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ARDS and Pneumothorax Study Guide Review, Exams of Nursing

A.T. Still University of Health Sciences (ATSU)Nursing

A study guide review of Acute Respiratory Distress Syndrome (ARDS) and Pneumothorax. It covers the pathophysiology, predisposing factors, inclusion criteria to confirm ARDS diagnosis, hypoxic vasoconstriction, pulmonary hypertension, risks and benefits of PEEP in ARDS, mechanical ventilation, types of ventilators, and ventilator settings. It also includes ABG's pH CO2 HCO3 PaO2 and how to measure post-intubation.

Typology: Exams

2023/2024

Available from 12/08/2023

Expertsolution
Expertsolution 🇺🇸

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ARDS and pneumothorax study guide review
ARDS and Pneumothorax
● Acute Respiratory Failure (ARF) - Bad
● Acute Lung Injury (ALI) - Worse
●Acute Respiratory Distress Syndrome (ARDS) – The Worst
●Pneumothorax
ABG’s
pH CO2 HCO3 PaO2
7.35-7.45 35-45 22-26 80-100
Fully compensated- pH normal ; partially- pH not normal: all abnormal
Acute Respiratory Distress Syndrome
● Most severe expression of Acute Lung Injury
● Results in severe respiratory failure: cannot breathe
● Often fatal; high mortality statistics
● Not a lung disease; ACUTE, severe alveolar inflammatory responses to other “triggers”
● Unpredictable course
Predisposing Factors:
“Triggered” by a local pulmonary inflammatory problem , usually within 72 hours of the trigger:
●Pneumonia …. #1 local trigger of ARDS
● Pulmonary contusion
● Smoke inhalation
● Near drowning
● Gastric aspiration into the lung
“Triggered” by a distant or systemic problem , usually within 72 hours of the trigger:
●Sepsis …. #1 systemic trigger of ARDS (30%)
● Pancreatitis
● Massive blood transfusions from a trauma
● Burns
● Large fluid resuscitation from shock
● Drug abuse or overdose
Pathophysiology:
1. Direct / Indirect injury to the alveolar-capillary membrane
2. Initiation of inflammatory-immune response
3. Activation of neutrophils, macrophages, and platelets
4. Release of chemical mediators- histamines
5. Increased microvascular permeability of the alveoli lining
6. Plasma proteins and fluids begin to FLOOD the alveoli spaces- vasodilation sends
stuff in- fluid/protein
7. Fine inspiratory crackles due to abnormal air turbulence through fluid-filled alveoli- fluid filled
alveoli
8. Decreased lung compliance and loss of surfactant from the flooding- damaged
surfactant: can’t be replaced. Surfactant- keep alveoli open
Inclusion Criteria to Confirm ARDS Diagnosis:
#1 A definitive cause or trigger for ARDS trigger
#2 Bilateral infiltrates on CXR whiteout
#3 P/F ratio (PaO2 /FiO2 ratio) < 300 P/F <300: diagnose
#4 No evidence of cardiogenic pulmonary edema (HF) noncardiogenic pulmonary edema
Bilateral Infiltrates on CXR: Diffuse and bilateral progressive lung infiltrates
“Lungs are whited out”
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ARDS and Pneumothorax ● Acute Respiratory Failure (ARF) - Bad ● Acute Lung Injury (ALI) - Worse ● Acute Respiratory Distress Syndrome (ARDS) – The Worst ● Pneumothorax ABG’s pH CO2 HCO3 PaO 7.35-7.45 35- 45 22- 26 80- 100 Fully compensated- pH normal; partially- pH not normal: all abnormal Acute Respiratory Distress Syndrome ● Most severe expression of Acute Lung Injury ● Results in severe respiratory failure: cannot breathe ● Often fatal; high mortality statistics ● Not a lung disease; ACUTE, severe alveolar inflammatory responses to other “triggers” ● Unpredictable course Predisposing Factors: “Triggered” by a local pulmonary inflammatory problem, usually within 72 hours of the trigger: ● Pneumonia …. #1 local trigger of ARDS ● Pulmonary contusion ● Smoke inhalation ● Near drowning ● Gastric aspiration into the lung “Triggered” by a distant or systemic problem, usually within 72 hours of the trigger: ● Sepsis …. #1 systemic trigger of ARDS (30%) ● Pancreatitis ● Massive blood transfusions from a trauma ● Burns ● Large fluid resuscitation from shock ● Drug abuse or overdose Pathophysiology:

