Hospital Acquired Conditions, Opioid Safety, Respiratory Compromise

New Report on Preventing Respiratory Compromise in Vulnerable Patients

The Respiratory Compromise Institute (RCI) has recently published a new report titled “Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients”. PPAHS is a member of RCI, along with other health organizations such as the Society of Hospital Medicine, American Association for Respiratory Care, and CHEST/American College of Chest Physicians.

The RCI Report is published by the American Association for Respiratory Care, and is the result of a workshop organized by the National Association for the Medical Direction of Respiratory Care to address the unmet needs of respiratory compromise from a clinical practice perspective. The writing committee was comprised of a diverse set of clinicians specializing in respiratory ailments: Timothy A Morris, MD; Peter C Gay, MD; Neil R MacIntyre, MD FAARC; Dean R Hess, PhD, RRT, FAARC; Sandra K Hanneman, PhD, RN; James P Lamberti, MD; Dennis E Doherty, MD; Lydia Chang, MD; and Maureen A Seckel, ACNS-BC, CCNS.

The report notes that respiratory compromise is one of the most serious contributing factors to in-hospital patient mortality amongst common conditions. The team found that the development of in-hospital respiratory failure is associated with a mortality rate of nearly 40%; this rate of death is “twice as high as myocardial infarction and several times higher than for cancer, stroke, congestive heart failure, and renal failure.”

The report identifies eight distinct subsets of respiratory compromise that pose a high risk of patient harm, but could be prevented with early detection and intervention. It also recommends detection strategies for these subsets of respiratory compromise, and suggests that there is an opportunity to update the triggers for rapid response teams to directly address these specific patient populations.

Most notable for readers of the Physician-Patient Alliance for Health & Safety (PPAHS) blog is the report’s section on respiratory compromise due to impaired control of breathing as a key risk category; a patient subset defined as those undergoing procedural/postoperative sedation, sleep apnea, and opioids or respiratory suppressant drugs. The report recommends two key monitoring strategies:

  1. Continuous and accurate measurement of gas exchange. The report notes that monitoring of blood oxygenation (typical with pulse oximetry) is fairly routine; however, other monitoring options such as end-tidal capnography, blood pressure, electrocardiogram, and transcutaneous PCO2 may detect respiratory compromise earlier.
  2. Clinical scales for risk assessment. The report suggests the use of clinical scales to measure consciousness, delirium, pain, and sleep apnea risk in patients. The STOPBang tool, Risk Index for Serious Opioid-Induced Respiratory Depression (RIOSORD), and the PCA Safety Checklist are all tools and clinical scales that have been highlighted by PPAHS in the past.

The team highlights that neither intermittent spot checks nor continuous electronic monitoring are sufficient in isolation to detect rapid respiratory depression, instead suggesting that a combination of the two be employed to effectively save patients.  

To read the full report, click here to access the abstract and full monograph on the Respiratory Care Journal.

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