[GeoStL] Re: (No To: geocaching@freelists.org
- From: "Jim Bensman" <jbensman1@xxxxxxxxxxx>
- To: <geocaching@xxxxxxxxxxxxx>
- Date: Wed, 16 Apr 2003 17:18:44 -0500
-
> Laura has now developed pneumonia and adult
> respiratory
> distress syndrome.
Actually it is Acute Respiratory Distress Syndrome. It is what my Dad died
of back in November. This is very serious. Only 60% survive and full
recovery can take over a year. However, 10 years ago no one survived ARDS.
Today they have new ways to treat it. If you survive it, you have to have
lots of therapy so you can walk again. There are lots of up and downs
dealing with it. It is very rough and people can use lots of support.
Here is some info I had from when my Dad had it.
WHAT IS ARDS?
Acute Respiratory Distress Syndrome (ARDS):
Acute Respiratory Distress Syndrome (ARDS) is an acute, severe injury to
most or all of both lungs. Patients with ARDS experience severe shortness of
breath and often require mechanical ventilation (life support) because of
respiratory failure. ARDS is not a specific disease; instead, it is a type
of severe, acute lung dysfunction that is associated with a variety of
diseases, such as pneumonia, shock, sepsis (a severe infection in the body)
and trauma. ARDS can be confused with congestive heart failure, which is
another common condition that can also cause acute respiratory distress. The
term Acute Lung Injury "ALI" is sometimes used in the same setting as ARDS,
but also includes less severe instances of generalized, acute lung injury.
UNDERSTANDING ARDS
To understand ARDS, it is important to review how the lungs work. Air, which
contains oxygen, is inhaled through the nose and mouth, and passes into the
windpipe (trachea). From the trachea, air flows through tubes called bronchi
into microscopic air sacs called alveoli. Very small blood vessels
(capillaries) are imbedded in the walls of these air sacs. Oxygen passes
through the thin walls of the alveoli into the bloodstream. Carbon dioxide,
a waste product of cellular function throughout the body, passes from the
bloodstream into the alveoli and then is exhaled.[Image]
At the onset of ARDS, lung injury may first appear in one lung, but then
quickly spreads to affect most of both lungs. When alveoli are damaged, some
collapse and lose their ability to receive oxygen. With some alveoli
collapsed and others filled by fluid, it becomes difficult for the lungs to
absorb oxygen and get rid of carbon dioxide. Within one or two days,
progressive interference with gas exchange can bring about respiratory
failure requiring mechanical ventilation.As the injury continues over the
next several days, the lungs, fill with inflammatory cells derived from
circulating blood and with regenerating lung tissue. Fibrosis (formation of
scar tissue) begins after about 10 days and cam become quite extensive by
the third week after onset of injury. Excessive fibrosis further interferes
with the exchange of oxygen and carbon dioxide. The sequential stages of
ARDS are described in further detail below.
WHAT CAUSES ARDS?
The cause of ARDS is not well known. Current scientific information supports
several theories about its development, but the precise reason ARDS occurs
remains unknown. What is known, however, is that ARDS can come about by
either of two basic mechanisms.
The first is a direct physical or toxic injury to the lungs. Examples
include inhalation of vomited stomach contents (aspiration), smoke or other
toxic fumes, and a severe 'bruising' of the lungs that usually occurs after
a severe blow to the chest.
The second mechanism is more common, but less understood. This is an
indirect, blood-born injury to the lungs. When a person is very sick or the
body is severely injured, some chemical signals are released into the
bloodstream. These signals reach the lung, and the lung reacts by becoming
inflamed, thus causing lung failure. Examples of this type of indirect lung
injury include the presence of severe infection (sepsis) and severe injury
(trauma) - the two most common factors in ARDS cases. Other examples are
severe bleeding (resulting in massive blood transfusions), severe
inflammation of the pancreas (pancreatitis) and some types of drug
overdoses.
Not everyone who has these problems, however, develops ARDS, which is
fortunate, since all of the above problems are common. There are no easy
answers as to why some patients with sepsis or trauma develop ARDS and
others do not.
