ARDS (Acute Respiratory Distress Syndrome) (Adult Inpatient)

Clinical Description

Care of the hospitalized patient experiencing new or worsening respiratory failure within 7 days of the initial insult, including bilateral infiltrates and refractory hypoxemia that cannot be explained by cardiac failure or generalized fluid overload.

Key Information

Higher PEEP (positive end expiratory pressure) and prone positioning may be more beneficial for those with moderate-severe ARDS (acute respiratory distress syndrome).

Refractory hypoxemia, lung compliance, respiratory mechanics and transpulmonary pressure measurements may be used to guide an optimal PEEP (positive end expiratory pressure) strategy.

Evidence does not support routine use of inhaled nitric oxide, inhaled prostanoids, beta-2 agonist or statin medication and ECLS (extracorporeal life support) in the adult population.

Psychiatric disorders, such as depression, posttraumatic stress disorder and anxiety may occur in patients who survive ARDS (acute respiratory distress syndrome) as a result of lengthy intensive care support.

Palliative care approach may be beneficial to improve quality of life issues, such as decreased lung function, cognitive deficits and other ongoing symptoms that may occur after ARDS (acute respiratory distress syndrome).

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

Effective Oxygenation

B. Patient, family or significant other will teach back or demonstrate education topics and points:

Education: Overview
Education: Self-Management
Education: When to Seek Medical Attention

Correlate Health Status

Correlate health status to:
- history, comorbidity
- age, developmental level
- sex, gender identity
- baseline assessment data
- physiologic status
- response to medication and interventions
- psychosocial status, social determinants of health
- barriers to accessing care and services
- health literacy
- cultural and spiritual preferences
- safety risks
- family interaction
- plan for transition of care

ARDS (Acute Respiratory Distress Syndrome)

Signs/Symptoms/Presentation

breath sounds abnormal
breath sounds diminished
lung compliance decreased
minute volume increased
oxygen demand increased
oxygen index increased
PaO2/FiO2 ratio less than or equal to 300 mmHg
plateau pressure (lung) increased
work of breathing increased

Vital Signs

heart rate increased
respiratory rate increased
blood pressure increased or decreased
SpO2 (peripheral oxygen saturation) decreased

Laboratory Values

ABG (arterial blood gas) abnormal
PaO2 (partial pressure of arterial oxygen) decreased

Diagnostic Results

CXR (chest x-ray) abnormal

Problem Intervention

Optimize Oxygenation, Ventilation and Perfusion

Provide oxygen therapy judiciously to avoid hyperoxemia; adjust to achieve oxygenation goal.
Use low tidal volume (e.g., 6 mL/kg or less for predicted body weight) and pressure (e.g., less than 30 cm H2O plateau) ventilation strategies to minimize the risk of lung overdistension and progression of lung injury.
Apply PEEP (positive end expiratory pressure) to improve oxygenation and lung compliance; consider higher PEEP and mean airway pressure for moderate-severe ARDS (acute respiratory distress syndrome).
Consider the use of corticosteroid therapy.
Promote conservative fluid strategy to achieve net even fluid balance once hemodynamically stable.
Monitor hemodynamic status closely to evaluate the effects of fluid volume expansion and impact of ventilation and disease on cardiac function; anticipate the need for vasoactive medication.
Maintain head of bed elevation with regular position changes to improve ventilator-perfusion mismatch; consider prone positioning to maximize alveolar recruitment and functional residual capacity.
Consider the use of sedation and short-term neuromuscular blockade to optimize oxygen delivery and tolerance to ventilation strategies.
Anticipate the need for adjunctive therapy, such as alveolar recruitment maneuvers and ECLS (extracorporeal life support) for refractory hypoxemia.

Associated Documentation

Airway/Ventilation Management
Head of Bed (HOB) Positioning
Lung Protection Measures
Stabilization Measures

Education

CPG-Specific Education Topics

Overview

description
signs/symptoms

Self-Management

activity
fluid/food intake
provider follow-up
rehabilitation therapy

When to Seek Medical Attention

unresolved/worsening symptoms

General Education Topics

General Education

admission, transition of care
orientation to care setting, routine
advance care planning
diagnostic tests/procedures
diet modification
opioid medication management
oral health
medication management
pain assessment process
safe medication disposal
tobacco use, smoke exposure
treatment plan

Safety Education

call light use
equipment/home supplies
fall prevention
harm prevention
infection prevention
MDRO (multidrug-resistant organism) care
personal health information
resources for support

Population-Specific Considerations

Pregnancy

ARDS (acute respiratory distress syndrome) in pregnancy is best managed in a hospital where obstetrics, adult and neonatal intensive care capabilities are available.
Medication effects and serum levels may be altered by pregnancy.
Medications and diagnostic imaging used to treat ARDS (acute respiratory distress syndrome) should not be withheld from a pregnant mother; however, potential fetal effects should be carefully considered when determining treatment.
While prone position is recommended for patients with ARDS (acute respiratory distress syndrome), it should be approached cautiously during pregnancy, taking into consideration gestational stage. Positioning aids may be used to maintain proper maternal alignment, should prone position be used.

References

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.