OBJECTIVES: Participants should be better able to: 1. Understand - - PDF document

RESPIRATORY COMPROMISE INSTITUTE - UPDATE

TIMOTHY A. MORRIS, MD

PROFESSOR OF MEDICINE UCSD MEDICAL CENTER SAN DIEGO, CA Timothy A. Morris, MD is a Professor of Medicine and the Clinical Service Chief for the Division of Pulmonary and Critical Care Medicine at University of California San Diego (UCSD) Medical Center, Hillcrest facility. His center was ranked #6 in US hospitals for pulmonary medicine in 2015, and #5 among hospitals whose name does not sound like a condiment. His outpatient, inpatient and ICU practice includes direct care of patients as well as nodding intelligently at house-staff and

• fellows. He is the longstanding Medical Director of the Pulmonary Function Laboratory and the

Department of Respiratory Care, which has been recognized for its quality and leadership by the American Association for Respiratory Care. He drives an electric car, had solar panels on his house and has eaten at least one vegan meal.

• Dr. Morris received his MD degree from Georgetown University School of Medicine in 1987, which,

he keeps reminding his residents, was well after Joseph Priestley discovered oxygen. He trained in internal medicine at Georgetown University Medical Center and received the Dudley P. Jackson Award as the Outstanding Resident for Excellence in Teaching. He did his fellowship in Pulmonary and Critical Care Medicine at UCSD, during which time he was awarded the American Lung Association of California Research Fellowship Grant and the ACCP Young Investigator

• Award. As a faculty member, he has received thirteen annual Outstanding Teaching Awards from

the UCSD Department of Medicine. He is the lead editor of the educational textbook, the Manual of Clinical Problems in Pulmonary Medicine. He served as President of the California Thoracic Society and as a member of numerous steering committees of the ACCP networks. The California Thoracic Society gave him their annual “Outstanding Clinician Award” in 2008.

• Dr. Morris’ NIH-funded research is in the area of pulmonary embolism. He is an author of the

current ACCP Consensus Guidelines on therapy for pulmonary embolism. He was a two-time recipient of the Distinguished Scholar in Thrombosis Award, American College of Chest Physicians for 2003-2007. He received the First Place Award for Best Research Abstract presented at CHEST by the American College of Chest Physicians in 2006. In 2009, he was awarded the “Certificate of Achievement from as the Clinical Expert in Pulmonary Embolism” by The American Thoracic Society and The CHEST Foundation: Award in Venous Thromboembolism by The American College of Chest Physicians. He also received the “Very Tall Pulmonary Doctor” certificate, the “Most Interesting Head Injury Story” award, the coveted “Most Italicized Words in a Paragraph Award” and the “Nobody Ever Reads This Far Into a Biography” award.

• Dr. Morris has two children, both of whom are in college. He constantly embarrasses them.

OBJECTIVES:

Participants should be better able to:

• 1. Understand the definition of respiratory compromise and the impact of respiratory

compromise on outcomes of hospitalized patients;

• 2. Understand the different mechanisms by which patients may progress from stability to

respiratory compromise to respiratory failure;

• 3. Define five categories of respiratory compromise and understand the mechanisms of

deterioration within each category.

T H U R S D A Y , M A R C H 3 , 2 0 1 6 1 0 :3 0 A M

3/8/2016 1

Respiratory Compromise

Timothy A. Morris, MD FCCP President, National Association for Medical Direction of Respiratory Care Clinical Service Chief, Division of Pulmonary, Critical Care Medicine and Sleep Medical Director of Respiratory Care and Pulmonary Function Laboratory University of California, San Diego

• Dr. Morris has declared no

conflicts of interest related to the content of his presentation.

3/8/2016 2

Conflicts of Interest

• None
• 1. What percentage of in-hospital

deaths are associated with respiratory conditions?

• A. 0-5%
• B. >5% - 10%
• C. >10% - 15%
• D. >15% - 20%
• E. >20% - 25%
• F. >25%

3/8/2016 3

• 1. What percentage of in-hospital

deaths are associated with respiratory conditions?

• A. 0-5%
• B. >5% - 10%
• C. >10% - 15%
• D. >1>20% - 25%
• E. >20% - 25%
• F. >25%

A. B. C. D. E. F.

0% 0% 48% 27% 18% 6%

• 2. The in-hospital mortality of

patients admitted with COPD is?

