ARDS Case Study A 62-year-old client has

ARDS Case Study A 62-year-old client has been experiencing a productive cough off and on for approximately three years. He decided to come to the emergency department because he reports difficulty breathing with exertion. He states he has had several bouts of chest colds during the past few years, but this time he says he “can’t seem to shake this round.” His wife reports he is allergic to penicillin. During his history the client stated he has smoked two packs of cigarettes a day for 25 years and is a retired coal miner. Crackles were noted in the lower bases of his lungs, with an occasional expiratory wheeze. He also reports he has been running a low-grade fever for approximately two-three days and has experienced chills and weakness. A chest x-ray indicates some consolidation in the right lower lobe. Bronchography revealed non-uniform tapering of the airway. The following are additional diagnostic data: Blood pressure: 158/98 mm Hg, heart rate: 107 beats per minute, respirations 32 breaths per minute, temperature 102oF, pulse oximetry: 90% on room air. ABG on room air: pH: 7.35, PO2: 52, PCO2: 54, HCO3: 30. Lab values as follows: WBCs 20,000 mm3, hematocrit: 56%. levels 30 minutes after the placement of the oxygen were: pH 7.35, PO2: 65, PCO2: 54, HCO3: 30. On the basis of this data, the client was diagnosed with chronic obstructive pulmonary disorder with an acute exacerbation of chronic bronchitis. Sputum cultures revealed a gram-positive organism, Streptococcus pneumonia. Mr. Bryant received erythromycin after a secondary diagnosis of pneumonia was made. He also received theophylline at this time. Mr. Bryant’s condition improved in response to the antibiotic and bronchodilator therapy. After several days of antibiotics and bronchodilator therapy, the client’s condition was improving, however he was still very dyspnic with any exertion. When encouraged to get out of bed, the client responded with “I get too winded, I just can’t do it right now.” At the initial morning assessment, the nurse assisted the client into the chair. He sat in the chair for 30 minutes and returned to bed. Upon return to the room, the client was found to be very restless, apprehensive, with complaints of shortness of breath, and chest pain with inspiration. Upon assessment, he had crackles in his lungs, labored respirations, pulse oximetry 86%, dusky color, and a warm, tender right calf. Vital signs were blood pressure: 170/90 mm Hg, hear rate: 124 beats per minute, respirations: 36 breaths per minute, and temperature: 100.1oF. The client was placed in a semi-fowlers position and oxygen was started at three liters per minute through a nasal cannula. The advanced healthcare provider was notified, and orders were received for an arterial blood gas, 12 lead EKG, right leg ultrasound, and chest x-ray. Results were as follows: ABG: pH 7.33, PCO2: 58, PaO2: 50, EKG: sinus tachycardia, doppler study: right calf deep vein thrombosis. A heparin bolus was administered followed by a continuous infusion. A spiral CT scan revealed a pulmonary embolism. The client was transferred to the intensive care unit for closer monitoring. He began to deteriorate, was intubated and placed on mechanical ventilation. His initial ventilator settings were IMV, rate: 14, tidal volume: 600, peep: 5 cm H2O, pressure support 10 mm Hg, and 60% FiO2. Antibiotics, aggressive pulmonary toileting, and sedation were started. AM labs and diagnostics: ABG: pH 7.35, PO2 75, PCO2 46, HCO3 28.9 Chest x-ray revealed a “ground-glass appearance” Assessment findings revealed crackles and wheezes on the right, pink-tinged sputum suctioned from the endotracheal tube, and rising peak inspiratory pressures on the ventilator. Vent settings were adjusted as follows: FiO2 increased to 80%, peep increased to 10 cm H2O, and mode changed to pressure regulated volume control (PRVC). What are the rationales for these interventions? Discuss the pathophysiology of ARDS. How do you diagnosis ARDS? What do the vent settings mean? Discuss differences in ventilatory modes. What is the significance of increased peak pressures? What is included in the care of a client on a ventilator? After these changes and aggressive pulmonary toileting for several days, the client’s vital signs and respiratory effort stabilized: Blood pressure: 130/60 mm Hg, heart rate: 120 beats per minute, respirations: 14 breaths per minute, temperature 101oF pH 7.39, PCO2 46.2, PO2 90, HCO3 30.5 Over several days, the client’s oxygen levels gradually stabilized, and he was weaned from ventilatory support. The client was extubated ten days after intubation and received oxygen by nasal cannula. Tissue hypoxia is a major finding in ARDS. Describe signs and symptoms found on assessment that would be seen with ARDS in the following systems: central nervous, pulmonary, cardiovascular, renal, and gastrointestinal/hepatic. What is the goal of treatment for ARDS? What are the principal treatments for ARDS including types of ventilatory support? What are medical complications seen with ARDS? Why is sedation so important? What are the most common types of clients who develop ARDS?

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