Acute Respiratory

Distress
Syndrome &
Respiratory
Failure
Presented by: Sardar Ayub Khan
Acknowledgement: M. Mirza &
AHN team
Acute Respiratory Distress
Syndrome (ARDS)
⚫ Acute respiratory distress syndrome (ARDS; previously
called adult respiratory distress syndrome) 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 dyspnea, hypoxemia and diffused pulmonary
infiltrates.
⚫ This condition is often lethal, usually requiring
mechanical ventilation and admission to an Intensive
care unit.
⚫ Another names are shock lung, or non-cardiogenic
pulmonary edema or wet lung.
ARDS/ARF 2
Incidence
⚫ ARDS has been
associated with a
mortality rate of
as high as 50% to
60%
⚫ Survival rate can
be improved if
cause can be
determined and
early and
aggressive
treatment is
implemented
ARDS/ARF 3
 CAUSES/RISK FACTORS
Direct or indirect injury to the lungs:

⚫ Pneumonia
⚫ Inhalation of large amount of smoke or other toxin.
⚫ Chest trauma
⚫ Inhalation of gastric content
⚫ Drug ingestion and overdose
⚫ Fat or air embolism
⚫ Hematological disorders (DIC)
⚫ Non pulmonary infection (septicemia, pancreatitis)

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 Pathophysiology
Injury

Disruption of Alveolar Capillary Membrane

(permeability increases)

Non-Cardiogenic Pulmonary Edema

Hypoxemia Decreased Compliance

(Force, 2012)
Pathophysiology
Primary injury

Inflammatory chemical mediator and cytokines

release. Moreover, activated neutrophils release
proteolytic enyzmes.

Damage to alveolar capillary membrane (increase

permeability)

Alveolar edema, decrease/ inactivation

surfactant (atelectasis), formation of hyaline
membrane

ARDS/ARF 6
Pathophysiology cont…
Decreased lung compliance, atelectasis, hyaline
membrane formation (stiff lung) and decrease
in functional residual capacity

Increased work of Impaired gas

breathing exchange

Respiratory Failure
ARDS/ARF 7
ARDS/ARF 8
 Sign & symptoms

⚫ Hypoxemia
⚫ Dyspnea (audible, labored breathing, shortness of
breath)
⚫ Tachypnea (abnormally rapid breathing)
⚫ Cyanosis
⚫ Presence of abnormal infiltrates in the lungs
(detected by chest x-rays)
⚫ Patient show air hunger, retraction,
cyanosis
⚫ Auscultation – abnormal sounds may be present
(crackles) ARDS/ARF 9
Crackle sound
https://www.youtube.com/watch?v=LHqqvr

m2j6g

Retraction

ARDS/ARF 10
Diagnostic procedure
⚫ Arterial
blood gas analysis reveals
hypoxemia
⚫ Complete blood count: increased white
blood cells
⚫ Chest x-ray: show the presence of fluid in
the lungs.
⚫ Echocardiogram may help exclude any
heart problems that can cause fluid build-up
in the lung.
⚫ Sputum analysis
ARDS/ARF 11
Medical management
Goals
⚫ Define and treat the cause
⚫Provide adequate ventilation and improve
gas exchange
⚫ Provide adequate perfusion
⚫ Proper Positioning
⚫ Preventing complications

ARDS/ARF 12
 Medical Management
⚫ Non invasive ventilation using BIPAP
⚫ Mechanical ventilation with
endotracheal intubation, to maintain
adequate blood oxygen levels
Pharmacologic Management
• Sedation and muscle relaxant to reduce
anxiety and restlessness in intubation.
• Antibiotics
• Corticosteroids

ARDS/ARF 13
 Complications Of Bipap

•Airway dryness
•Aspiration
•Claustrophobia
•Dry mouth
•Eye irritation from an air leak
•Gastric distension and insufflation
•Pressure areas from mask, tubing and strapping
• Secretion build up inside the mask
 Nursing Interventions for
Patients on BIPAP
• Bipap settings and ABGS
• First switch on then apply mask.
• Feed and suction timings
• Mouth care, Back care, Hygiene care, NG care,
eye care
• DVT prophylaxis: stockings
• Positioning
• Fluid replacement for continuous Bipap.
 Nursing Interventions for
Patients on BIPAP
• Appropriate size of mask
• Alarms, Air leaks, Mask fit:
bearded
• Need for Restrain and care
• Tubing change
• Monitor the progress,
improvement & compliance
of the patient
• Facial skin protection :
Comfeel
Prone Positioning in ARDS
•  In prone positioning, patients
lie on their abdomen in a
monitored setting. 
• In the prone position, lung
compression is less, improving
lung function.
• Prone positioning redistributes
blood and air flow more evenly,
reducing imbalance and
improving gas exchange. 
• less support from the ventilator is
needed to achieve adequate
oxygen levels. This may reduce
risk of ventilator-induced lung
injury, which occurs from
overinflation and excess
stretching of certain portions of
the lung.
Prone Positioning in ARDS

