ARDs

Acute Respiratory Distress Syndrome

By Karine Frangulyan
February 11, 2011
Definitions

 ARDS is a sudden, progressive form of

respiratory failure characterized by:
- severe dyspnea
- refractory hypoxemia
- diffuse bilateral infiltrates
ARDS Definitions

 ARDS follows acute and massive lung injury

◦ 150 – 200 mmHg < PaO2/FIO2 < 250 – 300 mmHg

 •ARDS
◦ –PaO2/FIO2 < 150 – 200 mmHg
 ARDS

 Other names for ARDS:

◦ Shock Lung
◦ Wet Lung
◦ Post-Traumatic Lung
◦ Congestive Atelectasis
◦ Capillary Leak Syndrome
◦ Adult Hyaline Membrane Disease
Etiology of ARDS

 ARDS develops as a result of ischemia in the

alveolar capillary membrane during shock,
oxygen toxicity, inhalation of noxious fumes
or fluids (e.g., gastric acid), or inflammation
from pneumonia or sepsis.
Risk Factors for ARDS
 Direct Pulmonary Trauma
▪ Viral, bacterial or fungal pneumonias
▪ Lung contusion
▪ Fat embolus
▪ Aspiration
▪ Massive smoke inhalation
▪ Inhaled Toxins
▪ Prolonged exposures to high concentrations of
oxygen
Risk Factors for ARDS
Indirect Pulmonary Trauma
▪ Sepsis
▪ Shock
▪ Multisystem trauma ▪ Idiopathic
▪ Disseminated Intravascular ▪ Prolonged heart bypass
surgery
…….coagulation ▪ Massive blood transfusions
▪ Pancreatitis ▪ Pregnancy-induced
▪ Uremia hypertension
▪ Drug overdose ▪ Increased intracranial
▪ Anaphylaxis pressure
▪ Radiation Therapy
Pathophysiology of ARDS
 The hallmark is a massive inflammatory response
by the lungs that increases permeability of the
alveolar membrane with resultant fluid movement
into the interstitial and alveolar spaces.

 This leads to the development of non-cardiogenic

pulmonary edema, which decreases lung
compliance and impairs oxygen transport.
Stages of ARDS
1. Exudative (acute) phase > 1-4 days
◦ Basement membrane disruption
 Type I pneumocytes destroyed
 Type II pneumocytes preserved
◦ Surfactant deficiency
 inhibited by fibrin
 decreased type II production
◦ Microatelectasis / alveolar collapse
Stages of ARDS
2. Proliferative phase > 7 - 10 days
◦ Type II pneumocyte
 proliferate
 differentiate into Type I cells
 reline alveolar walls
◦ Fibroblast proliferation
 interstitial/alveolar fibrosis
Stages of ARDS
3. Fibrotic phase - >14 days
◦ Characterized by:
 local fibrosis
 vascular obliteration
◦ Repair process:
 resolution vs fibrosis
Clinical Manifestations
 Acute dyspnea/tachypnea
◦ rales/rhonchi/wheezing

 Resistant hypoxemia
◦ PaO2/FIO2 < 150  200 mmHg

 CXR
◦ diffuse, bilateral infiltrates

 No evidence of LV failure
◦ (PAWP < 18 mmHg)
Outcome management
 The keys to successful management of ARDS
are early detection and initiation of
treatment.
 Goals of medical management are:

◦ Respiratory and Ventilatory support

◦ Maintenance of hemodynamic stability
◦ Treatment of the underlying cause
◦ Prevention of complications
Medical Management
 Respiratory and Ventilatory support
◦ The goal is to use the least amount of Fio2 and
PEEP possible to maintain O2 saturation at or above
90% while decreasing the potential of O2 toxicity.
◦ Inverse ratio ventilation (IRV)
◦ Nitric Oxide
◦ Antioxidants
◦ Prone position
◦ Kinetic Therapy
Medical Management
 Maintenance of hemodynamic stability
◦ Used to observe the effect of fluids and degree of
pulmonary edema.
◦ Inotroic agents (e.g., dobutamine or dopamine) may
be indicated to improve cardiac output and to
increase systemic blood pressure.
Medical Management
 Treatment of the underlying cause
◦ Administration of antibiotics if infection is
suspected or present.
◦ Administration of steroids to reduce inflammatory
response. Indiscriminate use to be avoided.
Medical Management
 Prevention of complications such as:
◦ Cardiac Dysrhythmias
◦ Sepsis from invasive lines
◦ Disseminated intravascular coagulation (DIC)
Nursing Management
 Placing the client in prone position
 Evaluation of client’s response to treatment
 Monitoring for complications
 Emotional support of clients family
 Practice Questions
Question #1

1. Which intervention would be most likely to prevent

ARDS?

a. Teach cigarette smoking cessation

b. Maintaining adequate serum K levels
c. Monitoring pts for signs of hypercapnia
(d). Replacing fluids, adequately during hypovolemic
states
Practice Questions
Question #2

Early sign of ARDS in a pt at risk?

a. Elevated CO2 level

(b). Hypoxia not responsive to O2
c. Metabolic acidosis
d. Severe, unexplained electrolyte imbalance
References
 Black, J.M., Hawks, J.H. (2009) Medical-
surgical nursing clinical management for
positive outcome. 8th Edition. St. Louis,
Missouri: Sounders Elsevier.
 www.ards.org