 Hi, welcome to Nursing School Explained. This video on Acute Respiratory Distress Syndrome, also known as ARDS or ARDS. Now this is a syndrome that has got a lot of attention lately because this is the end of 2020 and we know that a lot of patients who have COVID are in danger for developing this. So let's take a look as to what the cause is. So ARDS can have a variety of causes such as aspiration, pneumonia, viral or bacterial, sepsis, severe massive trauma, PE and pulmonary embolism, near drowning when lungs get filled with water, acute pancreatitis because of all the inflammation that occurs on the left upper quadrant, coronary artery, bypass graft, surgery because of all the surgical changes, as well as DIC, disseminated intravascular coagulopathy, shock, etc. So as you can see there's a multitude of causes that can lead to this. So let's look at physiologically what is going on. So over here we have the normal pulmonary capillary alveolar structure. So we have the pulmonary artery that goes down into the pulmonary capillaries, CO2 diffuses into the alveolus, O2 diffuses into the pulmonary vein and then the oxygenated blood gets carried to the body and the cells. Now what happens in ARDS, there is an injury to this alveolar alveolar capillary membrane and whenever an injury occurs for any of these reasons up here, the immune system is triggered and this cascade of immune cells want to come and help fight whatever is the cause of the problem and so there's this cascade of cellular and biochemical changes that triggers these immune cells that are usually well intended such as neutrophils, macrophages, lymphocytes, monocytes and all of those produce cytokines and cytokines are basically cells that help promote the immune system to do its job and especially with COVID you have probably heard of the term cytokine storm. So now we have this massive immune response, all these cells that want to come fight any of these causes and therefore in order for these mediators to be released from the pulmonary capillaries, this permeability has to be opening up so they have to all be released and what happens when the cells are released, they're released in fluid and so then we have this interstitial edema that occurs between the alveolas and the pulmonary capillaries so this increased fluid that happens here and then if we have basically this alveolas that's now covered in fluid it's not going to be able to perform the oxygen and CO2 exchange as a normal alveolas would. Now this increased vascular permeability causes the interstitial edema and then the lungs get kind of stiff because they lose their compliance, their ability to open and contract as the chest wall expands and then recoils and then platelets also come to play they aggregate and release more chemical mediators which then means that more cells are being attracted to the alveolar capillary membrane and the fluid crosses that membrane and as you can see here this alveolas is swollen it's very puffy and now that fluid level is just increasing here so basically this alveolas you could think of is drowning in this fluid that all these chemical mediators from the immune system are causing and this alveola edema then does not allow for the oxygen and CO2 exchange and therefore the patient is going to have this acute respiratory distress syndrome so signs and symptoms as you can imagine when there is all this edema and the alveola are filling up with fluid the patient's respiratory rate is going to go up because they're going to have this air hunger there's going to be increased work of breathing and because fluid accumulates it's going to be audible with the set of scope in crackles and bronchi because now we have fluid here all this congestion that we can hear the patient will be restless because their O2 levels dropping and their CO2 is building up they might have altered level of consciousness because of the increased work of breathing and the distress that they're in their sympathetic nervous system will respond with tachycardia they might be cyanotic because we're now not perfusing so this oxygen exchange is not happening so the cells are starved of oxygen they might be have power and so be really pale and of course their oxygenation their O2 saddle will be low now diagnostic tests that are used to diagnose this is a chest SX-ray a very simple test and it usually shows diffuse bilateral infiltrates and remember that infiltrates usually mean fluid accumulation then on a chest X-ray air shows us black and fluid shows white and this is then called a white out on a chest X-ray because now you can't see any more air filled because the alveolar are drowning in this fluid and the fluid again is represented by these white patches that are just diffuse all over the patient's lungs now a chest CT can also be performed which is a much more detailed test or if we suspect a perfusion abnormality such as a pulmonary embolism and then certainly we'll need blood tests such as a blood count CMP arterial blood gases because we want to know exactly how our relationship between the O2 and CO2 are happening and maybe how the kidneys are compensating we want to get a urinalysis again checking for the kidney's ability to function and how they are able to concentrate because anything that concerns the respiratory symptom also can be damaged into the cardiac system we want to get an EKG and then certainly a blood or sputum culture because we have all this causes such as pneumonia or sepsis or trauma DIC shock that could be the underlying causes here now for complications so this is a severe severe critically ill patient who will require a lot of intensive care and complications include mods