  1. Direct / Indirect injury to the alveolar-capillary membrane
  2. Initiation of inflammatory-immune response
  3. Activation of neutrophils, macrophages, and platelets
  4. Release of chemical mediators- histamines
  5. Increased microvascular permeability of the alveoli lining
  6. Plasma proteins and fluids begin to FLOOD the alveoli spaces- vasodilation sends stuff in- fluid/protein
  7. Fine inspiratory crackles due to abnormal air turbulence through fluid-filled alveoli- fluid filled alveoli
  8. Decreased lung compliance and loss of surfactant from the flooding- damaged surfactant: can’t be replaced. Surfactant- keep alveoli open Inclusion Criteria to Confirm ARDS Diagnosis: #1 A definitive cause or trigger for ARDS trigger #2 Bilateral infiltrates on CXR whiteout #3 P/F ratio ( PaO2 /FiO2 ratio ) < 300 P/F <300: diagnose #4 No evidence of cardiogenic pulmonary edema (HF) noncardiogenic pulmonary edema Bilateral Infiltrates on CXR: Diffuse and bilateral progressive lung infiltrates “Lungs are whited out”

Pathogenesis: alveolar flooding

  1. Increased microvascular permeability of the alveoli lining
  2. Plasma proteins and fluids begin to FLOOD the alveoli spaces
  3. Results in non-hydrostatic Pulmonary Edema
  4. Leads to Severe Respiratory Failure Priority Management Treatment Goals: support, find/treat trigger, prevent a secondary lung event
  5. Rapid identification and treatment of the underlying “trigger” of the ARDS
  6. Prevention of secondary lung event (i.e. pneumonia)
  7. Supportive treatment Medical and Nursing Management ● Mechanical ventilation with PEEP and increased FiO ● Optimal ventilation / perfusion positioning & CPT- continuous percussion therapy ● High Fowler’s position- minimal 30 ● Maintain adequate rest periods ● Vigilant surveillance for secondary pulmonary injuries ● Prevent aspiration, oxygen toxicity, ventilator-induced lung injury, pneumonia ● Ventilator: increased PEEP and FIO2, low tidal volumes, High fowlers, rest, percussion therapy Mechanical Ventilation Guidelines ● Low tidal volume- amount of air inspired and expired; lower volume for stiff lungs: 400- 600 ● High FIO2 – need to be concerned about oxygen toxicity: need oxygen due to hypoxemia ● Oxygen toxicity- >50% FIO2 greater than 24 hours: neuro- seizure, nausea, ringing in ears, restlessness; lungs- severe chest pain and harsh cough ● Use of higher and higher PEEP ● Maintain Pulse Oximeter > or equal 90 to 92% Supportive Therapies for ARDS – Key to Remember Treatments even Pharmacological treatments are Supportive and non-specific ● Diuresis as long as there is no hypotension- give hypertonic: D5, albumin ● Conservative to limited Intravenous fluids if no hypotension ● Antibiotics only if +Infection ● Neuromuscular Blocking Agents- block muscle contraction (acetylcholine) such as Vecuronium which decrease WOB and pressure in lung and improves oxygenation = Must Sedate and put on ventilator when giving NMBA’s ● Sedation such as Versed or Propofol ● Arterial line for frequent ABG monitoring- also can monitor BP ● Pain control such as Fentanyl ● Prone Positioning ● Inhaled nitric oxide or Inhaled Epoprostenol (Flolan) ● ECMO (Extracorporeal Membrane Oxygenation) Therapy Body Position With Severe ARDS: Prone positioning for patients with severe ARDS ● Significantly decreased mortality ● Reduces absolute pulmonary shunting ● Improves oxygenation, ventilation and perfusion ● Allows for mobilization of secretions ● Allows for recruitment of collapsed alveoli ● Use clinical judgment of length of time Pulmonary Vasodilators: ● Before we discuss Pulmonary Vasodilators Need to remember the pulmonary response to hypoxia=