• A. 0-5%
• B. >5% - 10%
• C. >10% - 15%
• D. >15% - 20%
• E. >20% - 25%
• F. >25%

3/8/2016 4

• 2. The in-hospital mortality of patients

admitted with COPD is?

• A. 0-5%
• B. >5% - 10%
• C. >10% - 15%
• D. >15% - 20%
• E. >20% - 25%
• F. >25%

A. B. C. D. E. F.

0% 12% 19% 19% 19% 31%

• 3. Among in-hospital patients with

pneumococcal pneumonia, which of the following is true:

• A. HCAP has less than half the 30 day mortality of

CAP

• B. HCAP has about the same 30 day mortality as

CAP

• C. HCAP has more than twice the 30 day mortality
• f CAP

3/8/2016 5

• 3. Among in-hospital patients with

pneumococcal pneumonia, which of the following is true:

• A. HCAP has less than half

the 30 day mortality of CAP

• B. HCAP has about the same

30 day mortality as CAP

• C. HCAP has more than twice

the 30 day mortality of CAP

A. B. C.

0% 86% 14%

• 4. Among in-hospital patients with

pneumococcal pneumonia, which of the following is true:

• A. HCAP has less than half the ICU admission

rate of CAP

• B. HCAP has about the same ICU admission rate

as CAP

• C. HCAP has more than twice the ICU admission

rate of CAP

3/8/2016 6

• 4. Among in-hospital patients with

pneumococcal pneumonia, which of the following is true:

• A. HCAP has less than half the

ICU admission rate of CAP

• B. HCAP has about the same

ICU admission rate as CAP

• C. HCAP has more than twice

the ICU admission rate of CAP

A. B. C.

0% 79% 21%

• 5. Pulse oximetry would be least

likely to give an early warning sign

• f respiratory deterioration in which

type of patient?

• A. Obese post-op patient on an opiate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

3/8/2016 7

• 5. Pulse oximetry would be least

likely to give an early warning sign of respiratory deterioration in which type

• f patient?
• A. Obese post-op patient on an
• piate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

A. B. C. D. E.

53% 10% 13% 7% 17%

• 6. Telemetry EKG would be least

likely to give an early warning sign

• f respiratory deterioration in which

type of patient?

• A. Obese post-op patient on an opiate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

3/8/2016 8

• 6. Telemetry EKG would be least

likely to give an early warning sign of respiratory deterioration in which type

• f patient?
• A. Obese post-op patient on an
• piate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

A. B. C. D. E.

30% 30% 20% 10% 10%

• 7. Vital signs q 6 h would be least

likely to give an early warning sign of respiratory deterioration in which type of patient?

• A. Obese post-op patient on an opiate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

3/8/2016 9

• 7. Vital signs q 6 h would be least

likely to give an early warning sign of respiratory deterioration in which type

• f patient?
• A. Obese post-op patient on an
• piate infusion
• B. Bacterial pneumonia
• C. Status asthmaticus
• D. Congestive heart failure
• E. Acute pulmonary embolism

A. B. C. D. E.

43% 19% 19% 8% 11%

Respiratory Compromise

• A state in which there is a high likelihood of

decompensation into respiratory failure or death, but for which specific interventions (enhanced monitoring or therapies) might prevent or mitigate decompensation.

3/8/2016 10

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

3/8/2016 11

In-hospital deaths

1. Le Guen M and Tobin A. Epidemiology of in-hospital mortality in acute patients admitted to a tertiary level hospital. Internal medicine journal. 2016.

Survival of COPD patients in resp failure admitted to ICU

1. Ai-Ping, et al. In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study. Journal/Chest. 128(2)518-524

24.5% in-hospital mortality

3/8/2016 12

Pulmonary embolism as a cause of inpatient death

Baglin et al. J Clin Path 1997

HCAP vs CAP

1. Rello J, Lujan M, Gallego M, Valles J, Belmonte Y, Fontanals D, Diaz E and Lisboa T. Why mortality is increased in health-care- associated pneumonia: lessons from pneumococcal bacteremic pneumonia. Chest. 2010;137:1138-44.

