Endotracheal Intubation-Mv - Set 3 - Sja

Front 1

- acute progressive form of acute respiratory failure where alveoli-capillary membrane becomes damaged and more permeable to intravascular fluid

- PaO2 remains low despite increases of FIO2

- degree of impairment depends upon (P/F ratio)

- normal is >400

- ARDs is<200

- acute lung injury (ALI) 200-300- mortality rate from ARDs is apx. 50%

Back 1

Acute Respiratory Syndrome (ARDs)

Front 2

- aspiration of gastric contents

- viral or bacterial pneumonia

- SEPSIS **most common**

- MODS or SIRS

- Severe massive trauma

- Embolism

- Near drowning

- O2 toxicity

- shock states

Back 2

Predisposing Conditions to ARDs

Front 3

- Stimulation of the inflammatory and immune system which in turn causes the attraction of neutrophils to the pulmonary interstitum.

- because of "a predisposing injury this occurs: increased capillary membrane permeability, destruction of elastin, collagen, formation of pulmonary emboli, pulmonary vasoconstriction.

Back 3

Etiology and Pathophysiology of ARDs

Front 4

1. injury or exudative phase

2. Reparative or proliferative phase

3. Fibrotic phase

Back 4

3 phases of ARDs

Front 5

- occurs 1-7 days (usually 24-48 hours) after initial insult

- interstitial edema developes - intrapulmonary shunt develops as alveoli fill with fluid and blood cannot be oxygenated

- widespread atelectasis

- decrease in lung compliance - necrotic cells, protein and fibrin lining the alveoli causing (sever mismatch and shunting)

- lungs become less compliant- pt must generate higher airway pressure to inflate lungs

- decrease compliance of the lungs increase the pt. WOB.

Back 5

Injury of Exudative Phase of ARDs

Front 6

- begins 1-2 weeks after insult

- influx of neutrophils, monocytes, lymphocytes as part of the inflammatory process

dense fibrous tissue, increase pulmonary vascular resistance and pulmonary HTN can occur, lung compliance continues to decrease, hypoxia worsens, if this phase is NOT STOPPED, widespread fibrous will develop

Back 6

Reparative or Proliferate phase of ARDs

Front 7

- occurs 2-3 weeks after initial injury (chronic or late phase of ARDs)

- Lung has completely remodeled

diffuse scarring and fibrosis, decrease in lung compliance, surface area for gas exchange is reduced which results in pulmonary HTN

Back 7

Fibrotic Phase

Front 8

- can be very subtle (usually several hours -1-2 days)

- mild dyspnea, tachypnea, cough and restlessness, fine crackles or normal, ABGs will show mild hypoxemia and respiratory alkalosis (because of fast RR),

Back 8

Clinical Manifestations of ARDs

Front 9

as condition progresses symptoms worsen

- respiratory distress and WOB worsen

- tachypnea and intercostal retractions

- mental status changes

- diffuse crackles and rhonchi

** hypoxemia despite increase FIO2 by mask, cannula or mechanical ventilation is the hallmark of ARDs** - hypercapnia signified respiratory muscle fatigue and HYPOventilation, metabolic acidosis and target organ dysfunction

Back 9

Clinical Manifestations of ARDs

Front 10

- major cause of death MODS accompanied by sepsis (kidneys, liver and heart)

- VAP

- Barotrauma - rupture of alveoli during MV

"permissive hypercapnia" allows PCO2 to be higher than normal, gradual rise in PCO2 to allow brain and systemic circulation to compensate. CAN NOT use if pt. has ICP

Back 10

Comlications of ARDs

Front 11

- Volutrauma- alveoli can crack that allows fluid to come in and out.

- use lower VT

- Stress Ulcers - 30% of ARDs pts.

- use PPI protonix and sucralfate(Carafate)

Back 11

Complications of ARDs

Front 12

- correct hypoxemia = face mask or cannula will be inadequate, pt must have mechanical Vent.

- use LOWEST possible O2 to prevent toxicity, and FIO2 of >60% increases risk.

Back 12

Nursing Care for ARDs pt.

Front 13

- PPV (positive pressure vent.)

- FIO2 60% to maintain PaO2 60%

- FIO2 >60% for >48 hours toxicity can develop

- Use PEEP

- 5 cm is physiological but can be as high as 10-20 cm H20 (leave pt. on PEEP decrease FIO2)

Back 13

Nursing Care for ARDs pt.

Front 14

- increase in intrathoracic pressure= compromises venous return to heart

- dec. BP, dec. CO, inc. HR (RT WOULD NEED TO DECREASE PEEP)

- barotrauma - ruptured bleds - WORST CASE PNEUMOTHORAX

- volutrauma - cracks/fractures in alveoli - causes fluid to increase or decrease

Back 14

Complications of PEEP

Front 15

- ADD airway pressure

- pressure control inversion ratio

- high frequency ventilation

- ECMO (allows lungs to heal)

Back 15

what to do if hypoxemia persists with PEEP

(better to be on higher PEEP than higher FIO2)

Front 16

- allows for better perfusion

Back 16

Prone Position

(takes many nurses to accomplish)

Front 17

if pt. gets a air emboli

Back 17

place pt. on left side

Front 18

stimulates postural drainage and vibrations to add chest physiotherapy

Back 18

continuous LATERAL rotation therapy

(moves fluid around)

Front 19

- maintain CO

- Hemodynamic monitoring

arterial line - continuous monitoring of BP and ABGs

- infusion of Dobutrex or dopamine (increase CO)

- infusion of PRBC to increase O2 carrying capacity

- maintain nutrition and fluid balance

Back 19

Nursing Care for pt. with ARDs w/PEEP