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Careplan

Oct.01.2020

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: ARDS: 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 maintain prescribed oxygen saturation level.
  • 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).
  • 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.
  • Prepare for adjunctive therapy, such as corticosteroids, alveolar recruitment maneuvers and ECLS (extracorporeal life support).

Associated Documentation

  • Airway/Ventilation Management
  • Lung Protection Measures
  • Stabilization Measures

Education

CPG-Specific Education Topics

Overview

  • description

  • signs/symptoms

ARDS: 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

  • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 211: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019, May;133(5), e303-e319. doi:10.1097/AOG.0000000000003241 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Annane, D.; Pastores, S. M.; Rochwerg, B.; Arlt, W.; Balk, R. A.; Beishuizen, A.; . . . & Marik, P. E. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Medicine. 2017;43(12), 1751-1763. doi:10.1007/s00134-017-4919-5 [Quality Measures,Clinical Practice Guidelines]
  • Aoyama, H.; Uchida, K.; Aoyama, K.; Pech-livanoglou, P.; Englesakis, M.; Yamada, Y.; Fan, E. Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis. JAMA Network Open. 2019;2(7), e198116. doi:10.1001/jamanetworkopen.2019.8116 [Metasynthesis,Meta-analysis,Systematic Review]
  • ARDS Definition Task Force; Ranieri, V. M.; Rubenfeld, G. D.; Thompson, B. T.; Ferguson, N. D.; Caldwell, E.; Fan, E.; Camporota, L.; Slutsky, A. S. Acute respiratory distress syndrome: The berlin definition. JAMA. 2012;307(23), 2526-2533. doi:10.1001/jama.2012.5669 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Cho, Y. J.; Moon, J. Y.; Shin, E. S.; Kim, J. H.; Jung, H.; Park, S. Y.; . . . & Lee, S. J. Clinical practice guideline of acute respiratory distress syndrome. Tuberculosis and Respiratory Diseases. 2016;79(4), 214-233. doi:10.4046/trd.2016.79.4.214 Source[Quality Measures,Clinical Practice Guidelines]
  • Claesson, J.; Freundlich, M.; Gunnarsson, I.; Laake, J. H.; Møller, M. H.; Vandvik, P. O.; Varpula, T.; Aasmundstad, T. A. Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome. Acta Anaesthesiologica Scandinavica. 2016;60(6), 697-709. doi:10.1111/aas.12713 [Quality Measures,Clinical Practice Guidelines]
  • Claesson, J.; Freundlich, M.; Gunnarsson, I.; Laake, J. H.; Vandvik, P. O.; Varpula, T.; Aasmundstad, T. A. Scandinavian clinical practice guideline on mechanical ventilation in adults with the acute respiratory distress syndrome. Acta Anaesthesiologica Scandinavica. 2015;59, 286-297. doi:10.1111/aas.12449 [Quality Measures,Clinical Practice Guidelines]
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  • Fan, E.; Del Sorbo, L.; Goligher, E. C.; Hodgson, C. L.; Munshi, L.; Walkey, A. J.; Adhikari. N. K. J.; Amato, M. B. P.; Branson, R.; Brower, R. G.; Ferguson, N. D.; Gajic, O.; Gattinoni, L.; Hess, D.; Mancebo, J.; Meade, M. O.; McAuley, D. F.; Pesenti, A.; Ranieri, V. M.; Rubenfeld, G. D.; Rubin, E.; Seckel, M.; Slutsky, A. S.; Talmor, D.; Thompson, B. T.; Wunsch, H.; Uleryk, E.; Brozek, J.; Brochard, L. J.; American Thoracic Society; European Society of Intensive Care Medicine; Society of Critical Care Medicine. An official american thoracic Society/European society of intensive care Medicine/Society of critical care medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine. 2017;195(9), 1253-1263. doi:10.1164/rccm.201703-0548ST [Quality Measures,Clinical Practice Guidelines]
