Respiratory failure occurs when one of the gas-exchange functions—oxygenation or CO2 elimination—fails.2 In clinical studies evaluating the incidence or impact of respiratory insufficiency, the condition may be defined in a variety of ways, such as: a decrease in respiratory rate, a reduction in oxygen saturation of hemoglobin, or as a change in arterial blood gasses.3,4,5,6,7
Definitions and corresponding terms used to represent respiratory insufficiency in literature vary significantly.
Respiratory insufficiency, sometimes referred to as pulmonary insufficiency, is a condition in which the lungs fail to adequately provide oxygen and/or remove carbon dioxide from the body. 2 In clinical studies evaluating the incidence or impact of respiratory insufficiency, the condition may be defined in a variety of ways, such as: a decrease in respiratory rate, a reduction in oxygen saturation of hemoglobin, or as a change in arterial blood gasses.3,4,5,6,7 Definitions and corresponding terms used to represent respiratory insufficiency in literature vary significantly.
|Cacho 20103||Apnea||Cessation of respiratory activity for 30 or more seconds|
|Overdyk 20075||Bradypnea||Respiratory rate <10 lasting 3 min or more|
SpO2 <90% for > 3 min
|Weingarten 201510||Hypoventilation||Hypoventilation (3 episodes of fewer than 8 breaths per minute), apnea (episode of apnea lasting at least 10 seconds), hypoxemia (3 episodes of SpO2 less than 90%), or pain/sedation mismatch|
|Sun 20156||Hypoxemia||SpO2 values less than 90% for at least 10 minutes|
|Hanna 20054||Respiratory Depression||Respiration rate of less than 8 breaths per minute or SpO2 less than 90%|
The incidence of respiratory insufficiency ranges from 5% to 41% of patients.5,8 This variation is a product of the variation of respiratory insufficiency definitions, as well as the diverse number of patient population and settings utilized in clinical studies investigating respiratory insufficiency.
|Study||Population||Definition||Percentage of Patient Suffering Respiratory Insufficiency|
|Grosse-Sundrup 20128||Post-operative patients||SpO2 < 90%||5%|
|Vaessen 20169||GI procedural sedation||SpO2 < 92 % for < 5 minutes||7.20%|
|Overdyk 20075||Postsurgical PCA||SpO2 <90%) for > 3 min||12%|
|Sun 20156||Postoperative noncardiac surgery||SpO2 < 90% for < 10 minutes||21%|
|Weingarten 201510||Postoperative pain management||3 episodes of < 8 BPM, 0 BPM for >= 10 seconds, 3 episodes of SpO2 < 90%, or pain/sedation mismatch||23.70%|
|Hanna 20054||Postoperative pain management||Respiration rate < 8 BPM or SpO2 < 90%||27%|
|Overdyk 20075||Postsurgical PCA||Respiration rate <10 lasting 3 min or more||41%|
Respiratory failure describes a loss of pulmonary function that results in hypoxemia or hypercarbia.2 Respiratory failure is the most common postoperative pulmonary complication,11 though the incidence rates reported by various clinical studies depend in part on how respiratory failure is defined. In clinical studies, respiratory failure may be defined in several ways; often it is defined as a respiratory condition requiring intervention such as mechanical ventilation or unplanned intubation, or use of naloxone. 12
The incidence of respiratory failure ranges from 0.83% to 6%.12,13 and depends on the definition of respiratory failure and the study population.
|Percentage of patients suffering respiratory failure by definition and patient population11,12,13,14,15,16
|Study||Definition||Percentage of patients suffering respiratory failure|
|Ramachandran 201112||Placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercapnia, or respiratory acidosis within 30 days of the operation.||0.83|
|Alvarez 201514||Placement of an endotracheal tube and mechanical ventilation or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis within 30 days postoperatively.||1.03|
|Hua 201215||Placement of an endotracheal tube and mechanical ventilation or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis within 30 days postoperatively.||2.2|
|Canet 201511||PaO2 <8kPa or SpO2 <90% on room air but responding to mask/nasal supplemental oxygen.||4.2|
|Fischer 201313||Unanticipated intubation during the postoperative period, or failure to wean from mechanical ventilation in 48 hours.||6|
There are several underlying causes of respiratory failure. Often multiple underlying causes act synergistically. A retrospective analysis of 177 patients requiring reintubation among 18,579 surgical patients by Grosse-Sundrup et al. determined that on average 2.5 causes precipitating respiratory failure were reported per patient.8
|Precipitating Cause*||Approximate % of Precipitating Cause|
|Impaired brain function||24|
|Prophylactic preventive measure||6|
|*On an average, 2.5 reasons for respiratory failure were reported per patient|
Incidence of respiratory adverse events in moderate to deep procedural sedation is often underestimated, still reported in published clinical studies17 and its consequences may, even if rarely, lead to death.17
The outcomes pledge program by Medtronic will help you measure the incidence of adverse events in your own setting, with your own clinical team and your own protocols and assess the impact of capnography monitoring on the prevention of such events.
