Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome

Acute Respiratory Distress Syndrome

Introduction
Acute respiratory distress syndrome, or ARDS, is a serious respiratory condition that has a
mortality rate of approximately 50%. It is seen most frequently in patients with respiratory or
chest trauma; however, the most common risk factor is the presence of sepsis. Symptoms vary
depending on the severity of the infection, but they can rapidly progress to profound respiratory
failure and multiple organ dysfunction syndrome (MODS), which is the most common cause of
death associated with ARDS. It is crucial for nurses to understand the pathophysiology and
presentation of ARDS so they can rapidly intervene when an at-risk patient develops the
condition.

Overview
ARDS is a sudden and progressive form of acute respiratory failure (ARF). In this condition, the
alveolar-capillary membrane becomes damaged and more permeable to intravascular fluid,
leading the alveoli to fill with fluid. This results in:
• Severe dyspnea
• Hypoxemia refractory to supplemental oxygen
• Reduced lung compliance
• Diffuse pulmonary infiltrates

More than 150,000 cases of ARDS are reported in the United States annually, with mortality
around 50%. Patients with both ARDS and gram-negative septic shock have a mortality rate of
approximately 70% to 90%.

Risk Factors
The nurse should be aware of common risk factors for development of ARDS so that at-risk
patients can be closely monitored.
The Common Risk Factors For Development Of ARDS
Direct Lung Injury
Common Causes

• Sepsis (most common cause)

• Aspiration of gastric contents or other substances
• Viral or bacterial pneumonia

Less Common Causes

• Chest trauma
• Embolism: fat, air, amniotic fluid, thrombus
• Inhalation of toxic substances
• Near drowning
• Oxygen toxicity
 • Radiation
• Pneumonitis

Indirect Lung Injury

Common Causes

• Sepsis (especially gram-negative infection)

• Severe massive trauma

Less Common Causes

• Acute pancreatitis
• Cardiopulmonary bypass
• Disseminated intravascular coagulation
• Opioid drug overdose (eg, heroin)
• Severe head injury
• Shock states
• Transfusion-related

Etiology and Pathophysiology

Etiology
An exact cause for damage to the alveolar-capillary membrane is not known. However, many
changes are thought to be caused by stimulation of the inflammatory and immune systems,
which attracts neutrophils to the pulmonary interstitium. The neutrophils cause a release of
biochemical, humoral, and cellular mediators that produce changes in the lungs, including
increased pulmonary capillary membrane permeability, destruction of elastin and collagen,
formation of pulmonary microemboli, and pulmonary artery vasoconstriction.

Pathophysiology
The three phases of ARDS are the injury phase, the reparative phase, and the fibrotic phase.

Phase Timeframe Events

Injury/Exudative 1-7 days after • Interstitial and alveolar edema (noncardiogenic
lung injury pulmonary edema)
• Atelectasis

Reparative/Proliferative 1-2 weeks after • Influx of granulocytes, monocytes, and lymphocytes

lung injury • Fibroblast proliferation

Fibrotic 2-3 weeks after • Chronic or late phase of ARDS

lung injury • Lung completely remodeled by collagenous and
fibrous tissues
• Diffuse scarring and fibrosis resulting in decreased
lung compliance and decreased surface area for gas
exchange
Phase Timeframe Events
• Pulmonary hypertension resulting from fibrosis

The progression of ARDS varies. Some patients survive the acute phase of lung injury, and
complete recovery occurs within a few days. Others progress to the fibrotic phase, requiring
long-term mechanical ventilation, with a poor chance of survival.

Clinical Manifestations
Clinical manifestations of ARDS depend on the cause and the other body systems involved.
The patient may not exhibit respiratory symptoms for 1 or 2 days after the initial injury. Without
treatment, ARDS will progress in four phases.

ARDS will Progress in Four Phases

Progression 1

• The patient may exhibit:

o Tachypnea
o Dyspnea
o Cough
o Restlessness
o Confusion
• Normal breath sounds or fine, scattered crackles may be heard on chest auscultation.
• Arterial blood gases (ABGs) will indicate mild hypoxemia and respiratory alkalosis.
• Chest x-ray may reveal normal findings or show evidence of minimal scattered interstitial
infiltrates.

