#34 Acute Respiratory Distress Syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) has a stubbornly high mortality rate with current estimates at about 40%. Critical care veteran Kathleen Vollman, MSN, RN, CCNS lays the foundation of ARDS starting with pathophysiology followed by the “8 Ps” of evidence-based supportive care and summary of long-term prognosis.

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Meet the guest: Kathleen Vollman

Kathleen Vollman has been a critical care nurse for over 40 years. 

Currently, as owner of ADVANCING NURSING she brings her passion, enthusiasm and knowledge to help arm nurses and organizations with the tools they need to improve their practice and impact patient outcomes.

The Berlin Definition

The Berlin Definition of ARDS requires that all of the following criteria be present for diagnosis (UpToDate):

  1. Acute onset: Respiratory symptoms must have begun within one week of a known clinical insult, or the patient must have new or worsening symptoms during the past week
  2. Bilateral opacities must be present on a chest radiograph or computed tomographic (CT) scan
  3. Rule out cardiogenic pulmonary edema: The patient’s respiratory failure must not be fully explained by cardiac failure or fluid overload
  4. PaO2/FiO2 < 300. A moderate to severe impairment of oxygenation must be present, as defined by the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2). The severity of the hypoxemia defines the severity of the ARDS:
    • Mild ARDS – The PaO2/FiO2 is 200 to 300
    • Moderate ARDS – The PaO2/FiO2 is 100 to 200
    • Severe ARDS – The PaO2/FiO2 is ≤100

 The 8 Ps

Supportive evidence-based care practices for patients with ARDS à la Kathleen Vollman.

  1. Prevention. Prevent secondary infections such as ventilator associated pneumonia (VAP), central line associated bloodstream infection (CLABSI), and catheter associated urinary tract infection (CAUTI) which will increase mortality
  2. PEEP. Focus on lung-protecting strategies such as low tidal volumes and even ECMO
  3. Pipes
  4. Pump (Pipes and pump go together 😉). Strive for euvolemia. Determine if your patient is responding to fluid boluses using the passive leg raise maneuver (PLR), IVC ultrasound, etc. (fantastic info from Life in the Fast Lane about fluid responsiveness)
  5. Paralysis. Reduce ventilator asynchrony by starting with analgesics, followed by sedatives and lastly: paralytics
  6. Position. Proning can recruit alveoli in dependent regions, reduces hyperinflation of non-dependent regions (prevents VALI), drains sections (Vollman, 2021)
  7. Protein. Start enteral feeding within 24-48 hours of intubation
  8. Protocols. A-F bundle. Read about it the ICU liberation campaign on the Society of Critical Care website.