What is Respiratory Compromise, Respiratory Failure & Arrest

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

Discover below the different types and which respiratory and monitoring solutions from Medtronic can help with the early identification of respiratory compromise.

Respiratory failure occurs when one of the gas-exchange functions—oxygenation or CO2 elimination—fails.² In clinical studies evaluating the incidence or impact of respiratory insufficiency, the condition may be defined in a variety of ways, such as: a decrease in respiratory rate, a reduction in oxygen saturation of hemoglobin, or as a change in arterial blood gasses.^3,4,5,6,7

Definitions and corresponding terms used to represent respiratory insufficiency in literature vary significantly.

What is respiratory insufficiency

DEFINITION

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Respiratory insufficiency definition

Respiratory insufficiency, sometimes referred to as pulmonary insufficiency, is a condition in which the lungs fail to adequately provide oxygen and/or remove carbon dioxide from the body. ² In clinical studies evaluating the incidence or impact of respiratory insufficiency, the condition may be defined in a variety of ways, such as: a decrease in respiratory rate, a reduction in oxygen saturation of hemoglobin, or as a change in arterial blood gasses.^3,4,5,6,7 Definitions and corresponding terms used to represent respiratory insufficiency in literature vary significantly.

Study	Term	Definition
Cacho 2010³	Apnea	Cessation of respiratory activity for 30 or more seconds
Overdyk 2007⁵	Bradypnea	Respiratory rate <10 lasting 3 min or more
Overdyk 2007⁵	Desaturation	SpO₂ <90% for > 3 min
Weingarten 2015¹⁰	Hypoventilation	Hypoventilation (3 episodes of fewer than 8 breaths per minute), apnea (episode of apnea lasting at least 10 seconds), hypoxemia (3 episodes of SpO₂ less than 90%), or pain/sedation mismatch
Sun 2015⁶	Hypoxemia	SpO₂ values less than 90% for at least 10 minutes
Hanna 2005⁴	Respiratory Depression	Respiration rate of less than 8 breaths per minute or SpO₂ less than 90%

INCIDENCE

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How common is respiratory insufficiency?

The incidence of respiratory insufficiency ranges from 5% to 41% of patients.^5,8 This variation is a product of the variation of respiratory insufficiency definitions, as well as the diverse number of patient population and settings utilized in clinical studies investigating respiratory insufficiency.

Study	Population	Definition	Percentage of Patient Suffering Respiratory Insufficiency
Grosse-Sundrup 2012⁸	Post-operative patients	SpO₂ < 90%	5%
Vaessen 2016⁹	GI procedural sedation	SpO₂ < 92 % for < 5 minutes	7.20%
Overdyk 2007⁵	Postsurgical PCA	SpO₂ <90%) for > 3 min	12%
Sun 2015⁶	Postoperative noncardiac surgery	SpO₂ < 90% for < 10 minutes	21%
Weingarten 2015¹⁰	Postoperative pain management	3 episodes of < 8 BPM, 0 BPM for >= 10 seconds, 3 episodes of SpO₂ < 90%, or pain/sedation mismatch	23.70%
Hanna 2005⁴	Postoperative pain management	Respiration rate < 8 BPM or SpO₂ < 90%	27%
Overdyk 2007⁵	Postsurgical PCA	Respiration rate <10 lasting 3 min or more	41%

What is respiratory failure?

DEFINITION

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Respiratory Failure Definition

Respiratory failure describes a loss of pulmonary function that results in hypoxemia or hypercarbia.² Respiratory failure is the most common postoperative pulmonary complication,¹¹ though the incidence rates reported by various clinical studies depend in part on how respiratory failure is defined. In clinical studies, respiratory failure may be defined in several ways; often it is defined as a respiratory condition requiring intervention such as mechanical ventilation or unplanned intubation, or use of naloxone. ¹²

INCIDENCE

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How common is respiratory failure?

The incidence of respiratory failure ranges from 0.83% to 6%.^12,13and depends on the definition of respiratory failure and the study population.

Percentage of patients suffering respiratory failure by definition and patient population^{11,12,13,14,15,16}
Study	Definition	Percentage of patients suffering respiratory failure
Ramachandran 2011¹²	Placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercapnia, or respiratory acidosis within 30 days of the operation.	0.83
Alvarez 2015¹⁴	Placement of an endotracheal tube and mechanical ventilation or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis within 30 days postoperatively.	1.03
Hua 2012¹⁵	Placement of an endotracheal tube and mechanical ventilation or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis within 30 days postoperatively.	2.2
Canet 2015¹¹	PaO₂ <8kPa or SpO₂ <90% on room air but responding to mask/nasal supplemental oxygen.	4.2
Fischer 2013¹³	Unanticipated intubation during the postoperative period, or failure to wean from mechanical ventilation in 48 hours.	6

UNDERLYING CAUSES

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What causes respiratory failure?

There are several underlying causes of respiratory failure. Often multiple underlying causes act synergistically. A retrospective analysis of 177 patients requiring reintubation among 18,579 surgical patients by Grosse-Sundrup et al. determined that on average 2.5 causes precipitating respiratory failure were reported per patient.⁸

Precipitating Cause*	Approximate % of Precipitating Cause
Pulmonary edema	51
Atelectasis	46
Pneumonia	28
Impaired brain function	24
Aspiration	22
Airway obstruction	14
Other	9
Anesthesia related	7
Hypotension	6
Prophylactic preventive measure	6
Myocardial infarction	5
Pulmonary embolism	5
Agitation	4
Pneumo/hemothorax	3
Cardiac Arrest	2
*On an average, 2.5 reasons for respiratory failure were reported per patient

Incidence of respiratory adverse events in moderate to deep procedural sedation is often underestimated, still reported in published clinical studies¹⁷ and its consequences may, even if rarely, lead to death.¹⁷

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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What is respiratory arrest?