Progression 2
As ARDS progresses, symptoms worsen because of increased fluid accumulation in the lungs
and decreased lung compliance.
The nurse may observe:

• Tachycardia
• Diaphoresis
• Changes in sensorium with decreased mentation
• Cyanosis
• Pallor
• Scattered to diffuse crackles and rhonchi on auscultation
• Hypoxemia, despite administration of supplemental oxygen, a hallmark of ARDS
• Hypercapnia, signifying respiratory muscle fatigue and hypoventilation

Progression 3
As ARDS progresses, profound respiratory distress requires endotracheal intubation and positive
pressure ventilation (PPV).
 • The chest x-ray reveals whiteout or white lung as consolidation and coalescing infiltrates
pervade the lungs, leaving few recognizable air spaces.
• Pleural effusions may be present.
• The patient may have severe hypoxemia and hypercapnia.
• Metabolic acidosis, with symptoms of target organ or tissue hypoxemia, may develop if
therapy is not promptly started.

Final stages

• Complications may develop as a result of ARDS itself or its treatment. The primary cause
of death in ARDS is MODS, often accompanied by sepsis.
• The vital organs most commonly affected by MODS are the kidneys, liver, and heart.

Diagnostic Evaluations
No specific test can be used to diagnose ARDS. Rather, diagnosis is made based on vital signs,
clinical manifestations, and findings on a chest x-ray. The nurse knows that careful assessment of
patients at risk for ARDS can be instrumental in rapid diagnosis and initiation of treatment.
Findings that support a diagnosis of ARDS are refractory hypoxemia with a partial arterial
oxygen tension/fractional concentration of oxygen in inspired gas (PaO2/FiO2) ratio <200,
detection of new bilateral interstitial or alveolar infiltrates on chest x-ray, and pulmonary artery
occlusion pressure of 18 mm Hg or less with no evidence of heart failure.

Complications of Acute Respiratory Distress Syndrome

Complications may develop as a result of ARDS itself or its treatment. The nurse must be aware
of potential complications associated with ARDS in order to monitor for and inform the health
care provider of any changes in the patient’s clinical status.

Classification Type of Complications

Infection • Catheter-related infection (eg, central and peripheral intravenous [IV]
catheters, urinary catheters)
• Sepsis

Respiratory Complications • Oxygen toxicity

o Pulmonary barotrauma (eg, pneumothorax,
pneumomediastinum, subcutaneous emphysema)
o Pulmonary emboli
o Pulmonary fibrosis
o Ventilator-associated pneumonia

Cardiovascular • Dysrhythmias
Complications • Decreased cardiac output

Gastrointestinal • Paralytic ileus

Complications • Pneumoperitoneum
• Stress ulceration and hemorrhage
Classification Type of Complications
Renal Complications • Hypermetabolic state with dramatically increased nutrition
requirements
• Acute kidney injury

Hematologic Complications • Anemia

• Disseminated intravascular coagulation
• Thrombocytopenia
• Venous thromboembolism

Endotracheal Tube • Laryngeal ulceration

Complications • Tracheal malacia
• Tracheal stenosis
• Tracheal ulceration

CNS and Psychological • Delirium

Complications • Sleep deprivation
• Posttraumatic stress disorder

Key Points
• ARDS is an acute form of respiratory failure, resulting in damage to the alveolar-
capillary membrane and causing the lungs to fill with fluid.
• The cause of ARDS is not known, but risk factors include sepsis, aspiration, pneumonia,
chest trauma, acute pancreatitis, and opioid drug overdose.
• ARDS has three phases: the injury or exudative phase, the reparative or proliferative
phase, and the fibrotic phase.
• Initially, respiratory symptoms may not be present.
• Clinical manifestations progress in severity from normal/fine crackles on auscultation and
normal ABG values and chest x-ray findings to profound respiratory failure with
complete consolidation of the lungs visible on chest x-ray.
• No definitive diagnostic test for ARDS exists. The nurse may observe refractory
hypoxemia, abnormalities on chest x-ray, and/or decreased pulmonary artery pressure.
• Complications of ARDS may affect the kidneys, heart, or liver. Death usually occurs as a
result of MODS or sepsis

QUIZ:

Question 1: The nurse knows that patients with which diagnoses are at risk of developing acute
respiratory distress syndrome (ARDS)?
Select all that apply.

