Copyright 2006 by Mosby, Inc. Slide 1 PART IX Diffuse Alveolar Disease.

PART IXPART IX

Diffuse Alveolar DiseaseDiffuse Alveolar Disease

Chapter 27 Chapter 27 Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome

Figure 27-1. Figure 27-1. Adult respiratory distress syndrome.Adult respiratory distress syndrome.

Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Interstitial and intra-alveolar edema Interstitial and intra-alveolar edema and hemorrhageand hemorrhage

Alveolar consolidationAlveolar consolidation Intra-alveolar hyaline membraneIntra-alveolar hyaline membrane Pulmonary surfactant deficiency or Pulmonary surfactant deficiency or

abnormalityabnormality AtelectasisAtelectasis

Other Names Used to Identify ARDSOther Names Used to Identify ARDS Adult respiratory distress syndromeAdult respiratory distress syndrome Adult hyaline membrane diseaseAdult hyaline membrane disease Capillary leak syndromeCapillary leak syndrome Congestion atelectasisCongestion atelectasis Da Nang lungDa Nang lung Hemorrhagic pulmonary edemaHemorrhagic pulmonary edema Noncardiac pulmonary edemaNoncardiac pulmonary edema Oxygen pneumonitisOxygen pneumonitis Oxygen toxicityOxygen toxicity

Etiology: Etiology: Multitude of FactorsMultitude of Factors

In alphabetical order, some of the better-known causesIn alphabetical order, some of the better-known causes AspirationAspiration Central nervous system diseaseCentral nervous system disease Cardiopulmonary bypassCardiopulmonary bypass Congestive heart failureCongestive heart failure Disseminated intravascular coagulationDisseminated intravascular coagulation Drug overdoseDrug overdose Fat or air emboliFat or air emboli InfectionsInfections Inhalation of toxins and irritantsInhalation of toxins and irritants

Etiology: Etiology: Multitude of FactorsMultitude of Factors

In alphabetical order, some of the better-known causesIn alphabetical order, some of the better-known causes Inhalation of toxins and irritantsInhalation of toxins and irritants Immunologic reactionImmunologic reaction Massive blood transfusionsMassive blood transfusions Nonthoracic traumaNonthoracic trauma Oxygen toxicityOxygen toxicity Pulmonary ischemiaPulmonary ischemia Radiation-induced lung injuryRadiation-induced lung injury Shock (hypovolemia)Shock (hypovolemia) BurnsBurns Thoracic traumaThoracic trauma

Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with ACUTE RESPIRATORY with ACUTE RESPIRATORY DISTRESS SYNDROMEDISTRESS SYNDROME

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by AtelectasisAtelectasis (see Figure 9-7), (see Figure 9-7), Alveolar ConsolidationAlveolar Consolidation (see Figure 9-8), and (see Figure 9-8), and Increased Alveolar-Capillary Membrane Increased Alveolar-Capillary Membrane ThicknessThickness (see Figure 9-9)—the major (see Figure 9-9)—the major anatomic alterations of the lungs associated anatomic alterations of the lungs associated with ARDS (see Figure 27-1).with ARDS (see Figure 27-1).

Figure 9-7. Atelectasis clinical scenario. Figure 9-7. Atelectasis clinical scenario.

Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Vital signsVital signs Increased respiratory rateIncreased respiratory rate Increased heart rate, cardiac output, Increased heart rate, cardiac output,

blood pressureblood pressure

Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Substernal/intercostal retractionsSubsternal/intercostal retractions CyanosisCyanosis Chest assessment findingsChest assessment findings

Dull percussion noteDull percussion note Bronchial breath soundsBronchial breath sounds CracklesCrackles

Figure 2-11. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.of alveolar consolidation.

Figure 2-16. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung Auscultation of bronchial breath sounds over a consolidated lung unit.unit.

Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures

Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1% N N or N N or

Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC N or

VC IC ERV RV/TLC% N

Decreased Diffusion Capacity Decreased Diffusion Capacity (DL(DLCOCO))

Arterial Blood GasesArterial Blood Gases

Mild to Moderate ARDSMild to Moderate ARDS Acute alveolar hyperventilation with hypoxemiaAcute alveolar hyperventilation with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

Time and Progression of Disease

Alveolar Hyperventilation

90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Disease OnsetPa

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.

Arterial Blood GasesArterial Blood Gases

Severe ARDSSevere ARDS Acute chronic ventilatory failure with hypoxemiaAcute chronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

Time and Progression of Disease

Alveolar Hyperventilation

90Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Acute Ventilatory FailureDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.

Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2

Hemodynamic Indices Hemodynamic Indices (Severe ARDS)(Severe ARDS)

CVP CVP RAPRAP PAPA PCWPPCWP

COCO SVSV SVISVI CICI

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR

Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph Increased density Increased density Ground-glass appearanceGround-glass appearance

Figure 27-2. Figure 27-2. Chest X-ray of a patient with moderately severe ARDS.Chest X-ray of a patient with moderately severe ARDS.

General Management of General Management of ARDSARDS

Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol Hyperinflation therapy protocolHyperinflation therapy protocol Mechanical ventilation protocolMechanical ventilation protocol

Common ARDS mechanical ventilationCommon ARDS mechanical ventilationstrategy:strategy: Low-tidal volumes and high respiratory ratesLow-tidal volumes and high respiratory rates

4 to 8 mL/kg4 to 8 mL/kg Ventilatory rates as high as 35 breaths per minuteVentilatory rates as high as 35 breaths per minute PEEP and/or CPAP—to offset atelectasisPEEP and/or CPAP—to offset atelectasis

The therapeutic goals of low-tidal volumeThe therapeutic goals of low-tidal volumeventilationventilation

1.1. Decrease high transpulmonary pressureDecrease high transpulmonary pressure

2.2. Reduce overdistention of the lungsReduce overdistention of the lungs

3.3. Decrease barotraumaDecrease barotrauma

Medications and procedures commonlyMedications and procedures commonlyprescribed by the physicianprescribed by the physician AntibioticsAntibiotics DiureticsDiuretics CorticosteroidsCorticosteroids

Classroom DiscussionClassroom DiscussionCase Study: ARDSCase Study: ARDS

Copyright 2006 by Mosby, Inc. Slide 1 PART IX Diffuse Alveolar Disease.

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