3/8/2016 13

Aspiration Pneumonia in Hospitalized Patients

1. Lanspa, et al. Mortality, morbidity, and disease severity of patients with aspiration pneumonia. Journal/Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2013. 8(2)83-90

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

3/8/2016 14

IDSA/ATS criteria for CAP severity

• Minor criteria

– Respiratory rate ฀30 breaths/min – PaO2/FiO2 ratio ฀250 – Multilobar infiltrates – Confusion/disorientation – Uremia – Leukopenia – Thrombocytopenia – Hypothermia – Hypotension requiring aggressive fluid resuscitation

1. IDSA/ATS Guidelines for CAP in Adults 1. Lanspa, et al. Mortality, morbidity, and disease severity of patients with aspiration pneumonia. Journal/Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2013. 8(2)83-90

IDSA/ATS CAP criteria doesn’t work well for aspiration

3/8/2016 15

Complications in respiratory patients might not be respiratory!

1. Corrales-Medina, et al. Cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality. Journal/Circulation. 2012. 125(6)773-781

CAP inpatients (n = 1343)

Mortality is worse if deterioration does not lead to change in care

1. Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Levi L, Zveibil F, Mandel M, Mnatzaganian G, Goldschmidt N, Ekka-Zohar A, Weiss-Salz I. Survival of critically ill patients hospitalized in and out of intensive care. Crit Care Med. 2007;35(2):449-457.

Mortality

3/8/2016 16

Early intervention is best; but better late than never

1. Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Levi L, Zveibil F, Mandel M, Mnatzaganian G, Goldschmidt N, Ekka-Zohar A, Weiss-Salz I. Survival of critically ill patients hospitalized in and out of intensive care. Crit Care Med. 2007;35(2):449-457.

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

3/8/2016 17

ICU Admission Criteria: Respiratory

• Acute respiratory failure requiring ventilatory support
• Pulmonary emboli with hemodynamic instability
• Patients in an intermediate care unit who are

demonstrating respiratory deterioration

• Need for nursing/respiratory care not available in

lesser care areas such as floor / IMU

• Massive hemoptysis
• Respiratory failure with imminent intubation

1. Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 1999;27:633-638. “Retired” Revision Underway

Factors influencing respiratory failure

• Severity
• Risk

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Stable Right ventricular strain ICU admission criteria Hypotension Shock Cardiopulmonary arrest

Mortality Severity indicators

Progression of severity in acute pulmonary embolism

Uncontrolled pain Alert, pain free ICU admission criteria Delirium Uncontrolled airway Aspiration

Mortality Risk indicators

Progression of risk in opiate anagesia

3/8/2016 19

Severe CAP

1. Sirvent, et al. Predictive factors of mortality in severe community-acquired pneumonia: a model with data on the first 24h of ICU

• admission. Journal/Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias. 2013. 37(5)308-315

Severity scores and mortality

1. Sirvent, et al. Predictive factors of mortality in severe community-acquired pneumonia: a model with data on the first 24h of ICU

• admission. Journal/Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias. 2013. 37(5)308-315

3/8/2016 20

CURB-65

One point each for:

• Confusion of new onset
• Blood Urea nitrogen greater than 19 mg/dL
• Respiratory rate of 30 bpm or greater
• SBP< 90 mmHg systolic or DBP< 60 mmHg
• age 65 or older

1. Lim WS, van der Eerden MM, Laing R, et al. (2003). "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study". Thorax 58 (5): 377–82. doi:10.1136/thorax.58.5.377. PMC 1746657. PMID 12728155.

ICU Admission Criteria: Respiratory

• Acute respiratory failure requiring ventilatory support
• Pulmonary emboli with hemodynamic instability
• Patients in an intermediate care unit who are

demonstrating respiratory deterioration

• Need for nursing/respiratory care not available in

lesser care areas such as floor / IMU

• Massive hemoptysis
• Respiratory failure with imminent intubation

1. Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 1999;27:633-638. “Retired” Revision Underway

3/8/2016 21

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

Rapid Response Criteria

• Any staff member (nurse, physical therapist,

respiratory therapist, physician) is worried about the patient

• Acute change in heart rate <40 or >130 bpm
• Acute change in systolic blood pressure <90 mmHg
• Acute change in respiratory rate <8 or >28 per min
• Acute change in saturation <90 percent despite O2
• Acute change in conscious state
• Acute change in urinary output to <50 ml in 4 hours

Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Changes/EstablishCriteriaforActivatingtheRapidResponseTeam.aspx

3/8/2016 22

RRTs may not change mortality rates

1. Chan, et al. Hospital-wide code rates and mortality before and after implementation of a rapid response team. Journal/JAMA : the journal of the American Medical Association. 2008. 300(21)2506-2513

Effect of RRTs on Mortality

1. Maharaj R, Raffaele I and Wendon J. Rapid response systems: a systematic review and meta-analysis. Critical care (London, England). 2015;19:254.