A. Septic shock
B. Severe head injury
C. Acute heart failure
D. Amniotic fluid embolus
E. Chronic kidney disease (CKD)
RATIONALE: Patients with sepsis or septic shock are at the highest risk for developing ARDS.
This is especially true when the sepsis is due to a gram-negative infection. The nurse should
monitor respiratory status of these patients closely. Patients with severe head injuries can have a
secondary injury to the lungs resulting from central nervous system damage. This can result in
the development of ARDS, and the nurse should monitor these patients accordingly. Patients
with any type of embolism—fat, air, amniotic fluid, or thrombus—are at higher risk for
developing ARDS. The nurse should monitor the respiratory status of these patients accordingly.

Question 2: A patient is diagnosed with acute respiratory distress syndrome (ARDS) two days
after a crushing chest injury during a motor vehicle collision. Which statement best explains the
cause of the patient's worsening symptoms?

A. Pulmonary vessels are dilated.

B. The immune system is inhibited.
C. Pulmonary compliance is increased.
D. Inflammatory mediators are released.

RATIONALE: Injury to the lung tissue results in an influx of inflammatory mediators and
immune cells to the area of injury. These cells cause a release of mediators that induce changes
in the lungs, which eventually progress to ARDS.

Question 3: The nurse is teaching a nursing student about acute respiratory distress syndrome
(ARDS). The student asks how to recognize symptoms of the disease as it progresses. In which
order does the nurse describe the symptoms?

Tachypnea and cough

Decreased mental status
Respiratory distress
Decreased urine output

RATIONALE: In the first day or two after the initial injury, the patient may have no respiratory
symptoms. In the first phase of the illness, the patient may experience tachypnea, cough,
dyspnea, and restlessness. Arterial blood gas values, findings on chest x-ray, and breath sounds
on auscultation may be normal. As the disease progresses, the patient may have a rapid heartbeat,
be cyanotic or pale, or have changes in mental status. The nurse will note crackles or rhonchi on
auscultation, and the patient will have hypoxemia despite use of supplemental oxygen. Next, the
patient will have profound respiratory distress and failure requiring intubation and ventilation. A
chest x-ray may reveal white lungs, and the patient may develop metabolic acidosis. If the
patient’s condition continues to worsen, severe complications, such as multiple organ
dysfunction syndrome (MODS), may develop. Kidneys are often the first affected organs, and
initial symptoms of MODS are reflected in decreased urine output.

Treatment Goals
The overall goals for the patient with ARDS include maintaining a partial pressure of oxygen in
arterial blood (PaO2) of at least 60 mm Hg and adequate lung volume to maintain normal pH.
A patient recovering from ARDS will exhibit:
• PaO2 within normal limits for age or baseline values on room air
• Oxygen saturation in arterial blood (SaO2) greater than 90%
• A patent airway
• Clear lungs on auscultation
• Respiratory Support

The goal of oxygen therapy is to correct hypoxemia. The nurse can work with the respiratory
therapist and physician to promote ventilation and oxygenation through several interventions.

Oxygen Therapy
• Use a nasal cannula or facemask with high-flow systems that deliver higher oxygen
concentrations.
• Give the lowest concentration of oxygen that results in a PaO2 of 60 mm Hg or greater.
• When FiO2 exceeds 60% for more than 48 hours, the risk for oxygen toxicity is
increased.
• Patients with severe ARDS and refractory hypoxemia need intubation with mechanical
ventilation.
• Mechanical Ventilation
• Endotracheal intubation and PPV are needed when hypoxemia does not respond to other
treatments.
• Use of positive end-expiratory pressure (PEEP) keeps lungs partially expanded and
prevents total collapse of alveoli.
• If hypoxemic failure persists, alternative modes and therapies may be used. These include
airway pressure release ventilation, pressure-control inverse-ratio ventilation, high-
frequency ventilation, and permissive hypercapnia (low tidal volumes that allow the
positive pressure of carbon dioxide in arterial blood (PaCO2) to increase slowly).

