para>Supportive care while identifying the underlying cause of ARDS continues to be important in the management of pregnant women with ARDS. However, fetal well-being, possible need for delivery, and physiologic changes associated with pregnancy must be considered. � �
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
All patients with ARDS should be managed in an ICU setting. � �
- Consider prone positioning.
- Identify and treat underlying condition.
- Circulatory support, adequate fluid volume, and nutritional support
- Supplemental oxygen
- Monitoring blood gases, pulse oximetry, bedside pulmonary function test
- Support ventilation using lung-protective strategies and PEEP.
- Monitor for systemic hypotension and hypovolemia without fluid overload.
- BP support, if necessary
- Vasopressor agents
- Fluid management with IV crystalloid solutions while monitoring pulmonary status
- Pulmonary catheter pressure monitoring
- Treat underlying disease process.
- Prevent complications.
IV Fluids
- Maintain the intravascular volume at the lowest level consistent with adequate perfusion (assessed by metabolic acid " �base balance and renal function).
- If perfusion is inadequate after restoration of intravascular volume (e.g., septic shock), vasopressor therapy is indicated.
- Increase oxygen content with packed erythrocyte transfusions as necessary.
- Provide appropriate nutritional support with enteral or parenteral nutrition.
- Steroid therapy
Nursing
May include any or all of the following: � �
- Skin, eye, and mouth care
- DVT prophylaxis
- GI prophylaxis
- Suctioning
- Ensure adequate level of sedation and/or paralysis while on mechanical ventilation.
- Oxygen supplementation
- Nebulizer therapy
- Chest physiotherapy
- Tracheostomy care
- Explain all procedures to patient and family; reduce anxiety.
Discharge Criteria
- Supplemental oxygen
- Nutrition counseling
- Family monitoring of signs and symptoms of respiratory distress
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Vital capacity and static lung compliance are important measures of lung mechanics.
- Daily labs are needed until the patient is no longer critical.
- CXRs to assess endotracheal tube placement, the presence of progressing infiltrates, catheter placement, and complications of mechanical ventilation (e.g., air leaks)
- A Swan-Ganz catheter to assess oxygen delivery, oxygen consumption, and cardiac output may be helpful but has not been shown to improve survival.
DIET
- Nutritional support
- Conservative fluid management shortens ventilator and ICU time but does not affect survival.
PATIENT EDUCATION
ARDS support center and brochure titled "Learn About ARDS " �: www.ards.org � �
PROGNOSIS
- Mortality rate is 43% (10).
- Survivors may have pulmonary sequelae with mild abnormalities in oxygenation, diffusion, and lung mechanics, as well as some pulmonary symptoms of cough and dyspnea.
- The prognosis worsens with elevated cardiac troponin-T levels in ARDS patients (11).
COMPLICATIONS
- Permanent lung disease
- Oxygen toxicity
- Barotrauma
- Superinfection
- Multiple organ dysfunction syndrome
- Death
REFERENCES
11 Ranieri � �VM, Rubenfeld � �GD, Thompson � �BT, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526 " �2533.22 Riviello � �ED, Kiviri � �W, Twagirumugabe � �T, et al. Hospital incidence and outcomes of ARDS using the Kigali modification of the Berlin definition [published online ahead of print September 9, 2015]. Am J Respir Crit Care Med.33 Petrucci � �N, Iacovelli � �W. Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev. 2004;(2):CD003844.44 Gu � �XL, Wu � �GN, Yao � �YW, et al. Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients? A meta-analysis of randomized controlled trials. Crit Care. 2014;18(3):R111.55 Meduri � �GU, Bridges � �L, Shih � �MC, et al. Prolonged glucocorticoid treatment is associated with improved ARDS outcomes: analysis of individual patients ' data from four randomized trials and trial-level meta-analysis of the updated literature [published online ahead of print October 27, 2015]. Intensive Care Med.66 Afshari � �A, Brok � �J, M � �ller � �AM, et al. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) and acute lung injury in children and adults. Cochrane Database Syst Rev. 2010;(7):CD002787.77 Afshari � �A, Brok � �J, M � �ller � �AM, et al. Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev. 2010;(8):CD007733.88 Duggal � �A, Ganapathy � �A, Ratnapalan � �M, et al. Pharmacological treatments for acute respiratory distress syndrome: systematic review. Minerva Anestesiol. 2015;81(5):567 " �588.99 Lyu � �G, Wang � �X, Jiang � �W, et al. Clinical study of early use of neuromuscular blocking agents in patients with severe sepsis and acute respiratory distress syndrome [in Chinese]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2014;26(5):325 " �329.1010 Zambon � �M, Vincent � �JL. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest. 2008;133(5):1120 " �1127.1111 Rivara � �MB, Bajwa � �EK, Januzzi � �JL, et al. Prognostic significance of elevated cardiac troponin-T levels in acute respiratory distress syndrome patients. PLoS One. 2012;7(7):e40515.
ADDITIONAL READING
- Cole � �DE, Taylor � �TL, McCullough � �DM, et al. Acute respiratory distress syndrome in pregnancy. Crit Care Med. 2005;33(10)(Suppl):S269 " �S278.
- Wheeler � �AP, Bernard � �GR. Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet. 2007;369(9572):1553 " �1564.
CODES
ICD10
J80 Acute respiratory distress syndrome � �
ICD9
518.52 Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery � �
SNOMED
67782005 Adult respiratory distress syndrome (disorder) � �
CLINICAL PEARLS
- ARDS is a syndrome characterized by an abrupt onset of diffuse lung injury with severe hypoxemia and bilateral pulmonary infiltrates.
- Treatment of ARDS requires aggressive supportive care in an ICU setting while also addressing the underlying cause.
- The benefit of invasive monitoring of vital signs, cardiac output, and PAWP has been questioned by large clinical trials.