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Introduction

Respiratory compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency and failure, respiratory arrest or death, but in which specific interventions (continuous monitoring and therapies) might prevent or mitigate decompensation.1 

Many in-hospital declines may be preventable with better respiratory monitoring and early intervention.2,3,4

Respiratory abnormalities are the most common type of abnormalities prior to ICU admission. 5 Moreover, inpatients with respiratory insufficiency, arrest and failure originating on the general care floor have higher mortality rates, longer length of stay and ICU stays compared to other patients.6

Therefore, implementing better strategies for prevention, monitoring for and management of respiratory abnormalities in patients could lead to improved patient outcomes and decreased costs.

POSTOPERATIVE RESPIRATORY INSUFFICIENCY

Respiratory insufficiency is one of the most common and serious complications during postoperative period.7 Postoperative respiratory insufficiency risk is increased in emergency surgical procedures (particularly procedures related to trauma), procedures involving the chest or upper abdomen, as well as procedures requiring prolonged anesthesia.7 Additional important risk factors include prolonged sedation, neuromuscular blockade, cardiovascular instability, immobilization and respiratory problems.8 Typically, respiratory insufficiency treatment strategies are directed at addressing the cause of the insufficiency and restoration of pulmonary function.7 Therefore, it is important to have consistent strategies for respiratory insufficiencyprevention, including monitoring and preoperative conditioning in high-risk patients.8 

RESPIRATORY FAILURE IN SURGICAL PATIENTS IN EUROPE

IMPACT OF POSTOPERATIVE RESPIRATORY FAILURE

Postoperative respiratory failure is the most frequent postoperative pulmonary complication with major impact on patient outcome and health costs.9 The pathogenesis of postoperative failure isdependent upon factors related to patient status, as well as anaesthetic and surgical procedure employed.10 The incidence of postoperative respiratory failure in the general surgical populations varies between 0.2% and 3.4% (Canet and Gallart, 2014). 10

Discover below what impact respiratory compromise has and which respiratory and monitoring solutions from Medtronic can help with the early identification.

Respiratory compromise imposes substantial burdens on patient health and hospital costs.

RESPIRATORY FAILURE IN SURGICAL PATIENTS IN EUROPE

RESPIRATORY FAILURE IN PROCEDURAL SEDATION IN EUROPE

Respiratory Compromise is common and deadly in procedural sedation, but it is also preventable.

Recent research has demonstrated a reduction in respiratory compromise (from respiratory insufficiency to failure) during procedural sedation with the use of capnography monitoring.11 Specifically, use of capnography was associated with less mild and severe oxygen desaturation, which may have contributed to reduced need for assisted ventilation.11

ACUTE RESPIRATORY FAILURE

Acute respiratory failure implies the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient (Gurka and Balk, 2008).12 Hypoxic respiratory failure (type 1) is defined as hypoxia without hypercapnia and with an arterial partial pressure of oxygen (PaO2) of <60 mmHg (<8 kPa) on room air at sea level.13 Hypercapnic respiratory failure (type 2) is defined as hypoxia with an arterial partial pressure of carbon dioxide (PaCO2) of >50 mmHg (>6.5 kPa) on room air at sea level.13  

CHRONIC RESPIRATORY FAILURE

Chronic respiratory failure typically refers to a combination of chronic hypoxemia, hypercapnea and compensatory metabolic alkalosis, resulting in chronically low oxygen levels or chronically high carbon dioxide levels.14,15 The condition is usually caused by chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, and idiopathic interstitial pneumonia.

Impact of Respiratory Failure in Procedural Sedation in Europe

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Improving detection of patient deterioration in the general hospital ward environment21

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REAL-WORLD EVIDENCE FOR RESPIRATORY COMPROMISE PREVENTION IN PROCEDURAL SEDATION

Incidence of respiratory adverse events in moderate to deep procedural sedation is often underestimated, still reported in published clinical studies22 and its consequences may, even if rarely, lead to death.22

The outcomes pledge program by Medtronic will help you measure the incidence of adverse events in your own setting, with your own clinical team and your own protocols and assess the impact of capnography monitoring on the prevention of such events.

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Microstream™ Capnography Monitors

May provide an early warning of respiratory compromise. 23,24,25

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McGRATH™ MAC video laryngoscope

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Puritan Bennett™ 980 acute care ventilator

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Resources

  • * Remote=locations or surgical procedures performed outside the OR

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

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

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

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

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

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

  • 7. Teba L., Omert, L.A. Postoperative respiratory insufficiency. Am Fam Physician. 1995 1;51(6):1473-80.

  • 8. Kösek, V. & Wiebe, K. Postoperative respiratory insufficiency and its treatment. Der Chirurg; Zeitschrift fur Alle Gebiete der Operativen Medizen. 2015, 86(5):437-443.

  • 9. Blum, J.M., Stentz, M.J., Dechert, R. et al. Preoperative and intraoperative predictors of postoperative acute respiratory distress syndrome in a general surgical population. Anesthesiology 2013. 118:19-29.

  • 10. Canet, J. & Gallart, L. Postoperative respiratory failure: pathogenesis, prediction, and prevention. Curr Opin Crit Care. 2014; 20:56-62.

  • 11.  Saunders, R., Struys, M., Pollock, R. F., Mestek, M., & Lightdale, J. R. (2017). Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis. BMJ open, 7(6), e013402. doi:10.1136/bmjopen-2016-013402.

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

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

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

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

  • 16. Post-operative patients with Respiratory Compromise have a mortality rate of 10.4% compared to 0.4% of those who do not develop Respiratory Compromise - Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Canet et al EJA 32(7):458–470, JUL 2015

  • 17. Canet et al. Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. EJA 32(7):458–470, JUL 2015

  • 18. Medtronic data analysis

  • 19. Metzner, J, Posner, K. and Domino, K. The risk and safety of anesthesia at remote locations: the US closed claims analysis Article in Current opinion in anaesthesiology · 2009. 2(4):502-8.

  • 20. Hinkelbein, J., Lamperti, M., Akeson, J., Santos, J., Costa, J. ... Fitzgeraldy, R. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults - Eur J Anaesthesiol 2017; 34:1–19

  • 21. Vincent, J.L., Einav, S., Pearse, R., Jaber, S., Kranke, P., Overdyk, F.J., Whitaker, D.K., Gordo, F., Dahan, A. and Hoeft A. – Eur J Anaesthesiol 2018; 35:325–333.

  • 22. Leslie K, Allen ML, Hessian EC, Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: A prospective cohort study. Br J Anaesth. 2017;118(1):90–9. https://pubmed.ncbi.nlm.nih.gov/28039246/

  • 23. Cacho, G., Perez-Calle, J. L., Barbado, A., Lledo, J. L., Ojea, R., & Fernandez-Rodriguez, C. M. Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig. 2010;102(2):86-89.

  • 24. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. Continuous respiratory monitoring and a “smart” infusion system improve safety of patient-controlled analgesia in the postoperative period. 2008. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4).

  • 25. Overdyk, F. J., Carter, R., Maddox, R. R., Callura, J., Herrin, A. E., & Henriquez, C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007;105(2):412-418.

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