Positioning
• Some patients with ARDS are able to breathe better in a prone position.
• Patient is placed in a face-down position anywhere from 12 to 20 hours. This improves
oxygenation.
• Consider providing kinetic therapy, which provides continuous, slow, side-to-side turning
of the patient by rotating the actual bed frame.
• Maintain the lateral movement of the bed, at least 40 degrees to each side (total arc of at
least 80 degrees), for 18 of every 24 hours; however, the nurse will still need to turn the
patient every 2 hours to prevent skin breakdown.
• Stimulates postural drainage, helps mobilize pulmonary secretions, and improves
ventilation/perfusion ratio.

Interprofessional Care
Management of ARDS involves treating the underlying cause or injury. In addition to respiratory
support, the nurse must work with other health care professionals and departments to provide
care for the patient. This may include the respiratory therapist, physical therapist, physicians of
different specialties, and the providers in the intensive care unit. The nurse may need to arrange
consultations with the dietician to discuss nutritional needs or the chaplain to provide support to
the patient or family. The patient may also need care after discharge, requiring the social worker
or case manager to become involved in discharge planning.

Hemodynamic Monitoring
Patients receiving PPV and PEEP frequently experience decreased cardiac output. Hemodynamic
monitoring is essential to see trends, detect changes, and adjust therapy as needed.

An arterial catheter, also known as an A-line, is inserted for continuous monitoring of blood
pressure (BP) and sampling of blood for determination of ABG values.
Use of inotropic drugs, such as dobutamine or dopamine, may also be necessary.

Fluid Balance
Maintenance of nutrition and fluid balance is challenging in the patient with ARDS.
Parenteral or enteral feedings are started to meet the high-energy requirements of these patients.
Enteral nutrition is usually started before parenteral nutrition because of the increased risk of
infection associated with parenteral means and the need to preserve gastrointestinal (GI)
function.

Increasing pulmonary capillary permeability results in fluid in the lungs and causes pulmonary
edema.

Fluid restriction is usually prescribed, and diuretics are used as necessary. At the same time, the
patient may be volume depleted and therefore prone to hypotension and decreased cardiac output
from mechanical ventilation and PEEP.

Monitor fluid status carefully.

Key Points
• The treatment goal for a patient with ARDS is to maintain a PaO2 of at least 60 mm Hg
and oxygen saturation (SaO2) of at least 90% on room air.
• The nurse should initiate oxygen therapy with a nasal cannula or mask that can deliver a
high oxygen concentration to maintain PaO2.
• Refractory hypoxemia necessitates intubation and mechanical ventilation.
• The nurse can consider placing the patient in the prone position or on a continuous lateral
rotation bed to promote oxygenation.
• PEEP is most frequently used to keep the lungs and alveoli partially expanded.
• Hemodynamic monitoring to maintain cardiac output and careful monitoring of fluid and
electrolyte balances are often required.

QUIZ:

Question 1: A patient has developed acute respiratory distress syndrome (ARDS) after aspiration
and is now arriving at the hospital by ambulance. The patient is hyperventilating and has been
receiving oxygen at a rate of 15 L/min via a simple facemask. Which provider order would the
nurse anticipate?
A. Change to a nonrebreather mask.
B. Reduce oxygen concentration to 6 L/min.
C. Administer intravenous furosemide to reduce fluids.
D. Prepare for intubation and mechanical ventilation with positive end-expiratory pressure
(PEEP).

RATIONALE: Intubation and mechanical ventilation with PEEP will be required because the
patient is still hyperventilating even after receiving a large amount oxygen. PEEP should be used
to help the patient breathe.

Question 2: A nurse is caring for a patient with severe acute respiratory distress syndrome
(ARDS). The patient had an arterial catheter placed in the morning. The nurse observed a
decrease in cardiac output and blood pressure after vital signs were measured in the afternoon.
What medication does the nurse anticipate administering?

A. Dopamine
B. Furosemide
C. Antibiotics
D. Epinephrine

RATIONALE: Dopamine is an inotropic drug that can be used to increase cardiac output and
blood pressure.

