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 UR SD A Y , M A R C H 3 , 2 0 1 6 1 0 : 3 0
AM
3/8/2016
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.
1
3/8/2016
Conflicts of Interest
• None
1. What percentage of in-hospital
deaths are associated with
respiratory conditions?
A.
B.
C.
D.
E.
F.
0-5%
>5% - 10%
>10% - 15%
>15% - 20%
>20% - 25%
>25%
2
3/8/2016
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%
48%
27%
18%
6%
0%
0%
A.
B.
C.
D.
E.
F.
2. The in-hospital mortality of
patients admitted with COPD is?
A.
B.
C.
D.
E.
F.
0-5%
>5% - 10%
>10% - 15%
>15% - 20%
>20% - 25%
>25%
3
3/8/2016
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%
31%
19%
19%
19%
12%
0%
A.
B.
C.
D.
E.
F.
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
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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
86%
14%
0%
A.
B.
C.
C. HCAP has more than twice
the 30 day mortality of CAP
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
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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
79%
21%
0%
A.
B.
C.
C. HCAP has more than twice
the ICU admission rate of
CAP
5. Pulse oximetry would be least
likely to give an early warning sign
of respiratory deterioration in which
type of patient?
A.
B.
C.
D.
E.
Obese post-op patient on an opiate infusion
Bacterial pneumonia
Status asthmaticus
Congestive heart failure
Acute pulmonary embolism
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5. Pulse oximetry would be least
likely to give an early warning sign of
respiratory deterioration in which type
of patient?
53%
A. Obese post-op patient on an
opiate infusion
B. Bacterial pneumonia
C. Status asthmaticus
D. Congestive heart failure
E. Acute pulmonary embolism
17%
13%
10%
A.
B.
7%
C.
D.
E.
6. Telemetry EKG would be least
likely to give an early warning sign
of respiratory deterioration in which
type of patient?
A.
B.
C.
D.
E.
Obese post-op patient on an opiate infusion
Bacterial pneumonia
Status asthmaticus
Congestive heart failure
Acute pulmonary embolism
7
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6. Telemetry EKG would be least
likely to give an early warning sign of
respiratory deterioration in which type
of patient?
30%
A. Obese post-op patient on an
opiate infusion
B. Bacterial pneumonia
C. Status asthmaticus
D. Congestive heart failure
E. Acute pulmonary embolism
30%
20%
10%
A.
B.
C.
10%
D.
E.
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.
B.
C.
D.
E.
Obese post-op patient on an opiate infusion
Bacterial pneumonia
Status asthmaticus
Congestive heart failure
Acute pulmonary embolism
8
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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
43%
19%
19%
11%
8%
A.
B.
C.
D.
E.
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.
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3/8/2016
Why define “respiratory compromise”?
• Respiratory illness is just another reason for
hospitalization
• The care of patients who are worsening is
obvious
• 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
obvious
• 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
10
3/8/2016
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
24.5%
in-hospital
mortality
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
11
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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-careassociated pneumonia: lessons from pneumococcal bacteremic pneumonia. Chest. 2010;137:1138-44.
12
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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
obvious
• 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
13
3/8/2016
IDSA/ATS criteria for CAP severity
• Minor criteria
–
–
–
–
–
–
–
–
–
1.
Respiratory rate 􏰃30 breaths/min
PaO2/FiO2 ratio 􏰃250
Multilobar infiltrates
Confusion/disorientation
Uremia
Leukopenia
Thrombocytopenia
Hypothermia
Hypotension requiring aggressive fluid resuscitation
IDSA/ATS Guidelines for CAP in Adults
IDSA/ATS CAP criteria doesn’t work well for aspiration
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
14
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Complications in respiratory patients
might not be respiratory!
CAP inpatients (n = 1343)
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
Mortality
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.
15
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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
obvious
• 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
16
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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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3/8/2016
Progression of severity in acute
pulmonary embolism
Mortality
ICU admission criteria
Stable
Right ventricular
strain
Hypotension
Shock
Cardiopulmonary
arrest
Severity indicators
Progression of risk in opiate
anagesia
Mortality
ICU admission criteria
Uncontrolled
pain
Alert,
pain free
Delirium
Uncontrolled
airway
Aspiration
Risk indicators
18
3/8/2016
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
19
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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
20
3/8/2016
Why define “respiratory compromise”?
• Respiratory illness is just another reason for
hospitalization
• The care of patients who are worsening is
obvious
• 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
21
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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.
22
3/8/2016
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
23
3/8/2016
Why define “respiratory compromise”?
