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Condition that is a severe, life-threatening consequence of certain pulmonary and systemic insults. It is thought to result from a dramatic change in the permeability of the alveolar-capillary membrane, allowing the movement of fluid and proteins into alveolar air spaces. These changes are followed by inactivation of surfactant, bringing about a significant alteration in lung compliance. 50% mortality rate.

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Acute Respiratory Distress Syndrome (ARDS)

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Hallmark condition in ARDS where flooded airspaces allow no inspired gas to enter, so the blood perfusing those alveoli remains at the mixed venous O2 content no matter how high the fractional inspired O2 (Fio2).

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Refractory Hypoxemia

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Percentage of air (room air) that is composed of oxygen (O2).

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21%

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"Wherever there is inflammation, there is _____________." -JD

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edema

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1. Exudative Phase 2. Proliferative Phase 3. Fibrotic Phase

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phases of ARDS (Diffuse Alveolar Damage (DAD))

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Phase of ARDS characterized by... -Basement membrane disruption: Type I pneumocytes destroyed, Type II pneumocytes preserved -Surfactant deficiency: inhibited by fibrin, decreased type II production -Microatelectasis/alveolar collapse -Some persons survive this phase and make a full recovery -days 1-7 of Diffuse Alveolar Damage (DAD)

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Exudative (Acute) Phase

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Phase of ARDS characterised by... -Type II pneumocyte proliferation and differentiation into Type I cells to reline the alveolar walls -Fibroblast proliferate resulting in interstitial and alveolar fibrosis -days 3-10 of Diffuse Alveolar Damage (DAD)

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Proliferative Phase

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Phase of ARDS characterized by... -Local fibrosis -Vascular obliteration -Poor chance of survival and may require long-term mechanical ventilation ->1-2 weeks of Diffuse Alveolar Damage (DAD)

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Fibrotic (Chronic) Phase

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-Direct lung injury -Indirect lung injury

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causes of ARDS

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-Aspiration -Near drowning -Pneumonia -Fat emboli

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Direct lung injury

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Type of lung injury that may be caused by: -Sepsis -Shock states -Cardiopulmonary bypass -Acute pancreatitis -Burns -Drug overdose

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Indirect lung injury

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-Raise the head of the bed and suction the patients trach secretions. -Avoid foods that increase salivation such as rasions, lemons, salty foods, and sour foods. -Prevention: Be aware of risk factors -Nutritional support: TF or TPN (better to use the gut than TPN because you don't want the gut to get lazy) -Psychological support: unknown outcome, use of ventilator

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interventions for ARDS

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EARLY: dyspnea, tachypnea, cough, restlessness, crackles, mild hypoxemia, respiratory alkalosis MORE SEVERE: previous symptoms worsen, decreased lung compliance, diffuse crackles, refractory hypoxemia more evident, diffused infiltrates revealed on chest x-ray (white lung)

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ARDS s/s

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-Hx precipitating factors: aspiration, near drowning, sepsis, shock -ABGs: refractory hypoxemia (low Pa02 in spite of increasing FiO2) -Chest x-ray reveals "white lung"

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diagnostic tests for ARDS

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-Oxygen: give lowest concentration that results in PaO2 60 mm Hg or greater; monitor SaO2; Often intubation with mechanical ventilation needed because PaO2 cannot be maintained at acceptable levels. -Ventilatory support: to restore arterial oxygen level; Use the lowest possible FiO2 and PEEP to improve oxygenation -Cardiovascular support: Fluid management (hemodynamic monitoring), Give fluid and vasopressors to maintain blood pressure against the lungs (pulmonary BP must be >Lung pressure); Vasoactive meds (to maintain CO), Normalize hemoglobin (only necessary if trama causes blood loss) -Rx: antibiotics (infection), anti-pyretics (fever)

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treatment for ARDS

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Therapy used for immobile patient (often on respiratory ventilation) used help mobilize pulmonary secretions by placing the patient on their stomach.

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Proning

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Therapy used for immobile patient (often on respiratory ventilation) used to help mobilize pulmonary secretions by having the patients bed slowly rock side to side.

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Continuous Lateral Rotation (CLTR)

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Process in which air is moved in and out of the lungs by mechanical means.

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Mechanical Ventilation

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-Falure to maintain adequate ventilation (RR > 35, RR 50 and pH < 7.25) -Inability to maintain adequate oxygenation (paO2 60%)

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indications for Mechanical Ventilation

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6 examples of conditions requiring Mechanical Ventilation? Top slide on page 7*** (SCNST/A)

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shock, COPD, neuromuscular disease, spinal cord injury, thoracic/abdominal surgery

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Negative pressure mechanical ventilator where the patient is encased by the machine. This type of devise is no longer in use.