Question 3: A nurse is assessing a patient with acute respiratory distress syndrome (ARDS) who
is intubated and receiving mechanical ventilation. Arterial blood gases reveal a partial pressure
of oxygen in arterial blood (PaO2) of 55 mm Hg. The nurse knows that the respiratory therapist
may recommend which types of treatment?
Select all that apply.

A. Permissive hypercapnia
B. Continuous positive airway pressure
C. Airway pressure release ventilation
D. Pressure-control inverse-ratio ventilation
E. Extubation and use of a nonrebreather mask

RATIONALE: Permissive hypercapnia is an alternative setting during mechanical ventilation

that allows a slow increase in the positive pressure of carbon dioxide and is sometimes used
when hypoxemia persists despite use of positive end-expiratory pressure. Airway pressure
release ventilation is an alternative setting during mechanical ventilation and is sometimes used
when hypoxemia persists despite use of positive end-expiratory pressure. Pressure-control
inverse-ratio ventilation is an alternate setting used during mechanical ventilation when
hypoxemia persists despite use of positive end-expiratory pressure.

Overview
The nurse works with the interdisciplinary team to correct hypoxemia and prevent further
complications after a diagnosis of ARDS. The nurse must understand the underlying conditions
that contribute to a diagnosis of ARDS. The underlying condition must be treated, and the patient
must be closely monitored for signs of improvement or decline.

Nursing Assessment
Assessment parameters for ARDS are very similar to those for ARF. The nurse will:
• Monitor patient’s respiratory status for decline
• Assess perfusion and oxygenation
• Watch for signs of end-organ damage
• Observe patient’s urine output for signs of kidney involvement (Low hourly output can
also indicate decreasing cardiac output.)

Collaboration Pearl
Nurses are a vital link in identifying subtle changes in their patients. It is necessary to look at
trends, not just what is happening right now. The nurse needs to report to the provider any
change in patient status, laboratory values, or response to treatment.

Nursing Interventions: Maintaining Cardiac Output

Nursing care is focused on treating hypoxemia and preventing further complications from poor
tissue perfusion. The nurse should be aware of the pathophysiology related to decreasing cardiac
output in patients receiving PEEP so appropriate monitoring can be performed.

Maintaining Cardiac Output and Tissue Perfusion

Patients receiving PPV and PEEP frequently experience decreased cardiac output. When caring
for a patient with decreased CO, the nurse should give IV fluids and administer medications
(usually dopamine or dobutamine) as ordered. It is important for the nurse to actively monitor
blood pressure and the other vital signs.

Hemodynamic monitoring (eg. central venous pressure [CVP], cardiac output, central venous
oxygen saturation, venous oxygen saturation) via central venous or pulmonary artery pressure, or
arterial pressure-based cardiac output monitoring, is essential. If the cardiac output falls, it may
be necessary to administer crystalloid fluids or colloid solutions or to lower PEEP.

Packed red blood cells are used to increase hemoglobin and thus the oxygen-carrying capacity of
the blood. The hemoglobin level is usually kept around 9 to 10 g/dL (90 to 100 g/L) with a
functional oxygenation saturation (SpO2) of 90% or more (when PaO2 is greater than 60 mm
Hg).

Nursing Interventions: Fluid Balance and Nutrition

Maintenance of nutrition and fluid balance is challenging in the patient with ARDS. The nurse
should:
• Consult with a dietitian to determine optimal caloric needs.
 • Provide enteral or parenteral feedings as ordered to meet the high-energy requirements of
these patients. Enteral formulas enriched with omega-3 fatty acids may improve the
clinical outcomes of patients with ARDS.
• Monitor hemodynamic parameters (eg, CVP, stroke volume variation), daily weights, and
intake and output to assess the patient’s fluid status.

Controversy exists as to the benefits of fluid replacement with crystalloids versus colloids.
Critics of colloid replacement believe that proteins in colloids may leak into the pulmonary
interstitium, increasing the movement of fluid into the alveoli. Advocates of colloid replacement
believe that colloids help keep fluid from leaking into the alveoli.

Case Study: The Patient with Acute Respiratory Distress Syndrome

Mr. Whaley is a 55-year-old man who recently had bowel surgery but developed ARF
postoperatively.

