when assessing the patient with acute respiratory distress, what should the nurse expect to observe?

Learning Outcome

List the causes of astute respiratory distress syndrome (ARDS)
Describe the presentation of ARDS
Summarize the treatment of ARDS
Talk over the role of the nurse in the direction of ARDS

Introduction

Acute respiratory distress syndrome (ARDS) is a life-threatening status of seriously sick patients, characterized by poor oxygenation, pulmonary infiltrates, and acuity of onset. On a microscopic level, the disorder is associated with capillary endothelial injury and diffuse alveolar damage.

ARDS is defined as an astute disorder characterized past bilateral lung infiltrates and astringent progressive hypoxemia in the absence of whatever show of cardiogenic pulmonary edema. ARDS is divers by the patient's oxygen in arterial blood (PaO2) to the fraction of the oxygen in the inspired air (FiO2). These patients commonly take a PaO2/FiO2 ratio of less than 200.

Once ARDS develops, patients usually have varying degrees of pulmonary artery vasoconstriction and may subsequently develop pulmonary hypertension. ARDS carries a loftier mortality, and few constructive therapeutic modalities be to combat this condition.[1][two]

Nursing Diagnosis

Impaired gas exchange related to increased alveolar-capillary permeability, interstitial edema, and decreased lung compliance
Ineffective breathing pattern
Ineffective airway clearance
Action intolerance
Chance for aspiration
Anxiety (specify level: balmy, moderate, severe, panic)

Causes

ARDS has many risk factors. As well pulmonary infection or aspiration, extra-pulmonary sources include sepsis, trauma, massive transfusion, drowning, drug overdose, fat embolism, inhalation of toxic fumes, and pancreatitis. These extra-thoracic illnesses and/or injuries trigger an inflammatory cascade culminating in pulmonary injury.[3]

Risk Factors

Estimates of ARDS incidence in the United States range from 64.2 to 78.9 cases/100,000 person-years. Twenty-5 percent of ARDS cases are initially classified as mild and 75% as moderate or severe. Still, a 3rd of the balmy cases go on to progress to moderate or severe disease.[one] A literature review revealed a mortality subtract of 1.1% per year for the period 1994 through 2006. Nevertheless, the overall pooled bloodshed charge per unit for all the studies evaluated was 43%.[2]

Risk factors for ARDS include:

Avant-garde age
Female gender
Smoking
Alcohol apply

Assessment

The syndrome is characterized by the evolution of dyspnea and hypoxemia, which progressively worsens within hours to days, frequently requiring mechanical ventilation and intensive care unit of measurement-level intendance. The history is directed at identifying the underlying cause which has precipitated the affliction. When interviewing patients that can communicate, they oftentimes outset to mutter of balmy dyspnea initially, but inside 12 to 24 hours, the respiratory distress escalates, becoming astringent and requiring mechanical ventilation to prevent hypoxia. The etiology may be obvious in the case of pneumonia or sepsis. Yet, in other cases, questioning the patient or relatives on recent exposures may also be paramount in identifying the causative agent.

The physical examination will include findings associated with the respiratory system, such every bit tachypnea and increased endeavour to exhale. Systemic signs may also exist axiomatic depending on the severity of disease, such as central or peripheral cyanosis resulting from hypoxemia, tachycardia, and altered mental condition. Despite 100% oxygen, patients take low oxygen saturation. Breast auscultation commonly reveals rales, especially bibasilar, only are oft auscultated throughout the chest.

Evaluation

The diagnosis of ARDS is made based on the following criteria: acute onset, bilateral lung infiltrates on chest radiography of a non-cardiac origin, and a PaO/FiO ratio of less than 300 mmHg. It is further sub-classified into mild (PaO2/FiO2 200 to 300 mmHg), moderate (PaO2/FiO2 100 to 200 mmHg), and severe (PaO2/FiO2 less than 100 mmHg) subtypes. Mortality and ventilator-gratuitous days increment with severity. A CT scan of the chest may be required in pneumothorax cases, pleural effusions, mediastinal lymphadenopathy, or barotrauma to properly identify infiltrates every bit pulmonic in location.

