ARDS

Question 1

What is acute respiratory distress syndrome ?

Answer 1

its a sudden progressive form of acute respiratory failure

Question 2

what does acute respiratory distress syndrome allow to happen to our alveolis ?

Answer 2

alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
( alveoli fill with fluid )

Question 3

patients with ARDS, usually end having clinical manifestations like ?

Answer 3

severe dyspnea
hypoxia
decreased lung compliance

Question 4

what is the biggest predisposition or cause of patients contracting acute respiratory distress syndrome ?

Answer 4

sepsis

Question 5

what is sepsis ?

Answer 5

systemic infection

Question 6

how do we treat sepsis ?

Answer 6

antibiotics

Question 7

if the antibiotics are working what happens ?
if the antibiotics are not working ?

Answer 7

they get better
fever, low blood pressure, increase heart rate

Question 8

dr brooks says, if your patients come into the unit with pneumonia, are they at risk of developing sepsis ?

if they get sepsis, they are at risk for ?

Answer 8

yes

ARDS

Question 9

ards is something that happens quickly, and can you explain the patho to me on how this happens quickly?

Answer 9

you get a bunch of fluids in your lungs and scarring in your lungs all at the same time

fluids decrease the gas exchange
scarring decrease lung compliance, in other words allow you to take a deep breath

Question 10

Ards can happen 2 ways, can you name both ways?

Answer 10

direct lung injury
indirect lung injury

Question 11

what is the direct lung injury for ards?

Answer 11

something that directly hurts the lung
aspiration
pneumonia
pulmonary embolism
near drowning

Question 12

what is the indirect lung injury for ards?

Answer 12

problem from elsewhere in the body that move towards favorable lung enviroemtn and proliferate ( something that alerts lung function, not directly to the lung )

examples
sepsis and massive trauma
shock
acute pancreatitis

Question 13

what is the pathophysiology behind acute respiratory distress syndrome ?

Answer 13

neutrophils are attracted to the lungs, either from a direct cause like pulmonary embolism or an indirect cause like sepsis throughout the body and activate inflammatory and immune responses

Question 14

what are the 4 pathophysiology examples and or conditions that are going on in the body when you develop acute respiratory distress syndrome ?

Answer 14

increase pulmonary capillary membrane permeability

destruction of elastin and collagen

formation of pulmonary micro emboli

pulmonary artery vasoconstriction

Question 15

we understand that the following 4 are the things that are going on inside the body when we develop acute respiratory distress syndrome, but can you elaborate on each one more in depth

• increase pulmonary capillary membrane permeability
• destruction of elastin and collagen
• formation of pulmonary micro emboli
• pulmonary artery vasoconstriction

explain to me what is going on and in detail

Answer 15

leaky capillaries
- ( fluid around your alveoli )
less lung compliance
- ( not as stretchy or good )
decreased perfusion
- ( small clots = gas exchange goes down )
increased pulmonary pressures
- ( pulmonary hypertension )

Question 16

the pathophysiology changes in ARDs goes through 3 phases, what are they ?

Answer 16

Injury or exudative phase
reparative or proliferative phase
fibrotic or fibroproliferative phase

Question 17

when does the injury or exudative phase occurs ?

Answer 17

24-72 hours after initial injury to the lung ( directly or indirectly ) and can last up to 7 days

Question 18

what are the 2 things that are going on in the injury or exudative phase ?

Answer 18

hypoxemia causes increase work of breathing
cardiac output increase then to decrease

Question 19

so this injury or exudative phase will cause hypoxemia in patients, resulting in them to have increase work of breathing, what are some things we see on a patient with ards?

Answer 19

increase WOB
increase RR

Question 20

why does cardiac output increase then decrease when you are in the injury or exudative phase with ards?

Answer 20

because it’ll increase intitallty to try to compensate, however as condition worsens the blood pressure and heart will fall and hypoventilation occurs leading to decreased perfusion throughout the body

Question 21

something important to note with ARDS, you are going to want to send the patient off to do a chest x-ray, however what are you going to see when they are in this injury/ early phase of ards?

Answer 21

nothing, it takes time to be shown on chest x-ray, most of the time you’ll see symptoms of it before hand

Question 22

when does reparative or proliferative phase happen ?

Answer 22

1-2 weeks after initial lung injury

Question 23

what is the x-ray going to look like in the reparative or proliferative phase ?

Answer 23

filled with fluid

Question 24

what is going inside with the reparative or proliferative phase ?

Answer 24

lung becomes dense and fibrous and lung compliance continues to drop heavily

scarring and inflammation are still going on

Question 25

when does the fibrotic or fibroproliferative phase happen ?

Answer 25

2-3 weeks after initial lung injury

Question 26

what is going on inside the body when we are in the fibrotic or firboproliferativu phase?

Answer 26

everything is literally just 100x worse, the likeliness of them surviving is like zero to none, everything is hard, lung compliance just keeps getting worse, area for gas exchange is just near to nothing and pulmonary hypertension is at its all high time cause if the lack of perfusion in the body

Question 27

clinical progression some patients are able to survive the acute phase of lung injury and their pulmonary edema resolves and make a complete recovery within a week or so, however how likely are patients who enter the fibrotic phase able to survive? usually they also end up requiring what ?

Answer 27

not for long, long term mechanical ventilation

Question 28

do you think their are factors that determine patients recovery ? if so can you name some?

Answer 28

nature of initial injury, comorbidities, complications and genetic predisposition

Question 29

how are patients in the early phase of ards going to look like ? like clinical manifestations wise 24-72 hours

Answer 29

mild dyspnea tachypnea cough restlessness

Question 30

how are patients ABGs and chest x-ray going to be looking like when they are in the early phase of ards?

