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ACUTE RESPIRATORY DISTRESS
SYNDROME
(ARDS)

Presented By:
Atul Lawrence
Medical Surgical Nursing

1
INTRODUCTION TO RESPIRATORY SYSTEM

Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli

2
INTRODUCTION TO RESPIRATORY SYSTEM
contd…………

Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli...
INTRODUCTION TO RESPIRATORY SYSTEM
contd…………

Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli...
RESPIRATORY DISTRESS SYNDROME (ARDS)
• Acute respiratory distress syndrome (ARDS) is a life-threatening

lung condition th...
DEFINITION
• Acute respiratory distress syndrome (ARDS) is a
sudden and progressive form of acute
respiratory failure in w...
ETIOLOGY & RISK FACTORS
• Direct Lung Injury
– Common causes
• Aspiration of gastric contents or other substances.
• Viral...
ETIOLOGY & RISK FACTORS
• Indirect Lung Injury
– Common causes
• Sepsis
• Severe traumatic injury
– Less common causes
• A...
SCHEMATIC REPRESENTATION OF PATHOPHYSIOLOGY OF ARDS
Lung injury
Release of Vasoactive substances
(serotonin, histamine, br...
CLINICAL MANIFESTATIONS
• Early signs/symptoms
–
–
–
–
–
–

Restlessness
Dyspnea
Low blood pressure
Confusion
Extreme tire...
CLINICAL MANIFESTATIONS

CONTD…………

Late signs & symptoms
– Severe difficulty in breathing i.e., labored, rapid
breathing....
DIAGNOSITC EVALUATION
• History of above symptoms
• On physical examination
– Auscultation reveals abnormal breath sounds
...
COMPLICATIONS
• Common complications are;
– Nosocomial pneumonia:
– Barotrauma
– Renal failure

• Other complications are ...
MEDICAL MANAGEMENT
• Persons with ARDS are hospitalized and require
treatment in an intensive care unit.
• No specific the...
Intubation Procedure
Preoxygenate with 100% oxygen to
provide apneic or distressed patient
with reserve while attempting t...
Intubation Procedure
Insert Laryngoscope
Intubation Procedure
Mr sanjay. M. Peerapur, Principal, KLES
Institute of Nursing Sciences, Hubli

‹#›
Intubation Procedure
After displacing the epiglottis
insert the ETT.
The depth of the tube for a male
patient on average i...
Intubation Procedure
Confirm tube position:
By auscultation of the chest
Bilateral chest rise
Tube location at teeth
C...
Intubation Procedure
Stabilize the ETT
Ventilator Settings
Terminology
•A/C: Assist-Control
•IMV: Intermittent Mandatory Ventilation
•SIMV: Synchronized Intermit...
Ventilator Settings
Terminology (con’t)
•PRVC: Pressure Regulated Volume
Control
•PEEP: Positive End Expiratory Pressure
•...
Settings
1.
2.
3.
4.

5.
6.
7.

Trigger mode and sensitivity
Respiratory rate
Tidal Volume
Positive end-expiratory pressur...
Trigger
 There are two ways to initiate a ventilator-delivered

breath: pressure triggering or flow-by triggering
 When ...
Tidal Volume
 The tidal volume is the amount of air delivered with

each breath. The appropriate initial tidal volume
dep...
Respiratory Rate
 An optimal method for setting the respiratory rate has

not been established. For most patients, an ini...
Positive End-Expiratory Pressure
(PEEP)
 Applied PEEP is generally added to mitigate end-

expiratory alveolar collapse. ...
Flow Rate
 The peak flow rate is the maximum flow delivered by

the ventilator during inspiration. Peak flow rates of 60
...
Inspiratory Time: Expiratory Time
Relationship (I:E Ratio)
 During spontaneous breathing, the normal I:E ratio is

1:2, i...
Fraction of Inspired Oxygen
 The lowest possible fraction of inspired oxygen (FiO2)

necessary to meet oxygenation goals ...
MODES of VENTILATION
Control Mode

Delivers pre-set volumes at a pre-set
rate and a pre-set flow rate.
The patient CANNOT generate
spontaneous ...
Assist/Control Mode
•Delivers pre-set volumes at a preset rate and a pre-set flow rate.
•The patient CANNOT generate
spont...
SYCHRONIZED
INTERMITTENT MANDATORY
VENTILATION (SIMV):
Delivers a pre-set number of breaths at a
set volume and flow rate...
SIMV cont.

