A patient requiring mechanical ventilation - Essay Example

? Case Study of a Patient Suffering from ARDS and requiring Mechanical Ventilation, ECMO and Nursing Care Number School Abstract This case study is for a 38 year old female patient, by name Rita (name changed to protect identity), who developed ARDS, from sepsis and required treatment on a mechanical ventilator and ECMO. She also developed renal complications, aspiration pneumonia and there was deterioration of the cardiopulmonary function (See Appendix 1). Rita received treatment through mechanical ventilation along with antibiotic treatment, and tracheostomy. Her condition initially worsened, but slowly, Rita managed to recover. She was hospitalised for 4 weeks and needed the tracheostomy tube to be in place for 9-weeks following discharge. In general it is found that collaborations between the intensive care nurse and the intensive care specialist is vital for evaluating and managing the patient and to ensure that the outcomes are fruitful. In general, the mortalities for ARDS are high (40 to 50%), mainly due to the ineffective traditional methods of managing such patients that have been utilised in the past. However, with use of several evidence-based protocols, the outcomes can be improved. Some of the measures that were provided to Rita included include mechanical ventilation, tracheostomy, prone positioning (HOB elevation), antibiotic administration (as she had sepsis), ECMO (due to sudden drop in the partial pressure of oxygen), sedation protocols, supportive therapy, RBC packed cell and platelet transfusion and a conservative fluid strategy. Rita developed renal complications and aspiration pneumonia, which were effectively managed. A careful nursing plan requires to be chalked out to cater to the individual needs of the patient. Ideal treatment would ensure speedy recovery and early resumption of normal activities by the patient. Case Study of a Patient Suffering from ARDS and requiring Mechanical Ventilation and Nursing Care Introduction This case study is of a 38-year old female, by name Rita, who was suffering from acute distress respiratory syndrome (ARDS), due to sepsis and requiring mechanical ventilation and a nursing care plan. ARDS is a condition in which the lungs are unable to perform their usual function of absorbing oxygen (Ensure Care Plan 2011). ARDS usually may follow critical illnesses, serious injuries or developed after major surgeries. The condition is a form of pulmonary oedema not from a proper cardiac cause, which occurs due to a drop in pressure in the pulmonary arteries (ARDS Training 2010). In ARDS, there is leakage of fluids and proteins into the air sacs and the interstitial lung tissues leading to pulmonary oedema (caused from damage to the alveoli-capillary mechanism) (Austin CC 2012). There may be several mediators involved in the damage of the alveoli-capillary mechanism including microorganisms, toxins, allergens, neutrophils, TNF, etc. After injury, the symptoms can develop within en 24 to 72 hours, and the respiratory functions tend to deteriorate leading to decreased lung volumes and compliance (Ensure Nursing Plan 2011). Due to the damage to the pneumocytes type 2, the lungs collapse and there is a decrease in the volume of the lungs. Fibrocytes convert the intra-alveolar fluid to a fibrous tissue and leads to poor ventilation (causing hypoxemia). When ARDS progresses, the patient can develop respiratory failure and can lead to arrest of the cardiopulmonary functions (Ensure Nursing Plan 2011). Usually ARDS develops from an underlying cause or a lung disorder and may vary depending upon the geographical location, age group, etc. Some of the causes of ARDS include direct injuries (may be trauma, chemical, oxygen toxicity, damage from free radicals, thermal or burns, drug overdose, or sepsis), drowning (or near drowning) or hemorrhagic shock (ARDS Training 2010). The incidence of ARDS is about 140,000 to 150,000 cases each year, and about 40 to 50% of the affected cases develop mortalities (Ensure Care Plans 2011). This is a case study of a 38 year old female patient Rita, who initially had backache which deteriorated over a few days, and she further developed dyspnea and breathlessness (which are major signs of ARDS). She was admitted to the hospital and her condition worsened further, resulting in hypotension and renal failure. Due to the severe respiratory symptoms (especially breathlessness and dyspnea), and unstable vitals, she required to undergo mechanical ventilation (See Appendix 1 for Complaints and Findings). However, after using the ventilator her problems did not reduce and respiratory function worsened, due to rupture of the lung alveoli arising from the high pressure of the ventilator air required to enter into the lungs. The air escaped from the lungs, and accumulated inside the chest wall leading to a potentially dangerous condition called ‘pneumothorax’. In order to permit the air present in the chest wall to escape, a tube was