Subjective • Mr. Whaley is intubated and receiving mechanical ventilation. Mr. Whaley is
Data sedated and paralyzed and is unable to communicate.
• His wife and two adult children are at the bedside and voicing concerns and
questions regarding his progress.

Objective Data • General: Sedated, paralyzed, well-nourished man; head of bed elevated 45 degrees;
skin cool with moderate diaphoresis
Physical • Respiratory: No accessory muscle use, retractions, or paradoxical breathing;
Assessment respiratory rate 18 breaths/min and in phase with ventilator; SpO2 85%; fine
crackles at lung bases
• Cardiovascular: BP 100/60 mm Hg
• Gastrointestinal: Surgical dressing dry and intact; colostomy draining
serosanguinous fluid
• Urologic: Indwelling bladder catheter draining concentrated urine less than 30
mL/hr

Diagnostic • ABGs: pH 7.15, PaO2 56 mm Hg, PaCO2 57 mm Hg, bicarbonate level 16 mEq/L,
Findings oxygen saturation 86%
• PaO2/FiO2 ratio <200
• Chest x-ray: new bilateral, scattered interstitial infiltrates

Key Points
• Collaboration with an interdisciplinary team is required to appropriately treat ARDS.
• Assessment parameters include the patient’s respiratory status, oxygenation, and signs of
organ damage.
• High PEEP can lead to decreased cardiac output, requiring the nurse to monitor for
hemodynamic status changes.
• Maintaining nutrition and fluid balance is challenging because a patient with ARDS
requires a lot of calories but cannot tolerate a large amount of fluids because of the
pathophysiologic changes that occur with ARDS. The nurse should consult with a
dietician and closely monitor fluid status.
QUIZ:

Question 1: The nurse is concerned about which findings when assessing Mr. Whaley at the start
of a shift?
Select all that apply.

A. Urine output of <30 mL/hr

B. Mr. Whaley’s chest x-ray results
C. Respiratory rate of 18 breaths/min
D. Blood pressure of 100/60 mm Hg
E. Partial arterial oxygen tension (PaO2) of 56 mm Hg

RATIONALE: Low urine output can indicate decreasing cardiac output and kidney function,
which can indicate complications that require immediate intervention. A chest x-ray showing
new infiltrates is concerning because it can indicate the development of acute respiratory distress
syndrome in this patient. The nurse should report the findings to the physician. PaO2 of 56 is
below the normal range and requires further assessment by the nurse. Mr. Whaley may need the
ventilator settings adjusted.

Question 2: A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) and
notes a hemoglobin of 7 g/dL. The nurse anticipates what order?

A. Bolus of normal saline

B. Administration of furosemide
C. Administration of colloid solutions
D. Transfusion of packed red blood cells (RBCs)

RATIONALE: The patient's hemoglobin level is low, indicating the need for packed RBC
transfusion. The goal of treatment is to raise the hemoglobin level to at least 9 to 10 g/dL.

Question 3: The nurse is receiving a report on a patient diagnosed with acute respiratory distress
syndrome (ARDS). The patient is intubated and mechanically ventilated. On assessment, the
nurse notes crackles in the lungs, poor skin turgor, and decreased capillary refill. The patient is
receiving nothing by mouth (NPO) with normal saline solution infusing at 100 mL/hr. Urine
output was 100 mL over the last 4 hours. Which action should the nurse perform first?

A. Administer dopamine as ordered.

B. Advance the patient to a regular diet.
C. Obtain an order for enteral nutrition.
D. Obtain an order to administer 5% dextrose in water (D5W) with the normal saline solution.

RATIONALE: A patient with a urine output of less than 30 mL/hr and ARDS is likely
experiencing decreased cardiac output. A medication such as dopamine or dobutamine is needed
to support cardiac output and function.
Summary
ARDS is triggered by an injury to the lungs such as trauma, pneumonia, embolism, aspiration
and most frequently, sepsis. Initially, the patient may not have respiratory symptoms. However,
the disease can progress rapidly from mild symptoms, such as dyspnea and cough, to profound
respiratory distress requiring mechanical ventilation. Death can occur as a result of MODS or
other complications. The nurse must be aware of risk factors and clinical manifestations of this
condition so that the health care team can intervene early and minimize severity. Nursing
interventions focus on restoration of normal respiratory function, maintaining fluid and
nutritional balances, and aggressive hemodynamic monitoring.

