WHY FOCUS ON RESPIRATORY COMPROMISE?

Changes in respiratory vital signs that accompany respiratory compromise often precede in-hospital deterioration and are associated with increased mortality due to the high likelihood of decompensation into respiratory insufficiency and failure, as well as respiratory arrest. 1,2,3,4

Many in-hospital declines may be preventable with better respiratory monitoring and early intervention.5,6,7 

Respiratory abnormalities are the most common type of abnormalities prior to ICU admission.8Moreover, inpatients with respiratory insufficiency, arrest and failure originating on the general care floor have higher mortality rates, longer length of stay and ICU stays compared to other patients.9

Therefore, implementing better strategies for prevention, monitoring for and management ofinsufficiency, arrest and failure in patients could lead to improved patient outcomes and decreased costs.

What is respiratory insufficiency?

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What is acute respiratory failure?

Acute respiratory failure refers to the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient. Hypoxic respiratory failure (type 1) is defined as hypoxia without hypercapnia and with an arterial partial pressure of oxygen (PaO2) of <60 mmHg (<8 kPa) on room air at sea level.20 Hypercapnic respiratory failure (type 2) is defined as hypoxia with an arterial partial pressure of carbon dioxide (PaCO2) of >50 mmHg (>6.5 kPa) on room air at sea level.21

What is chronic respiratory failure?

Chronic respiratory failure typically refers to a combination of chronic hypoxemia, hypercapneaand compensatory metabolic alkalosis, resulting in chronically low oxygen levels or chronically high carbon dioxide levels.22,23 The condition is usually caused by chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, and idiopathic interstitial pneumonia.

Respiratory Compromise Often Precedes In-Hospital Deterioration

Research has demonstrated that respiratory dysfunction is a known precursor of many in-hospital adverse events, and its presence prior to the adverse events is associated with a higher rate of mortality.24 Clinical studies evaluating the relationship between abnormal vital sign observations and patient outcome have shown the respiratory parameters are the most predictive of adverse outcome. 2-4, 25-27

Decline of Respiratory Compromise May Be Preventable With Better Monitoring

Multiple clinical studies have evaluated the utility of integrating continuous monitoring of patient respiratory status to increase early identification of respiratory compromise and improve outcome. 7,14

Learn more about each of these studies outlining the importance of continuous monitoring.

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  • 1. Respiratory Compromise Insitute. http://www.respiratorycompromise.org/. 2017

  • 2. Barfod, C., Lauritzen, M. M., Danker, J. K., et al. Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2012;20:28.

  • 3. Buist, M., Bernard, S., Nguyen, T. V., Moore, G., & Anderson, J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004;62(2):137-141.

  • 4. Chaboyer, W., Thalib, L., Foster, M., Ball, C., & Richards, B. Predictors of adverse events in patients after discharge from the intensive care unit. Am J Crit Care. 2008;17(3):255-263; quiz 264.

  • 5. Lee, L. A., Caplan, R. A., Stephens, L. S., et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659-665.

  • 6. Quach, J. L., Downey, A. W., Haase, M., Haase-Fielitz, A., Jones, D., & Bellomo, R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care. 2008;23(3):325-331.

  • 7. Taenzer, A. H., Pyke, J. B., McGrath, S. P., & Blike, G. T. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112(2):282-287.

  • 8. TCTMD. Respiratory Compromise: Recognition and Management in Clinical Settings. https://www.tctmd.com/respiratory-compromise-recognition-management-clinical-settings. 2019.

  • 9. Kelley, S., Agarwal, S., Parikh, N., Erslon, M., & Morris, P. Respiratory Insufficiency, arrest and failure among medical patients on the general care floor. Crit Care Med 2012; (12):1–328.

  • 10. Stedman, T. L. (2008). Stedman's Medical Dictionary for the Health Professions & Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

  • 11. 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.

  • 12. 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.

  • 13. 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.

  • 14. 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.

  • 15. 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.

  • 16. Fichtner, F., Mörer, O; Laudi, S; Weber-Carstens, S; Nothacker, M; Kaisers, U. Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Acute Respiratory Insufficiency. Dtsch Arztebl Int 2018; 115(50): 840-7.

  • 17. Baum, G. Differential diagnosis of chronic respiratory insufficiency. Med Clin North Am. 1973. 57(3):623-635.

  • 18. Vitacca, M. Telemonitoring in patients with chronic respiratory insufficiency: expectations deluded? Thorax. 2016: 71(4):299-301.

  • 19. Goldstone, J.C., Green, M., Moxham, J. Maximum relaxation rate of the diaphragm during weaning from mechanical ventilation. Thorax 1994;49:54–60.

  • 20. Gurka, D.P., Balk, R.A. Acute Respiratory Failure. Critical Care Medicine (Third Edition). Parillo, J.E., Dellinger, R.P. 2008, Pages 773-794 (38).

  • 21. BMJ Best Practice. Acute respiratory failure. https://bestpractice.bmj.com/topics/en-us/853. 2019.

  • 22. ACP Hospitalist. Chronic respiratory failure. https://acphospitalist.org/archives/2011/03/coding.htm. 2019.

  • 23. Matsumoto, M. & Nakazato, M. Clinical applications of ghrelin for chronic respiratory diseases. Methods in Enzymology 2012: 399-407.

  • 24. Considine J. The role of nurses in preventing adverse events related to respiratory dysfunction: literature review. J Adv Nurs 2005; 49(6):624-33.

  • 25. Ljunggren M, Castren M, Nordberg M, et al. The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population. Scand J Trauma Resusc Emerg Med. 2016;24:21.

  • 26. Peberdy MA, Ornato J P, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-792.

  • 27. Vohra HA, Goldsmith IR, Rosin MD, et al. The predictors and outcome of recidivism in cardiac ICUs. Eur J Cardiothorac Surg. 2005;27(3):508-511.

  • 28. Ochroch, E. A., Russell, M. W., Hanson, W. C., 3rd, et al. The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor.Anesth Analg. 2006;102(3):868-875.