being inserted. Her accessory muscles of respiration were fatigued due to the excessive load, and hence required sedation protocols. Following several days of ventilation, the patient developed aspiration pneumonia, which was managed by administering antibiotics. According to the NHLBI (NIH), aspiration pneumonia is a potential risk that can develop following the use of ventilators and need to be treated with antibiotics (NIH NHLBI 2012). To ensure that long-term ventilation could be provided to the patient as per her needs, a tracheostomy was being done. The patient’s partial pressure of oxygen (PaO2) was below 50 mm Hg and the PEEP level was 20 cm of water. To ensure that the patient was comfortable, she was placed in the prone positioning (HOB Elevation) and a neuromuscular agent was being administered to improve the PO2. However, the patient’s condition did not improve any further. Extracorporeal membrane oxygenation (ECMO) was initiated to help prevent the development of cardiopulmonary function (Alatassi 2012). The patient required close monitoring of all vitals, pH, blood gas partial pressures, blood chemistry, and also required RBC packed cell transfusion and platelet concentrate administration. Following this, the patient’s condition improved. The patient’s kidney function restored and the pulmonary oedema reduced. Overall the patient, remained in the hospital for about 4 weeks, and the tracheostomy tube remained in position up until 9 weeks following discharge from the hospital (ARDS Training 2010). Case Report and Methods Care priorities are essentially required for patients affected with ARDS. It is important to note that the pulmonary function deterioration may worsen the condition of the patient in general as it can lead to multi-organ failure. Hence, efforts should be made by the nurse to improve delivery of oxygen to the lungs so that the functioning of various systems may not deteriorate through hypoxemia and poor oxygen perfusion (BMJ 2011). Efforts should be initiated to protect the airways and maintain their function. The main objectives of using mechanical ventilation in this patient are four fold. The first patient oriented goal would be to achieve adequate signs of perfusion. This could be monitored through pulse oximetry readings which should be above 90%. If the level falls below 90% it suggests that the perfusion would not be adequate. Secondly, the patient’s arterial blood gas analysis should show normal baseline limits, and the patient would be closely monitored through ABG analysis. Thirdly, the patient should be able to breathe normally without any aid or unnecessary fatigue of the muscles of respiration or any accessory muscles of respiration. Both oxygenation and ventilation need to be taken into consideration. The HOB elevation of 30 degrees needs to be maintained. By elevating the HOB, the chances of aspiration would be reduced and the lung expansion would be encouraged. The last objective would be to ensure that tissue perfusion is adequate, and to monitor the same, changes in the ECG, cardiac rhythm and conduction defects should be noted. When hypoxia occurs, dysrhythmias may develop resulting in mortalities, and often careful monitoring for dysrhythmias is essential to ensure that the hypoxia is not life-threatening. In general, the goal of treatment should aim to use low tidal volumes, ensuing that the end inspiratory plateau pressure is reduced (Pearson Education 2010). In most instances, the cause of ARDS is due to lung injury that may be direct or due to indirect mechanisms. The direct mechanism works by directly entering the lungs and causing damage, whereas the indirect mechanisms damage is initiated by the respective factor gaining an entry to the lung through the blood stream. The direct routes include reaching the lungs through airways or from trauma to the chest wall. These include aspiration of gastric contents, pneumonia, inhalation of smoke, drowning, radiation injury, post-surgical, post-lung transplant, pulmonary embolism, etc. Indirect mechanisms include sepsis, trauma, pancreatitis, burns, recreational drug abuse, DIC and shock. When the patient is affected with ARDS, the alveolar cells present in the alveolar wall and the capillaries are injured due to which the direct or indirect mechanisms of injury get activated. When the alveolar capillary membrane is injured, fluid tends to accumulate into the lungs which seriously affects with the exchange of gases in the lungs. Indirect lung injury has been noted to be the most common cause of ARDS. A chain reaction that sets off arising from inflammation, and blood cells combine with various vasoactive agents such as cytokines and chemokines, and initiate the inflammatory process. In this patient, the injuries mechanism arises from indirect injury caused from serious infections caused by bacteria (Gallagher 2009). Sepsis and infections can result in internal multi-organ injury and multi-organ failure. When the patient develops ARDS, respiratory failure can