3/8/2016 23

Effect of RRTs on Mortality

1. Maharaj R, Raffaele I and Wendon J. Rapid response systems: a systematic review and meta-analysis. Critical care (London, England). 2015;19:254.

Rapid Response Criteria

• Any staff member (nurse, physical therapist,

respiratory therapist, physician) is worried about the patient

• Acute change in heart rate <40 or >130 bpm
• Acute change in systolic blood pressure <90 mmHg
• Acute change in respiratory rate <8 or >28 per min
• Acute change in saturation <90 percent despite O2
• Acute change in conscious state
• Acute change in urinary output to <50 ml in 4 hours

Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Changes/EstablishCriteriaforActivatingtheRapidResponseTeam.aspx

3/8/2016 24

Why define “respiratory compromise”?

• Respiratory illness is just another reason for

hospitalization

• The care of patients who are worsening is
• bvious
• Existing “rescue systems” are already adequate

– ICU – Rapid response teams

• My hospital won’t benefit by focusing on

respiratory patients at risk of respiratory failure

Hospital Risk-Adjusted Mortality Rates

1. http://www.medicare.gov/hospitalcompare/compare.html#vwgrph=1&cmprTab=3&cmprID=050077%2C050024%2C050757&cmpr Dist=0.5%2C8.3%2C8.4&dist=25&loc=92103&lat=32.749789&lng=-117.1676501&AspxAutoDetectCookieSupport=1

3/8/2016 25

Effect of defining “pneumonia” to include “resp failure/sepsis”

1. Rothberg MB, Pekow PS, Priya A, Lindenauer PK. Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis. Ann Intern Med. 2014;160(6):380-388.

PNA mortality: excluding resp failure/sepsis PNA mortality: including resp failure/sepsis

Effect of defining “pneumonia” to include “resp failure/sepsis”

1. Rothberg MB, Pekow PS, Priya A, Lindenauer PK. Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis. Ann Intern Med. 2014;160(6):380-388.

PNA mortality: excluding resp failure/sepsis PNA mortality: including resp failure/sepsis High mortality hospitals

3/8/2016 26

Effect of defining “pneumonia” to include “resp failure/sepsis”

1. Rothberg MB, Pekow PS, Priya A, Lindenauer PK. Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis. Ann Intern Med. 2014;160(6):380-388.

PNA mortality: excluding resp failure/sepsis PNA mortality: including resp failure/sepsis Low mortality hospitals

Conclusions

• Respiratory illness hospitalizations can be high risk
• Respiratory patients deteriorate in a variety of ways
• Rescue systems neglect important signals
• Opportunity to benefit patients and hospitals

3/8/2016 27

Respiratory Compromise Institute

• Define “respiratory compromise”
• Categorize subsets of respiratory compromise

– Monitoring – intervention

• Establish coalition of interested parties
• Clinical Advisory Committee
• Implementation

Respiratory Compromise Institute

• Define “respiratory compromise”
• Categorize subsets of respiratory compromise

– Monitoring – intervention

• Establish coalition of interested parties
• Clinical Advisory Committee
• Implementation

3/8/2016 28

Definition

• “Respiratory compromise” is defined as a

state in which there is a high likelihood of decompensation into respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Presumption

• Compromise temporally precedes failure

3/8/2016 29

Respiratory Illness

Stable respiratory illness Respiratory Compromise Respiratory Failure Mortality ICU admission criteria

Mortality from pulmonary embolism

1.