Assessment of left ventricular office may be required to differentiate from or quantify the contribution of congestive heart failure to the overall clinical picture. This cess can be accomplished via invasive methods such equally pulmonary artery catheter measurements or non-invasively, such every bit cardiac echocardiography or thoracic bioimpedance, or pulse contour analysis. However, the use of pulmonary avenue catheters is controversial and should be avoided if clinically possible, and noninvasive measures for assessment should be exhausted beginning. Bronchoscopy may be required to assess pulmonary infections and obtain material for culture.

Other laboratory and/or radiographic tests volition be guided by the underlying disease process, which has triggered the inflammatory process that has led to the development of ARDS. Likewise, laboratory tests will be needed as patients with ARDS are highly likely to develop or be affected by associated multi-organ failure, including but not limited to renal, hepatic, and hematopoietic failures. Regularly obtaining consummate blood count with differential, comprehensive metabolic console, serum magnesium, serum ionized calcium, phosphorus levels, blood lactate level, coagulation panel, troponin, cardiac enzymes, and CKMB are recommended if clinically indicated.[three][iv][5]

Medical Management

Unfortunately, no drug has been proven to be effective in preventing or managing ARDS. The main treatment strategy is supportive care, forth with adequate nutrition. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional back up until bear witness of improvement is observed. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies tin can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS. Intendance is placed in preventing volutrauma (exposure to big tidal volumes), barotrauma (exposure to high plateau pressures), and atelectrauma (exposure to atelectasis).[1][6]

A lung-protective ventilatory strategy is advocated to reduce lung injury. The NIH-NHLBI ARDS Clinical Network Mechanical Ventilation Protocol (ARDSnet) sets the following goals: Tidal volume (V) from 4 to 8 mL/kg of platonic torso weight (IBW), respiratory rate (RR) up to 35 bpm, SpO2 88% to 95%, plateau pressure level (P) less than thirty cm Water, pH goal seven.xxx to 7.45, and inspiratory-to-expiratory time ratio less than 1. To maintain oxygenation, ARDSnet recognizes the benefit of PEEP. The protocol allows for a low or a high PEEP strategy relative to FiO2. Either strategy tolerates a PEEP of upwards to 24 cm HO in patients requiring 100% FiO2. The inspiratory-to-expiratory time ratio goal may demand to be sacrificed and an changed inspiratory-to-expiratory fourth dimension ratio strategy instituted to better oxygenation in a sure clinical situation.

Novel invasive ventilation strategies have been adult to improve oxygenation. These include airway pressure level release ventilation and loftier-frequency oscillation ventilation. These open up-lung ventilation strategies can be supplemented with recruitment maneuvers. Patients with mild and some with moderate ARDS may do good from non-invasive ventilation to avoid endotracheal intubation and invasive mechanical ventilation. These modalities include continuous positive airway pressure (CPAP), bi-level airway pressure (BiPAP), proportional-assist ventilation, and high flow nasal cannula.

A plateau pressure level of less than xxx cm HO can be achieved using several strategies. Again, this is to reduce the risk of barotrauma. One strategy is to maintain equally low a V and PEEP equally possible. Also, increasing the rise and/or inspiration times can besides assistance maintain the P goal. Finally, the period rate can be decreased as an adjunct to decreasing the P. High P is as well a product of decreased lung compliance from non-cardiogenic pulmonary edema, a salient characteristic of ARDS pathophysiology.

Improving lung compliance will improve P and oxygenation goal attainment. Neuromuscular blockade has been used in this attempt. Neuromuscular blockers instituted during the starting time 48 hours of ARDS improved 90-day survival and increased fourth dimension off the ventilator.[12] Other causes of decreased lung compliance should be sought and addressed. These include, but are not limited to, pneumothorax, hemothorax, thoracic compartment syndrome, and intraabdominal hypertension. Prone position has shown benefits in nearly l% to 70% of patients. The comeback in oxygenation is rapid and allows a reduction in FiO2 and PEEP. The prone position is safe, but there is a take a chance of dislodgement of lines and tubes. It is believed that in the decumbent position, there is the recruitment of dependent lung zones, improved diaphragmatic excursion, and increased functional rest chapters. To derive the benefits, the patient needs to exist maintained in the prone position for at to the lowest degree 8 hours a mean solar day.