Studies have identified that recent cigarette smoking and chronic alcohol
abuse may be associated with ARDS, but these actions are not considered to
be causative factors. The presence of other lung diseases such as asthma,
emphysema, chronic bronchitis or lung cancer, does not seem to be a factor
in causing ARDS, although these may complicate the course of the syndrome.
No one can predict with any certainty who will get ARDS and who will escape
it. This unpredictable nature makes ARDS a complication of other illnesses
that may be serious enough by themselves.
THE STAGES OF ARDS
ARDS has generally been characterized into three stages. In full-blown
cases, these three stages unfold sequentially over a period of several weeks
to several months.
1 Exudative stage: Characterized by accumulation in the alveoli of excessive
fluid, protein and inflammatory cells that have entered the air spaces from
the alveolar capillaries. The exudative phase unfolds over the first 2 to 4
days after onset of lung injury.
2 Fibroproliferative (or proliferative) stage: Connective tissue and other
structural elements in the lungs proliferate in response to the initial
injury. Under a microscope, lung tissue appears densely cellular. Also, at
this stage, there is a danger of pneumonia sepsis and rupture of the lungs
causing leakage of air into surrounding areas.
3 Resolution and Recovery: During this stage, the lung reorganizes and
recovers. Lung function may continue to improve for as long as 6-12 months
and sometimes longer, depending on the precipitating condition and severity
of the injury. It is important to remember that there may be and often are
different levels of pulmonary recovery amongst individuals who suffer from
ARDS.
Some experts recognize a fourth phase of ARDS. This is the period longer
than six to twelve months after onset, when some patients experience
continued health problems caused by the acute illness. These problems may
include cough, limited exercise tolerance and fatigue. Others experience
anxiety, depression and flashback memories of their critical illness, which
are very similar to post-traumatic stress disorder. This fourth phase is
incompletely characterized, and is very much in need of research.
ARDS TREATMENT
Treatment primarily involves supportive care in an intensive care unit
(ICU), including use of a mechanical ventilator (vent) and supplemental
oxygen. The goal of mechanical ventilation is to support the patient's
breathing during the time needed for the patient's lungs to heal. Good
progress has been made recently in improving the use of ventilators. For the
most recent information regarding lower tidal volumes used in ventilation
you will want to discuss with your physician an article titled, "Ventilation
with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for
Acute Lung Injury and the Acute Respiratory Distress Syndrome" which was
provided by the ARDSNetwork. This article was published in the New England
Journal of Medicine in the May 4, 2000 issue and you may find this journal
in your hospital library. Using this technique has shown a decrease in
mortality.
ARDS patients frequently receive medications to reduce anxiety and
discomfort and help conserve energy. Sometimes, these medications make
patients very sleepy.
The use of paralytic drugs has been substantially reduced in recent years.
Only a small percentage of ARDS patients need this treatment. The use of the
many adjuncts to ARDS management are tailored to the individuals and depend
on severity of illness and other factors.
Medications are used to reverse the underlying condition if possible, to
prevent and treat complications of critical illness, and to alleviate
patient distress, such as pain, air hunger, anxiety and severe confusional
states. Antibiotics are commonly used to treat confirmed or suspected
infections. Vasopressors (""pressors"") such as dopamine or Neosynephrine
may be needed to maintain adequate blood pressure. Pain relievers such as
morphine and fentanyl and anti-anxiety drugs such as Ativan or Versed are
usually required to improve patient tolerance of mechanical ventilation.
Other medications may be used to prevent bleeding from the stomach or to
reduce the risk of blood clot formation in the veins of the legs or arms.
After the first 2 or 3 days, patient nutrition is resumed, if possible.
Until the patient can eat again by mouth, food is given in liquid form into
a central vein (total parenteral nutrition ""TPN"") or into the stomach or
intestine through a feeding tube (total enteral nutrition ""TEN"") If liquid
feeding is required for longer than one or two weeks, a surgical procedure
may be performed to place a tube through the abdominal wall directly into
the stomach or intestine (""G-tube"", ""J-tube"", or ""PEG"").
