ARDS (Case study)

Patrick Laird, DNP(C), MSN, RN, ACNP-BC, CCRN;
Susan D. Ruppert, PhD, RN, ANP-BC, NP-C, FCCM, FAANP,
2011.
Published on Wolters Kluwer Health
Case Study

 Pathophysiology of the
disease
 ECMO
 Summary
 First patient encounter
 Day 2-4
 V/S
 P/E
 Lab result
 CXR
 Plan
Outline:

55 y/o male recently diagnosed with influenza A.
Presented to the emergency department (ED)
accompanied by his wife with worsening shortness of
breath, fever, productive cough ( green ) sputum, and
new onset altered mental status.
 Primary assessment revealed oxygen saturation of 61% on room air.
Respirations were labored with abdominal accessory muscle use.
 BIPAP was used but his respiratory status continued to deteriorate -------
( intubation ) .
 Difficult intubation.

 After intubation the patient became hypotensive.
A Levophed drip was initiated.
 Once hemodynamically stable the patient was
admitted to the intensive care unit (ICU) for
continued management.
Continue

 CHIEF COMPLAINT :
“Shortness of breath and confusion”
 PAST MEDICAL AND SURGICAL HISTORY :
• Hypertension — Diagnosed in 2009.
• Hyperlipidemia — Diagnosed in 2009.
• No history of surgical procedures.
• Denied any history of smoking and drinks approximately
2 alcoholic beverages per week.
 SOCIAL AND FAMILY HISTORY :
Married for 28 years , Employed with Anadarko petroleum
division. His parents both diagnosed with hypertension
treated with medication.

CURRENT HOSPITAL MEDICATIONS :
 Levophed infusion at 0.4 μg/kg/min intravenous
(IV).
 Propofol infusion at 55 μg/kg/min IV.
 Protonix 40 mg IV daily.
 Lovenox 40 mg subcutaneous daily.
 Azithromycin 500 mg IV daily.

 REVIEW OF SYSTEMS :
Patient orally intubated at the time of interview and
examination.
Chest :
Complains of increased dyspnea and cough with
increased green sputum production 2 days prior
to admission.
Heart:
Complains of weakness for 10 days prior to arrival.
Urinary system:
decrease in normal urinary output because of
decreased oral intake.

Neurological :
His wife reports change in his mental status over
last 2 days. States patient is “not making any
sense and is saying inappropriate things.

Vent management:
IBW = 90 Kg
A/C VC
Tube size 8 Fr, at point of 22 near lip line.

VS:
 Temp.: 37.2oC.
 HR: 93b/min.
 RR: 16 b/min.
 BP: 8950 mmHg.
 O2 Sat.: 86%
Day
2

Overall status:
 General: well nourished.
 Skin: No skin rashes/lesions observed.
 HEENT.
 Chest: Symmetrical expansion.
 Heart: (S1, S2) are noted. Regular
rhythm. No murmurs, gallops, or rubs
are appreciated.
 Abdomen: Soft, nontender and
nondistended.
Day
2

Cont.
 Extremities: Warm. No edema, clubbing, or
cyanosis was appreciated.
 Capillary refill: +2 seconds. Nail beds are
pale.
 Neurological: Sedated on mechanical
ventilation.
Spontaneous movement of all 4 extremities is
noted. Does not follow verbal commands.
Day
2

CXR:
 Endotracheal tube tip located 2 cm above
the carina.
 Interval worsening perihilar air space
opacity suggestive of worsening
pulmonary edema or ARDS.
 No pneumothorax or pleural effusion.
Day
2

ABG:
parameters Values
pH: 7.42
PCO2: 41 mmHg.
PO2: 34 mmHg.
HCO3: 26 mmol/L
Normal acid base balance with
sever hypoxemia.
Day
2