Machine Breaths

Spontaneous Breaths
PRESSURE REGULATED
VOLUME CONTROL (PRVC):
• This is a volume targeted, pressure
limited mode. (available in SIMV or
AC)
• ...
PRVC
POSITIVE END
EXPIRATORY PRESSURE
(PEEP):
• This is NOT a specific mode, but is rather an
adjunct to any of the vent modes....
PEEP cont.

Pressure above zero

PEEP is the
amount of
pressure
remaining in the
lung at the END
of the expiratory
phase.
Continuous Positive Airway
Pressure (CPAP):
• This IS a mode and simply means that a preset pressure is present in the cir...
HIGH FREQUENCY
VENTILATION
Oxygenation
• Oxygenation is primarily controlled by the
Mean Airway Pressure (Paw) and the FiO2.
• Mean Airway Pressure i...
Initial Settings
•
•
•
•
•
•
•
•

Select your mode of ventilation
Set sensitivity at Flow trigger mode
Set Tidal Volume
Se...
Post Initial Settings
• Obtain an ABG (arterial blood gas)
about 30 minutes after you set your
patient up on the ventilato...
ABG
• Goal:
• Keep patient’s acid/base balance within
normal range:
• pH
• PCO2
• PO2

7.35 – 7.45
35-45 mmHg
80-100 mmHg
TROUBLESHOOTING
TROUBLESHOOTING

• Anxious Patient
– Can be due to a malfunction of the ventilator
– Patient may need to be suctioned
– Fr...
Low Pressure Alarm

• Usually due to a leak in the circuit.
– Attempt to quickly find the problem
– Bag the patient and ca...
High Pressure Alarm
• Usually caused by:
– A blockage in the circuit (water
condensation)
– Patient biting his ETT
– Mucus...
Low Minute Volume Alarm
• Usually caused by:
– Apnea of your patient (CPAP)
– Disconnection of the patient from
the ventil...
Accidental Extubation
• Role of the Nurse:
– Ensure the Ambu bag is attached to the
oxygen flowmeter and it is on!
– Attac...
OTHER
• Anytime you have concerns,
alarms, ventilator changes or any
other problem with your
ventilated patient.

–Call fo...
TURNING PATIENT PRONE ON VOLLMAN PRONE POSITIONER

55
PATIENT LYING PRONE ON VOLLMAN PRONE POSITIONER

56
LATERAL ROTATION THERAPY BED

57
MEDICAL MANAGEMENT

contd…….

• Medications :
– Antibiotics
– Anti-inflammatory drugs; such as corticosteroids
– Diuretics...
NURSING DIAGNOSIS
1. Ineffective breathing pattern related to decreased
lung compliance, decreased energy as characterized...
NURSING DIAGNOSIS

CONTD……..

5. Impaired physical mobility related to monitoring
devices, mechanical ventilation & medica...
Acute respiratory distress syndrome (ARDS)
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Acute respiratory distress syndrome (ARDS)

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Acute respiratory distress syndrome (ARDS)