• Prone positioning may improve heart function

in some patients. In the prone position, blood
return to the chambers on the right side of the
heart increases and constriction of the blood
vessels of the lung decreases. This may help
the heart pump better, resulting in improved
oxygen delivery to the body
• Because the mouth and nose are facing down
in the prone position, secretions produced by
the disease process in the lung may drain
better.
OETT

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ARDS/ARF 15
3/23/2021 ARDS/ARF 16
 Complications
⚫Multi-organ failure
⚫Irreversible pulmonary fibrosis (permanent
scarring of lung tissue)
⚫Nosocomial infection
⚫Mechanical trauma from Ventilator:
Barotrauma
⚫DVT or pulmonary embolism
⚫VAP

ARDS/ARF 17
 Nursing Diagnosis
⚫ Altered breathing pattern r/t decrease lung
compliance/ decrease surfactant AEB
dyspnea/tachypnea/Abnormal ABGs
⚫ In effective airway clearance r/t interstitial edema/
/increased airway resistance/ inability to clear up
pulmonary secretions AEB cyanosis/ cough/
restlessness/ Dyspnea/ abnormal lung sounds
⚫ Impaired gas exchange r/t Atelectasis/ VP mismatch/
Formation of hyaline membrane/ alveolar collapse
AEB cyanosis, restlessness, abnormal ABGs

ARDS/ARF 18
Nursing Diagnosis

⚫ Altered tissue perfusion R/t decrease alveolar

perfusion AEB cyanosis/ Decrease LOC/
Hypotension
⚫ Activity intolerance r/t fatigue/ weakness AEB
feeling of tiredness and weakness
⚫ Anxiety R/T fear of death, change in health
status/ change in environment AEB patient
verbalization
⚫ Decrease Cardiac output R/T increase
intrapulmonary edema AEB Low BP, tachycardia
Nursing intervention
⚫ Place the patient in semi fowlers or high fowlers
position.
⚫ Encourage fluid intake
⚫ Reassurance
⚫ Reduce anxiety and restlessness
⚫ Promote rest
⚫ Provide ventilator care or high flow oxygen
supply
⚫ Frequent suctioning
⚫ Physiotherapy

ARDS/ARF 19
Respiratory Failure

ARDS/ARF 20
 Two Aspects of Respiratory
System
⚫ Ventilation (movement of gases in and out of alveoli due to
action of respiratory muscles, respiratory center in CNS
and pathway that connect CNS and respiratory muscles),
hypercapnic/hypoxemic failure.

⚫ Gas exchange (movement of gases across the alveolar-

capillary membrane (diffusion issue). Cause severe
hypoxemia but minimal hypercapnia because increase in
ventilation and greater diffusion rate of carbondioxide.
hypoxemic respiratory failure.

⚫ Usually respiratory disorders have some aspects of

ventilatory and gas exchange failure (both).

ARDS/ARF 21
 Respiratory Failure

⚫ Failure of lungs to perform gas exchange.

⚫ It is defined as a fall in arterial oxygen tension (PaO2) to

less than 50 mm Hg (hypoxemia) and a rise in arterial
carbon dioxide tension (PaCO2) to greater than 50 mm
Hg (hypercapnia), with an arterial pH of less than 7.35.

⚫ It is not a specific disease but occur as a result of conditions

that impairs ventilation, compromise matching of
ventilation and perfusion/gas diffusion.

ARDS/ARF 22
 Acute Respiratory Failure
It is the respiratory failure appearing in
the patient whose lungs was structurally
and functionally normal before the onset
of the present disease
⚫In ARF, the lung usually returns to its
original state.
⚫Upper airway obstruction cause due to drug
overdose, anesthesia, head injury, stroke,
and brain tumors etc
ARDS/ARF 23
 Chronic Respiratory failure (CRF)
⚫ Itis the respiratory failure seen in patients
with chronic lungs diseases such as
chronic bronchitis, emphysema, and black
lung disease (coal miner’s disease),
COPD.
⚫ In CRF patients develop a tolerance to the
gradually worsening Hypoxia and
hypercapnia

ARDS/ARF 24
Types of Respiratory Failure
Type 1 Respiratory Failure (hypoxemic): is associated with
damage to lung tissue which prevents adequate oxygenation
of the blood. However, the remaining normal lung is still
sufficient to excrete carbon dioxide. This results in low
oxygen, and normal or low carbon dioxide levels. Arterial
oxygen pressure (PaO2) is <8 kPa (60 mm Hg) with normal
or low arterial carbon dioxide pressure (PaCO2).
⚫ Type 2 Respiratory Failure (hypercapnic): occurs when
alveolar ventilation is insufficient to excrete the carbon
dioxide being produced. Inadequate ventilation is due to
reduced ventilatory effort or inability to overcome increased
resistance to ventilation. It affects the lung as a whole, and
therefore carbon dioxide accumulates, presenting with PaO2
of <8 kPa (60 mm Hg) or normal, with hypercapnia PaCO2
>6.0kPa (> 50 mm Hg).