• Respiratory illness is just another reason for
hospitalization
• The care of patients who are worsening is
obvious
• 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
24
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PNA mortality: including resp failure/sepsis
Effect of defining “pneumonia” to
include “resp failure/sepsis”
PNA mortality: excluding 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: including resp failure/sepsis
Effect of defining “pneumonia” to
include “resp failure/sepsis”
High mortality
hospitals
PNA mortality: excluding 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.
25
3/8/2016
PNA mortality: including resp failure/sepsis
Effect of defining “pneumonia” to
include “resp failure/sepsis”
Low mortality
hospitals
PNA mortality: excluding 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.
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
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3/8/2016
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
27
3/8/2016
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
28
3/8/2016
Respiratory Illness
ICU admission criteria
Mortality
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality from pulmonary embolism
1.
2.
Douketis. JAMA 1998; 279:458-62
Kasper, et al. J Am Coll Cardiol, 1997
29
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Severity: Pulmonary Embolism
Mortality
ICU admission criteria
Stable
RV strain
Hypotension
Shock
Cardiopulmonary
arrest
Severity indicators
Risk: Aspiration Pneumonia
Mortality
ICU admission criteria
Uncontrolled
pain
Alert,
pain free
Delirium
Uncontrolled
airway
Aspiration
Risk indicators
30
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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
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All happy families are alike;
each unhappy family is
unhappy in its own way.”
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Mortality
ICU admission criteria
Stable
COPD exacerbation
WOB >> reserve;
Other complications
Hypercarbic
respiratory failure
Severity indicators
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Asthma exacerbation
Mortality
ICU admission criteria
Mild exacerbation
WOB >> reserve;
Other complications
Respiratory failure
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.
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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
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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
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Day 2
• Exam
– Hypertensive
– Sleepy, hard to arouse but responsive
– Pulse oximetry 96%
CXR Day 2
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Arterial Blood Gases
2 years
ago
FIO2
50.0
Art Site
Arterial
pH
7.43
pCO2
39
pO2
193 (H)
O2 saturation 100
Day 2
0.21 (RA)
Arterial
7.16 (L)
70 (H)
50 (L)
88.1
With 40%
face mask
40.0
Arterial
7.16 (L)
70 (H)
85
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
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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
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Arterial Blood Gases after intubation
2 years
ago
FIO2
50.0
Art Site
Arterial
pH
7.43
pCO2
39
pO2
193 (H)
O2 saturation 100
Day 2
0.21 (RA)
Arterial
7.16 (L)
70 (H)
50 (L)
88.1
After
intubation
40.0
Arterial
7.40
37
85
96
1 day after
intubation
40.0
Arterial
7.47 (H)
37
103
98
RCCOB
• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?
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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
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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
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Hospital course
• Day 2-6
– Treatment of cellulitis
– Standard inpatient precautions
• Head of bed elevated
• “Aspiration precautions”
Day 7
• Desat to 85% on RA
42
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Questions
• Was failure from increasing severity, risk or both?
• What could have detected the compromise?
• What type of intervention might have helped?
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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
observation, 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
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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
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Later on Day 1
• More dyspneic, wheezing
• Working very hard to breath
• Declining mental status, but still breathing hard
CXR later on Day 1
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Arterial Blood Gases
Day 1
21:33
FIO2
Flow Rate
Art Site
pH, Art (T)
pCO2, Art
(T)
pO2, Art (T)
O2 Sat, Art
(Est)
Day 1
23:25
30.0
2
Arterial
7.29 (L)
61 (H)
Arterial
7.31 (L)
58 (H)
78
94.3
81
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
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3/8/2016
CXR after intubation
Arterial Blood Gases
Day 1
21:33
FIO2
Flow Rate
Art Site
pH, Art (T)
pCO2, Art
(T)
pO2, Art (T)
O2 Sat, Art
(Est)
Day 1
23:25
30.0
After
intubation
100.0
Later that
day
40.0
2
Arterial
7.29 (L)
61 (H)
Arterial
7.31 (L)
58 (H)
Arterial
7.42
39
Arterial
7.32 (L)
48 (H)
78
94.3
81
95.2
511 (H)
99.9
185 (H)
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3/8/2016
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.
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3/8/2016
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
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3/8/2016
Hospital Course
• Day 2-3
– ICU, extubated
• Day 4
– Withdrawing
CXR on Day 4
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3/8/2016
Day 5
• Tachypnea RR=50
CXR Day 5
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3/8/2016
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?
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3/8/2016
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
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3/8/2016
PE: Monitor by hemodynamics
PE: Screen by PESI score
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3/8/2016
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
of deterioration may enhance the ability to
predict and prevent respiratory failure.
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3/8/2016
Thank you!
57