  1. 1. ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) Presented By: Atul Lawrence Medical Surgical Nursing 1
  2. 2. INTRODUCTION TO RESPIRATORY SYSTEM Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 2
  3. 3. INTRODUCTION TO RESPIRATORY SYSTEM contd………… Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 3
  4. 4. INTRODUCTION TO RESPIRATORY SYSTEM contd………… Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 4
  5. 5. RESPIRATORY DISTRESS SYNDROME (ARDS) • Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting into the blood. • Acute respiratory distress syndrome was first described in 1967 by Ashbaugh and colleagues. • ARDS is also referred with variety of terms like • Stiff Lung • Shock lung • Wet lung • Post traumatic lung • Adult respiratory distress syndrome • Adult hyaline membrane disease • Capillary leak syndrome & • Congestive atelectasis. Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 5
  6. 6. DEFINITION • Acute respiratory distress syndrome (ARDS) is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid resulting in severe dyspnea, hypoxemia and diffuse pulmonary infiltrates. Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 6
  7. 7. ETIOLOGY & RISK FACTORS • Direct Lung Injury – Common causes • Aspiration of gastric contents or other substances. • Viral/bacterial pneumonia – Less Common causes • Chest trauma • Embolism: fat, air, amniotic fluid • Inhalation of toxic substances • Near-drowning • O2 toxicity • Radiation pneumonitis Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli 7
  8. 8. ETIOLOGY & RISK FACTORS • Indirect Lung Injury – Common causes • Sepsis • Severe traumatic injury – Less common causes • Acute pancreatitis • Anaphylaxis • Prolonged Cardiopulmonary bypass surgery • Disseminated intravascular coagulation • Multiple blood transfusions • Narcotic drug overdose (e.g., heroin) • Nonpulmonary systemic diseases • Severe head injury • Shock • Massive blood transfusion. Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli contd……. 8
  9. 9. SCHEMATIC REPRESENTATION OF PATHOPHYSIOLOGY OF ARDS Lung injury Release of Vasoactive substances (serotonin, histamine, bradykinin) Damaged alveolar cell Surfactant production Alveolocapillary membrane permeability Alveolar Compliance and recoil Vascular narrowing & obstruction Bronchoconstriction Outward migration of blood cells & fluids from capillaries Atelectasis Hyaline membrane formation Pulmonary Edema Lung compliance Impairment in gas exchange ARDS Pulmonary hypertension 9
  10. 10. CLINICAL MANIFESTATIONS • Early signs/symptoms – – – – – – Restlessness Dyspnea Low blood pressure Confusion Extreme tiredness Change in patient’s behavior • Mood swing • Disorientation • Change in LOC – If pneumonia is causing ARDS then client may have • Cough • Fever 10
  11. 11. CLINICAL MANIFESTATIONS CONTD………… Late signs & symptoms – Severe difficulty in breathing i.e., labored, rapid breathing. – Shortness of breath. – Tachycardia – Cyanosis (blue skin, lips and nails) – Think frothy sputum – Metabolic acidosis – Abnormal breath sounds, like crackles – PaCo2 with respiratory alkalosis. – PaO2 11
  12. 12. DIAGNOSITC EVALUATION • History of above symptoms • On physical examination – Auscultation reveals abnormal breath sounds • The first tests done are : – Arterial blood gas analysis – Bood tests – Chest x-ray – Bronchoscopy – Sputum cultures and analysis • Other tests are : – Chest CT Scan – Echocardiogram 12
  13. 13. COMPLICATIONS • Common complications are; – Nosocomial pneumonia: – Barotrauma – Renal failure • Other complications are : – O2 toxicity, – stress ulcers, – Tracheal ulceration, – Blood clots leading to deep vein thrombosis & – pulmonary embolism. 13
  14. 14. MEDICAL MANAGEMENT • Persons with ARDS are hospitalized and require treatment in an intensive care unit. • No specific therapy for ARDS exists. • Supportive measures : – Supplemental oxygen – Mechanical respirator – Positioning strategies • Turn the patient from supine to prone. • Another position is lateral rotation therapy • Fluid therapy 14
  15. 15. Intubation Procedure Preoxygenate with 100% oxygen to provide apneic or distressed patient with reserve while attempting to intubate. Do not allow more than 30 seconds to any intubation attempt. If intubation is unsuccessful, ventilate with 100% oxygen for 3-5 minutes before a reattempt.
  16. 16. Intubation Procedure Insert Laryngoscope
  17. 17. Intubation Procedure
  18. 18. Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli ‹#›