Key Points
• ARDS is an acute form of respiratory failure, resulting in damage to the alveolar-
capillary membrane and causing the lungs to fill with fluid.
• The cause of ARDS is not known, but risk factors include sepsis, aspiration, pneumonia,
chest trauma, acute pancreatitis, and opioid drug overdose.
• ARDS has three phases: the injury or exudative phase, the reparative or proliferative
phase, and the fibrotic phase.
• Initially, respiratory symptoms may not be present.
• Clinical manifestations progress in severity from normal/fine crackles on auscultation and
normal ABG values and chest x-ray findings to profound respiratory failure with
complete consolidation of the lungs visible on chest x-ray.
• No definitive diagnostic test for ARDS exists. The nurse may observe refractory
hypoxemia, abnormalities on chest x-ray, and/or decreased pulmonary artery pressure.
• Complications of ARDS may affect the kidneys, heart, or liver. Death usually occurs as a
result of MODS or sepsis.
• The treatment goal for a patient with ARDS is to maintain a PaO2 of at least 60 mm Hg
and oxygen saturation (SaO2) of at least 90% on room air.
• The nurse should initiate oxygen therapy with a nasal cannula or mask that can deliver a
high oxygen concentration to maintain PaO2.
• Refractory hypoxemia necessitates intubation and mechanical ventilation.
• The nurse can consider placing the patient in the prone position or on a continuous lateral
rotation bed to promote oxygenation.
• PEEP is most frequently used to keep the lungs and alveoli partially expanded.
• Hemodynamic monitoring to maintain cardiac output and careful monitoring of fluid and
electrolyte balances are often required.
• Collaboration with an interdisciplinary team is required to appropriately treat ARDS.
• Assessment parameters include the patient’s respiratory status, oxygenation, and signs of
organ damage.
• High PEEP can lead to decreased cardiac output, requiring the nurse to monitor for
hemodynamic status changes.

Maintaining nutrition and fluid balance is challenging because a patient with ARDS requires
a lot of calories but cannot tolerate a large amount of fluids because of the pathophysiologic
 changes that occur with ARDS. The nurse should consult with a dietician and closely
monitor fluid status.

FINAL QUIZ:

Question 1: A patient is being evaluated for acute respiratory distress syndrome (ARDS). On
assessment of the patient, the nurse notes tachypnea, dyspnea, and confusion. For which test
would the nurse expect to prepare the patient to confirm the diagnosis of ARDS?

A. Chest x-ray
B. Measurement of arterial blood gases (ABGs)
C. Complete blood count (CBC) with platelets
D. Magnetic resonance imaging (MRI) of the chest with contrast

RATIONALE: A chest x-ray is commonly used to detect the presence of ARDS. Initially, the x-
ray may reveal normal findings or minimal evidence of infiltrates. Severe cases of ARDS may
show a "white lung" on x-ray because of massive infiltration.

Question 2: A patient with aspiration pneumonia presents with a heart rate of 128 beats/min,
respiratory rate of 32 breaths/min, blood pressure of 148/92 mm Hg, and functional saturation of
oxygen on 88% on room air. The patient reports shortness of breath (SOB) and fatigue. Which
blood test would the nurse anticipate first?

A. Blood glucose
B. Chemistry panel
C. Measurement of arterial blood gases (ABGs)
D. Prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR)

RATIONALE:

Question 3: The nurse is caring for a patient with acute respiratory distress syndrome (ARDS)
who is having difficulty breathing and an oxygen saturation of 85%. The patient's spouse is at the
bedside and asks why the patient is having difficulty breathing. What is the best response by the
nurse?

A. “Your spouse has multiple organ dysfunction syndrome.”

B. “This is the normal course of ARDS and should resolve in a few days.”
C. “Your spouse has refractory hypoxemia, which is low blood oxygen that is not being resolved
with the therapies we are trying.”
D. “Your spouse is probably feeling a little anxious, which can make it feel as if he/she is having
difficulty breathing. The oxygen saturation level is normal.”