● Hypoxic Vasoconstriction – when some areas of the lung are diseased, unable to deliver oxygen to blood. To help adapt to this, pulmonary arterioles in that area start to constrict and this effectively shuttles blood away from damaged areas of the lungs and toward healthy lung tissue. ● However, if the problem is widespread, this mechanism can backfire because now have widespread vasoconstriction and lead to Pulmonary Hypertension ● Most often used in ARDS: ● Inhaled Nitrous Oxide - iNO ● Inhaled Epoprostenol (Flolan) – iEPO ● Sildenafil (Viagra) – oral ● The purpose of these vasodilators is to: -> improve V/Q mismatch -> decrease pulmonary vascular resistance -> decrease pulmonary artery pressure Pulmonary Hypertension: trying to shuttle blood away from the bad areas- causes pulmonary HTN: can lead to r sided HF ● In Pulmonary Hypertension – the pulmonary arterioles and capillaries become narrowed, blocked or destroyed. ● This makes it harder for blood to flow through the lungs and raises pressure within the lungs' arteries. ● As the pressure builds, the right ventricle must work harder to pump blood through the lungs and can eventually lead to RSHF (Cor Pulmonale). Risks and Benefits of PEEP in ARDS Risks Benefits Pneumothorax Overdistention of alveoli Opens collapsed alveoli Stabilizes flooded alveoli Improves lung compliance Increases Total Lung Capacity Decreases absolute shunting Mechanical Ventilation: do not want to keep them on it ➢ Purpose: Used when patient is ➢ unable to maintain a patent airway ➢ unable to maintain adequate gas exchange ➢ when patient is resp. failure

  • Note: If see ABG’s showing several acidosis such as pH 7.1 – 7.2 -> need **immediate intubation and mechanical ventilation. Tube 2 sonimeters above the Carina Measures Post-Intubation:
  1. Check for End- Tidal CO2 purple-yellow: in correct area; lower than PACO2 (32-37)** ● Easy cap II CO2 detector connects to ETT and uses ambu bag and give 6 breaths and to confirm placement. “Color turns from purple to yellow”

Complications of PEEP: * Note: The problem with continually adding this positive pressure into patient: decrease venous return

  1. Just from putting the patient on ventilator, giving positive pressure and then by adding additional (+) pressure from PEEP, ↑’s intrathoracic pressures and therefore decreasing venous return which will lead to: ↓ B/P, ↓ COP
  2. Also by adding this pressure, ↑ risk of Baratrauma (pneumothorax) and Volutrauma – fractures develop in alveoli that allow fluid and protein to seep into lungs and may lead to pulmonary edema. ● HYPOTENSION ● Decreased Cardiac Output (COP) ● Baratrauma (Pneumothorax) ● Volumtrauma Ventilator Modes: ● Continuous Mandatory Ventilation (CMV)- Does all work of breathing ● Assist Control (A/C)- Will deliver set TV, RR, FIO2 & PEEP Weaning Modes: Synchronized Intermittent Mandatory Vent (SIMV) ➢ Will deliver set TV, RR, FIO2 & PEEP (if ordered) Pressure Support Ventilation (PSV) ➢ Pt must be able to initiate own breaths, so patient must be spontaneous breathing. Increased Risk for VAP: Factors that lead to VAP include:
    • Oropharangeal Colonization
    • Gastric Colonization
    • Aspiration
    • Compromised Lung Defenses Nursing Interventions for Prevention of VAP: ● VAP Bundle includes: ● ↑ HOB 30 degrees and > to prevent gastric and oropharayngeal aspiration ● Assess need for mechanical ventilation – Daily assess for weaning ● Sedation Vacation: Daily awakening -> Interrupt sedation of patient to determine patient’s ability to wean VAP Bundle: ● Remember – Cannot wean someone who is heavily sedated ● That’s why Propofol is good to use cause short ½-life ● Oral Care to prevent oral tracheal contamination includes:
    1. Chest physiotherapy to promote mobilization of secretions
    2. Suctioning including subglottic suctioning
    3. Tooth brushing
    4. Chlorohexidine oral care q 12 hours ● Check ETT cuff pressures - to prevent aspiration ❑ Gastrointestinal prophylactic medication- protonix ❑ Deep vein thrombosis prophylaxis

