Pulmonary Embolism, Acute Respiratory Failure, Acute Respiratory Distress Syndrome

What occurs in the exudative phase of ARDS? When does it occur?

- 24-28 hours after injury - Alveolar capillary membrane dilate d/t inflammatory mediators --> Fluid/protein moves into interstitial space --> Edema Surfactant producing alveolar cells are get damaged --> Atelectasis

What are some lab tests that can be done for ARDS?

- ABGs - CBC w/ differential - Sputum/Blood/Urine culture - CMP - Coagulation studies - Electrolyte panels - Liver function tests - Renal function tests

What are some diagnostic tests you would do for a patient going through respiratory failure?

- ABGs - Venous oxygen saturation - Hemoglobin and hematocrit - CXR - CT - Sputum cultures

What are 4 risk factors for hypercapnic respiratory failure?

- Acute asthma - Narcotic use - Myasthenia gravis or any PNS disorder that impairs chest wall movement - Trauma to chest wall

What is ARDS characterized by?

- Acute onset < 7 days - Refractory hypoxemia - Bilateral infiltrates secondary to noncardiogenic pulmonary edema - Decreased lung compliance

What are 9 nursing assessments for a PE pt?

- Airway - Oxygenation - Frequent vital signs - Chest pain - Lab values (ABG onset) - ABG (disease progression) - Lactic acid levels - Coagulation studies - Urine output

What 7 nursing assessments should be made for a respiratory failure patient?

- Airway - Vital signs including O2 sat - ABGs - Cardiac monitoring - Neurological assessment - Breath sounds - Skin coloration

What 4 nursing actions may be done with ARDS pt?

- Airway suctioning - Meds - Pt positioning/activity (Prone, elevate HOB, frequent position changes, ROM exercises) - Infection protection/prevention

What medications might an ARDS patient take?

- Antibiotics - Corticosteroids - Neuromuscular blocking agents or paralytics - Pain and sedatives

What are some medical treatment for PE?

- Anticoagulation - IV isotonic fluid - Decrease blood viscosity - Inotropic agent - Overcome PVR to maximize CO - Norepinephrine or vasopressin - Manage hypotension

What medication therapy would you use to tx nonsymptomatic PE patients w/ low-risk clot?

- Anticoagulation - Oral factor Xa inhibitor - Coumadin (Warfarin)

When is an IVC filter indicated?

- Anticoagulation is contraindicated - Recurrent PE despite anticoagulation therapy - Evidence of hemodynamic or respiratory dysfunction severe enough that another PE could be fatal

What are 6 direct causes of ARDS?

- Aspiration - Chest trauma - Pneumonia - Pulmonary contusion - Inhalation injury - Pulmonary embolus

What 3 complications are associated w/ ARDS?

- Barotrauma - Renal failure/multisystem organ dysfunction syndrome - Ventilator associated pneumonia

What are 2 examples of noninvasive positive-pressure ventilation (NPPV)?

- Bilevel positive airway pressure (BiPAP) - Continuous positive airway pressure (CPAP)

What causes hypercoagulability?

- Cancer - Oral contraceptives - Dehydration/hemoconcentration - Sickle cell anemia - Polycythemia vera - Abrupt discontinuation of anticoagulants

What are 3 complications of respiratory failure?

- Cardiac failure - Multiple organ dysfunction - Death

What are 3 intermediate clinical manifestations of respiratory failure?

- Confusion - Lethargy - Pink skin condition (d/t increased CO2)

What are 2 late clinical manifestations of respiratory failure?

- Cyanosis - Comna

What are the 6 clinical manifestations of fibrotic phase?

- Decrease left heart preload d/t right HF - Decrease BP - Decrease CO - Refractory hypoxemia - Severe tissue hypoxia - Lactic acidosis

What are some risk factors for PE?

- Deep vein thrombosis - Prolonged immobility - Obesity - Smoking - Chronic heart disease - Fracture (hip or leg) - Hip and knee replacement - Major surgery - Major trauma - Spinal cord injury - Hx of previous VTE - Malignancy

What are some patient education for PE?

- Disease process - Exercise regimen - Cardiac-prudent diet w/ minimal saturated fat - Adequate fluid intake - Smoking cessation - Medications - Bleed precuations - Diet (limit high in vitamin K) - S/s of recurrent PE/DVT

What are some patient education points for a pt with respiratory failure?

