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Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP Education Specialist

The 6 P's of ARDS Management. Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN. The 6 P's of ARDS Management. Objectives Identify the 5 criteria for the diagnosis of ARDS.

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Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP Education Specialist

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  1. The 6 P's of ARDS Management Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

  2. The 6 P's of ARDS Management • Objectives • Identify the 5 criteria for the diagnosis of ARDS. • Discuss the common etiologies that lead to ARDS. • Describe the priorities in the management of patients with ARDS.

  3. The 6 P's of ARDS Management diffuse lung injury resulting in noncardiogenic pulmonary edema due to increase in capillary permeability

  4. The 6 P's of ARDS Management

  5. The 6 P's of ARDS Management

  6. The 6 P's of ARDS Management • refractory hypoxemia • diminished compliance • diffuse infiltrates on chest x-ray • normal PAOP • PaO2 / FiO2 ratio < 200

  7. The 6 P's of ARDS Management

  8. The 6 P's of ARDS Management

  9. The 6 P's of ARDS Management • Etiology • shock • trauma • infections • inhaled toxins

  10. The 6 P's of ARDS Management • Etiology • aspiration • near-drowning • massive blood transfusions • fat or amniotic fluid emboli • pancreatitis

  11. The 6 P's of ARDS Management • Phase I & II • subclinical respiratory distress • ABGs (respiratory alkalosis) • hyperventilating

  12. The 6 P's of ARDS Management • Phase III • established respiratory distress • pulmonary shunt > 10% above baseline • chest x-ray shows infiltrates • crackles in lung bases

  13. The 6 P's of ARDS Management • Phase IV • severe respiratory failure • rising pCO2 • rising physiologic shunt • white-out on chest x-ray

  14. The 6 P's of ARDS Management • Diagnosis • history • signs/symptoms • labs (ABGs) • x-ray • hemodynamics

  15. The 6 P's of ARDS Management • Treatment • establish patent airway • restore arterial O2 level

  16. The 6 P's of ARDS Management Add PEEP • Mechanical Ventilation • conventional with PEEP • PC / IRV • HFJV • APRV

  17. The 6 P's of ARDS Management • Goals of mechanical ventilation in ARDS are to: • maintain oxygenation • avoiding oxygen toxicity and the complications of mechanical ventilation

  18. The 6 P's of ARDS Management • maintain oxygen saturation in the range of 85-90% • aim of reducing the fraction of inspired oxygen (FIO2) to less than 60% within the first 24-48 hours • usually requires the use of moderate-to-high levels of PEEP

  19. The 6 P's of ARDS Management • experimental studies have shown that mechanical ventilation may promote a type of acute lung injury (ALI) termed ventilator-associated lung injury • protective ventilation strategies using low tidal volumes and limited plateau pressures improves survival when compared with conventional tidal volumes and pressures

  20. The 6 P's of ARDS Management • ARDS Network study • patients with ALI and ARDS were randomized to mechanical ventilation • tidal volume of 12 mL/kg of predicted body weight and an inspiratory pressure of 50 cm water or less • tidal volume of 6 mL/kg and an inspiratory pressure of 30 cm water or less

  21. The 6 P's of ARDS Management • the study was stopped early after interim analysis of 861 patients demonstrated that subjects in the low-tidal-volume group had a significantly lower mortality rate (31% versus 39.8%)

  22. The 6 P's of ARDS Management • mechanical ventilation with a tidal volume of 6 mL/kg predicted body weight is recommended, with adjustment of the tidal volume to as low as 4 mL/kg if needed to limit the inspiratory plateau pressure to 30 cm water or less

  23. The 6 P's of ARDS Management • increase the ventilator rate and administer bicarbonate as needed to maintain the pH at a near normal level (7.3)

  24. The 6 P's of ARDS Management • High-frequency ventilation uses low tidal volumes and high respiratory rates. • diminishes alveolar distention • compared to conventional ventilation in adults demonstrates early improvement in oxygenation but no improvement in survival.