or multiple organ dysfunctional system which basically means because now none of the organs are being perfused this oxygen exchange is not happening so now we're not getting any oxygen in all our important organs and here specifically the kidneys the liver and the heart are not being perfused and that can lead to kidney liver and heart failure the patient can get ventilator associated pneumonia or VAP they can get burial trauma stress ulcers and then renal failure like I said from the decreased perfusion low blood pressure and it can lead to death and their trauma I'll come back to that so for treatment or nursing care because we are having trouble getting the body oxygenated we need to give the patient O2 oxygen administration and meticulous nursing care for anybody who's admitted with these signs and symptoms or diagnosis is very important because this is a process that happens not clearly it doesn't happen within a few minutes but it also doesn't happen over a few days so if we frequently assess our patients and want for these signs and symptoms specifically any changes in lung sounds we're able to hopefully prevent some of these changes and just put the patient on some oxygen get some of the diagnostic tests and get them treated so they can get better but a lot of times the patient will need to be intubated and so they will need positive pressure ventilation with PEEP which is positive end expiratory pressure and that is basically a ventilator setting and positive pressure ventilation basically means that when the patient is taken an inhalation that extra oxygen is being blown into the patient's lungs so these alveoli that are now all congested the air comes in and pushes out the fluid so that we can hopefully push some of that fluid back and then get that oxygenation get these capillaries oxygenated again that's what this positive end expiratory pressure here is with the positive pressure ventilation and that is a ventilator setting that I'll discuss in a different video but because we're now adding extra pressure to the lungs and these alveoli might already not be as elastic as they should be we can cause barotrauma basically blowing out or blowing up some of these alveoli so now air is escaping through the alveoli because there's this opening now and then it can get into that into that pleural cavity causing a pneumothorax or possibly even a tension pneumothorax so that's also another complication that can happen here from this barotrauma now as for nursing care because the patient is basically basically drowning in this fluid because of all these alveoli are filling up we need to position the patient and typically what we think about is we sit the patient up elevate the head of the bed but in ARDS this is not sufficient many times the patient will be positioned prone which means on their belly you've probably also heard about that with covid because the the change remember the fluid is always heavier and it will settle with the gravity so if we can now change the patient or turn them around now we can basically the fluid will come to the front of the alveoli and the back will be able to be profused so by kind of constantly rotating the patient we can ventilate different parts of the alveoli that are saturated in this fluid and there is front positioning there's lateral rotation where the patient will be maybe at 45 degrees and then rotated side to side and then there's also kinetic rotation and then the most important part here besides all the oxygenation is to maintain cardiac output and tissue perfusion because again the cells are starved of oxygen often there is decreased cardiac output because of this positive pressure that we're administering to the patient to keep the alveoli open but remember the more pressure we exert in that plural cavity the less room there is for that blood return from the superior inferior vena cava to return to the heart because now this positive pressure that we're trying to push into the lungs is taking up space there's only so much space available so because of this peak and decreased contractility the patient's cardiac output might be down so we'll require hemodynamic monitoring such as a central line central venous pressure pulmonary artery pressure and cardiac output monitoring as well as the patient will probably have an arterial line so that we can see exactly what their blood pressure is at any given time the patient will require IV fluids which might not be enough so they might also need positive inotropes to help with that contractility problem and those drugs are the butamine and dopamine that are most commonly used here and then if there is a problem with low blood volume or the patient is anemic for any of these reasons that we discussed over here then the patient will also require packed RBCs so that we now boost the patient's hemoglobin level so that they can the hemoglobin and the red blood cells can transport the O2 to the cells that that's so desperately needed so this concludes this video on ARDS I hope it has helped you gain a better understanding of how severe ARDS can be and how many different issues or underlying causes can cause ARDS and what happens physiologically and what we can do from a nursing perspective to keep an eye on these patients very closely so that hopefully they don't suffer and have to be placed on a ventilator or even if they do with all this meticulous monitoring and positioning particularly to help them get that oxygenation to their bodies and their tissues that's all desperately needed thanks for watching this video nursing school explain please give me a thumbs up if you liked it subscribe share with your friends and I'll see you soon