develop. The lung receives the blood from various parts of the body, and cytokines and chemokines may be deposited in the lung tissue. The alveoli-capillary mechanism may be damaged from various substances, resulting in the alveoli-capillary membrane becoming leaky. The alveoli tend to get flooded with the inflammatory fluid due to which oxygenation and perfusion is reduced and the patient develops shortness of breath and respiratory failure. The surfactant present in the lung is lost, due to which the alveoli gets destabilised. The lungs then tend to collapse and breathing becomes very difficult (Gallagher 2009). ARDS may be caused by a range of microorganisms, including bacteria, and viruses. Bacterial causes are more common in the developing nation, and often due to overcrowding and poor living conditions, the bacteria tend to be highly virulent and resistant to a majority of antibiotics. Several viruses that can result in the development of pneumonia can also be related to ARDS. ARDS can also be related to H1N1 influenza that may develop during epidemics and result in severe respiratory distress. In this instance, the 38-year old female patient has developed ARDS from sepsis (ARDS Training 2010). Gallagher (2009) has considered the progress of ARDS to be divided into 3 phases, including acute exudative phase, proliferative phase and fibrotic phase. In the acute exudative phase, there would be damage to the alveolar capillary mechanism and flooding of the alveoli with a proteinous fluid. The surfactant is then inactivated due to which the alveoli tend to collapse. The patient develops hypoxemia and this would not get relieved with oxygen supplementation. The second phase is the proliferative phase is characterised by resolution of the acute condition and repair of the lung, such that the patient may either fully recover or move into the fibrotic phase. In the fibrotic phase (third phase), the normal lung structure is replaced by fibrous tissue due to which progressive vascular occlusion and pulmonary hypertension develops. Such patients require long-term mechanical ventilation with oxygen supplementation. Results and Discussion It has been noted that though the mortality of ARDS is high, it has certainly improve over the last few years as beneficial evidences have been found related to the use of mechanical ventilation and effective nursing care to improve outcomes. Besides, a lot has been understood from the pathophysiology of the condition and the inflammatory process involved. Currently, a lot of research is being conducted in the area of genetic research and understanding the role of genes and genetic mutations in the development of the condition, although the same is still in the infancy stages. Currently, no specific genetic association has been understood, however, even when 2 patients have the same characteristics and develop the same disorder, one may suffer from ARDS whilst the other may not, and efforts are being made to understand if any genetic explanation may be present (ARDS Training 2010) On the other hand, life-saving mechanical ventilation provided to the patient as may not be holistic care for the patient or effective treatment, but sometimes cause further damage to the already diseased lungs. Over time, ventilator-induced damage may worsen and result in more permanent damage (such as fibrosis) (Quick 2011). An NIH Study in 2000 found that when the ARDS were given smaller ventilator breaths, the chances of survival were higher, and if the breath was made large, there were chances of the inflammation of the lungs worsening. However, in general, the value of the PEEP for an individual patient needs to be carefully determined (ARDS Training 2010). The PEEP should be carefully titrated with the partial pressure of inspired oxygen. Even though higher PEEP levels does not reduce the mortality rate, higher levels of PEEP does ensure safety and improve the level of oxygen perfusion in the patients. When the hypoxemia levels are higher, the PEEP levels can be increased to benefit the patient (BMJ 2011). Another finding being noted is that early removal of sedation is certainly beneficial for the patient and helps reduce the chances of pneumonia through aspiration (ARDS Training 2010). Sedation is mainly used to help reduce the patient-ventilator dyssynchrony and often different sedation protocols are being used to help guide the level of sedation needed. In case there is difficulty in oxygenation, heavy sedation has been recommended, and further, paralytic drugs are being suggested to help reduce the dyssynchrony. The scale used on Rita was the Richmond agitation sedation scale or RASS, though other such as Riker or Ramsey scale can also be utilised (BMJ 2011). Having a Head of bed (HOB) elevation angle of 30 to 45 degrees would also be beneficial. Prone positioning of the patient can help improve the oxygenation but does not affect the mortality rates. In a study, it was noted that prone positioning of patients with severe ARDS helped to