ARDS/ARF 25
Causes
⚫ Causes of type 1 respiratory failure include: acute
respiratory distress syndrome, pulmonary
oedema, pneumonia, chronic pulmonary fibrosis,
pneumothorax, pulmonary embolism, pulmonary
hypertension.
⚫ Type 2 respiratory failure is commonly caused by
COPD, asthma, chest-wall deformities, respiratory
muscle weakness and Central nervous system
depression (CNS depression) CNS depression is
associated with reduced respiratory drive and is
often a side effect of sedatives and strong opioids.

ARDS/ARF 26
S/S

ARDS/ARF 27
Management
⚫ Management of respiratory failure includes not only
supportive measures as well as treatment of the underlying
cause.
⚫ Depending on presentation, interventions aim to
correct hypoxemia or hypercapnia and respiratory
acidosis.
⚫ Correction of hypoxemia: aim to maintain adequate
oxygenation, achieved with an arterial oxygen pressure
(PaO2) of 60 mm Hg. The inspired oxygen concentration
should be adjusted at the lowest level which is sufficient for
tissue oxygenation. Oxygen can be delivered via nasal canula,
simple face mask, non rebreathing mask or high flow nasal
canula. In severe cases, patient may require invasive
ventilatory support.
⚫ Correction of hypercapnia and respiratory acidosis: this is
achieved by treating the underlying cause or providing
ventilatory support.
ARDS/ARF 28
Major consideration for
Respiratory Failure
For hypoxemia: supplementary oxygen but
cautiously.
For hypercapnia: hyperventilate but this also
increase work of breathing

ARDS/ARF 29
Nursing Diagnosis for
Respiratory failure:
⚫ Impaired gas exchange/ ineffective breathing pattern r/t
disease process/ artificial airway as evidence by abnormal
ABGs finding and Respiratory rate

⚫ Ineffectiveairway clearance related to increase mucus

production associated with mechanical ventilation as
evidence by wheezes and crackles in lung field.

⚫ Activity Intolerance

⚫ Risk of infection
 Nursing diagnosis For
Ventilated patients
• Impaired spontaneous ventilation R/t respiratory
failure AEB decrease O2 sats, adventitious
breath sounds/ inability to maintain airway
• Ineffective Airway clearance R/T endotracheal
intubation AEB excessive secretions/
adventitious lung sounds
• Ineffective breathing pattern R/T inadequate O2/
Respiratory muscle weakness AEB abnormal
ABGs/ decreased O2 sats
Nursing diagnosis For Ventilated patients
• Impaired verbal communication R/T artificial airway/
intubation AEB inability to speak
• Risk for infection R/t intubation/ invasive devices
• Imbalanced nutrition less than body requirement related
to increase metabolic demand/ inability to swallow AEB
decrease bowel sounds, muscle mass loss, weight loss
• Risk for Impaired skin integrity R/t immobility,
impaired circulation, poor nutritional status AEB
discoloration of skin surfaces/ formation of pressure
ulcer
• Ineffective family coping R/T change in the ability to
communicate/ inadequate coping mechanism AEB
destructive behavior/ delayed decision making
 Nursing Interventions for
Ventilated Patients
• Care with Respect and dignity
• Prevention of infection – 5 moments of hand hygiene
• Monitor saturation, vitals, auscultate breath sounds,
GCS assessment.
• Ventilator modes, settings and alarms.
• Nebs, Suction when needed, hyperventilate and then
recheck OETT position.
• Cuff pressure and CXR
• Assess need to lower sedation doses.
• Prevent infection: Vent: VAP, Foleys: CRE, VRE,
hospital Acquired infections: MRSA
Nursing Interventions for Ventilated Patients
• Monitor IV access for phlebitis
• Frequent positioning, air mattress for pressure
ulcers.
• NG care: positioning, suction timing,
dressing, aspiration.
• Back care and Eye care
• DVT prophylaxis, stockings
• Foot Drop
• Frequent Mouth care: Q3-4 hourly
• Monitoring cuff pressure.
• Assess for complications: shock
 Family Teachings
Seeing a loved one attached to Ventilator is
frightening!
Hand hygiene before touching and after leaving-
prevent infections.
• Keep them informed.
• Identify Family needs.
• Shared decision making
• Respect patient and family values : Holy water,
Holy verses recitation, Taweez- infection
• Never give false reassurance
 Positive and Negative Pressure
ventilation
https://www.youtube.com/watch?v=ljI3uB5B-2A
ARDS/ARF 31