Non-ventilatory strategies have included decumbent positioning and bourgeois fluid management in one case resuscitation has been achieved.[xiv][seven][8] Extracorporeal membrane oxygenation (ECMO) has recently been advocated as salvage therapy in refractory hypoxemic ARDS.[nine] Nutritional back up via enteral feeding is recommended. A loftier-fat, low-sugar diet containing gamma-linolenic acid and eicosapentaenoic acid has been shown in some studies to improve oxygenation. Care must also be taken to foreclose force per unit area sores; thus, frequent patient repositioning or turning is recommended when viable. Skin checks per nursing routine are besides brash. Physical therapy should be involved in exercising the patient when they are liberated from mechanical ventilation and stable to participate in therapy.

Nursing Direction

Manage nutrition
Treating the underlying cause or injury
Improve oxygenation with mechanical ventilation
Suction oral cavity
Give antibiotics
Deep venous thrombosis prophylaxis
Stress ulcer prophylaxis
Detect for barotrauma
Monitor blood chemistry and fluid levels

When To Seek Assistance

Hypotension
Persistent hypoxia
Elevated peak airway pressures
Decreasing urine output
High fever
Unresponsive

Outcome Identification

The outcomes for most patients with ARDS are guarded. Even those who recover have a prolonged recovery, marked by musculus wasting, polyneuropathy, and weakness.

Monitoring

ICU care with continuous monitoring.

Coordination of Care

ARDS is a serious disorder of the lung which has the potential to cause death. Patients with ARDS may require mechanical ventilation because of hypoxia.[x] The direction is usually in the ICU with an interprofessional healthcare squad. ARDS has effects beyond the lung. Prolonged mechanical ventilation often leads to bedsores, deep venous thrombosis, multi-organ failure, weight loss, and poor overall functioning. It is of import to have an integrated approach to ARDS direction considering it usually affects many organs in the body. These patients need nutritional back up, chest physiotherapy, handling for sepsis if present, and potentially hemodialysis. Many of these patients remain in the infirmary for months and even those who survive confront severe challenges due to a loss of muscle mass and cognitive changes (due to hypoxia). There is ample show showing that an interprofessional team approach leads to amend outcomes as information technology facilitates communication and ensures timely intervention.[11] The team and responsibilities should consist of the following:

Intensivist for managing the patient on the ventilator and other ICU-related issues like pneumonia prevention, DVT prophylaxis, and gastric stress prevention
Dietitian and nutritionist for nutritional back up
Respiratory therapist to manage the ventilator settings
Pharmacist to manage the medications, which include antibiotics, anticoagulants, diuretics, amid others
Pulmonologist to manage the lung diseases
Nephrologist to manage the kidneys and oversee renal replacement therapy if needed
Nurses to monitor the patient, motion the patient in bed, educate the family
Concrete therapist to practice the patient, regain muscle function
Tracheostomy nurse to assistance with maintaining tracheostomy and weaning
Mental health nurse to assess for depression, feet, and other psychosocial issues
Social worker to assess the patient financial situation, transfer for rehab, and ensure there is an adequate follow-upward
Clergyman for spiritual intendance

Outcomes

Despite advances in critical care, ARDS even so has loftier morbidity and mortality. Even those who survive tin have a poorer quality of life. While many take a chance factors are known for ARDS, at that place is no mode to prevent the condition. Likewise the restriction of fluids in high-risk patients, shut monitoring for hypoxia by the team is vital. The before the hypoxia is identified, the meliorate the outcome. Those who survive have a long recovery period to regain functional status. Many continue to have dyspnea fifty-fifty with mild exertion and thus are dependent on care from others.

Health Pedagogy and Health Promotion

Even though many risk factors for ARDS are known, there is no mode of preventing ARDS. However, careful direction of fluid in loftier-risk patients can be helpful. Steps should be taken to foreclose aspiration by keeping the head of the bed elevated before feeding.

Belch Planning

Discharge planning should include medication reconciliation, detailed domicile intendance planning (whether past family members or in-home/visiting nursing), and plans for follow-upwards visits and evaluations. Patients and caregivers must be counseled on signs of when to contact the clinician in the consequence of exacerbation or deterioration of the patient's condition.

Review Questions

Effigy

Astute Respiratory Distress Syndrome. Image courtesy S Bhimji Physician

References

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Source: https://www.ncbi.nlm.nih.gov/books/NBK568726/