Question

Alarms in your patient’s room start to sound. In going into the room you find that your patient is in severe respiratory distress despite being on the ventilator. Her current oxygen saturations are 72% however they may be inaccurate due to the use of vasopressors. Her BP is 78/35, HR 118/m and respiratory rate of 26/minute. Your co-workers come in and immediately begin to bag her with the ambu-bag while you notify the physician. Prior to leaving the room, you notice that her chest has uneven expansion and when you listen to her lungs, you hear minimal breath sounds on the right side of her chest.

Answer the following questions:

1. What do you think is going on with this patient? What might have caused this complication?

Answer 1

1.ARDS- PNEUMOTHORAX.

Acute respiratory distress syndrome (ARDS) is defined as a rapidly progressive acute onset respiratory failure (arterial hypoxemia with PO2/FiO2 ratio less than 200 mmHg regardless of PEEP level), with bilateral radiographic infiltrates, without evidence of left atrial hypertension (or pulmonary artery wedge pressure less than 18 mmHg). This complex syndrome, which is characterized by broad clinical presentations, is caused by a variety of insults, such as bacterial or viral pneumonia, non-pulmonary sepsis, major trauma, amniotic fluid embolism, transfusions, aspiration of gastric contents, drug reactions etc., and is associated with high 180-day mortality, approaching 31% in adult patients. Pneumothorax appears as a frequent and potentially fatal complication in patients with ARDS, especially in those who need mechanical ventilation support.

Many factors may precipitate the occurrence of pneumothorax in ARDS, such as the mechanical ventilation settings, the clinical severity of ARDS and the underlying pulmonary pathology (like preexisting emphysema). Furthermore, the incidence of pneumothorax seems to be related to the duration of ARDS, varying from 30% of all patients with early ARDS (up to 1 week) to 46% in intermediate ARDS (between 1 to 2 weeks) and complicating a total of 87% of patients with late ARDS (more than 2 weeks). This increase at the incidence of pneumothorax in late ARDS appears to be related to the lung structural changes occurring over time. It must kept in mind, that diagnostic procedures used in patients with ARDS, such as bronchoalveolar lavage and lung biopsy are accompanied with high risk of pneumothorax development, often with persistent air leaks.