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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 ldquoOutstanding Clinician Awardrdquo in 2008 Dr Morrisrsquo 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 ldquoCertificate of Achievement from as the Clinical Expert in Pulmonary Embolismrdquo by The American Thoracic Society and The CHEST Foundation Award in Venous Thromboembolism by The American College of Chest Physicians He also received the ldquoVery Tall Pulmonary Doctorrdquo certificate the ldquoMost Interesting Head Injury Storyrdquo award the coveted ldquoMost Italicized Words in a Paragraph Awardrdquo and the ldquoNobody Ever Reads This Far Into a Biographyrdquo 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
THURSDAY MARCH 3 2016 1030 AM
382016
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
382016
2
Conflicts of Interest
bull None
1 What percentage of in-hospital
deaths are associated with
respiratory conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
3
1 What percentage of in-hospital
deaths are associated with respiratory
conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt1gt20 - 25
E gt20 - 25
F gt25
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 gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
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
THURSDAY MARCH 3 2016 1030 AM
382016
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
382016
2
Conflicts of Interest
bull None
1 What percentage of in-hospital
deaths are associated with
respiratory conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
3
1 What percentage of in-hospital
deaths are associated with respiratory
conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt1gt20 - 25
E gt20 - 25
F gt25
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 gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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
382016
2
Conflicts of Interest
bull None
1 What percentage of in-hospital
deaths are associated with
respiratory conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
3
1 What percentage of in-hospital
deaths are associated with respiratory
conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt1gt20 - 25
E gt20 - 25
F gt25
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 gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
2
Conflicts of Interest
bull None
1 What percentage of in-hospital
deaths are associated with
respiratory conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
3
1 What percentage of in-hospital
deaths are associated with respiratory
conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt1gt20 - 25
E gt20 - 25
F gt25
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 gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
3
1 What percentage of in-hospital
deaths are associated with respiratory
conditions
A 0-5
B gt5 - 10
C gt10 - 15
D gt1gt20 - 25
E gt20 - 25
F gt25
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 gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
4
2 The in-hospital mortality of patients
admitted with COPD is
A 0-5
B gt5 - 10
C gt10 - 15
D gt15 - 20
E gt20 - 25
F gt25
A B C D E F
0
12
191919
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 of CAP
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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
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
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
7
5 Pulse oximetry 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
A B C D E
53
1013
7
17
6 Telemetry EKG 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
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
8
6 Telemetry EKG 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
A B C D E
30 30
20
1010
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
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
9
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 embolismA B C D E
43
19 19
811
Respiratory Compromise
bull 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
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
10
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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
JournalChest 128(2)518-524
245
in-hospital
mortality
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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 20101371138-44
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
13
Aspiration Pneumonia in Hospitalized Patients
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
14
IDSAATS criteria for CAP severity
bull Minor criteria
ndash Respiratory rate 111309130 breathsmin
ndash PaO2FiO2 ratio 1113091250
ndash Multilobar infiltrates
ndash Confusiondisorientation
ndash Uremia
ndash Leukopenia
ndash Thrombocytopenia
ndash Hypothermia
ndash Hypotension requiring aggressive fluid resuscitation
1 IDSAATS Guidelines for CAP in Adults
1 Lanspa et al Mortality morbidity and disease severity of patients with aspiration pneumonia JournalJournal of hospital medicine
an official publication of the Society of Hospital Medicine 2013 8(2)83-90
IDSAATS CAP criteria doesnrsquot work well for aspiration
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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 JournalCirculation 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
200735(2)449-457
Mo
rta
lity
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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
200735(2)449-457
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
17
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
Factors influencing respiratory failure
bull Severity
bull Risk
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
18
Stable Right ventricular strain
ICU admission criteria
Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
Progression of severity in acute
pulmonary embolism
Uncontrolled pain
Alertpain free
ICU admission criteria
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
Progression of risk in opiate
anagesia