  19. 19. Intubation Procedure After displacing the epiglottis insert the ETT. The depth of the tube for a male patient on average is 21-23 cm at teeth The depth of the tube on average for a female patient is 19-21 at teeth.
  20. 20. Intubation Procedure Confirm tube position: By auscultation of the chest Bilateral chest rise Tube location at teeth CO2 detector – (esophageal detection device)
  21. 21. Intubation Procedure Stabilize the ETT
  22. 22. Ventilator Settings Terminology •A/C: Assist-Control •IMV: Intermittent Mandatory Ventilation •SIMV: Synchronized Intermittent Mandatory Ventilation •Bi-level/Biphasic: Non-inversed Pressure Ventilation with Pressure Support (consists of 2 levels of pressure)
  23. 23. Ventilator Settings Terminology (con’t) •PRVC: Pressure Regulated Volume Control •PEEP: Positive End Expiratory Pressure •CPAP: Continuous Positive Airway Pressure •PSV: Pressure Support Ventilation •NIPPV: Non-Invasive Positive Pressure Ventilation
  24. 24. Settings 1. 2. 3. 4. 5. 6. 7. Trigger mode and sensitivity Respiratory rate Tidal Volume Positive end-expiratory pressure (PEEP) Flow rate Inspiratory time Fraction of inspired oxygen
  25. 25. Trigger  There are two ways to initiate a ventilator-delivered breath: pressure triggering or flow-by triggering  When pressure triggering is used, a ventilator-delivered breath is initiated if the demand valve senses a negative airway pressure deflection (generated by the patient trying to initiate a breath) greater than the trigger sensitivity.  When flow-by triggering is used, a continuous flow of gas through the ventilator circuit is monitored. A ventilator-delivered breath is initiated when the return flow is less than the delivered flow, a consequence of the patient's effort to initiate a breath
  26. 26. Tidal Volume  The tidal volume is the amount of air delivered with each breath. The appropriate initial tidal volume depends on numerous factors, most notably the disease for which the patient requires mechanical ventilation.
  27. 27. Respiratory Rate  An optimal method for setting the respiratory rate has not been established. For most patients, an initial respiratory rate between 12 and 16 breaths per minute is reasonable
  28. 28. Positive End-Expiratory Pressure (PEEP)  Applied PEEP is generally added to mitigate end- expiratory alveolar collapse. A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O may be used in patients undergoing low tidal volume ventilation for acute respiratory distress syndrome (ARDS)
  29. 29. Flow Rate  The peak flow rate is the maximum flow delivered by the ventilator during inspiration. Peak flow rates of 60 L per minute may be sufficient, although higher rates are frequently necessary. An insufficient peak flow rate is characterized by dyspnea, spuriously low peak inspiratory pressures, and scalloping of the inspiratory pressure tracing
  30. 30. Inspiratory Time: Expiratory Time Relationship (I:E Ratio)  During spontaneous breathing, the normal I:E ratio is 1:2, indicating that for normal patients the exhalation time is about twice as long as inhalation time.  If exhalation time is too short “breath stacking” occurs resulting in an increase in end-expiratory pressure also called auto-PEEP.  Depending on the disease process, such as in ARDS, the I:E ratio can be changed to improve ventilation
  31. 31. Fraction of Inspired Oxygen  The lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals should be used. This will decrease the likelihood that adverse consequences of supplemental oxygen will develop, such as absorption atelectasis, accentuation of hypercapnia, airway injury, and parenchymal injury
  32. 32. MODES of VENTILATION
  33. 33. Control Mode Delivers pre-set volumes at a pre-set rate and a pre-set flow rate. The patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.
  34. 34. Assist/Control Mode •Delivers pre-set volumes at a preset rate and a pre-set flow rate. •The patient CANNOT generate spontaneous volumes, or flow rates in this mode. •Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.
  35. 35. SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV): Delivers a pre-set number of breaths at a set volume and flow rate. Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths. Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking
  36. 36. SIMV cont. Machine Breaths Spontaneous Breaths
  37. 37. PRESSURE REGULATED VOLUME CONTROL (PRVC): • This is a volume targeted, pressure limited mode. (available in SIMV or AC) • Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit. • The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with each breath.
  38. 38. PRVC
