The opioid epidemic has brought more attention to respiratory compromise, but there continues to be insufficient awareness of this potential complication in hospitals, said hospitalist Thomas Frederickson, MD, MBA, FACP.
Dr. Frederickson is a member of the clinical advisory committee for the Respiratory Compromise Institute, a nonprofit alliance of medical societies representing hospital medicine, anesthesiology, and other specialties, medical director for hospital medicine at CHI Health, and an assistant professor of medicine at Creighton University School of Medicine in Omaha, Neb.
Dr. Frederickson recently spoke with ACP Hospitalist about how hospitalists can better recognize respiratory compromise before it's too late.
Q: What is respiratory compromise, and when does it occur in the hospital?
A: Respiratory compromise is a state that is likely to lead to respiratory failure, including potential decompensation and death. Almost all patients in the hospital are at some risk of respiratory decompensation. Some patients are at more risk, such as patients with sleep apnea. Some disease states put patients at higher risk, for example, any patient with metabolic acidosis from any cause is at risk for hyperventilation, respiratory muscle fatigue, and respiratory failure. Other common risk factors include chest trauma, chest surgery, or any intrathoracic pathology, especially if it causes pleurisy and pain. In addition, sedating medications and medications that decrease the respiratory drive, such as opioids, put patients at risk, especially if there is underlying or baseline organ dysfunction, such as renal failure. In short, we tend to think mostly of intrathoracic pathology putting patients at risk, but the risks are broader. Obviously, many patients have multiple risk factors.
Q: Which patients are at risk for progression of respiratory compromise in the hospital, and what are some preventive interventions?
A: We really need more research, and the research is ongoing. The Respiratory Compromise Institute is sponsoring and supporting researchers in an attempt to delineate the risk factors and the interventions to prevent the progression to respiratory failure and respiratory arrest. But that doesn't mean there aren't things that we can do now.
For example, we know which patients are going to be at higher risk during the postop period if they're on opioids, and which opioids and which doses and which delivery systems—PCA [patient-controlled analgesia] versus intermittent IV dosing versus oral—are going to put them at greater risk. We also know strategies that can mitigate the risk, such as using multimodal analgesia and implementing appropriate monitoring for at-risk patients.
Awareness of appropriate monitoring, the limitations of some types of monitoring, and the risks of alarm fatigue are important. For example, oximetry is of limited value and is a very late indicator of patients at risk of hypoventilation and respiratory arrest from medications that depress respiratory drive, such as opioids, especially for patients on supplemental oxygen. Frequent alarms, often associated with sleep apnea, confound oximetry monitoring. All hospitals need to have policies about which types of monitoring to use in which situations, and the health care team needs to understand the limits of oximetry and the indications for capnography. Lastly, opioid-sparing strategies and proper monitoring need to be included in order sets, and pharmacy review policies also need to be in place for high-risk medications and dosages.
Q: What is the role of hospitalists in particular in addressing this?
A: To me, there's an obvious role, and that is just to be aware of what the risk factors are, to the extent that we know what they are. But I'd say even a bigger role is to become involved and to advocate in your hospitals for quality improvement around appropriate order sets for patients on opioids and in all other aspects of making the hospital safer and patients less likely to progress to respiratory failure. These include monitoring policies, screening protocols, and policies around educating patients (and families) who are receiving opioids.
Q: What are your top tips for hospitalists?
A: Always be aware of your prescribing. Think about it, and remember that your pharmacist is your friend. Get advice from the pharmacist, especially when people are on multiple medications and you're having a difficult time controlling pain. Involve other important team members and have a team approach. Get the nursing perspective, and involve anesthesia and respiratory therapy. The more complicated the patient, the more the wisdom and integration of the team will work together for patients' good.
Q: Are there any resources you would recommend?
A: The Society of Hospital Medicine a few years ago asked me to work with some really great colleagues across the country to put together the RADEO [Reducing Adverse Drug Events related to Opioids] Guide, which is an excellent, well-referenced, comprehensive and step-by-step quality improvement guide for decreasing adverse events related to opioids in the inpatient setting. It also touches on transitions of care and making care transitions more safely. That can be downloaded from the Society of Hospital Medicine's website for free.
Another really good resource is the recent standard regulation from The Joint Commission. On Jan. 1, 2018, they implemented new and revised pain assessment and management standards for accredited hospitals. It is very well referenced, and their website is an excellent resource. The Respiratory Compromise Institute is a good source for blogs, podcasts, and announcements on the latest scientific research and presentations.