  25. The 6 P's of ARDS Management • Fluid Management • maintain adequate perfusion • isotonic solutions • fluid restriction • consider diuretics

  26. The 6 P's of ARDS Management • primary ARDS due to aspiration, pneumonia, or inhalational injury  treated with fluid restriction • secondary ARDS due to remote infection or inflammation  requires initial fluid and potential vasoactive drug therapy • essential in directing initial treatments to stabilize the patient

  27. The 6 P's of ARDS Management • Improve systemic O2Delivery • modest volume expansion • vasopressors/vasodilators

  28. The 6 P's of ARDS Management • Sedation • control anxiety & physical activity • may require addition of neuromuscular blocker • suggestions: • propofol • versed

  29. The 6 P's of ARDS Management • Positioning • “good lung” in dependent position • both lungs are equally injured • beneficial positions include: • prone • right lung down

  30. The 6 P's of ARDS Management • 60-75% of patients with ARDS have significantly improved oxygenation when turned from the supine to the prone position • improvement in oxygenation is rapid and often substantial enough to allow reductions in FiO2 or level of CPAP

  31. The 6 P's of ARDS Management • Possible mechanisms for improvement are: • recruitment of dependent lung zones • increased functional residual capacity (FRC) • improved diaphragmatic excursion • increased cardiac output • improved ventilation-perfusion matching

  32. The 6 P's of ARDS Management • despite improved oxygenation with the prone position, randomized controlled trials of the prone position in ARDS have not demonstrated improved survival

  33. The 6 P's of ARDS Management • Pharmacologic Therapy • corticosteroids • antimicrobials • non - steroidal anti - inflammatory agents • anti – pyretic • “Star – Trek Meds”

  34. The 6 P's of ARDS Management • No drug has proved beneficial in the prevention or management of acute respiratory distress syndrome (ARDS).

  35. The 6 P's of ARDS Management • Hemoglobin • 12 to 15 gm / dL • factors decreasing offloading: • hypophosphatemia • alkalosis • hypothermia

  36. The 6 P's of ARDS Management • Nutritional Support • often overlooked in ARDS • ingredients required: • stress amino acid • trace elements • omega 3 / omega 6 • Oxepa or Impact

  37. The 6 P's of ARDS Management • patients who required mechanical ventilation within 48 hours of developing acute lung injury received either trophic or full enteral feeding for the first 6 days

  38. The 6 P's of ARDS Management • Initial lower-volume trophicenteral feeding did not improve • ventilator-free days • 60-day mortality • infectious complications • it was associated with less gastrointestinal intolerance

  39. The 6 P's of ARDS Management • Other Therapeutics • nitric oxide • surfactant • ECMO • partial liquid ventilation

  40. The 6 P's of ARDS Management Extracorporeal Membrane Oxygenation (ECMO) • Description • type of cardiopulmonary bypass • CO2 removal; O2 replacement • ventilated (lower VT, FiO2, & PEEP)

  41. The 6 P's of ARDS Management Extracorporeal Membrane Oxygenation (ECMO) • Complications • technical difficulties • cannula malposition • hemorrhage • sepsis

  42. The 6 P's of ARDS Management • ECMO appeared to improve survival in patients with H1N1-associated ARDS who could not be oxygenated with conventional mechanical ventilation

  43. The 6 P's of ARDS Management • randomized controlled trial that compared partial liquid with conventional mechanical ventilation • partial liquid ventilation resulted in increased morbidity • pneumothoraces • hypotension • hypoxemic episodes • trend toward higher mortality

  44. The 6 P's of ARDS Management Case Study • 48 - year old alcoholic with GI bleed & pancreatitis • severe epigastric pain, acute abdomen • ultrasound confirms enlarged, edematous pancreas • hemodynamically unstable • refractory hypoxemia

  45. The 6 P's of ARDS Management Case Study HR 130 BP 80 / 50 / 62

  46. The 6 P's of ARDS Management Case Study HR 130 BP 80 / 50 / 62 CI 2.2 PAP 15 / 8 / 10 PAOP / CVP 2 / 1

  47. The 6 P's of ARDS Management Case Study PVRI 290 SVRI 2218 SVI 28 LVSWI/RVSWI 22.8 / 2.6

  48. The 6 P's of ARDS Management Case Study ABGs (.70 FiO2) pH 7.38 pCO2 45 pO2 50 SaO2 .83 HCO3 27 SvO2 60%

  49. The 6 P's of ARDS Management Case Study PaO2 / FiO2 Ratio (P/F) • 50 / .70 • 71 Normal = > 300 ALI = < 250 ARDS = < 200

  50. The 6 P's of ARDS Management Case Study Laboratory Values Na 150 Cl 96 Hgb / Hct 12.1 / 36.3 CO2 26

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