  39. 39. POSITIVE END EXPIRATORY PRESSURE (PEEP): • This is NOT a specific mode, but is rather an adjunct to any of the vent modes. • PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase. • Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation.
  40. 40. PEEP cont. Pressure above zero PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase.
  41. 41. Continuous Positive Airway Pressure (CPAP): • This IS a mode and simply means that a preset pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath. • CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB. • The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation.
  42. 42. HIGH FREQUENCY VENTILATION
  43. 43. Oxygenation • Oxygenation is primarily controlled by the Mean Airway Pressure (Paw) and the FiO2. • Mean Airway Pressure is a constant pressure used to inflate the lung and hold the alveoli open. • Since the Paw is constant, it reduces the injury that results from cycling the lung open for each breath
  44. 44. Initial Settings • • • • • • • • Select your mode of ventilation Set sensitivity at Flow trigger mode Set Tidal Volume Set Rate Set Inspiratory Flow (if necessary) Set PEEP Set Pressure Limit Humidification
  45. 45. Post Initial Settings • Obtain an ABG (arterial blood gas) about 30 minutes after you set your patient up on the ventilator. • An ABG will give you information about any changes that may need to be made to keep the patient’s oxygenation and ventilation status within a physiological range.
  46. 46. ABG • Goal: • Keep patient’s acid/base balance within normal range: • pH • PCO2 • PO2 7.35 – 7.45 35-45 mmHg 80-100 mmHg
  47. 47. TROUBLESHOOTING
  48. 48. TROUBLESHOOTING • Anxious Patient – Can be due to a malfunction of the ventilator – Patient may need to be suctioned – Frequently the patient needs medication for anxiety or sedation to help them relax • Attempt to fix the problem • Call your RT
  49. 49. Low Pressure Alarm • Usually due to a leak in the circuit. – Attempt to quickly find the problem – Bag the patient and call your RT.
  50. 50. High Pressure Alarm • Usually caused by: – A blockage in the circuit (water condensation) – Patient biting his ETT – Mucus plug in the ETT – You can attempt to quickly fix the problem – Bag the patient and call for your RT.
  51. 51. Low Minute Volume Alarm • Usually caused by: – Apnea of your patient (CPAP) – Disconnection of the patient from the ventilator – You can attempt to quickly fix the problem – Bag the patient and call for your RT.
  52. 52. Accidental Extubation • Role of the Nurse: – Ensure the Ambu bag is attached to the oxygen flowmeter and it is on! – Attach the face mask to the Ambu bag and after ensuring a good seal on the patient’s face; supply the patient with ventilation. – Bag the patient and call for your RT.
  53. 53. OTHER • Anytime you have concerns, alarms, ventilator changes or any other problem with your ventilated patient. –Call for your RT –NEVER hit the silence button!
  54. 54. TURNING PATIENT PRONE ON VOLLMAN PRONE POSITIONER 55
  55. 55. PATIENT LYING PRONE ON VOLLMAN PRONE POSITIONER 56
  56. 56. LATERAL ROTATION THERAPY BED 57
  57. 57. MEDICAL MANAGEMENT contd……. • Medications : – Antibiotics – Anti-inflammatory drugs; such as corticosteroids – Diuretics – Drugs to raise blood pressure – Anti-anxiety – Muscle relaxers – Inhaled drugs (Bronchodilators) 58
  58. 58. NURSING DIAGNOSIS 1. Ineffective breathing pattern related to decreased lung compliance, decreased energy as characterized by dyspnea, abnormal ABGs, cyanoisis & use of accessory muscles. 2. Impaired gas exchange related to diffusion defect as characterized by hypoxia (restlessness, irritability & fear of suffocation), hypercapnia, tachycardia & cyanosis. 3. Risk for decreased Cardiac output related to positive pressure ventilation 4. Ineffective protection related to positive pressure ventilation, decreased pulmonary compliance & increased secretions as characterized by crepitus, altered chest excursion, abnormal ABGs & restlessness. 59
  59. 59. NURSING DIAGNOSIS CONTD…….. 5. Impaired physical mobility related to monitoring devices, mechanical ventilation & medications as characterized by imposed restrictions of movement, decreased muscle strength & limited range of motion. 6. Risk for impaired skin integrity related to prolonged bed rest, prolonged intubation & immobility. 7. Knowledge deficit related to health condition, new equipment & hospitalization as characterized by increased frequency of questions posed by patient and significant others. 60

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