1. ACUTE RESPIRATORY DISTRESS
SYNDROME
(ARDS)
Presented By:
Atul Lawrence
Medical Surgical Nursing
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2. INTRODUCTION TO RESPIRATORY SYSTEM
Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli
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3. INTRODUCTION TO RESPIRATORY SYSTEM
contd…………
Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli
3

4. INTRODUCTION TO RESPIRATORY SYSTEM
contd…………
Mr sanjay. M. Peerapur, Principal, KLES Institute of Nursing Sciences, Hubli
4

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
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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
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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
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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…….
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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
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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
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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
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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
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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.
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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
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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. Intubation Procedure
Insert Laryngoscope

17. Intubation Procedure

18. Mr sanjay. M. Peerapur, Principal, KLES
Institute of Nursing Sciences, Hubli
‹#›

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. Intubation Procedure
Confirm tube position:
By auscultation of the chest
Bilateral chest rise
Tube location at teeth
CO2 detector – (esophageal
detection device)

21. Intubation Procedure
Stabilize the ETT

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. 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

25. 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

26. 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

27. 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.

28. 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

29. 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)

30. 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

31. 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

32. 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

33. MODES of VENTILATION

34. 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.

35. 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.

36. 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

37. SIMV cont.
Machine Breaths
Spontaneous Breaths

38. 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.

39. PRVC

40. 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.

41. PEEP cont.
Pressure above zero
PEEP is the
amount of
pressure
remaining in the
lung at the END
of the expiratory
phase.

42. 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.

43. HIGH FREQUENCY
VENTILATION

44. 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

45. 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

46. 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.

47. ABG
• Goal:
• Keep patient’s acid/base balance within
normal range:
• pH
• PCO2
• PO2
7.35 – 7.45
35-45 mmHg
80-100 mmHg

48. TROUBLESHOOTING

49. 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

50. Low Pressure Alarm
• Usually due to a leak in the circuit.
– Attempt to quickly find the problem
– Bag the patient and call your RT.

51. 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.

52. 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.

53. 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.

54. 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!

55. TURNING PATIENT PRONE ON VOLLMAN PRONE POSITIONER
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56. PATIENT LYING PRONE ON VOLLMAN PRONE POSITIONER
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57. LATERAL ROTATION THERAPY BED
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58. MEDICAL MANAGEMENT
contd…….
• Medications :
– Antibiotics
– Anti-inflammatory drugs; such as corticosteroids
– Diuretics
– Drugs to raise blood pressure
– Anti-anxiety
– Muscle relaxers
– Inhaled drugs (Bronchodilators)
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59. 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.
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60. 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.
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