- Disease process - Meds - Pulmonary rehabilitation (Breathing techs, energy conservation, exercise) - Infection prevention - Diet and adequate hydration - Smoking cessation

What are some symptoms of PE?

- Dyspnea - Pleuritic chest pain - Tachypnea - JVD - Use of accessory muscles - Hypotension - Tachycardia - Anxious, restless, confused - Hemoptysis

What are 6 early clinical manifestations of respiratory failure?

- Dyspnea - Restlessness - Anxiety - Fatigue - Increased BP - Tachycardia

What are some imaging studies that are used as diagnostics for PE?

- ECG - Chest XR - CT w/ contrast - V/Q scan - Pulmonary angiography - Lower extremity venous ultrasound

What are 8 possible nursing interventions for PE pt?

- Elevate HOB - IV fluids - Anticoagulation meds - Thrombolytic meds - Inotropic meds - Norepinephrine meds - Institute bleeding precautions - Be prepared for intubation and resuscitation

What are some s/s of VAP?

- Fever - Leukocytosis - Increase respiratory effort - Purulent secretions

What are 4 complications of IVC filter?

- Filter migration - Erosion of vena cava wall - Obstruction d/t filter thrombosis - Procedural complications

What are some s/s of hypercapnic respiratory failure?

- Headache - Confusion - Decreased LOC - Increase somnolence - Tachycardia - Tachypnea - Dizziness - Flushed

What 9 nursing assessments should be done with ARDS?

- Hemodynamic monitoring (Vital signs, SpO2, Central venous pressure or pulmonary artery pressure monitoring) - Neurological assessment and pupillary assessment q1-2 hours - Respiratory assessment - Monitor urine output - Monitor mechanical ventilation - Monitor ECG - Lab tests (ABGs, Serum lactate levels, Liver/renal fx, blood/sputum/urine cultures, CBC) - Skin assessment - CXR

What are 5 absolute contraindications to thrombolytic therapy?

- Hx of hemorrhagic stroke - Active intracranial neoplasm - Recent surgery - Recent trauma - Active or recent internal bleeding

What are the 3 clinical manifestations of proliferative phase of ARDS?

- Hypercapnia - Refractory hypoxemia - Increase work of breathing

What are 5 clinical manifestations of the exudative phase of ARDS?

- Hyperventilation - Tachycardia - Respiratory alkalosis - Increase CO - Noncardiogenic pulmonary edema

What medication would you expect a symptomatic PE pt to have?

- IV heparin therapy

What are some medications to tx respiratory failure?

- Inhaled bronchodilators - Inhaled steroids - Diuretics - Sedation - Antibiotics

What are 3 alternatives to weight-based heparin?

- Low molecular weight heparin - Fondaparinux - Unfractionated heparin

What are the 3 classes of PE?

- Massive - Submassive - Low risk

What are 5 tx for ARDS?

- Mechanical ventilation - Positioning - Medications - Hydration - Nutrition

What are the manifestations of low-risk PE?

- Normal BP - No right ventricular dysfunction - No elevated biomarkers (troponin or BNP)

What are the manifestations of submassive PE?

- Normal BP - Right ventricular dysfunction - Myocardial necrosis (elevated troponin I and BNP)

What 8 nursing actions should could be done for a respiratory failure patient?

- Oxygen - Meds - Elevate HOB; sit in chair - Position good lung down - Chest PT and suctioning; ambulate - IV fluids/hydration - Nutritional support - Be prepared for noninvasive/invasive positive-pressure ventilatory support

What are 4 examples of a nonthrombotic pulmonary embolus?

- Piece of tumor - Amniotic fluid - Air - Fat

What lab studies would be ordered for PE?

- Plasma D-dimer level - ABGs - BNP - Troponin I an dT

What causes venous stasis?

- Prolonged bedrest/immobility - Obesity - Burns - Pregnancy - Vasculitis/thrombophlebitis - Bacterial endocarditis - Any postop patient

What are the manifestations of massive PE?

- Prolonged hypotension - R/L ventricular dysfunction - Shock and/or cardiac arrest

What are 3 risk factors for hypoxemia respiratory failure?

- Pulmonary edema - Pulmonary embolus - Pneumonia

What is ECG used for with PEs?