• Douketis. JAMA 1998; 279:458-62

2. Kasper, et al. J Am Coll Cardiol, 1997

3/8/2016 30

Severity: Pulmonary Embolism

Stable RV strain Hypotension Shock Cardiopulmonary arrest

Mortality Severity indicators

ICU admission criteria

Risk: Aspiration Pneumonia

Uncontrolled pain Alert, pain free Delirium Uncontrolled airway Aspiration

Mortality Risk indicators

ICU admission criteria

3/8/2016 31

Presumptions

• Compromise temporally precedes failure
• Respiratory compromises of different

etiologies have important similarities

Presumptions

• Compromise temporally precedes failure
• Respiratory compromises of different

etiologies have important similarities

– Or at least subgroups have similarities

3/8/2016 32

All happy families are alike; each unhappy family is unhappy in its own way.”

― Leo Tolstoy first line of Anna Karenina COPD exacerbation

Stable COPD exacerbation WOB >> reserve; Other complications Hypercarbic respiratory failure

Mortality

ICU admission criteria

Severity indicators

3/8/2016 33

Asthma exacerbation

Mild exacerbation WOB >> reserve; Other complications Respiratory failure

Mortality

ICU admission criteria

Severity indicators

Presumptions

• Compromise temporally precedes failure
• Respiratory compromises of different

etiologies have important similarities

– Or at least subgroups have similarities

• Data can be used to identify discrete clinical

points at which special observation and interventions might be helpful.

3/8/2016 34

Types of respiratory compromise

• Due to Impaired Control of Breathing
• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance
• Due to Hydrostatic Pulmonary Edema
• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

Types of respiratory compromise

• Due to Impaired Control of Breathing

(RCCOB)

• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance
• Due to Hydrostatic Pulmonary Edema
• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

3/8/2016 35

RCCOB

DK 66 yo man with alcoholism

• Day 1

– Admitted agitated and hallucinating – PMH: alcoholism, depression, hypothyroidism – TSH high, T4 low – “unable to stay awake > 20 seconds at at time

CXR Day 1

3/8/2016 36

Day 2

• Exam

– Hypertensive – Sleepy, hard to arouse but responsive – Pulse oximetry 96%

CXR Day 2

3/8/2016 37

Arterial Blood Gases

2 years ago Day 2 With 40% face mask FIO2 50.0 0.21 (RA) 40.0 Art Site Arterial Arterial Arterial pH 7.43 7.16 (L) 7.16 (L) pCO2 39 70 (H) 70 (H) pO2 193 (H) 50 (L) 85 O2 saturation 100 88.1 96

Alveolar gas: room air

• pAO2 = (FiO2 x 713) – paCO2/0.8

= (0.21 x 713) – 70/0.8 = 150 – 87.5 = 62.5

• paO2 = 50
• “A-a gradient” = pAO2 – paO2

= 62.5 - 50 = 12

Normal A-a = (age/4) – 4 = (66/4) – 4 = 16.5 – 4 = 12.5

3/8/2016 38

Alveolar gas: with oxygen

• pAO2 = (FiO2 x 713) – paCO2/0.8

= (0.40 x 713) – 70/0.8 = 285 – 87.5 = 198

CXR Day 2 – after intubation

3/8/2016 39

Arterial Blood Gases after intubation

2 years ago Day 2 After intubation 1 day after intubation FIO2 50.0 0.21 (RA) 40.0 40.0 Art Site Arterial Arterial Arterial Arterial pH 7.43 7.16 (L) 7.40 7.47 (H) pCO2 39 70 (H) 37 37 pO2 193 (H) 50 (L) 85 103 O2 saturation 100 88.1 96 98

RCCOB

• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?

3/8/2016 40

Opportunities?

• Respiratory compromise was due to impaired

control of breathing

• Failure was from increasing severity
• PaCO2, measurement of ventilation, etc. might

have detected the compromise.

• Medical treatment (thyroid hormone replacement)

might have helped.

Types of respiratory compromise

• Due to Impaired Control of Breathing

– Control of airway

• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance
• Due to Hydrostatic Pulmonary Edema
• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

3/8/2016 41

Control of airway

JY: 84 yo man with little medical care at home

• Day 1

– “found down” – Dx’d with sepsis due to cellulitis – Pleasant but not always alert

CXR Day 1

3/8/2016 42

Hospital course

• Day 2-6

– Treatment of cellulitis – Standard inpatient precautions

• Head of bed elevated
• “Aspiration precautions”

Day 7

• Desat to 85% on RA

3/8/2016 43

Questions

• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?