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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 JournalMedicina 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 JournalMedicina intensiva Sociedad Espanola de Medicina Intensiva y Unidades Coronarias 2013 37(5)308-315
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
20
CURB-65
One point each for
bull Confusion of new onset
bull Blood Urea nitrogen greater than 19 mgdL
bull Respiratory rate of 30 bpm or greater
bull SBPlt 90 mmHg systolic or DBPlt 60 mmHg
bull 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) 377ndash82 doi101136thorax585377 PMC 1746657
PMID 12728155
ICU Admission Criteria Respiratory
bull Acute respiratory failure requiring ventilatory support
bull Pulmonary emboli with hemodynamic instability
bull Patients in an intermediate care unit who are
demonstrating respiratory deterioration
bull Need for nursingrespiratory care not available in
lesser care areas such as floor IMU
bull Massive hemoptysis
bull 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 199927633-638 ldquoRetiredrdquo Revision Underway
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
21
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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 JournalJAMA 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) 201519254
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
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) 201519254
Rapid Response Criteria
bull Any staff member (nurse physical therapist
respiratory therapist physician) is worried about
the patient
bull Acute change in heart rate lt40 or gt130 bpm
bull Acute change in systolic blood pressure lt90 mmHg
bull Acute change in respiratory rate lt8 or gt28 per min
bull Acute change in saturation lt90 percent despite O2
bull Acute change in conscious state
bull Acute change in urinary output to lt50 ml in 4 hours
Institute for Healthcare Improvement
httpwwwihiorgresourcesPagesChangesEstablishCriteriaforActivatingtheRapidResponseTeamaspx
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
24
Why define ldquorespiratory compromiserdquo
bull Respiratory illness is just another reason for
hospitalization
bull The care of patients who are worsening is
obvious
bull Existing ldquorescue systemsrdquo are already adequate
ndash ICU
ndash Rapid response teams
bull My hospital wonrsquot benefit by focusing on
respiratory patients at risk of respiratory failure
Hospital Risk-Adjusted Mortality Rates
1 httpwwwmedicaregovhospitalcomparecomparehtmlvwgrph=1ampcmprTab=3ampcmprID=0500772C0500242C050757ampcmpr
Dist=052C832C84ampdist=25amploc=92103amplat=32749789amplng=-1171676501ampAspxAutoDetectCookieSupport=1
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
25
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
High mortality
hospitals
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
26
Effect of defining ldquopneumoniardquo to
include ldquoresp failuresepsisrdquo
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 2014160(6)380-388
PNA mortality excluding resp failuresepsis
PN
A m
ort
alit
y in
clu
din
g r
esp
fa
ilure
se
psis
Low mortality
hospitals
Conclusions
bull Respiratory illness hospitalizations can be high risk
bull Respiratory patients deteriorate in a variety of ways
bull Rescue systems neglect important signals
bull Opportunity to benefit patients and hospitals
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
27
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
Respiratory Compromise Institute
bull Define ldquorespiratory compromiserdquo
bull Categorize subsets of respiratory compromise
ndash Monitoring
ndash intervention
bull Establish coalition of interested parties
bull Clinical Advisory Committee
bull Implementation
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
28
Definition
bull ldquoRespiratory compromiserdquo 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 andor therapies) might
prevent or mitigate decompensation
Presumption
bull Compromise temporally precedes failure
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
29
Respiratory Illness
Stable
respiratory illness
Respiratory
Compromise
Respiratory
Failure
Mortality
ICU admission criteria
Mortality from pulmonary embolism
1 Douketis JAMA 1998 279458-62
2 Kasper et al J Am Coll Cardiol 1997
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
30
Severity Pulmonary Embolism
Stable RV strain Hypotension Shock Cardiopulmonary arrest
Mortality
Severity indicators
ICU admission criteria
Risk Aspiration Pneumonia
Uncontrolled pain
Alertpain free
Delirium Uncontrolled airway
Aspiration
Mortality
Risk indicators
ICU admission criteria
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
31
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
32
All happy families are alike
each unhappy family is
unhappy in its own wayrdquo
― Leo Tolstoy
first line of Anna Karenina
COPD exacerbation
Stable
COPD exacerbation
WOB gtgt reserve
Other complications
Hypercarbic
respiratory failure
Mortality
ICU admission criteria
Severity indicators
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
33
Asthma exacerbation
Mild exacerbation WOB gtgt reserve
Other complications
Respiratory failure
Mortality
ICU admission criteria
Severity indicators
Presumptions
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data can be used to identify discrete clinical
points at which special observation and
interventions might be helpful
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
34
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
Types of respiratory compromise
bull Due to Impaired Control of Breathing
(RCCOB)
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
35
RCCOB
DK 66 yo man with alcoholism
bull Day 1
ndash Admitted agitated and hallucinating
ndash PMH alcoholism depression hypothyroidism
ndash TSH high T4 low
ndash ldquounable to stay awake gt 20 seconds at at time
CXR Day 1
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
36
Day 2
bull Exam
ndash Hypertensive
ndash Sleepy hard to arouse but responsive
ndash Pulse oximetry 96
CXR Day 2
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
37
Arterial Blood Gases
2 years
ago
Day 2 With 40
face mask
FIO2 500 021 (RA) 400
Art Site Arterial Arterial Arterial
pH 743 716 (L) 716 (L)
