ARF And ARDS

Question 1

Risk Factors of ARDS

Answer 1

• Aspiration (gastric secretions, drowning, hydrocarbons)
• COVID-19 pneumonia
• Drug ingestion and overdose
• Fat or air embolism
• Hematologic disorders (disseminated intravascular coagulation, massive transfusions, cardiopulmonary bypass)
• Localized infection (bacterial, fungal, viral pneumonia)
• Major surgery
• Metabolic disorders (pancreatitis, uremia)
• Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances
• Sepsis
• Shock (any cause)
• Trauma (pulmonary contusion, multiple fractures, head injury)

Question 2

ARDS Physical assessment

Answer 2

Findings:
* Intercostal Retractions
* Crackles on auscultation

Question 3

ARDS Chest X-ray Assessment

Answer 3

Findings:
* Progressive pulmonary Edma
* Quickly worsening bilateral infiltrates
* Increasing alveolar dead space

Question 4

ARDS Diagnostics BNP

Answer 4

• Brain natriuretic peptide (BNP) level- Differentiate between ARDS and cardiogenic pulmonary edema. Higher levels of BNP are associated with a decreased odds for ARDS

Question 5

ARDS Diagnostic-Echocardiography

Answer 5

• Echocardiography- Transthoracic echocardiogram my be used if the BNP is not conclusive.

Question 6

ARDS Diagnostic-Pulmonary artery catheterization

Answer 6

• Pulmonary artery catheterization Findings:
  Absence of elevated left atrial pressure

Question 7

Mild ARDS

Answer 7

arterial oxygen tension (PaO2)/fraction of inspired oxygen (FIO2) > 200 mm Hg but ≤300 mm Hg,

Question 8

Moderate ARDS

Answer 8

PaO2/FIO2 > 100 mm Hg but ≤200 mm Hg,

Question 9

Severe ARDS

Answer 9

PaO2/FIO2 ≤ 100 mm Hg

Question 10

ARDS Medical Management

Answer 10

Identification and treatment of underlying cause

Question 11

ARDS Medical Mgt Supportive Measures

Answer 11

Supportive measures:
* Supplemental oxygen
* Intubation
* Mechanical ventilation with PEEP
* Circulatory support
* Prone positioning- Up tp 16 hrs per day
* Sedation
* Paralysis
* Nutritional therapy
* Frequent repositioning

Question 12

Acute Respiratory Failure

Answer 12

(Happens suddenly without warning)
A sudden and life-threatening deterioration of the gas exchange function of the lungs and indicates their failure to provide adequate oxygenation or ventilation for the blood.

Question 13

ARF- Early Signs

Answer 13

Early
* Restlessness
* Tachycardia
* Hypertension
* Fatigue
* Headache

Question 14

ARF- Late Signs

Answer 14

Late
* Confusion
* Lethargy
* Central cyanosis
* Diaphoresis
* Respiratory arrest

Question 15

ARF- Characteristics of Hypoxia

Answer 15

Hypoxia- a decrease in arterial oxygen tension, PAO2 less than 60 mm HG

Question 16

ARF-Characteristics of Hypercapnia

Answer 16

Hypercapnia- Increase in arterial carbon dioxide tension PACO2, greater than 50 mm HG

Question 17

ARF- Characteristics of Respiratory Acidosis

Answer 17

Respiratory Acidosis- an arterial PH less than 7.35

Question 18

Endotracheal Intubation – timeframe

Answer 18

ET intubation may be used for no longer than 14 to 21 days,

by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing.

Question 19

ABCDEF Bundle

Answer 19

The ABCDEF bundle consists of the following components:
A: Assess, prevent, and manage pain.
B: Both spontaneous awakening and spontaneous breathing trials.
C: Choice of analgesic and sedation.
D: Delirium assessment, prevention, and management.
E: Early mobility and exercise.
F: Family engagement and empowerment.

Question 20

Delirium and Post intensive Care Syndrome (PICS)-
ABCDEF Bundle

Answer 20

It is believed that implementing this bundle can mitigate risks for delirium and possibly PICS. The goals of this bundle are to improve communication among members of the health care team, standardize care related to the assessment and use of sedation, provide nonpharmacologic interventions in the management of delirium, provide early exercise and ambulation, and incorporate family’s concerns and participation in care planning

Question 21

COVID-19 Considerations- PEEP

Answer 21

PEEP > 5 cm H2O should be delivered (although the patient should be closely monitored for barotrauma if the PEEP is >10 cm H2O);

Question 22

COVID-19 Considerations- Low doses of Corticosteroids

Answer 22

Low dosages of intravenous corticosteroids (e.g., dexamethasone, methylprednisolone) may be prescribed;

Question 23

COVID-19 Considerations-Nitric Oxide

Answer 23

Nitric oxide should not be routinely prescribed; however, for patients with severe ARDS refractory to other treatments, nitric oxide might be tried;

Question 24

COVID-19 Considerations- Prone Positioning

Answer 24

For the patient with moderate or severe ARDS, prone positioning for 12 to 16 hours daily is recommended, if feasible; and

Question 25

COVID-19 Considerations- Neurological Assessments

Answer 25

It has been reported that more patients with COVID-19 and ARDS who are mechanically ventilated have neurologic impairment (e.g., delirium, encephalopathy) than other patients with ARDS who are mechanically ventilated

Question 26

COVID-19 Considerations- Increased Sedative Requirements

Answer 26

sedative requirements for these patients are reportedly higher than for most other patients with ARDS

Question 27

COVID-19 Considerations- Airborne Isolation

Answer 27

The nurse caring for these patients must also practice isolation precautions and minimize interactions with the patient, which can serve to make the patient feel more isolated and agitated.

Question 28

Ventilator Considerations- PEEP- Anxiety

Answer 28

Anxiety causes:
* Tube blockage
* Decreased oxygen level
* Ventilator malfunction

Question 29

Ventilator Considerations- PEEP- Sedation

Answer 29

Sedation may be required to decrease the patient’s oxygen consumption, allow the ventilator to provide full support of ventilation, and decrease the patient’s anxiety. Sedatives:
*lorazepam
*midazolam
*dexmedetomidine
*propofol
*short-acting barbiturates.

Question 30

Ventilator Considerations- PEEP- Neuromuscular blocking agents

Answer 30

If the PEEP level cannot be maintained despite the use of sedatives, neuromuscular blocking agents (paralytic agents) may be given to paralyze the patient. Examples of these agents include:
*pancuronium
*vecuronium
*atracurium
*rocuronium

Question 31

Ventilator Considerations- PEEP- Analgesics

Answer 31

Analgesia must be given concurrently with neuromuscular blocking agents. The nurse must anticipate the patient’s needs regarding pain and comfort.