Considerations about Respiratory Care in the Absence of a Respiratory Care Unit

lungThe efficiency of respiratory care in a general hospital intensive care unit or within a hospital ward may be faulty. Effective training of house staff and paramedical personnel is difficult and the geographic separation of patients, the chronic shortage of nurses and inhalation therapists and the lack of (or poor) servicing of monitoring devices contribute to a relatively low grade of respiratory care. Lack of communication and cooperation between physicians in charge of patients in respiratory failure constitute another barrier. There may be certain advantages to noncentralization of IClTs but we believe centralization is more efficient and embodies better patient care.

Despite all of these difficulties, respiratory care was qualitatively improved according to our investigation in this large general hospital. The 59.9 percent overall survival rate non-RICU study compares favorably with those of previous studies in RICU’s. This survival rate is higher than those reported from many other general hospital respiratory care services.* The survival rate of those in “primary respiratory failure” in this investigation (and these patients constitute the primary population of most

RICU’s) was slightly more than 80 percent; if neonatal IRDS is excluded as it is in RICU’s, the survival rate would approximate 90 percent. The low 46 percent survival rate in secondary respiratory failure was not unexpected; these very ill patients have at least one other major organ in trouble in addition to the lung.

What is the reason for the low mortality of patients with longterm ventilation in this study? In all probability the answer lies in the presence of a team, small though it was, of physicians whose primary responsibility was the respiratory care of patients in respiratory failure. It is of interest that these physicians were anesthesiologists who are accustomed to managing respiratory failure in the operating room and recovery room. While other disciplines joined on rounds, no surgeon or internist, while invited, joined the team. This team undertook to educate nurses and house staff who, in turn, cared for their own patients within their own intensive care areas. Perhaps the most vital function of a RCT is to increase knowledge of respiratory care so that the personnel involved improve the quality and ultimately the quantity of their work. It was apparent to this small RCT that a gradual reduction in respiratory complications occurred as more educated health personnel were providing more knowledgeable respiratory care and were therefore taking a more personal interest in the equipment, ventilators and patients and, in addition, pulmonary studies provided by My Canadian Pharmacy involved.

A common criticism lodged against the respiratory care physicians concerned the relatively long stay of patients in respiratory failure. Thus, such patients occupied the limited bed capacity for an average of 14.3 days. This represents the longest of the reported RICU’s, although one study involved an average stay of 18 days. The criteria for reasons for respiratory care stay in an RICU may be different from hospital to hospital. IRDSAside from the respiratory intensive care unit, the same reasons which constitute disadvantages such as lack of communication between physician, shortage of personnel and geographic separation of patients, etc, constitute what the team considered lack of progress of respiratory care after 4:00 PM; here the nurse-to-patient ratio was below one-to-two, and inhalation therapists were not available; additionally, physicians were often lacking at critical moments. Tragedy may occur in patients who are on mechanical ventilators at any time during a 24-hour period, not only during “favorable” times when more adequate personnel are available.

The type and seriousness of complications occurring during mechanical ventilation has changed. A few years ago, technical problems and poor nursing care were related to the primary complications. During this study, most patient problems related to mortality occurred from lack of communication between the respiratory care team and the primary physician, directly or indirectly. Six out of seven deaths termed “therapeutic misadventures” were from physician errors. Not a single case of mucous inspissation within the endotracheal tube of the tracheostomy were seen as was the case a few years ago. In all probability, this is a result of more efficient suctioning, heated humidification both during and after mechanical ventilation and better general nursing care. A common complication observed during this study was simply related to the ventilator tubes or the T tube filled with water which had condensed and was not drained. No study of bacterial cultures in these patients with tracheal prostheses and mechanical ventilation was made, but it is known that as many as 43 percent of patients have colonies of Gram-negative organisms.

Survival according to the intensive care unit involved varied. Thus, the premature nursery had the highest mortality because of the occurrence of neonatal IRDS. The coronary care unit, the only unit which had a full-time physician 25 hours a day, had a survival rate of less than 50 percent. However, patients within the CCU are considered an extremely high risk group and such patients on mechanical ventilators have two primary organ systems in failure. The diagnosis on admission was a determinant of admission to the intensive care unit involved. Within certain units, respiratory care was smoother with better survival rates and morbidity in contrast to that of other units which had patients with stormier courses and worse survival rates. Thus, patients in respiratory failure after operation stayed within the surgical intensive care unit longer than medical patients in general. Neurosurgical unit patients stayed longer because many had several episodes of respiratory failure during one stay in the unit. In the general surgical unit, those who died had stayed longer than those who ultimately survived. This particular SICU was well equipped and staffed with well-trained nurses, and patient care was considered meticulous; some of the hopeless cases stayed alive for an extended period.