Respiratory compromise results in frequent intubations, high mortality rates, increased hospital stays, and a huge expense; by 2019, the cost of inpatient stays associated with respiratory compromise in the US is expected to exceed $37 billion.1 It is defined as a change in respiratory function that is likely to progress to respiratory insufficiency, respiratory failure or respiratory arrest and death, but in which early intervention might prevent further progress.2 In 2015, the Respiratory Compromise Institute (RCI) was formed to address the challenges of respiratory compromise across the all aspects of health care delivery in the US, including hospitals, nursing homes, and home environments.3 Acute respiratory compromise arising in hospitals in the US has been associated with in-hospital mortality of up to 40%.4-6 Furthermore, potentially reversible features, such as hypotension before the event, have shown a strong association with increased mortality,5,6 indicating that the condition is preventable.
At the annual meeting of the American Thoracic Society, in Washington DC, May 19–24, 2017, The Respiratory Compromise Institute (RCI) presented the results of two studies evaluating the impact of respiratory compromise on mortality in hospitalized patients based on Medicare claims data between January 1, 2012 and December 31, 2014. These studies estimated that at least 111,020 Medicare beneficiaries suffer from respiratory compromise each year.
The first study analysed claims data of patients who developed respiratory failure more than 24 h after hospital admission during medical (n=16,653, average age 73.2 years) or surgical (n=13,895, average age 72.4 years) inpatient stays. In-hospital mortality was higher for medical compared with surgical patients (32.7% versus 25.1%, p<0.0001).7 Mortality during the 30 days post-discharge was also higher in the medical group (15.3% versus 9.8%, p<0.0001). In both groups, hospital mortality was considerably worse in patients who developed acute kidney failure while in hospital (p<0.0001). The rate of intubation was high in both groups, and medical patients received more non-invasive mechanical ventilation than surgical patients (33% versus 14%, p<0.001). These are unacceptably high levels of mortality.
The lead author of the study, Sidney Braman, MD, of the Pulmonary, Critical Care and Sleep Medicine Division, Icahn School of Medicine at Mount Sinai, commented that these data confirm that respiratory compromise is an important safety issue in the hospital setting, particularly among elderly patients. However, with improved monitoring it can be identified, potentially preventing respiratory failure. Studies have already demonstrated that continuous patient monitoring is associated with a marked decrease in the length of stay in intensive care units and provides a positive return on investment.8 These new data add to the evidence in favor of increased adoption of this system across US hospitals.
In the second study, inpatient claims from patients who had hospital-acquired respiratory compromise (HARC) (n=16,653, average age 73.2 years), were compared with those of patients who had respiratory failure diagnosed at the time of hospital admission (n=18,503, average age 70.8 years).9 In-hospital mortality in patients with HARC was significantly higher than in those patients with respiratory failure diagnosed at hospital admission (32.7% versus 27.8%, p<0.0001). Mortality at 30 days post hospital discharge was also significantly higher in patients with HARC (15.3% versus 12.9%, p=0.0001). Therefore, in total, almost half (48.3%) of patients with HARC die in hospital or within 30 days of discharge. Interestingly, the patients with HARC were not necessarily those with underlying respiratory conditions but included chronic heart failure (45%), hypertension (38%), atrial fibrillation (35%), acute kidney failure (36%), pneumonia (31%) and septicemia (26%).
James P Lamberti, MD, Professor of Medicine at Virginia Commonwealth University Inova Campus and Medical Director of Respiratory Care Services at Inova Fairfax Hospital, commented that we may not be thinking of respiratory failure early enough in patients who do not have an underlying condition such as chronic obstructive pulmonary disease (COPD), and physicians need to evaluate these patient groups identify at-risk patients early. He also highlighted the need for further study of HARC.
These studies were limited by the fact that they were retrospective in design. There is a need for prospective observational studies to determine the progression of respiratory compromise. However, these data have highlighted the need for better monitoring and earlier treatment. Identifying patients in respiratory compromise and those in whom respiratory compromise is worsening should be an essential component of in-patient hospital care. Early recognition of respiratory compromise might also allow more efficient use of resources and more appropriate performance evaluation of health-care systems. Further study should enable the development of strategies for early identification and intervention of respiratory compromise in the hospital setting, as well as improving palliative care in this group of patients with a high risk of death.
References1. Agarwal SJ, Erslon MG, Bloom JD, Projected incidence and cost of respiratory failure, insufficiency and arrest in medicare population, 2019, Presented at Academy Health Congress, June 2011.