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

382016

57

Thank you