MORE ABOUT VENTILATORS:
A mechanical ventilator delivers breaths of oxygen-enriched air to the body
and removes breaths of carbon dioxide produced by the body, to help the body
maintain enough oxygen in the bloodstream while patients recover from ARDS
and their other injury(ies) or illness(es). A ventilator can breathe
completely for a patient or assist a patient's own breathing. The 'vent'
delivers breaths through an artificial airway or endotracheal tube. Since it
passes between the vocal cords, the tube interferes with the patient's
ability to speak. Positive end expiratory pressure (PEEP) is a special
setting on the ventilator that keeps the lungs expanded to help get oxygen
from the lungs into the bloodstream. Another important setting is tidal
volume control, which measures the amount of air used for inflating the
lungs. Usually the tube is inserted through the mouth or nose. Sometimes,
tracheostomy is performed (an opening is cut through the neck into the
trachea and the ventilation tube is inserted through this opening), ensuring
a safe airway. Many patients get tracheostomies to avoid tracheal injury
from an orotracheal or nasotracheal tube. Although the timing and necessity
of tracheostomy for this purpose are controversial, oftentimes it is the
practice to undergo tracheostomy after several weeks on the vent if it
appears that the patient will require long-term ventilation.
A decision to proceed with a tracheostomy is not an indication of a
worsening of the patient's condition, but rather that mechanical ventilation
is not being optimized by other means. A tracheostomy might afford the
patient a better pattern of breathing, hence a better possibility of
surviving ARDS.
WHAT TO EXPECT
The seriousness and unpredictability of ARDS can emotionally devastate
patients, family, friends, as well as doctors and nurses, especially since
very few cases of ARDS are alike. Some patients get better quickly within
several days, and others take weeks or months to improve. Some patients have
no complications and others seem to develop every possible complication of
ARDS. Finally, some victims die quickly, while others die after a long and
trying illness.
While ARDS is a very serious syndrome, people can and do survive! It is
important family and friends of the patient remain hopeful, and seek
guidance from others, including ARDS survivors, families and friends of
survivors.
The course of events after ARDS has developed is determined, in part, by the
degree of abnormality in lung function and by the illness or injury that led
to the development of ARDS. If the underlying medical condition(s)
stabilize(s) and no new complications develop, the lungs may begin to heal,
allowing the patient to breathe more on his/her own. In about one third of
ARDS cases, the ventilator may be removed within a week. In another third of
ARDS cases, the underlying conditions are so severe that even treatment is
unable to reverse the abnormalities. Such patients may have or develop,
progressive or irreversible damage to other vital organs. Sometimes the
healing process is further compromised by chronic illnesses or advanced age.
Although intensive medical care is sometimes able to prolong survival by a
few days, such patients often die within the first week. Those who survive
the first week, but whose ARDS has not yet improved, usually remain on the
'vent' for an average of 2-4 weeks, though it could be significantly longer.
Even upon satisfactory response to treatment of the underlying conditions, a
small number of patients have persistent inflammation in the lung(s) and
seem unable to begin the healing process. The outcome of patients who enter
this chronic stage is dependent on reversing the inflammation and preventing
or treating complications, especially infection. In any case, unusual or
experimental treatments may be considered. About one half of patients with
extreme cases of ARDS get better and leave the hospital, but recovery is
slow and may be incomplete.
ARDS COMPLICATIONS
Each patient's course with ARDS will be an individualized process. The
following are some of the complications which may be encountered:
Barotrauma (injury caused by pressure), or Volutrauma (injury caused by
volume of air used for inflating the lungs.) In ARDS, the lungs are
weakened, making them at risk of a rupture (pneumothorax). This leads to
accumulation of air in the pleural cavity, partially collapsing the lung(s).
A chest tube (sometimes more than one) is inserted to remove the air,
allowing the lung(s) to re-inflate.
Bacterial infections are a common complication of ARDS and contribute to
continued lung injury. Lung infection or pneumonia may be difficult to
diagnose in a patient with ARDS because the chest X-ray is already very
abnormal.
