ACUTE

RESPIRATORY
DISTRESS SYNDROME
Presented by – Sandhya harbola
Lecturer
ACUTE RESPIRATORY
DISTRESS SYNDROME
Definition

 Acute respiratory distress syndrome(ARDS)is

a sudden and the progressive form of acute
respiratory failure in which the alveolar
capillary membrane becomes damaged and
more permeable to intravascular fluid.
EPIDEMOLOGY
 Thealveoli fill with fluid, resulting in severe
dyspnea, hypoxemia refractory more to
supplemental O2, reduced lung compliance,
and diffuse pulmonary infiltrates Despite
supportive therapy.
Contd..
 Themortality rate from ARDS is
approximately 50%. Patients who have both
gram-negative septic shock and ARDS have a
mortality rate of 70% to 90 %.
ETIOLOGY
Direct Lung Injury
 Aspiration of gastric contents or other
substances
 Viral/bacterial pneumonia
 Chest trauma Embolism: fat, air, amniotic
fluid, thrombus
 Inhalation of toxic substances
 Near-drowning
Contd….
Indirect Lung Injury
 Common Causes Sepsis (especially gram-

negative infection) and Severe massive trauma

 Acute pancreatitis.
 Anaphylaxis.
 Cardiopulmonary bypass.
Contd…
 Disseminated intravascular coagulation.
 Multiple blood transfusions.
 Opioid drug overdose (eg, heroin).
Pathophysiology
The pathophysiologic changes in
ARDS are divided into three
phases:
 Injury or exudative phase

 Reparative or proliferative phase

 Fibrotic phase
 INJURY OR EXUDATIVE PHASE

 Injury or Exudative Phase occurs approximately 1

to 7 days (usually 24- 48 hr) after the initial direct
lung injury.
 fluid from the interstitial space crosses the alveolar

epithelium and enters the alveolar space.

REPARATIVE OR PROLIFERATIVE
PHASE
 Phase of ARDS begins 1 to 2 weeks after the
initial lung injury.
 During this phase, there is an influx of

neutrophils, monocytes, and lymphocytes and

fibroblast proliferation as part of the inflammatory
response.
Contd...

 Theinjured lung has an immense regenerative

capacity after acute lung injury.
FIBROTIC PHASE
 The fibrotic phase of ARDS occurs
approximately 2 to 3 weeks after the initial
lung injury.

 This phase is also called the chronic or late

phase of ARDS. By this time, the lung is
Completely remodeled by sparsely
collagenous and fibrous tissues.
Clinical Manifestations

 Dyspnea
 Tachypnea
 Cough
 Restlessness
 Hypoxemia
 Cyanosis and pallor
Contd….
 Respiratory Alkalosis
 Decreased Compliance
 Decreased Lung Volumes
 Decreased Functional

Residual Capacity(FRC)
 Tachycardia
 Diaphoresis
 Hyper-capnia signifies
that hypoventilation.
 Pleural effusions.
 DIAGONOSTIC
History and physical examination –
 Fever,
 Productive
 Cough,
 Pleuritic Chest Pain,
 And Witnessed Aspiration (May Suggest Infectious Or

Aspiration Pneumonia),
 Orthopnea (May Suggest Cardiogenic Pulmonary Edema),
 And Hemoptysis (May Suggest Cancer, Vasculitis, Or

Alveolar Hemorrhage).
 The skin should be examined for burns,
rashes, wounds, track marks, and systemic
manifestations of septic emboli; lymph nodes
should be examined for size and tenderness
(eg, possible infections or cancer); and
dentition should be examined for a possible
source of sepsis.
Imaging
 Chest radiography is also critical to evaluate for
etiologies of ARDS (eg, lobar consolidation and air
bronchograms consistent with pneumonia) as well as
for conditions that mimic ARDS, particularly acute
cardiogenic pulmonary edema (eg, pulmonary venous
congestion, pleural effusions, Kerley B lines, and
cardiomegaly).
Computed tomography (CT)
 computed tomography (CT) of the chest-be helpful
when there is a need for a more detailed pulmonary
evaluation (eg, seeking evidence for cavitation or
pleural effusions or chronic interstitial lung disease
that may be missed on chest radiograph).
Electrocardiography
 Electrocardiography should also be obtained to look
for evidence of cardiac dysfunction, including
arrhythmias, obvious changes consistent with right or
left ventricular strain, or ST segment changes to
suggest ischemia
Blood gas analysis
 Blood gas tests: show low oxygen levels in the
blood. Sometimes the CO2 level will be low because
the patient is hyperventilating to maintain their
oxygen level. This test indicates how well the lungs
are working.
TREATMENT
 MANAGEMENT OF HYPOXEMIA, patients with
ARDS are severely hypoxemic.
 Options available for improving arterial oxygen

saturation (SaO2) include:

 Use of high fractions of inspired oxygen (FiO 2)
 Decrease oxygen consumption
 Improve oxygen delivery
 Manipulate mechanical ventilatory support.
Supplemental oxygen
 Most patients require a high fraction of inspired
oxygen (FiO2), especially early in ARDS when
pulmonary edema is most severe.
 Prior to intubation high flow oxygen can be provided

through a face mask or high flow nasal cannula

(HFNC).
 Most patients with ARDS require intubation and
mechanical ventilation.