reduce the mortality rates, when retrospectively analysed (Gallagher 2009). However, in general there are certain complications that may be present with prone positioning including oedema of the face, bed sores, dislodging catheters or tubes, etc (BMJ 2011). An adequate but a conservative fluid administrative strategy in the ICU helps to reduce the time spend on the mechanical ventilator, and in total helps reduce the time actually spent in the ICU by the patient, as it helps manage the excessive fluids present in the lungs (ARDS Training 2010). The patient’s fluid balance has to be maintained at a neutral level of very slightly negative. However, symptoms of shock should not be present. The ideal goal is to ensure that the pulmonary artery occlusion pressure (PAOP) is below 8 and the central venous pressure (CVP) is below 4. When the fluid restrictions are maintained to a reasonable level, the pulmonary microvasculature pressure would reduce, thus effectively reducing lung oedema and lowering the chances of mortality from ARDS (BMJ 2011). If the chances of profound refractory hypoxemia are high and other measures have failed, extracorporeal membrane oxygenation (ECMO) may be administered as it helps to improve outcomes in ARDS adult patient (Sadahiro et al 2012). ECMO is indicated so as to improve the functioning of the cardiopulmonary system and if the partial pressure of oxygen (PaO2) has fallen to 40 mm of Hg (NIH NHBLI ECMO Study 2007 - Alatassi 2012). However, it should be utilised only in the case mechanical ventilation is provided within 14 days and in this case, Rita received ECMO on the 10th day following ventilation. Before ECMO was initiated, the cardiopulmonary function of Rita was not improving (Brodie and Bacchetta 2011). Conclusion ARDS is one of the challenging condition that may arise from several respiratory and non-respiratory causes and responsible for mortality. About 50% of the patients suffering from ARDS developed mortalities. Often the patients require long duration of care ranging 4 to 8 weeks (Hey 2003). Besides, the chances of complications developing in such patients are very high. Traditional methods used previously have failed several times but newer techniques that take evidence-based protocols into consideration have shown effective outcomes in managing a rather challenging condition (Laird 2011). Nursing care should be administered aggressively and efforts should be made to include psychosocial aspects in care. Sedation is helpful, but efforts should be made to use it as a protocol only if clearly indicated. Antibiotics, supportive care and prone positioning is also essential as part of the treatment for ARDS Management through a mechanical ventilator. ECMO therapy is needed in case mechanical ventilation fails to improve the partial pressure of oxygen and the cardiopulmonary functioning (Sandham 2012). One of the most important factors that can be beneficial to such a patient is collaborative roles between the intensive care nurse and the intensive care specialist to clinically evaluate the patient and develop suitable management protocols (Austin CC 2009). Bibliography Alatassi, A. 2012. ECMO and Critical Care. [online], Available: http://www.google.co.in/url?sa=t&rct=j&q=nih%20nhbli%20ecmo&source=web&cd=5&ved=0CFsQFjAE&url=http%3A%2F%2Fwww.rmsolutions.net%2Frmfiles%2FSHA21%2F013003.pdf&ei=MUbCT6rAOMisrAfS47C4CQ&usg=AFQjCNG775PE2POor_BmlcBcVGntOS6sTQ ART Training. 2010. ARDS. [online], Available: http://www.thoracic.org/education/breathing-in-america/resources/chapter-2-acute-respiratory-distress-syndrome.pdf Austin CC 2009. Mechanical ventilation Case studies. 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[online], Available: http://www.ucsfbenioffchildrens.org/pdf/manuals/12_ECMO.pdf Appendix 1 (~ 200 words) Clinical Scenario: Mrs. Rita James, 38 year old female patient (married with 2 children), who weighted 75 kg, 5’ 9” height, admitted following a 2nd day of history of severe backache, and on the 1st day of development of breathlessness and shortness of breath. Findings: The partial pressure of oxygen (PO2) was 67% on the first day and Partial Pressure of carbon dioxide was 44 mm Hg. The pH was 7.5, respiratory rate of 30 breathes/minute with Blood pressure of 80/60 mm Hg. Bilateral lung infiltrates was noticed on the chest X-ray and Cardio echography demonstrated no evidence of rise in left atria pressure (ruling out cardiac cause). GCS of 13 to 15 was present at the time of admission. Initially, the Partial pressure oxygen/carbon dioxide ratio was 108 mm Hg which increased to 162 mm hg within 24 hours after admission, and the PEEP settings were kept 10 cm H2O during ventilation. Diagnosis: A diagnosis of ARDS was made based on acute respiratory symptoms, below 200 mm Hg of pO2/pCO2 ration, Chest X-ray findings and lack of cardiogenic cause. Drugs: Patient was given IV sedatives (midazolam of 4 mg/hr), neuromuscular blocker (cisatracurium of 30 mg/hr) and analgesic agent (morphine of 3 mg/hr). Read More