3/8/2016 44

Opportunities?

• Respiratory compromise was due to impaired

control of airway

• Failure was from increased risk.
• A reliable assessment of aspiration risk might

have detected the compromise.

• Heightened aspiration precautions, increased
• bservation, etc. might have helped.

Types of respiratory compromise

• Due to Impaired Control of Breathing
• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance

(RCAW)

• Due to Hydrostatic Pulmonary Edema
• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

3/8/2016 45

RCAW

• “GN”: 24 yo man with bronchiectasis
• Day 1

– admitted with dyspnea, cough and fevers – Rx antibiotics – Called “sepsis” (WBCs, tachypnea, tachycardia)

CXR Day 1

3/8/2016 46

Later on Day 1

• More dyspneic, wheezing
• Working very hard to breath
• Declining mental status, but still breathing hard

CXR later on Day 1

3/8/2016 47

Arterial Blood Gases

Day 1 21:33 Day 1 23:25 FIO2 30.0 Flow Rate 2 Art Site Arterial Arterial pH, Art (T) 7.29 (L) 7.31 (L) pCO2, Art (T) 61 (H) 58 (H) pO2, Art (T) 78 81 O2 Sat, Art (Est) 94.3 95.2

paCO2 and pH

• If it is a respiratory acidosis

– 10 torr paCO2 -> 0.08 pH

• Case 1 (paCO2 = 60, pH = 7.29)

– paCO2 is increased by 20 from normal (40) – Expected pH is decreased by

• Normal - [(20/10) x 0.08]
• 7.4 -

[2 x 0.08]

• 7.4 -

0.016

• 7.24
• The pH change was all respiratory

3/8/2016 48

CXR after intubation Arterial Blood Gases

Day 1 21:33 Day 1 23:25 After intubation Later that day FIO2 30.0 100.0 40.0 Flow Rate 2 Art Site Arterial Arterial Arterial Arterial pH, Art (T) 7.29 (L) 7.31 (L) 7.42 7.32 (L) pCO2, Art (T) 61 (H) 58 (H) 39 48 (H) pO2, Art (T) 78 81 511 (H) 185 (H) O2 Sat, Art (Est) 94.3 95.2 99.9

3/8/2016 49

RCAW

• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?

Opportunities?

• Respiratory compromise was due to increased

airway resistance

• Failure was from increasing severity
• Some indication of the work of breathing might

have detected the compromise.

• Assistance with the work of breathing might have

helped.

3/8/2016 50

Types of respiratory compromise

• Due to Impaired Control of Breathing
• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance
• Due to Hydrostatic Pulmonary Edema

(RCHPE)

• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

RCHPE

SS: 50 yo man with cirrhosis

• Day 1

– admitted with massive GI bleed from esophageal varices – Rx’d TIPS

3/8/2016 51

Hospital Course

• Day 2-3

– ICU, extubated

• Day 4

– Withdrawing

CXR on Day 4

3/8/2016 52

Day 5

• Tachypnea RR=50

CXR Day 5

3/8/2016 53

CXR Day 6 Questions

• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?

3/8/2016 54

Opportunities?

• Respiratory compromise was due to pulmonary

edema (left ventricular failure)

• Failure was from increasing severity
• Markers of lung water (CXRs?) or of gas

exchange (paO2?) might have detected the compromise.

• Diuresis or BiPAP might have helped.

Types of respiratory compromise

• Due to Impaired Control of Breathing
• Due to Parenchymal Lung Disease
• Due to Increase Airway Resistance
• Due to Hydrostatic Pulmonary Edema
• Due to Pulmonary Vascular Disease / Right

Ventricular Failure

3/8/2016 55

PE: Monitor by hemodynamics PE: Screen by PESI score

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Future?

• Compromise temporally precedes failure
• Respiratory compromises of different

etiologies have important similarities

– Or at least subgroups have similarities

• Data will identify discrete clinical points at

which special observation and interventions might be helpful.

Conclusions

• High incidence of respiratory failure and death

among hospitalized patients

• Five general categories of respiratory

compromise, each of which has its own pattern of physiological deterioration.

• Standardized screening and monitoring

practices for patients with similar mechanisms

• f deterioration may enhance the ability to

predict and prevent respiratory failure.

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Thank you!