CBC
WBC 10.2 kg/mm3 4.0-10 kg/mm3
Hb 15.1 gm/dL 13.0-16.8 gm/dL
Platelets 325 kg/mm3 150-430 kg/mm3
Na 143 mEq/L 135-148 mEq/L
K 3.9 mEq/L 3.5-5.5 mEq/L
Cl 97 mEq/L 98-106 mEq/L
BUN 42 mg/dL 10-26 mg/dL
Cret. 2.2Mg/dL 0.5-1.2 mg/dL
BNP 18 0-100 pg/mL
Day
2

DIAGNOSTIC
IMPRESSIONS
Differential
Diagnoses:
ALI, ARDS,
pneumonia,
cardiogenic
pulmonary edema,
PE.
Working diagnosis
Acute respiratory
distress syndrome
(ARDS).
Additional Diagnoses:
CAP, severe sepsis,
recent influenza A
(H1N1), and acute
renal failure.
Day
2

Berlin definition:
ARDS is an acute, diffuse, inflammatory lung injury , defined
by:
Severity is defined by degree of oxygenation impairment.

RISK FACTORS:
Direct “pulmonary etiologies” Indirect “extrapulmonary etiologies”?
 Pneumonia.
 Aspiration.
 Inhalational injury.
 Pulmonary contusion.
 Fat emboli.
 Sepsis.
 massive blood transfusion.
 Burns.
 Acute pancreatitis.
 Severe trauma.

Pneumonia
35%
Sever Sepsis
26%
Aspiration
15%
Trauma
11%
Other
13%
Causes of ARDS
June 20, 2012,

Pathophysiology:
↓ surfactant
Accumulatio
n of fluid
Atelectasis
Pulmonary
edema
❶
❷

Pathophysiology
 Consequences of lung injury include:
 Impaired gas exchange
 V/Q mismatch
 Increased dead space
 Decreased compliance

PLAN
 The main goal is to optimize oxygenation and prevent
further inflammation that may lead to multi-organ failure
and that may done by :
 Low tidal volume
 Low PEEP/high Fio2
Initial ventilator settings
made by ED physician were not compliant
with current therapy recommendations. Ventilator
settings were adjusted in the ICU immediately
following initial evaluation.
Day
2

Ventilator management
A/C VC
IBW = 90 Kg
VT= 8mL/Kg = 700mL
PEEP= 10 cm H2O
RR = 18 bpm
Fio2 = 100%
VT= 6mL/kg = 540mL
PEEP= 14 cm H2O
Day
2

Community Acquired Pneumonia ..
 For the treatment of CAP for patients in the ICU
include a B-lactam, and either azithromycin or a
respiratory fluroquinolone.
 Patients with a penicillin allergy should receive a
respiratory fluroquinolone and aztreonam.

Neuromuscular blocking agents
 (NMBA) Are used :
 In the ICU to facilitate and optimize mechanical ventilation.
 To improve chest wall compliance, eliminate dysynchrony, and reduce
peak airway pressures.
 Muscle paralysis used :
 In decreasing the work of breathing and respiratory muscle blood flow
thereby reducing oxygen consumption

Cont.
 The patient displayed mild ventilator dysynchrony and refractory
hypoxemia.
 Paralytics were initiated to gain full control of ventilation and
eliminate ventilator asynchrony.
 Once paralytics were initiated, the patient’s ventilator asynchrony
resolved.

Subjective data ..
• Remains critically ill.
• Orally intubated on mechanical ventilation.
• Oxygen saturations remain less than 86%.
Day
4

Objective data ..
oVital Signs:
• T = 38.4 C
• Pulse = 102 B/min
• RR = 20 B/min
• BP = 101/52
• O2 sat =84 %
Day
4

Physical examination ..
No murmurs, gallops, or rubs.CV
Bilateral breath sounds with course crackles; diminished in bilateral bases; no
wheezes noted.
RESP
Warm, 2+ pitting edema to bilateral lower extremities, no cyanosis or clubbing
noted.
EXT
Paralyzed on Nimbex drip at 3 μg/kg/min , Sedated on
propofol infusion at 50 μg/kg/min.
NEURO
Day
4

• Norepinephrine at 0.5 μg/kg/min IV
• Nimbex at 3 μg/kg/min IV
• Propofol at 50 μg/kg/min IV
• Clindamycin 600 mg IV every 8 hours
• Rocephin 2 grams IV every 24 hours
• Albuterol/Atrovent unit dose nebulized every 4 hours .
Day
4
Current medications ..