A retrospective review of code blues among 143,581 hospital admissions determined that pulmonary edema is the most common precipitating cause of respiratory arrest.18
|Precipitating Cause*||% of Precipitating Cause|
|*Multiple causes attributed to some arrests|
*On an average, 2.5 reasons for respiratory failure were reported per patient.
1. Respiratory Compromise Institute. http://www.respiratorycompromise.org/. 2017.
2. Stedman, T. L. (2008).Stedman's Medical Dictionary for the Health Professions & Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
3. Cacho, G., Perez-Calle, J. L., Barbado, A., Lledo, J. L., Ojea, R., & Fernandez-Rodriguez, C. M. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig. 2010;102(2):86-89.
4. Hanna, M. H., Elliott, K. M., & Fung, M. Randomized, double-blind study of the analgesic efficacy of morphine-6- glucuronide versus morphine sulfate for postoperative pain in major surgery. Anesthesiology. 2005;102(4):815-821.
5. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia.Anesth Analg. 2007;105(2):412-418.
6. Sun, Z., Sessler, D. I., Dalton, J. E., et al. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg. 2015;121(3):709-715.
7. Weingarten, T. N., Herasevich, V., McGlinch, M. C., et al. Predictors of Delayed Postoperative Respiratory Depression Assessed from Naloxone Administration. Anesth Analg. 2015;121(2):422-429.
8. Grosse-Sundrup, M., Henneman, J. P., Sandberg, W. S., et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012;345:e6329.
9. Vaessen, H., Bruens, E., & Knape, J. Clinical analysis of moderate-to-deep-sedation by nonmedical sedation practitioners in 597 patients undergoing gastrointestinal endoscopy: a retrospective study. Endosc Int Open. 2016;4(5):E564-571.
10. Weingarten, T. N., Jacob, A. K., Njathi, C. W., Wilson, G. A., & Sprung, J. Multimodal Analgesic Protocol and Postanesthesia Respiratory Depression During Phase I Recovery After Total Joint Arthroplasty. Reg Anesth Pain Med. 2015;40(4):330-336.
11. Canet, J., Sabate, S., Mazo, V., et al. Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Eur J Anaesthesiol. 2015;32(7):458-470.
12. Ramachandran, S. K., Nafiu, O. O., Ghaferi, A., Tremper, K. K., Shanks, A., & Kheterpal, S. Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery. Anesthesiology. 2011;115(1):44-53.
13. Fischer, J. P., Shang, E. K., Butler, C. E., et al. Validated model for predicting postoperative respiratory failure: analysis of 1706 abdominal wall reconstructions. Plast Reconstr Surg. 2013;132(5):826e-835e.
14. Alvarez, M. P., Samayoa-Mendez, A. X., Naglak, M. C., Yuschak, J. V., & Murayama, K. M. Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database.Am Surg. 2015;81(8):820-825.
15. Hua, M., Brady, J. E., & Li, G. A scoring system to predict unplanned intubation in patients having undergone major surgical procedures.Anesth Analg. 2012;115(1):88-94.
16. Milgrom, D. P., Njoku, V. C., Fecher, A. M., Kilbane, E. M., & Pitt, H. A. Unplanned intubation: when and why does this deadly complication occur?Surgery. 2013;154(2):376-383.
17. Leslie K, Allen ML, Hessian EC, Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: A prospective cohort study. Br J Anaesth. 2017;118(1):90–9. https://pubmed.ncbi.nlm.nih.gov/28039246/
18. Husband, A., Mercer, I., Detering, K. M., Eastwood, G. M., & Jones, D. A. The epidemiology of respiratory arrests in a teaching hospital. Resuscitation. 2013.
19. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. (2008). Continuous Respiratory Monitoring and a "Smart" Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period.
20. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007;105(2):412-418.