Abnormal organ function may involve the liver, kidney(s), brain, blood or
immune system. Organ dysfunction may be related to the underlying illness,
to treatment, or may occur through the same inflammatory process which
injured the lungs. If kidney failure occurs, the patient is given dialysis
(treatment to remove waste products from the blood by circulating the blood
through a special machine). Liver failure is a difficult problem to treat,
since there is no replacement for the many functions the liver performs.
Ongoing infections, despite appropriate antibiotic therapy, may be due to
dysfunction of the immune system. Patients may become unconscious or
confused when they previously have been alert and oriented due to
dysfunction of the brain or central nervous system.
Blood transfusions or replacement of certain elements of the blood, such as
platelets, which are needed for clotting of the blood, may be required.
Delirium (also sometimes known as ""ICU psychosis""). The process that
injures the lungs in ARDS also often affects brain function. Many
medications, including pain relievers and anti-anxiety drugs, also adversely
affect thought and behavior. As a consequence, many victims of ARDS become
agitated and confused or disoriented after several days, especially as they
reawaken. Severe episodes are called delerium. In this condition, memory and
concentrating ability are impaired and awareness of time and place may be
lost. Many patients experience visual or auditory hallucinations.
Consciousness and confusion typically fluctuate over the course of the day.
For unknown reasons many patients are most agitated and confused in the
evening. Physical restraints and certain medications such as Haldol are used
to protect patients from themselves during periods of severe agitation.
Delirium generally resolves after several days as a patient continues to
recover from ARDS.
SURVIVAL AND MORTALITY
Thousands and thousands of Americans suffer from ARDS each year. Many more
suffer throughout the world. Until the recent past, this devastating
condition was uniformly fatal. However, since ARDS was first described in
1967, steady progress has been made in reducing mortality. Today, as many as
60% of ARDS victims recover to leave the hospital. More than ever before,
survivors are returning to productive and rewarding lives. Medical doctors
and scientists still have more work to do to further improve mortality and
functional independence after recovery.
FAMILY AND FRIEND SUPPORT
Choose the Doctor and Hospital Carefully. Hospitals differ in their ability
to care for patients who require intensive care. The best-equipped regional
referral hospitals have specialized ICUs for patients in severe respiratory
failure. These ICUs are staffed with around the clock and calendar by
doctors, nurses and therapists who are devoted exclusively to the care of
critically ill patients. These hospitals accept patients in transfer by
ground or air ambulance from other, smaller hospitals. Thus, it is important
to consider carefully the most appropriate place for the care of a loved one
in ARDS.
Participate actively in Medical Decision Making. Get to know the doctor in
charge early on. Convey your desire to remain informed and to participate in
medical decision making as appropriate. Many experienced doctors admit that
they work hardest for patients who are closely accompanied by concerned
family members who are constructively engaged in critical care.
Do They Know We're Here? Always gain permission from doctors and nurses
before attempting to interact with an ARDS patient. Many ARDS survivors
attest that even though they were on a 'vent', in a sleep-induced state,
they were, on some level, aware of the people and events around them. Many
family members and practitioners find that triggering the patient's senses
plays an important role in his/her recovery (i.e., talking, bringing in
pictures, playing soothing music, aroma therapy - if conducive to
environment, and touch; such as rubbing lotion on the patient's body).
Dreams: Many ARDS survivors recall vivid dreams, while in the sleep-induced
state. By stimulating the senses the dreams may be based on reality, which
might be helpful. Some dreams can be calming and others frightening. Talk to
your loved one about fun things you did together, laugh with your loved one
about silly things you did. Request that nurses explain to the patient
exactly what they are doing and why, when they clean the 'vent' and perform
other procedures.
Ban Negativity! It is vitally important that family and friends remain
positive in the patient's presence - leave fears and worries at the door.
Conduct all consults with the doctors/nurses away from the patient's
hospital room since patients may sense and be affected by stress dispersed
in their presence. Keep your faith and your hope strong, making sure that
everybody is encouraging and hopeful while with your loved one.However, it
is also important to be realistic. The mortality rate of ARDS has been
reduced in recent years but a significant number of ARDS patients succumb to
the syndrome.