RATIONALE: This patient has refractory hypoxemia associated with ARDS as evidenced by the
low oxygen saturation and difficulty breathing.
Question 4: A patient with pneumonia reports increased sweating, persistent coughing, shortness
of breath and palpitations. The nurse notes tachycardia and cyanosis. The patient is receiving
oxygen via a nasal cannula at 2 L/min. Which action would the nurse take next?

A. Administer an antipyretic.
B. Notify the health care provider.
C. Inform the respiratory therapist.
D. Give a bolus of normal saline solution.
E. Increase oxygen concentration to 6 L/min.

RATIONALE: The health care provider needs to be informed of the change in the patient's
status. The nurse should be prepared to change the oxygen delivery system or administer
additional medications. The respiratory therapist needs be informed of the change in the patient's
status because of a possible need for intubation or change in oxygenation/ventilation treatment.

Question 5: A nurse is caring for a patient with acute respiratory distress syndrome (ARDS). At
the start of the shift, the nurse finds that the patient has been placed in a prone position.
Functional saturation of oxygen (SpO2) is 93%. How does the nurse respond?

A. Initiate aspiration precautions.

B. Notify the primary healthcare provider.
C. Turn the patient to the supine position.
D. Continue to monitor per hospital protocol.

RATIONALE: No action is needed if the patient is comfortable and vital signs/oxygen saturation
are within normal limits. Some patients do better clinically when they are in the prone position.
Oxygenation may be improved when patients are in the prone position than when they are in the
supine position. Additionally, prone positioning could prevent ventilator-induced lung injury.

Question 6: The nurse is caring for a patient with acute respiratory distress syndrome (ARDS)
secondary to sepsis. The patient is receiving kinetic therapy. The nurse should ensure that the
nursing assistant performs which intervention?
A. Elevates the lower extremities.
B. Turns the patient every 2 hours.
C. Keeps the patient in a prone position.
D. Encourages the patient to ambulate each hour.

RATIONALE: Even though the patient is receiving kinetic therapy, he or she will still need to be
turned in order to prevent skin breakdown and development of pressure ulcers.
Question 7: A nurse is caring for a patient who is suspected of developing acute respiratory
distress syndrome (ARDS). The patient is receiving oxygen at 15 L /min through a nonrebreather
mask while awaiting further evaluation. What should the nurse implement for this procedure to
be most effective?

A. Ensure the mask fits snuggly on the patient’s face.

B. Encourage the patient to remove the mask when it becomes uncomfortable.
C. Obtain baseline vital signs before initiating oxygen supplementation therapy.
D. Encourage the patient to remove the mask periodically for deep breathing exercises.

RATIONALE: Ensuring the mask fits snugly and properly over the mouth and nose will ensure
that oxygen therapy is most effective.

Question 8: A patient with acute respiratory distress syndrome (ARDS) secondary to a chest
injury has crackles in the bilateral posterior lung fields. The nurse also notes tachycardia, delayed
capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH
7.56, PaO2 51, PaCo2 28, HCO3 24, SaO2 76%. Which provider order would the nurse
implement first?

A. Measure urine output.

B. Administer furosemide.
C. Place the patient in a prone position.
D. Prepare the patient for mechanical ventilation.

RATIONALE: Assessment and diagnostic data are consistent with hypoxemia and decreased
perfusion. The priority for this patient is restoring oxygenation.

Question 9: The nurse is caring for a patient diagnosed with acute respiratory distress syndrome
(ARDS). On assessment, the nurse notes crackles in the lungs and peripheral edema. Which
nursing assessments are appropriate for the nurse to obtain?

A. Skin integrity
B. Intake/output
C. Oxygen saturation
D. Blood glucose level
E. Serum albumin level

RATIONALE: Peripheral edema can cause impaired skin integrity or skin breakdown. The nurse
should assess and monitor for any of these changes. The patient is showing signs of fluid
overload. The nurse should monitor the intake and output in order to assess fluid status. The
nurse should continuously monitor oxygenation in the patient with ARDS; this is a priority.