pCO2 39 70 (H) 70 (H)
pO2 193 (H) 50 (L) 85
O2 saturation 100 881 96
Alveolar gas room air
bull pAO2 = (FiO2 x 713) ndash paCO208
= (021 x 713) ndash 7008
= 150 ndash 875
= 625
bull paO2 = 50
bull ldquoA-a gradientrdquo = pAO2 ndash paO2
= 625 - 50
= 12
Normal A-a = (age4) ndash 4 = (664) ndash 4 = 165 ndash 4 = 125
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
38
Alveolar gas with oxygen
bull pAO2 = (FiO2 x 713) ndash paCO208
= (040 x 713) ndash 7008
= 285 ndash 875
= 198
CXR Day 2 ndash after intubation
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
39
Arterial Blood Gases after intubation
2 years
ago
Day 2 After
intubation
1 day after
intubation
FIO2 500 021 (RA) 400 400
Art Site Arterial Arterial Arterial Arterial
pH 743 716 (L) 740 747 (H)
pCO2 39 70 (H) 37 37
pO2 193 (H) 50 (L) 85 103
O2 saturation 100 881 96 98
RCCOB
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
40
Opportunities
bull Respiratory compromise was due to impaired
control of breathing
bull Failure was from increasing severity
bull PaCO2 measurement of ventilation etc might
have detected the compromise
bull Medical treatment (thyroid hormone replacement)
might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
ndash Control of airway
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
41
Control of airway
JY 84 yo man with little medical care at home
bull Day 1
ndash ldquofound downrdquo
ndash Dxrsquod with sepsis due to cellulitis
ndash Pleasant but not always alert
CXR Day 1
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
42
Hospital course
bull Day 2-6
ndash Treatment of cellulitis
ndash Standard inpatient precautions
bull Head of bed elevated
bull ldquoAspiration precautionsrdquo
Day 7
bull Desat to 85 on RA
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
43
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
44
Opportunities
bull Respiratory compromise was due to impaired
control of airway
bull Failure was from increased risk
bull A reliable assessment of aspiration risk might
have detected the compromise
bull Heightened aspiration precautions increased
observation etc might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
(RCAW)
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
45
RCAW
bull ldquoGNrdquo 24 yo man with bronchiectasis
bull Day 1
ndash admitted with dyspnea cough and fevers
ndash Rx antibiotics
ndash Called ldquosepsisrdquo (WBCs tachypnea tachycardia)
CXR Day 1
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
46
Later on Day 1
bull More dyspneic wheezing
bull Working very hard to breath
bull Declining mental status but still breathing hard
CXR later on Day 1
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
47
Arterial Blood Gases
Day 1
2133
Day 1
2325
FIO2 300
Flow Rate 2
Art Site Arterial Arterial
pH Art (T) 729 (L) 731 (L)
pCO2 Art
(T)
61 (H) 58 (H)
pO2 Art (T) 78 81
O2 Sat Art
(Est)
943 952
paCO2 and pH
bull If it is a respiratory acidosis
ndash 10 torr paCO2 -gt 008 pH
bull Case 1 (paCO2 = 60 pH = 729)
ndash paCO2 is increased by 20 from normal (40)
ndash Expected pH is decreased by
bull Normal - [(2010) x 008]
bull 74 - [2 x 008]
bull 74 - 0016
bull 724
bull The pH change was all respiratory
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
48
CXR after intubation
Arterial Blood Gases
Day 1
2133
Day 1
2325
After
intubation
Later that
day
FIO2 300 1000 400
Flow Rate 2
Art Site Arterial Arterial Arterial Arterial
pH Art (T) 729 (L) 731 (L) 742 732 (L)
pCO2 Art
(T)
61 (H) 58 (H) 39 48 (H)
pO2 Art (T) 78 81 511 (H) 185 (H)
O2 Sat Art
(Est)
943 952 999
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
49
RCAW
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
Opportunities
bull Respiratory compromise was due to increased
airway resistance
bull Failure was from increasing severity
bull Some indication of the work of breathing might
have detected the compromise
bull Assistance with the work of breathing might have
helped
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
50
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
(RCHPE)
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
RCHPE
SS 50 yo man with cirrhosis
bull Day 1
ndash admitted with massive GI bleed from esophageal
varices
ndash Rxrsquod TIPS
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
51
Hospital Course
bull Day 2-3
ndash ICU extubated
bull Day 4
ndash Withdrawing
CXR on Day 4
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
52
Day 5
bull Tachypnea RR=50
CXR Day 5
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
53
CXR Day 6
Questions
bull Was failure from increasing severity risk or both
bull What could have detected the compromise
bull What type of intervention might have helped
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
54
Opportunities
bull Respiratory compromise was due to pulmonary
edema (left ventricular failure)
bull Failure was from increasing severity
bull Markers of lung water (CXRs) or of gas
exchange (paO2) might have detected the
compromise
bull Diuresis or BiPAP might have helped
Types of respiratory compromise
bull Due to Impaired Control of Breathing
bull Due to Parenchymal Lung Disease
bull Due to Increase Airway Resistance
bull Due to Hydrostatic Pulmonary Edema
bull Due to Pulmonary Vascular Disease Right
Ventricular Failure
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
55
PE Monitor by hemodynamics
PE Screen by PESI score
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you
382016
56
Future
bull Compromise temporally precedes failure
bull Respiratory compromises of different
etiologies have important similarities
ndash Or at least subgroups have similarities
bull Data will identify discrete clinical points at
which special observation and interventions
might be helpful
Conclusions
bull High incidence of respiratory failure and death
among hospitalized patients
bull Five general categories of respiratory
compromise each of which has its own
pattern of physiological deterioration
bull Standardized screening and monitoring
practices for patients with similar mechanisms
of deterioration may enhance the ability to
predict and prevent respiratory failure
382016
57
Thank you