Prepare to Tell Them. Start a journal. ARDS survivors have a great need to
know every detail of what happened while they were asleep. All family
members can contribute. A separate journal of 'good things' that are
happening in each person's life can also be used to read back to the patient
when he/she shows signs of alertness.
Prepare Yourself Daily. Prepare yourself for setbacks. ARDS is a roller
coaster ride. Like the patient, it is normal for family and friends to have
both good and bad days. Concentrate on the steps taken forward and view the
steps backwards as hurdles that can be overcome.
Take care of yourself. While a family member or close friend requires
intensive care, be sure to get enough sleep. Eat well. Attend to the basic
and emotional needs of others in the family. Preserve yourself for a
prolonged period of recovery when your critically ill love one will
especially need your strength and support.
A WORD ABOUT TERMINAL WITHDRAWAL OF LIFE SUPPORT.
Despite the best effort of the best doctors, nurses and family members,
approximately 40% of ARDS victims succumb to their acute illness. In most
instances, death can be anticipated. The patient does not heal from acute
lung injury. Multiple organ failure may ensue. Sepsis may becomes refractory
to antibiotic therapy. The brain may be irreversibly damaged by stroke or
other injury. Today, terminal withdrawal is a legal and medically
appropriate alternative to indefinite intensive care for some patients who
cannot recover from ARDS. By this approach, intensive efforts to forestall
death are replaced by comfort care aimed at allowing a peaceful, dignified
death. At some point, either you or the doctor may raise the question as to
whether continuation of life support best serves the wishes and interests of
the patient. Frank, open discussions should follow focused on the question:
""what would the patient want us to do now?"" In search for answers to that
difficult question, turn first to written documents such as living wills and
medical advanced directives that the person may have written. Consider also
conversations they may have had with others about continuation of life
support. Engage close family members in these discussions. Many hospitals
also have Ethics Committees to assist families and care givers in
considering difficult decisions. Hospital chaplains or other members of the
clergy can be helpful as well.
RESEARCH ON ARDS:
Clinical and laboratory scientists around the world are engaged in research
aimed at improving the survival and functional recovery of patients who are
victimized by ARDS. Family members of patients in ARDS and survivors can
support the research effort by considering carefully requests to participate
in clinical research trials and requests for information. Some may wish to
contribute money to the research effort as well.
FOR MORE INFORMATION:
Please visit the web site of ARDS Support Center, Inc. at
http://www.ards.org (This site includes articles, FAQs, memorials, stories
and journals, links, and much more.)
> -----Original Message-----
> From: geocaching-bounce@xxxxxxxxxxxxx
> [mailto:geocaching-bounce@xxxxxxxxxxxxx]On Behalf Of Dan Henke
> Sent: Wednesday, April 16, 2003 3:14 PM
> To: undisclosed-recipients:
> Subject: [GeoStL] Re: (No To: geocaching@xxxxxxxxxxxxx
>
>
> -
>
> She will be in my prayers along with her husband and
> the new baby.....Thanks for keeping us informed
> Barbara...
>
> Dan (Thunder)
>
> --- Barbara Hunt <barbarastl@xxxxxxxxxxx> wrote:
> > -
> >
> > As you know, Laura (who you know as "purple") had
> > her
> > first baby on April 2. Right now, she's in
> > Barnes-Jewish
> > hospital in St. Louis in serious condition. Her
> > family has
> > requested prayers.
> >
> > After returning home from having the baby, her
> > C-section
> > incision site got much worse, then she developed an
> > abcess
> > and a high fever. By the time she returned to the
> > hospital
> > last week she had septicemia that would not respond
> > to
> > antibiotics.
> >
> > Laura has now developed pneumonia and adult
> > respiratory
> > distress syndrome. She is on a respirator in
> > intensive
> > care. Antibiotics are not helping so far, but she IS
> >
> > receiving the best care possible. Barnes-Jewish is
> > internationally known for excellent respiratory
> > care.
> >
> > Pray, if that's what you do. If you do something
> > else,
> > please do that.
> >
> >
> >
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