In a clinical education podcast produced by the Physician-Physician Alliance for Health Safety, Jeffrey S. Vender, MD. cautions that otherwise stable patients can quickly move down the dangerous path to respiratory compromise:
“There are numerous situations where patients with underlying pulmonary disease are in very chronic, but stable conditions. And, for a multitude of reasons, either a therapeutic intervention, the administration of pharmaceutical agents, in particular sedative agents and/or narcotics, as you’ve alluded to, or an underlying disease, like pneumonia, can make this stable respiratory condition and move it down the spectrum of patho-physiologic deterioration into respiratory compromise.”
Jeffrey S. Vender, MD is Clinical Professor at the University Of Chicago, Pritzker School of Medicine. He is also Chairman of the clinical advisory committee to the Respiratory Compromise Institute.
The Respiratory Compromise Institute is a coalition of medical and safety organizations devoted to raising awareness about respiratory compromise. Members of the Respiratory Compromise Institute consist of representatives from leading medical and safety organizations:
- American Association for Respiratory Care
- American College of Chest Physicians
- American College of Emergency Physicians
- American Society of Anesthesiologists
- American Thoracic Society
- Canadian Society of Respiratory Therapists
- National Association of Clinical Nurse Specialists
- National Association of EMS Physicians
- National Association for Medical Direction of Respiratory Care
- Physician Patient Alliance for Health & Safety
- Society of Anesthesia & Sleep Medicine
- Society of Critical Care Medicine
- Society of Hospital Medicine
The Respiratory Compromise Institute defines respiratory compromise as “a potentially life threatening state of unstable respiratory health.” Respiratory Compromise “is a gradual, subtle imbalance in patient response that encompasses respiratory failure and arrest, with symptoms that manifest differently in each patient.”
Dr. Vender believes that “there’s been a lack of understanding of how to monitor better, or to recognize better, those patients at-risk.” He encourages clinicians to do “a better job of monitoring and understanding the drugs we use in those patients at risk, so we can reduce these complications.”
To read a transcript of the interview, please click here.
The podcast with Dr. Vender may be viewed on the PPAHS YouTube channel by clicking here.
Prevention is preferable to detection. The biggest single causative factor in unexpected respiratory arrest is hyperventilation that paralyzes respiratory chemoreceptors, causing respiratory arrest with the onset of sleep. The second biggest factor is combinations of sedatives and opioids that simultaneously undermine both primary and secondary respiratory drive. The third factor is cessation of painful stimulus in the presence of sedatives and opioids. Hyperventilation is inherently harmful and confers no benefits. It should always be avoided. CO2 supplementation can prevent unexpected respiratory arrest.
Presently available monitoring modalities cannot provide adequate warning of impending respiratory arrest. They can only warn of respiratory arrest after the fact, by which time brain damage and death are minutes away.
Dr. Coleman, you are absolutely correct. Prevention is always preferable to detection. However, continuous patient monitoring is like the canary in a coal mine. It provides an advanced warning of some danger. This is far preferable to not monitoring our patients. Thank you so much for your comments. I hope that this may encourage others to engage in this critical discussion.
The ultimate cause of respiratory arrest is brain hypoxia, by which time oxygen reserves are gone, so that brain damage and death occur with devastating speed. The available monitoring modalities, capnography and pulse oximetry, cannot provide advance warning, and they are plagued by false alarms. Anesthetists must learn to avoid hyperventilation and maintain “permissive hypercarbia” during anesthesia. Drug addicts must be educated to avoid the synergistic interaction of opioids and sedatives. Carbogen offers a cheap, simple treatment for respiratory arrest that is far more effective than oxygen alone.