- R/o MI - Assess myocardial damage - Ischemic changes results in inverted T waves and ST changes

What is chest xr used for in PE?

- R/o other causes of respiratory distress

What are 3 categories of embolus placement?

- Saddle PE - Central PE - Peripheral PE

What are 6 indirect causes of ARDS?

- Sepsis, shock - Pancreatitis - Burns - Multiple blood transfusions - Cardiopulmonary bypass - Drug/alcohol overdose

What are 5 relative contraindications to thrombolytic therapy?

- Severe HTN (SBP > 200 or DBP > 110) - Nonhemorrhagic stroke - Surgery in the past 10 days - Thrombocytopenia - Hx of bleeding tendencies

What 3 manifestations are the 1st indications of PE?

- Sudden onset of intense dyspnea - Pleuritic chest pain - Tachypnea

What are some s/s of hypoxemic respiratory failure?

- Tachycardia - Tachypnea - Increased BP - Restlessness, confusion, anxiety - Cyanotic - Decrease LOC - Coma

What causes damage to the endothelial wall?

- Trauma - IV drug use - Atherosclerosis

What ventilatory options may be considered to improve the refractory hypoxemia?

- reduce the tidal volume - increase the PEEP - Decrease the FiO2 - High frequency oscillating ventilation - Partial liquid ventilation

What is the therapeutic goal for IV heparin?

1.5 to 2.5 x normal value (40-90 seconds)

What is INR the therapeutic range for a PE pt?

2 to 3

How long does it take for warfarin to reach therapeutic levels?

3-5 days

How soon should enteral or parenteral nutrition be initiated when mechanical ventilation is involved?

48-72 hours

What is the normal venous oxygen saturation range?

60-80%

In regards to urine output for PE patient, what would indicate early sign of shock?

< 0.5 mL/kg/hr

What is acute respiratory failure?

A condition (not a disease) in which one or both of the gas-exchange function of the lungs are compromised

Why is adequate nutrition important for ARDS?

ARDS is a proinflammatory, hypermetabolic state

What is dead-space ventilation? And what kind of V/Q would you expect?

Adequate ventilation but no perfusion; High V/Q

What might cause a low V/Q?

Atelectasis or pneumonia

What chest xr findings might you find with a PE pt?

Atelectatic changes and infiltrates at the area of the embolism

What is the difference between BiPAP and CPAP?

BiPAP has 2 different airway pressures. One is higher during inhalation and the other is lower during exhalation which keeps the alveoli from collapsing during exhalation. CPAP maintains one continuous pressure through the respiratory cycle to keep the alveoli open through inspiration and expiration.

What are the adverse effects of alteplase?

Bleeding and cerebral hemorrhage

What must be tx in regards to respiratory failure?

Both underlying cause and oxygenation/ventilation issues

What is most commonly ordered to dx PE?

CT scan with contrast

What imaging study would you use for ARDS?

CXR - Identify bilateral infiltrates (hallmark sign of disease)

What are 2 types of embolectomy?

Catheter and surgical

What occurs in the fibrotic phase of ARDS?

Diffuse fibrosis and scarring --> Greatly impair gas exchange and compliance Pulmonary HTN worsens --> Right HF

What is catheter directed thrombolysis?

Direct administration to clot

What does alteplase do?

Dissolve clots

What are the 3 phases of ARDS?

Exudative, Proliferative, Fibrotic

True/False: Agitation indicates hypercapnia and somnolence indicates hypoxia.

False. Agitation = Hypoxia Somnolence = Hypercapnia

What is Virchow's triad?

Hypercoagulability, venous stasis, endothelial injury

What does a V/Q scan show with PE?

ID areas of lungs that are ventilated but not perfused

What causes hypercapnic respiratory failure?

Impaired ventilation d/t reduced ability of lungs and respiratory apparatus to adequate expand

What happens with VAP?

Inability of the epiglottis to close and potential drying out of the trachea and upper airways

What is shunt ventilation? And what kind of V/Q would you expect?

Inadequate ventilation with perfusion; Low V/Q

What does it mean to have a decreased venous oxygen saturation?

It may mean inadequate cardiac output. Tissues are extracting more oxygen than normal because of decreased oxygen delivery

Why is adequate hydration important in ARDS?

