1. Define the acute respiratory distress ?

is

severe,

life-threatening

medical

condition

characterized

by

widespread inflammation in the lungs , or it may be triggered by a

trauma or lung infection, it is usually the result of sepsis

2. Etiology/causes of ARD
1) Aspiration (gastric secretions, drowning)
2) Drug ingestion and overdose
3) Hematologic disorders
4) Prolonged inhalation of high concentrations of oxygen, smoke, or
corrosive substances
5) Localized infection (bacterial, fungal, viral pneumonia)
6) Metabolic disorders (pancreatitis, uremia)
7) Shock (any cause)
8) Trauma (pulmonary contusion, multiple fractures, head injury)
9) Major surgery
10)

Fat or air embolism

11)

Systemic sepsis

3. Pathophysiology of ARD

Injury to the lungs reduces blood flow to the lungs allowing platelets to
aggregate. Platelets release histamine ,these substances inflame and
damage the alveolar membrane and later increase capillary
permeability. The progression of events can be divided into three stages :-

Exudative

Proliferative
Fibrotic
1) Exudative
During this phase, the capillary membrane begins to leak, and proteinrich fluid fills the alveoli, profoundly disrupting the gas exchange .
Neutrophils begin to attach to the damaged membrane and may cross

into the alveoli, further impairing the gas exchange. Formation of

hyaline membranes in the alveoli and reduce alveolar gas exchange

2) Proliferative phase

Type II alveolar cells damaged, Limiting the production of surfactant,

resulting in further loss of alveolar function. As active surfactant is lost
the alveoli stiffen and collapse, leading to atelectasis, which increase
breathing effort. Ventilation /perfusion (VQ)mismatch and Hypoxemia
Decrease lung compliance . Pulmonary hypertension and right
ventricular failure

3) Fibrotic phase

Development of fibrotic tissue resulting in alveolar disfigurement and

Decreased lung compliance . Worsening of pulmonary hypertension lead
to Increased dead space ventilation .

4. Signs and symptoms of ARD

A. Severe dyspnea
B. Severe hypoxemia.
C. Rapid, shallow respiratory pattern and use of accessory muscles
D. Stiff lungs -difficult to ventilate
E. Tachypnea & tachycardia
F. Dry Cough
G. Cyanosis
H. Anxiety, Restlessness and altered level of consciousness.

5. Diagnostic test of ARD

listening to the chest with a stethoscope (auscultation) reveals
abnormal breath sounds, such as crackles, which may be signs of fluid
in the lungs. Often, blood pressure is low. Cyanosis (blue skin, lips,
and nails caused by lack of oxygen to the tissues) is often seen.

Tests used to diagnose ARDS include:

a. Arterial blood gas
b. Blood tests, including CBC and blood chemistries
c. Blood and urine cultures

d. Bronchoscopy
e. Chest x-ray
f. Sputum cultures and analysis
g. Tests for possible infections

6. Medical management of ARD

a) Supplemental oxygen and prepare the patient for Intubation and
mechanical ventilation
b) Chest physiotherapy, postural drainage and suction
c) Transfusion therapy-platelets, packed RBCs
d) Antibiotics Amoxil and ampicillin
e) Analgesic-Morphine
f) Diuretics-furosemide
g) Anticoagulant
h) Anti-inflammatory-Steroids(Hydrocortisone)
i) Antacids
j) Sedation-Propofol, fentanyl and midazolam

7. Nursing management of ARD

a. Oxygen administration
b. Nebulizer therapy
c. Chest physiotherapy
d. Suctioning
e. Frequent assessment of the patient's status is necessary to
evaluate the effectiveness of treatment.
f. Maintain fluid restrictions
g. Administer iv fluids
h. Positioning -the nurse turns the patient frequently to improve
ventilation and perfusion in the lungs and enhance secretion
drainage.
i. Rest is essential to limit oxygen consumption and reduce oxygen
needs.
j. Monitor ventilator settings

k. Eye care is important as well, because the patient cannot blink,

increasing the risk of corneal abrasions.