Answer 30

mild hypoxemia normal

Question 31

how are patients in the late phase of ards going to look like ? like clinical manifestations wise

Answer 31

symptoms are 100x worse with increase fluid accumulation increase WOB -> respiratory distress tachypnea, intercostal retraction tachycardia cyanosis pallor crackles

Question 32

how is the chest x-ray going to be looking at in the later phases of ards?

Answer 32

showing diffuse and extensive bilateral interstital and alveolar infiltrates - literally their lungs are filled with fluid literally completely white or full of scaring

Question 33

how are the ABGs going to look like in the late presentation ? (2)

Answer 33

refractory hypoxemia hypercapnia

Question 34

refractory hypoxemia is a late presentation, but what does that mean ?

Answer 34

usually this is hypoxemia in patients who are in mechanical ventilations, so like not even the machine can help their breathing

Question 35

the following will be going through every system and how patients with arbs die, so your job Is to name reason why they do due to it. infection respiratory gi renal cardiac hematologic Endotracheal tube ( ET ) CNS

Answer 35

- Catheter-related - o2 toxicity, barotrauma, pe, pulmonary fibrosis,vap - stress ulcers, hemorrhage - acute kidney injury - dysrhythmias, decreased cardiac output - anemia, VTE - laryngeal ulceration, stenosis - delirium, PTSD, sleep deprivation

Question 36

what is the main cause of death with patients who have ards?

Answer 36

MODS sepsis vital organs affect - kidneys, lungs, liver, heart

Question 37

notes complications for ARDS - ventilator-associated pneumonia ( VAP ) - impaired host defense - invasive monitoring devices - aspiration of GI contents - prolonged mechanical ventilation strategies for prevention of VAP - good Hand hygiene - elevated HOB 30-45 degrees - oral care - stress ulcer prophylaxis - VTE prophylaxis

Question 38

patients with ards can also get something called barotrauma, what is it ?

Answer 38

high peak pressures cause rupture of over distended alveoli during mechanical ventilation

Question 39

how can we prevent barotrauma with patients suffering from ards?

Answer 39

patients should be ventilated with smaller tidal volumes and varying amounts of PEEP to reduce the risk

Question 40

stress ulcers are a common complication with patients suffering with ards, how does this occur with patients with ards?

Answer 40

the diversion of blood from gi tract to respiratory system to try to meet the demand of oxygen

Question 41

how do we correct stress ulcers and know that its being effective?

Answer 41

proton pump inhibitor & early feeding no more bleeding in stool -> testing for occult blood

Question 42

how is VTE a complication for patients who are having ards?

Answer 42

immbolity and venous status leading to increased risk of developing DVT and PE

Question 43

how do we prevent VTE from happening to patients with ards?

Answer 43

compression stockings early ambulation anticoagulants

Question 44

how does acute kidney injury happen to patients who have ards?

Answer 44

from decreased renal perfusion and subsequent decreased delivery of oxygen to kidneys remember if you are not getting oxygen, the first thing your body does to try to compensate is to ignore the kidneys = decreased urine output

Question 45

what is the management for acute kidney injury with patients with ards?

Answer 45

monitor input and output Daily bun and creatinine levels dialysis

Question 46

to recap, what were the big 4 complications for ards?

Answer 46

barotrauma stress ulcers VTE acute kidney injury

Question 47

notes patients who end up surviving ards can end up having things like - anxiety - memory and attention issues - inability to focus - nightmares - depression - PTSD ( up to 5 years later )

Question 48

what are some things we are going to do on assessment with patients on ards?

Answer 48

past health history medications surgery or other treatments tachycardia progressing to bradycardia extra heart sounds abnormal heart sounds hypertension to hypotension somnolence, confusion, delirium

Question 49

something I want to mention is that when a patient is having ards, what happens first then progresses into what ?

Answer 49

it starts off with hypertension then into hypotension

Question 50

nursing diagnoses - anxiety, ineffective breathing patterns, airway clearance, risk for imbalanced fluid volume, impaired gas exchange nursing planning - adequate lung ventilation to maintain normal PH - clear lungs on auscultation - resolution of precipitating factors

Question 51

what are some nursing implementation we are going to do for our patients with ARDS? (7)

Answer 51

oxygen administration PEEP prone positioning ECMO mechanical ventilation pain meds nutrition

Question 52

when is the best practice to do prone positioning for patients of ards? for how long ?

Answer 52

early ards 16 hours per day

Question 53

what is another positioning strategies we can do for patients with ards?

Answer 53

continuous lateral rotation therapy - side to side turning of the bed Frame less than 40 degrees 18 of every 24 hours - helps you not have fluid sitting in one place

Question 54

what is kinetic therapy ?

Answer 54

patient rotated side to side at 40 degrees or greater

Question 55

sometimes we may want to give pain and sedation pills to do what for patients with ards?

Answer 55

help with pain, discomfort and reduce anxiety

Question 56

why do we want to promote tissue perfusion with patients with ards?

Answer 56

to help avoid hemodynamic compromise and overall be able to give blood and oxygen to the rest of the body in order to breathe better and avoid other complications

Question 57

why do we want to maintain fluid balance and nutrition for patients with ards?

Answer 57

because it burns off so much calories trying to breathe and we want to avoid other complications remember start 24-48 hours

Question 58

notes ards evaluation expected outcomes - independenly maintain a patent airway - achieve normal or baseline respiratory system and function - maintain adequate oxygenation as shown by normal or baseline abgs - have normal hemodyanmic status - be free of complications

Question 59

remember we want at the end is adequate breathing!