Primary Nursing Diagnosis

Impaired gas exchange related to increased alveolar-capillary permeability, interstitial edema, and decreased lung compliance

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Anxiety control

INTERVENTIONS. Airway insertion and stabilization; Airway management; Respiratory monitoring; Oxygen therapy; Mechanical ventilation; Anxiety reduction

U PLANNING AND IMPLEMENTATION Collaborative

MECHANICAL VENTILATION. The treatment for ARDS is directed toward the underlying cause and maintaining gas exchange. To this end almost all patients with ARDS require endo-tracheal intubation and mechanical ventilation with a variety of positive-pressure modes. Common methods for mechanical ventilation include pressure-controlled ventilation with an inverse inspiratory-expiratory ratio. This mode alters the standard inspiratory-expiratory ratio of 1:2 to 1:3 by prolonging the inspiratory rate and changing the ratio to 1:1. It also controls the amount of pressure in each breath to stabilize the alveoli and to re-establish the functional residual capacity (FRC) to normal levels. If possible, the physician attempts to limit the fraction of inspired oxygen (FiO) to less than 0.50 (50%) to reduce complications from oxygen toxicity. Positive end-expiratory pressure (PEEP) is often added to the ventilator settings to increase the FRC and to augment gas exchange. Lung-protective, pressure-targeted ventilation, a method whereby controlled hypoventilation is allowed to occur, minimizes the detrimental effects of excessive airway pressures and has also been used in ARDS with positive outcomes.

Pharmacologic Highlights

General Comments: Use of genetically engineered surfactant has been studied In ARDS but has not demonstrated the success that has occurred in premature infants with surfactant deficiency. Corticosteroids have been widely used in ARDS, yet studies have not consistently demonstrated any improvement in patient outcomes and remain controversial. Some evidence exists that prolonged treatment with low-dose corticosteroids may benefit patients with unresolving ARDS, particularly by reversing the process of fibroproliferation. If the patient is difficult to ventilate, she or he may receive skeletal muscle relaxants such as vecuronium (Norcuron), which are neuromuscular-blocking agents that paralyze the patients skeletal muscles. These medications are used only when the patients gas exchange is so poor as to threaten his or her life. Neuromuscular-blocking agents paralyze the patient without affecting mental status, so the patient requires sedation to counteract the accompanying fear and anxiety that occur when the patient is unable to move.

Medication or Drug Class

Dosage

Description

Rationale

Nitric oxide

Inhalation route;

Pulmonary vascular

Decreases pulmonary vascular

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