Maintain circulatory volume and thin secretions

Explain how a patient would be placed on a nonrebreather mask w/ 100 FIO2.

Mask is placed over the nose and mouth and then secured w/ elastic band. The oxygen flow meter is turned to max setting. The reservoir bag should be inflated to ensure that the patient is receiving 100% oxygen.

What is measurement of venous oxygen saturation?

Measures the amount of oxygenated blood returning to the heart to determine the adequacy of perfusion at the tissue level.

What is the primary tx for refractory hypoxemia?

Mechanical ventilation

A PaO2/FIO2 ratio of 200-300 would be indicative of what?

Mild ARDS

A PaO2/FIO2 ratio of 100-200 would be indicative of what?

Moderate ARDS

What occurs in the proliferative phase of ARDS?

Neutrophils cross damaged ACM --> Release toxic mediators --> Damage ACM --> Impair diffusion --> V/Q worsens --> Pulmonary HTN d/t vasoconstriction in lungs d/t hypoxemia Widespread fibrotic changes --> Lungs stiff and noncompliant --> Increased work of breathing

What is intrapulmonary shunting?

No gas exchange at all bc of a shunting of blood past collapsed alveoli

How is low risk PE characterized?

No indications of heart dysfunction, elevated biomarkers, or hypotension

What is a pulmonary embolism?

Obstruction of one or more of the branches of the pulmonary artery by a particulate matter that has an origin elsewhere in the body.

What is the 1st tx for respiratory failure?

Oxygen

What might cause a high V/Q?

PE

What is central PE?

PE found in the main branch of the pulmonary artery or in either the right or left branch of the pulmonary artery

What is peripheral PE?

PE found in the peripheral or small branches of the pulmonary arteries

What is saddle PE?

PE that straddles the bifurcation of the pulmonary artery (fully or partially obstructing both branches)

How is warfarin monitored?

PT/INR

How is hypercapnic respiratory failure characterized?

PaCO2 > 50 mmHg; pH < 7.35; hypoxemia may/may not be present

How is hypoxemic respiratory failure characterized?

PaO2 < 60 mmHg despite increased inspired O2 w/ normal or low PaCO2

What does a positive D-dimer mean?

Possible PE, requires further testing. Must order a CTA Chest or VQ Scan

What is rheolytic catheter embolectomy?

Pressurized saline erode clot

What does a inferior vena cava filter do?

Prevent recurrent PEs

What position should an ARDS patient be in to help with breathing?

Prone

What is the antidote for heparin?

Protamine sulfate

What is the most definitive imaging study to diagnose PE?

Pulmonary angiography

What does a high-ventilation, low-perfusion scenario indicate?

Pulmonary embolus

Why would a CXR be ordered for a patient having respiratory failure?

R/o HF, pulmonary congestion, pneumonia, and pneumothorax

Why would a CT be ordered for a patient w/ respiratory failure?

R/o PE

Why would a sputum culture be ordered for a patient w/ respiratory failure?

R/o pathogenic cause of failure

What ABG findings would you expect to find in a PE pt?

Respiratory alkalosis at first but then metabolic acidosis later in the disease process

How are submassive PE characterized?

Right heart dysfunction but not hemodynamic instability

What is rotational catheter embolectomy?

Rotating tool break down clot

A PaO2/FIO2 ratio of less than 100 would be indicative of what?

Severe ARDS

How are massive PE characterized?

Sudden onset of sx adn can cause right HF and death

Why is adequate nutrition and hydration important in pts w/ respiratory failure?

There is an increased work of breathing which requires nutrients and adequate hydration thins secretions

For hemodynamically compromised PE pts what medication therapy might you expect for them to be on?

Thrombolytic therapy (alteplase)

Why would a lower extremity venous ultrasound be ordered for a PE pt?

To check for DVT

True/False: In hypercapnic respiratory failure, the patient starts off as hypercabia first, then without adequate tx, could result in hypoxemia.

True

What are the two types of respiratory failure?

Type 1: Hypoxemic respiratory failure Type : Hypercapnic respiratory failure

What does high probability mean in V/Q scan?

V/Q mismatch

What does a pulmonary angiography do?

Visualize the pulmonary vasculature

What is the tx on discharge for a PE pt?

Warfarin (Coumadin)

What is IV heparin therapy dose based on?

Weight