Copyright © 2006 by Mosby, Inc. Slide 1 PART IX PART IX Diffuse Alveolar Disease Diffuse Alveolar Disease
Jan 18, 2018
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PART IXPART IX
Diffuse Alveolar DiseaseDiffuse Alveolar Disease
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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.
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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
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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
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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
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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
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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).
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Figure 9-7. Atelectasis clinical scenario. Figure 9-7. Atelectasis clinical scenario.
Copyright © 2006 by Mosby, Inc.Slide 9Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.
Copyright © 2006 by Mosby, Inc.Slide 10Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
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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
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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
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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.
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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.
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Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
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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
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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
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Decreased Diffusion Capacity Decreased Diffusion Capacity (DL(DLCOCO))
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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)
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Time and Progression of Disease
100
50
30
80
0
PaCO2
10
20
40
Alveolar Hyperventilation
60
70
90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaO2
Disease OnsetPa
O2 o
r PaC
O2
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood GasesArterial Blood Gases
Severe ARDSSevere ARDS Acute chronic ventilatory failure with hypoxemiaAcute chronic ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2
(Slightly)
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Time and Progression of Disease
100
50
30
80
0
PaO2
10
20
40
Alveolar Hyperventilation
60
70
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
Pa0 2
or P
aC0 2
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
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Oxygenation IndicesOxygenation Indices
QS/QT DO2 VO2 C(a-v)O2
Normal Normal
O2ER SvO2
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Hemodynamic Indices Hemodynamic Indices (Severe ARDS)(Severe ARDS)
CVP CVP RAPRAP PAPA PCWPPCWP
COCO SVSV SVISVI CICI
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
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Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph Increased density Increased density Ground-glass appearanceGround-glass appearance
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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.
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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
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General Management of General Management of ARDSARDS
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
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General Management of General Management of ARDSARDS
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
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General Management of General Management of ARDSARDS
Medications and procedures commonlyMedications and procedures commonlyprescribed by the physicianprescribed by the physician AntibioticsAntibiotics DiureticsDiuretics CorticosteroidsCorticosteroids
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Classroom DiscussionClassroom DiscussionCase Study: ARDSCase Study: ARDS