stages of ARDS1.Injury or Exudative stage2.Reparative or Proliferative

stage3.Fibrotic stage

Trivia Question 1Your patient is a 32 yo female

hospitalized as a result of a near-drowning. Upon assessment, you suspect ARDS when you observe all of the following except:A. TachypneaB. RetractionsC. ClubbingD. Cyanosis

AnswerYour patient is a 32 yo female

hospitalized as a result of a near-drowning. Upon assessment, you suspect ARDS when you observe all of the following except:A. TachypneaB. RetractionsC. ClubbingD. Cyanosis

Trivia Question 2Which of the following is NOT an

appropriate method for managing ARDS?A. ADH replacement therapyB. Aggressive respiratory support

w/PEEPC. Surfactant replacement therapyD. Sedation & positioning

AnswerWhich of the following is NOT a way

to manage ARDS?A. ADH replacement therapyB. Aggressive respiratory support

w/PEEPC. Surfactant replacement therapyD. Sedation & positioning

Trivia Time-Out: Journal #1• Title

– The Effects of Early and Repeated Prone Positioning in Pediatric Patients With Acute Lung Injury

• Objective– Evaluate the safety of placing pediatric patients with

ALI/ARDS prone for 20h/d during the acute phase of their illness

• Conclusions– Patients showed improvements in oxygenation without serious injury after prone positioning

Trivia Question 3Case Study QuestionYou note SOB, crackles throughout

all 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?

AnswerCrackles indicate fluid in the lungs

Rhonchi indicate mucus in the large airways

Trivia Question 4Case Study QuestionThe nurse from the previous shift

charted the following statement, “Crackles and rhonchi clear with vigorous coughing.” Based on your knowledge of pathophysiology, is this statement accurate? Why or why not?

AnswerNo, it’s not accurate as written. Rhonchi clears with coughing, but crackles do not.

Pictionary Challenge 1

Pictionary Challenge 2

Trivia Question 5Which complication affects 68% of

patients with ARDS?A. BarotraumaB. Volume pressure traumaC. PneumoniaD. Stress ulcers

AnswerWhich complication affects 68% of

patients with ARDS?A. BarotraumaB. Volume pressure traumaC. PneumoniaD. Stress ulcers

Trivia Time-Out: Journal #2• Title: The Effect of Intermittent Nasogastric Feeding on Preventing

Aspiration Pneumonia in Ventilated Critically Ill Patients

• Objective: Study conducted based on following hypotheses:– Critically ill ventilated patients receiving intermittent 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 intermittent 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 volume measurements were not significantly changed in either groups

Video ChallengeWhat symptom of respiratory

distress is this baby exhibiting?http://www.youtube.com/watch?v

=I6WvSY_pqi8&feature=relatedFacilitators: MUTE!

Answer: Retractions

Audio ChallengeWhat adventitious lung sound are

you hearing?

Answer: Rhonchi

Trivia Question 7Case Study QuestionYou are about to administer 40mg

furosemide (Lasix) IVP. What effect, if any, will furosemide have on G.S.’s breath sounds?

AnswerLasix is a diuretic, which will cause her to excrete excess fluids and thereby diminish the crackles.

Trivia Question 8Case Study QuestionName at least two actions you

should take before you give furosemide to G.S.

AnswerAssess the lab values

Electrolyte levels and kidney functionAssess BP and pulseTrack output

Empty catheter drainage bag and use urimeter for increased accuracy

Trivia Question 6Case Study Question

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 following:A. Call a Rapid Response Team codeB. Stop the infusionC. Gather equipment for the code respondersD. Assess G.S.’s heart (rate, rhythm, etc.)

Answer: B, D, A, CWhile 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 following:A. Call a Rapid Response Team codeB. Stop the infusionC. Gather equipment for the code respondersD. Assess G.S.’s heart (rate, rhythm, etc.)

Trivia Time-Out: Journal #3• Title: Reducing Hospital Standardized Mortality Rate With Early Interventions• Objective:

– Successfully 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

• Sample: 1,335 RRT consults and 207 medical ICU discharge follow-ups• 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 fell by 30%– Length of hospital stay decreased by half a day, opening 70 more beds/day– Overall unadjusted hospital mortality rates dropped from 2.8% to 2.4%– Achieved goal of 25% reduction in hospital standardized mortality rate

Trivia Question 9Case Study QuestionWhich of these values are outside of

the normal range?A. Na: 129 mmol/LB. K: 3.3 mmol/LC. pH: 7.38D. PaCO2: 49 mm HgE. HCO3: 36 mmol/L

Answer:Which of these values are outside of

the normal range?A. Na: 129 mmol/L LOW (136-

145)B. K: 3.3 mmol/L LOW (3.5-

5)C. pH: 7.38 OK (7.35-7.45)D. PaCO2: 49 mm Hg HIGH (35-

45)E. HCO3: 36 mmol/L HIGH (22-

26)

Trivia Question 10Case Study QuestionAnalyze G.S.’s ABGs:

pH: 7.38PaO2: 82 mm HgPaCO2: 49 mm HgHCO3: 36 mmol/LBE: +2.2SaO2: 91%

Answer: Respiratory Acidosis with Full Compensation

Trivia Question 11Case Study QuestionYou open G.S.’s medication drawer

to draw the furosemide into a syringe. You find one 20 mg ampule. The pharmacist tells you that it will be at least an hour before he can send the drug to you. What should you do?

Answer:Give 20 mg 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); shockB. SIRS; sepsisC. MODS (Multiple Organ Dysfunction

Syndrom); shockD. MODS; sepsis

AnswerThe major cause of death in ARDS is

_________________, often accompanied by ____________.A. SIRS (Systemic Inflammatory

Response Syndrome); shockB. SIRS; sepsisC. MODS (Multiple Organ Dysfunction

Syndrom); shockD. MODS; sepsis

Injury to alveolar-capillary membrane

Damaged type II alveolar cell

Hyaline membraneformation

ARDS

Vascularnarrowing

& obstruction

Bronchoconstriction

Injury to alveolar-capillary membrane

Damaged type II alveolar cell

↓Surfactantproduction

↓Alveolarcompliance & recoil

Atelectasis

Hyaline membraneformation

↓Lungcompliance

Impairment ingas exchange

ARDS

Release of inflammatory mediators

Alveolar-capillarymembrane permeability

Vascularnarrowing

& obstructionOutward migration

of blood cells &fluids from capillaries

Pulmonary edema

Pulmonaryhypertension

Bronchoconstriction

References Chen, Y., Chou, S., Lin, L. & Wu, L. (2006). The effect of intermittent nasogastric feeding on

prevention aspiration pneumonia in ventilated critically ill patients. Journal of Nursing Research, 14 (3), 167-180.

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), 156-163.

Deglin, J. H. & Vallerand, 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). Medical-Surgical 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), 178-182.

Pagana, K. D., & Pagana, T. J. (2007). Mosby’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