Chest X-ray films ..
• Bilateral infiltrates and pulmonary edema
• Endotracheal tube in adequate position above the
carina.
Day
4

ASSESSMENT ..
• ARDS
• Metabolic acidosis
• Septic shock
• Community acquired pneumonia
• Acute renal failure
• Recent influenza A (H1N1)
Day
4

PLAN ..
 Despite optimal medical therapy, the patient failed conventional
treatment, and without further intervention death was eminent.
Day
4

 Controversial ( adults )
 Common indications for use of ECMO in adults include
postcardiotomy, postcardiac transplant, severe refractory
heart failure, ARDS, pneumonia, trauma, or primary graft
failure following lung transplant.
Consult cardiovascular surgeon for
placement of extracorporeal membrane
oxygenation (ECMO):

 Use of ECMO results in 1 extra survivor for every 6 patient
treated .

 A total of 201 adult patients received mechanical ventilation
for confirmed or suspected influenza. 68 of these patients
received ECMO and the remaining 133 received
conventional mechanical ventilation.
 48 patients (71%) that received ECMO survived to ICU
discharge and 32 patients survived to hospital discharge.
Overall mortality of the ECMO group was 21%. The
researchers contributed the lower mortality to the age of the
study participants and the cause of ARDS (H1N1).

 Use of ECMO has a multitude of potential complications
including life-threatening bleeding, coagulopathy, air
embolism, thromboembolism, intracerebral hemorrhage
(in neonates), and limb ischemia.
 risks must carefully be weighed against benefit prior to
initiation

 Despite optimal medical therapy, the patient failed
conventional treatment, and without further intervention
death was eminent. After consulting cardiovascular
surgery, available therapy options were discussed with the
patient’s spouse and the decision was made to place the
patient on ECMO as salvage therapy.
In this scenario

 VT = 4-6 ml/kg
 RR= 5-10 bpm
 PEEP= 12-15 cm H2O
 Inspiratory time longer
 FiO2= 0.21
Recommended Ventilator Settings

day 4 : taken to OR , ECMO was
initiated.
ECMO for 6 days
day 10 ,returned to the OR for removal of
ECMO and insertion of a percutaneous
tracheostomy , and percutaneous
endoscopic gastrostomy (PEG) tube
placement

continued to make marked
improvements following removal of
ECMO .
Day 18 :was weaned from the ventilator.
Physical therapy, occupational therapy,
and speech therapy were consulted.
Day 21, the patient was discharged from
the ICU.
day 25 transferred to a long-term acute
care (LTAC) facility for continued
physical and occupational therapy

 On day 25 transferred to a long-term acute care facility for
continued physical and occupational therapy( 2 weeks ).
 The patient was discharged to his home with no physical or
cognitive deficits noted.
 Since his discharge from LTAC, the patient has returned to
work and has no limitations .

55 y/o male recently diagnosed with influenza A.
Presented to the emergency department (ED)
accompanied by his wife with worsening shortness
of breath, fever, productive cough ( green ) sputum,
and new onset altered mental status.
This case study explores the management of an
unusually complicated case of (ARDS) extending
over 52 days of hospitalization. Despite the
utilization of conventional medical treatments and
optimum respiratory support modalities, the patient’s
condition worsened and death was imminent without
salvage therapy. After cardiovascular surgery
consultation, (ECMO) therapy was initiated for 6
days. The patient recovered and was able to return
to regular employment.

Conclusion
 Acute respiratory distress syndrome (ARDS) is a life-
threatening medical condition where the lungs can't provide
enough oxygen for the rest of the body.
 ARDS can affect people of any age and usually develops as a
complication of a serious existing health condition.
 (ARDS) has a mortality rate of 34% to 58% .

ARDS (Case study)

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