  • Griffiths, M.; Fan, E.; Baudouin, S. V. New UK guidelines for the management of adult patients with ARDS. BMJ Open Respiratory Research. 2019;6, e000420. doi:10.1136/bmjresp-2019-00420 [Quality Measures,Clinical Practice Guidelines]
  • Hashimoto, S.; Sanui, M.; Egi, M.; Ohshimo, S.; Shiotsuka, J.; Seo, R.; Tanaka, R.; Tanaka, Y.; Norisue, Y.; Hayashi, Y.; Nango, E.; ARDS Clinical Practice Guideline Committee from the Japanese Society of Respiratory Care Medicine; Japanese Society of Intensive Care Medicine. The clinical practice guideline for the management of ARDS in Japan. Journal of Intensive Care. 2017;5, 50. doi:10.1186/s40560-017-0222-3 [Quality Measures,Clinical Practice Guidelines]
  • Lu, J.; Wang, X.; Chen, M.; Cheng, L.; Chen, Q.; Jiang, H.; Sun, Z. An open lung strategy in the management of acute respiratory distress syndrome: A systematic review and meta-analysis. Shock. 2017;48(1), 43-53. doi:10.1097/SHK.0000000000000822 [Metasynthesis,Meta-analysis,Systematic Review]
  • Munshi, L.; Del Sorbo, L.; Adhikari, N. K. J.; Hodgson, C. L.; Wunsch, H.; Meade, M. O.; Uleryk, E.; Mancebo, J.; Pesenti, A.; Ranieri, V. M.; Fan, E. Prone position for acute respiratory distress syndrome: A systematic review and meta-analysis. Annals of the American Thoracic Society. 2017;14(Supplement_4), S280-S288. doi:10.1513/AnnalsATS.201704-343OT Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Ni, Y. N.; Luo, J.; Yu, H.; Wang, Y. W.; Hu, Y. H.; Liu, D.; Lian, B. M.; Liang, Z. A. Can body mass index predict clinical outcomes for patients with acute lung injury/acute respiratory distress syndrome? A meta-analysis. Critical Care. 2017;21(1) doi:10.1186/s13054-017-1615-3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Papazian, L.; Aubron, C.; Brochard, L.; Chiche, J-D.; Combes, A.; Dreyfuss, D.; . . . & Faure, H. Formal guidelines: Management of acute respiratory distress syndrome. Annals of Intensive Care. 2019;9(1), 69. doi:10.1186/s13613-019-0540-9 Source[Quality Measures,Clinical Practice Guidelines]
  • Roberts, M. B.; Glaspey, L. J.; Mazzarelli, A.; Jones, C. W.; Kilgannon, H. J.; Trzeciak, S.; Roberts, B. W. Early interventions for the prevention of posttraumatic stress symptoms in survivors of critical issues: A qualitative systematic review. Critical Care Medicine. 2018;46(8), 1328-1333. doi:10.1097/CCM.0000000000003222 [Metasynthesis,Meta-analysis,Systematic Review]
  • Silversides, J. A.; Major, E.; Ferguson, A. J.; Mann, E. E.; McAuley, D. F.; Marshall, J. C.; Blackwood, B.; Fan, E. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: A systematic review and meta-analysis. Intensive Care Medicine. 2017, February;43(2), 155-170. doi:10.1007/s00134-016-4573-3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Tao, W.; Yang, L. Q.; Gao, J.; Shao, J. Neuromuscular blocking agents for adult patients with acute respiratory distress syndrome: A meta-analysis of randomized controlled trials. Journal of Trauma and Acute Care Surgery. 2018;85(6), 1102-1109. doi:10.1097/TA.0000000000002057 [Metasynthesis,Meta-analysis,Systematic Review]
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  • Vaquer, S.; de Haro, C.; Peruga, P.; Oliva, J. C.; Artigas, A. Systematic review and meta-analysis of complications and mortality of veno-venous extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome. Annals of Intensive Care. 2017;7(1), 51. doi:10.1186/s13613-017-0275-4 [Metasynthesis,Meta-analysis,Systematic Review]

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.

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