Case Study (ARDS) Situation: 23 y/o female in normal state of health Awoke with severe chills, vomiting, diarrhea, HA, Temp 103.7; Requests family to take her to the ER Background: Intrauterine device (IUD) placed 3 days prior No other PMH or PSH Neg hx of TB Neg hx of smoking, drugs or ETOH Physical assessment: Neg for shortness of breath, wheezing Neg for sputum production, cough hemoptysis Neg for orthopnea, chest pain Temp – 103.7 HR – 104 bpm RR – 24 BP-126/75 vitals are not concerning at this moment Lungs: CTA bilaterally WBC: 15,000 elevated Questions: Does the patient appear to have a pulmonary problem at this time? No What factors places this patient at RISK for the development of ARDS? Sepsis Medical Plan of Care: cultures then antibiotics: broad to start Empiric treatment of triple antibiotics for suspected infection Culture of IUD Blood Cultures X Admitted to med-surgical general bed Common diet VS q shift OOB protocol Twelve hours later: room air- 21% Chief compliant: Increasing SOB on RA and cough Assessment: RR 34; HR 120 bpm; POX 88% on RA Restlessness, Fine inspiratory crackles restlessness- something is going on; possible hypoxia ABG results: pH 7. PaCO2 71 mm Hg HCO3 26 mEq/ liter PaO2 62 mm Hg Questions: What is the patient’s acid-base status? Respiratory acidosis (uncompensated) What is the patient’s oxygenation status? Mild hypoxemia 30 minutes later: Assessment: RR 34; HR 120 bpm; POX 84% on 40% partial rebreather mask Alert and oriented Agitated and restless Portable chest x-ray ordered Repeat ABG results: pH 7.18; PaCO2 68 mm Hg; HCO3 28 mEq/ liter; PaO2 56 mm Hg Questions: What is the patient’s acid-base status? Respiratory acidosis (partially compensated) What is the patient’s oxygenation status? Moderate hypoxemic What should be the next action? Intubate (severe acidosis) ICU course:

PEEP: 5 cm.- positive end expository pressure: 2- 20 P/F ratio = 60 (Severe ARDS) [60/100 X 100 = 60] Questions A nurse is given a four-patient assignment. Which of the following clients should she evaluate first? A. A client with history of COPD sitting in chair utilizing purse-lip breathing B. A client with a APTT of 80 on a Heparin gtt. at 11 cc/hr. C. A client with an INR of 2.8 on Coumadin D. A client with a P/F ratio of 120 on a ventilator Which of the following reasons would explain why the client with ARDS has a SaO2 below 90% despite receiving 100% FiO2? A. In ARDS, there in increased PVR (pulmonary vascular resistance) B. In ARDS, the lung compliance is increased. C. In ARDS, the alveoli are refractory to oxygen. D. In ARDS, the alveoli trap CO A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? ● Chest X-Ray ● Auscultation of Breath sounds ● Pulse oximetry reading of 95% ● End tidal CO2 monitoring A client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assesses the client for findings associated with a risk associated with this type of ventilator. What is the risk? ● Hypoventilation ● Hypercapnia ● Respiratory Acidosis ● Barotrauma The client is on Pressure Support Ventilation (PSV) for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? ● The FiO2 will be increased. ● Weaning will continue. ● The client will be placed back on full ventilatory support. ● The client will be extubated. A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a “sucking” sound when the patient inhales and exhales. The patient’s chest x-ray shows a pneumothorax. What type of pneumothorax is this known as? A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax Which of the following is a LATE sign of the development of a tension pneumothorax? A. Hypotension B. Tachycardia C. Tracheal deviation

D. Dyspnea A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak. The patient in room 2569 puts on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.