DEFINITION

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Definition

Respiratory arrest is the cessation of breathing while the heart is still active.

INCIDENCE

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How common is respiratory arrest?

Husband et al. performed a retrospective review of code blues among 143,581 hospital admissions and documented a respiratory arrest rate of 0.57 per 1000 admissions.¹⁸

UNDERLYING CAUSES OF RESPIRATORY ARREST

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What causes respiratory arrest?

A retrospective review of code blues among 143,581 hospital admissions determined that pulmonary edema is the most common precipitating cause of respiratory arrest.¹⁸

Precipitating Cause*	% of Precipitating Cause
Pulmonary edema	25.6
Aspiration	18.3
Uncertain	17.1
Intracranial	14.6
Medication side-effect	14.6
Tracheostomy complication	12.2
Seizure	8.5
Shock	8.5
Sputum plugging	8.5
Bronchospasm	7.3
Airway obstruction	4.9
Neuromuscular	3.7
Pulmonary embolism	3.7
*Multiple causes attributed to some arrests

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*On an average, 2.5 reasons for respiratory failure were reported per patient.
1. Respiratory Compromise Institute. http://www.respiratorycompromise.org/. 2017.
2. Stedman, T. L. (2008).Stedman's Medical Dictionary for the Health Professions & Nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
3. 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.
4. Hanna, M. H., Elliott, K. M., & Fung, M. Randomized, double-blind study of the analgesic efficacy of morphine-6- glucuronide versus morphine sulfate for postoperative pain in major surgery. Anesthesiology. 2005;102(4):815-821.
5. 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.
6. Sun, Z., Sessler, D. I., Dalton, J. E., et al. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg. 2015;121(3):709-715.
7. Weingarten, T. N., Herasevich, V., McGlinch, M. C., et al. Predictors of Delayed Postoperative Respiratory Depression Assessed from Naloxone Administration. Anesth Analg. 2015;121(2):422-429.
8. Grosse-Sundrup, M., Henneman, J. P., Sandberg, W. S., et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012;345:e6329.
9. Vaessen, H., Bruens, E., & Knape, J. Clinical analysis of moderate-to-deep-sedation by nonmedical sedation practitioners in 597 patients undergoing gastrointestinal endoscopy: a retrospective study. Endosc Int Open. 2016;4(5):E564-571.
10. Weingarten, T. N., Jacob, A. K., Njathi, C. W., Wilson, G. A., & Sprung, J. Multimodal Analgesic Protocol and Postanesthesia Respiratory Depression During Phase I Recovery After Total Joint Arthroplasty. Reg Anesth Pain Med. 2015;40(4):330-336.
11. Canet, J., Sabate, S., Mazo, V., et al. Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Eur J Anaesthesiol. 2015;32(7):458-470.
12. Ramachandran, S. K., Nafiu, O. O., Ghaferi, A., Tremper, K. K., Shanks, A., & Kheterpal, S. Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery. Anesthesiology. 2011;115(1):44-53.
13. Fischer, J. P., Shang, E. K., Butler, C. E., et al. Validated model for predicting postoperative respiratory failure: analysis of 1706 abdominal wall reconstructions. Plast Reconstr Surg. 2013;132(5):826e-835e.
14. Alvarez, M. P., Samayoa-Mendez, A. X., Naglak, M. C., Yuschak, J. V., & Murayama, K. M. Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database.Am Surg. 2015;81(8):820-825.
15. Hua, M., Brady, J. E., & Li, G. A scoring system to predict unplanned intubation in patients having undergone major surgical procedures.Anesth Analg. 2012;115(1):88-94.
16. Milgrom, D. P., Njoku, V. C., Fecher, A. M., Kilbane, E. M., & Pitt, H. A. Unplanned intubation: when and why does this deadly complication occur?Surgery. 2013;154(2):376-383.
17. 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/
18. Husband, A., Mercer, I., Detering, K. M., Eastwood, G. M., & Jones, D. A. The epidemiology of respiratory arrests in a teaching hospital. Resuscitation. 2013.
19. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. (2008). Continuous Respiratory Monitoring and a "Smart" Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period.
20. 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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What is Respiratory Compromise?

Respiratory Compromise Definition

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

Discover below the different types and which respiratory and monitoring solutions from Medtronic can help with the early identification of respiratory compromise.

What is respiratory insufficiency?

Respiratory Insufficiency Definition

What is respiratory insufficiency

DEFINITION

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Respiratory insufficiency definition

Definitions and terms for respiratory insufficiency in a sampling of the clinical literature

INCIDENCE

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How common is respiratory insufficiency?

Percentage of patient suffering respiratory insufficiency by definition and patient population4,5,6,8,9,10

What is respiratory failure?

DEFINITION

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Respiratory Failure Definition

INCIDENCE

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How common is respiratory failure?

UNDERLYING CAUSES

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What causes respiratory failure?

Common precipitating causes of respiratory failure.

REAL-WORLD EVIDENCE FOR RESPIRATORY COMPROMISE PREVENTION IN PROCEDURAL SEDATION

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What is respiratory arrest?

DEFINITION

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Definition

INCIDENCE

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How common is respiratory arrest?

UNDERLYING CAUSES OF RESPIRATORY ARREST

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What causes respiratory arrest?

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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

Percentage of patient suffering respiratory insufficiency by definition and patient population^4,5,6,8,9,10

Nellcor™ pulse oximetry for continuous SpO₂