k.

ARDS
I.

Pathophysiology
In ARDS, pulmonary or systemic inflammation leads to release of cytokines
and other proinflammatory molecules. The cytokines activate alveolar
macrophages and recruit neutrophils to the lungs, which in turn release
leukotrienes, oxidants, platelet-activating factor, and proteases. These
substances damage capillary endothelium and alveolar epithelium, disrupting
the barriers between capillaries and airspaces. Edema fluid, protein, and
cellular debris flood the airspaces and interstitium, causing disruption of
surfactant, airspace collapse, ventilation-perfusion mismatch, shunting, and
pulmonary hypertension. The airspace collapse more commonly occurs in
dependent lung zones

II.

Causes
Causes of ARDS may involve direct lung injury (eg, pneumonia, acid
aspiration) or indirect lung injury (eg, sepsis, pancreatitis, massive blood
transfusion, nonthoracic trauma). Sepsis and pneumonia account for about
60% of cases.Assessment
Assessment
Acute hypoxemia may cause dyspnea, restlessness, and anxiety. Signs
include confusion or alteration of consciousness, cyanosis, tachypnea,
tachycardia, and diaphoresis. Cardiac arrhythmia and coma can result. Airway
closure causes crackles, detected during chest auscultation; the crackles are
typically diffuse but sometimes worse at the lung bases. Jugular venous
distention occurs with high levels of positive end-expiratory pressure (PEEP)
or right ventricular failure.
Treatment
Mechanical ventilation if saturation is < 90% on high-flow O2

III.

IV.

l. Tension Pneumothorax
I.

Pathophysiology
Tension pneumothorax develops when a lung or chest wall injury is such that it allows air into
the pleural space but not out of it (a one-way valve). As a result, air accumulates and
compresses the lung, eventually shifting the mediastinum, compressing the contralateral lung,
and increasing intrathoracic pressure enough to decrease venous return to the heart, causing
shock

II.

III.

IV.

Causes
Causes include mechanical ventilation (most commonly) and simple
(uncomplicated) pneumothorax with lung injury that fails to seal following
penetrating or blunt chest trauma or failed central venous cannulation.
Assessment
Symptoms and signs initially are dyspnea and pleuritic chest pain. The classic signs of a
tension pneumothorax are deviation of the trachea away from the side with the tension, a
hyper-expanded chest, an increased percussion note and a hyper-expanded chest that moves
little with respiration

Management
Needle decompression followed by tube thoracostomy

Treatment is immediate needle decompression by inserting a large-bore (eg, 14 or 16

gauge) needle into the 2nd intercostal space in the midclavicular line. Air will usually
gush out. Because needle decompression causes a simple pneumothorax, tube
thoracostomy should be done immediately thereafter.