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Iron Lung

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On the ventilator settings, Tidal Volume (TV)--which represents the amount of gas delivered with each breath--should be set at ______________.

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10 - 15 ml/kg

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On the ventilator settings, Rate--which represents the number of breaths delivered per minute--should be set at ___________.

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12 - 16/min

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On the ventilator settings, FiO2--which represents the amount of O2 delivered or oxygen concentration--should never be set higher than ____ for any extended period of time. However, the FiO2 may be raised as high as 100% for about 20 min maximum.

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50%

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A method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation by means of a mechanical impedance, usually a valve, within the circuit. The purpose is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange. Advantage include increase functional residual capacity (FRC), keeps the alveoli open, and it helps to lower FiO2 (Goal = PaO2 > 60 and SaO2 > 90 at the lowest FiO2 possible).

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Positive End-Expiratory Pressure (PEEP)

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On the ventilator settings, PEEP should be kept between _____________ to keep the alveoli from bursting.

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5 - 20 cm

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-Decreased cardiac output: pulse changes decreased BP, dec urine output (tx: inotropic agents) -Decreased BP (tx: fluids, vasopressors) -Tension pneumothorax (tx: chest tubes) -Increased ICP: prevents cerebral fluid drainage (use lowest possible setting)

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complications of PEEP

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Class of drugs that increase the hearts force of contraction. Examples include Digoxin, Dopamine, and Dobutamine.

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Positive Inotropic Agents

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Only the __________________ can work the ventilator. If something goes wrong with the vent, the nurse is to disconnect the vent and work the Ambu bag. The nurse can not adjust the vent settings.

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Respiratory therapist

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In starting and maintaining mechanical ventilation, this member of the health team... -Sets-up the equipment -Adjusts vent settings -Performs respiratory treatments -Arterial blood gases

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Respiratory therapist

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A physician who is specialized to direct and provide medical care in a hospital's intensive care unit (ICU).

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Intensivist

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A physician who is specialized in diseases of the lungs and bronchial tubes.

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Pulmonologist

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-Decreased Cardiac Output -Bronchospasm -Tension Pneumothorax -ETT Displacement (into Rt main bronchus) -Oxygen Toxicity -Ventilator Associated Pneumonia -Fluid Retention -Respiratory Alkalosis -Respiratory Acidosis -Gastric Distension -Pressure Sores -Muscle Disuse

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complications of Mechanical Ventilation

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Average insertion length of ETT for women.

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21 cm

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Average insertion length of ETT for men

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23 cm

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Use an ETT with __________________ through a ________ lumen above the cuff to prevent drainage accumulation while pt is intubated.

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continuous suction; dorsal

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Potential complication of mechanical ventilation where... -s/s: pulse changes, decreased BP, decreased urine output -Interventions: HOB flat, IV fluids, adjust vent settings/decrease PEEP

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Decreased Cardiac Output (CO)

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Potential complication of mechanical ventilation where... -s/s: pt fighting the ventilator -Interventions: tape ETT securely, continuous sedation, neuromuscular blockade

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Bronchospasm

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Potential complication of mechanical ventilation where... -s/s: mediastinal shift, dec breath sounds -Interventions: chest tubes, adjust vent settings/decrease PEEP

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Tension pneumothorax

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Potential complication of mechanical ventilation where... -s/s: decreased breath sounds on left side -Interventions: reposition/pull up ETT, follow up CXR, document ETT mark at lip line

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ETT Displacement (into Rt. main Bronchus)

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Potential complication of mechanical ventilation where... -s/s: dyspnea, restlessness, dec breath sounds, crackles -Interventions: use lowest FiO2 setting possible, pulmonary hygiene/suction

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Oxygen toxicity

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Potential complication of mechanical ventilation where... -s/s: fever, "increased?"***CALL KARIN/BECKY/ANN***, discolored foul smelling secretions -Interventions: hand washing, meticulous oral care, sterile technique when suctioning, turning pt frequently, keep HOB elevated when pt on TF, change vent circuit no more than q48hr

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Ventilator Associated Pneumonia

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Potential complication of mechanical ventilation where... -s/s: weight gain, inc secretions -Interventions: adjust vent settings/ call MD to get order for FiO2 setting change to be carried out by RT

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Fluid retention

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Potential complication of mechanical ventilation where... -s/s: dizziness, light-headedness, numbness of the hands and feet -Interventions: adjust vent settings (dec resp rate)