 During the peri-intubation period, 95 to 100 percent

oxygen should be given to ensure an adequate SPO 2.
Extracorporeal membrane oxygenation

 Extracorporeal membrane oxygenation

(ECMO) is a useful mechanism employed to
improve oxygenation in patients with ARDS.
Prone positioning

 Prone positioning is a therapeutic maneuver to

improve oxygenation and pulmonary
mechanics in patients with acute lung injury or
mechanically ventilated patients with acute
respiratory distress syndrome (ARDS) who
require high concentrations of inspired
oxygen.
Prone positioning
Lateral rotation therapy
 Therapy is used to mechanically rotate patients
continuously in bed (left-center-right).
 Promotes early mobilization.
 Decreases hemodynamic effects of immobility.
 Mobilizes pulmonary secretions to improve alveolar
gas exchange.
 Decreases risk for ventilator-associated events.
 Improves PaO2/FiO2 in hypoxemic acute lung injury
or acute respiratory distress syndrome (ARDS).
Lateral rotation therapy
Fluid management
 Optimal fluid management should provide adequate
oxygen delivery to the body, while avoiding
inadvertent increase in lung edema which further
impairs gas exchange. In ARDS patients, positive
fluid balance has been associated with prolonged
mechanical ventilation, longer ICU and hospital stay,
and higher mortality.
Medical management
Bronchodilators
 Levalbuterol
 Salmeterol
 Formoterol
 Albuterol
Sedatives
 Torelieve shortness of breath and prevent
agitation, the ARDS patient usually needs
sedation. Sometimes added medications called
paralytics are needed up front to help the
patient adjust to the ventilator.
Corticosteroids

 when ARDS results from fatty emboli or

chemical injury a short course of high dose of
corticosteroids may help, if given early.
Neuromuscular blocking agents
 itis prescribed to reduce the restlessness
of the patient (thereby reduce oxygen
consumption and carbon dioxide
production) and to facilitate ventilation.
For example; vecuronium.
Diuretics
 Diuretics are frequently administered to
critically ill patients to alleviate pulmonary
edema and may reduce lung injury. Several
studies have involved diuretics as part of
therapeutic intervention for ARDS, but
whether they could reduce mortality has not
been conclusively determined. Example;
frusemide.
Contd….
 The pulmonary wedge pressure is monitored and if
the pressure is below the established range volume
expanders medications are administered or if it is
above the range diuretics, and vasodilators are
administered.
 Nursing Diagnosis
 Impaired gas exchange related to increased alveolar-
capillary permeability and decreased lung compliance as
evidence by labored breathing

 Ineffective airway clearance related to increased interstitial

edema as evidence by shortness of breath

 Activity intolerance related to decreased lung compliance

as evidence restless behaviour of patient
Nursing Intervention
 Identify and treat cause of the Acute respiratory
distress syndrome
 Administer oxygen as prescribed.
 Position client in high fowler’s position.
 Restrict fluid intake as prescribed.
 Provide respiratory treatment as prescribed.
 Administer diuretics, anticoagulants or

corticosteroids as prescribed.
 Prepare the client for intubation and mechanical

ventilation using PEEP

Research article

 Title: Acute Respiratory Distress Syndrome

 Author: Matthey A. Michael, Zemans L. Rachel,
Mercat Alain
 Year: 2019
 Abstract: Acute respiratory distress syndrome
(ARDS) is a common cause of respiratory failure in
critically ill patients and is defined by the acute onset
of noncardiogenic pulmonary edema, hypoxemia, and
the need for mechanical ventilation.
 ARDS occurs most often in the setting of pneumonia,
sepsis, aspiration of gastric contents, or severe trauma
and is present in ~10% of all patients in intensive
care units worldwide. Despite some improvements,
mortality remains high at 30–40% in most studies.
Pathological specimens from patients with ARDS
frequently reveal diffuse alveolar damage, and
laboratory studies have demonstrated both alveolar
epithelial and lung endothelial injury, resulting in the
accumulation of protein-rich inflammatory
edematous fluid in the alveolar space.
Contd..
 Diagnosis is based on consensus syndromic criteria,
with modifications for under-resourced settings and
in pediatric patients. Treatment focuses on lung-
protective ventilation; no specific pharmacotherapies
have been identified. Long-term outcomes of patients
with ARDS are increasingly recognized as important
research targets, as many patients survive ARDS only
to have ongoing functional and/or psychological
sequelae.
Contd…
 Future directions include efforts to facilitate
earlier recognition of ARDS, identifying
responsive subsets of patients and ongoing
efforts to understand fundamental mechanisms
of lung injury to design specific treatments.
Conclusion

• Even though many risk factors for ARDS are known,

there is no way of preventing ARDS.
• Careful management of fluids in high-risk patients
can be helpful.
• Steps should be taken to prevent aspiration by
keeping the head of the bed elevated before feeding.
• Lung protective mechanical ventilation strategy in
patients without ARDS who are high risk would help
prevent ARDS
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 LeMone, P., Burke, K.M., Bauldoff, G., & Gubrud, P.
(2015). Medical-Surgical Nursing: Critical Reasoning in
Patient Care (6th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall.
 Suddarth's and Brunner. Textbook of medical surgical nursing:
13th ed. Vol 2. Wolters Kluwer India pvt ltd.