8. Complication of ARD
Since ARDS is an extremely serious condition which requires invasive
forms of therapy it is not without risk. Complications to be considered
are:
1) Multiple organ failure
2) Ventilator associated pneumonia
3) Death
4) Possible surgical intervention
5) Tracheostomy for prolonged respiratory failure

9. Define ET intubation

Endotracheal intubation is the placement of a tube into the trachea

(windpipe) in order to maintain an open airway in patients who are
unconscious or unable to breathe on their own. Oxygen, anesthetics, or
other gaseous medications can be delivered through the tube

10. Discuss the different types of the mechanical ventilation

setting
1) Positive end expiratory pressure (PEEP) is pressure applied upon
expiration. PEEP is applied using either a valve that is connected
to the expiratory port and set manually or a valve managed
internally by a mechanical ventilator. PEEP is a pressure that an
exhalation has to bypass, in effect causing alveoli to remain open
and not fully deflate. This mechanism for maintaining inflated

alveoli helps increase partial pressure of oxygen in arterial blood,

an increase in PEEP increases the PaO2.
2) Continuous positive airway pressure (CPAP) is a non-invasive
positive pressure mode of ventilation (NPPV). CPAP is a pressure
applied at the end of exhalation to keep the alveoli open and not
fully deflate. This mechanism for maintaining inflated alveoli
helps increase partial pressure of oxygen in arterial blood, an
appropriate increase in CPAP increases the PaO2.
3) Bilevel positive airway pressure (BPAP) is a mode used during
noninvasive positive pressure ventilation (NPPV). BPAP can be
described as a Continuous Positive Airway Pressure system with a
time-cycled change of the applied CPAP level. CPAP, BPAP and
other non-invasive ventilation modes have been shown to be
effective management tools for chronic obstructive pulmonary
disease and acute respiratory failure.
4) Synchronized Intermittent-Mandatory Ventilation (SIMV)
Guarantees a certain number of breaths, but unlike ACV, patient
breaths are partially their own, reducing the risk of hyperinflation
or alkalosis. Mandatory breaths are synchronized to coincide with
spontaneous respirations. Disadvantages of SIMV are increased
work of breathing and a tendency to reduce cardiac output, which
may prolong ventilator dependency. The addition of pressure
support on top of spontaneous breaths can reduce some of the work
of breathing. SIMV has been shown to decrease cardiac output in
patients with left-ventricular dysfunction

11. Discuss the nursing management of the patient on a

mechanical ventilation
o The nurse assesses for the presence of secretions by lung
auscultation at least every 2 to 4 hours.

o Measures to clear the airway of secretions include suctioning,

frequent position changes, and increased mobility as soon as
possible.
o If excessive secretions are identified by inspection or auscultation
techniques, suctioning should be performed.
o Maintaining the endotracheal or tracheostomy tube is an essential
part of airway management.
o The nurse positions the ventilator tubing so that there is minimal
pulling or distortion of the tube in the trachea, reducing the risk
of trauma to the trachea.
o Cuff pressure is monitored every 6 to 8 hours to maintain the
pressure at less than 25 mm Hg (optimal cuff pressure is 15 to 20
mm Hg). The nurse assesses for the presence of a cuff leak at the
same time.
o Tracheostomy care is performed at least every 8 hours, and more
frequently if needed, because of the increased risk for infection.
o The nurse administers oral hygiene frequently, because the oral
cavity is a primary source of contamination of the lungs in the
intubated and compromised patient.

12. Recognize the clinical progression of the patient with ARD

If the underlying disease or injurious factor is not removed, the quantity
of inflammatory mediators released by the lungs in ARDS may result in a
systemic inflammatory response syndrome or sepsis if there is lung
infection.The evolution towards shock or multiple organ dysfunction
syndrome follows paths analogous to the pathophysiology of sepsis. This
leads to the impaired oxygenation which is the central problem of ARDS,
as well as to respiratory acidosiswhich is often caused by ventilation
techniques such as permissive hypercapnia, which attempt to limit
ventilator-induced lung injury in ARDS. The result is a critical illness
in which the 'endothelial disease' of severe sepsis or SIRS is worsened by
the pulmonary dysfunction, which further impairs oxygen delivery.