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Respiratory alkalosis

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Potential complication of mechanical ventilation where... -s/s: enlarged abd girth, tympanic bowel sounds -Interventions: NGT, check tube placement, check cuff inflation

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Gastric distension

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Potential complication of mechanical ventilation where... -s/s: confusion, easy fatigue, lethargy, shortness of breath, sleepiness, seizures -Interventions: adjust vent settings (inc resp rate)

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Respiratory acidosis

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Potential complication of mechanical ventilation where... -s/s: ulceration on skin of the angle of mouth and sacral area -Interventions: turn patient Q2Hr, assess ETT and mouth guard placement QidDay and reposition PRN

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Pressure Sores

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Potential complication of mechanical ventilation where... -s/s: atrophy -Interventions: passive ROM

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Muscle Disuse

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Potential complication of mechanical ventilation where... -s/s: "fighting the ventilator," "biting" the ETT -Interventions: provide communication method, talk to pt, examine everything, call bell close, answer call bell immediately, emotional support, sedation (Versed), nuromuscular blockade (Norcuron), insert an oral airway

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Fear and Anxiety

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Common neuromuscular blockade medication used in mechanical ventilation.

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Norcuron

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Resp: make sure vent is functional, make sure pt is connected to the vent, respond to all alarms, reassure pt, *resp muscles are paralized* Ocular: eye drops, patch, *patient cannot blink* Sedate as necessary Assess/treat complication of immobility

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interventions for Neuromuscular Blockade

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Alarm set off by obstruction of air flow (kinks, secretions, pneumothorax, bucking the vent)

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high pressure alarm

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Alarm set off by loss of volume (leak in cuff, leak in hose, disconnected hose, or if the patient has extubated himself or herself).

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Low Pressure Alarm

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When in doubt about the cause of the ventilation alarm, the nurse's best action is to _______________ and call for help.

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manually ventilate

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A patient is on a mechanical ventilator. In what situation would you want to inc FiO2 and inc PEEP?

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PaO2 < 60 mm Hg

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A patient is on a mechanical ventilator. In what situation would you want to dec FiO2 and dec PEEP?

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PaO2 > 60 mm Hg

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A patient is on a mechanical ventilator. In what situation would you want to decrease the respiratory rate?

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pH > 7.45 (alkalosis), PaCO2 < 35 mm Hg

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A patient is on a mechanical ventilator. In what situation would you want to increase the respiratory rate?

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pH 45 mm Hg

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Normally ABGs are obtained ___________ after a vent setting change or when patient shows s/s of ___________________.

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20 min; resp distress

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When collecting an ABG specimen, use a ______________ syringe.

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heparinized

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Immediately following collection from a patient, place the ABG specimen on _________ and transport to _______.

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ice, lab

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When weaning a pt from dependence on mechanical ventilation, they should be weaned from the following support therapies in this order 1) __________, 2)__________, and 3)____________.

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vent; tube; oxygen

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In preparing the patient to be discontinued from the ventilator, take the patient off the vent for _____________ periods as long as the patient can tolerate.

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intermittent

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Vent Weaning Criteria: -Vital signs _________ -_________ respiratory muscle strength -Stable ABG's -- PaO2 of ___ with FiO2 ____ -__________ of disease condition -Patient is ____________ ready

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stable, adequate, 60 mm Hg, 40%, reversal, psychologically

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For pulmonary patients, it is important that they recieve their nutritional calories from __________________ instead of __________________ increase CO2 levels.

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fat & protein, carbohydrates (CHO)

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_________________ is the best time to start weaning from ventilation because the patient is most rested and has the most energy at this time.

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early morning

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Provide an ______________ that promotes a good nights sleep for vent patients. You may even give them a sleeping pill.

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environment

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Provide ___________ support during weaning from vent.

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emotional

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A method of respiratory ventilation used primarily in the treatment of sleep apnea. Also commonly used for those who are critically ill in hospital with respiratory failure, and in newborn infants as an alternative to tracheal intubation, or to allow for earlier extubation. An advantage is that this device has alarms. A disadvantage is that this device does use a ventilator.

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Continuous Positive Air Pressure (CPAP)

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-Observe for s/s of hypoxia (tachypnea, restlessness, arrhythmia - PVCs) -Observe for fatigue (use of accessory muscles, increased resp rate) -Continue oxygen therapy, ABG monitoring (after every vent settings change), respiratory assessment (pulse ox), bronchodilator therapy, chest PT/Suctioning, provide for adequate nutrition, provide for adequate rest

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interventions for Vent Weaning

Med Surg Test 2 – ARDS & Ventilator Therapy – Flashcards

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