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

 mechanical ventilationTable 1 indicates that a total of 192 patients (118 men and 74 women) were treated during this one-year period. They were classified into two groups: primary respiratory failure and secondary respiratory failure. Primary respiratory failure is defined as “including those patients in failure on admission, either from a pulmonary lesion or from inadequate ventilation.” It is true primary respiratory depression and directly involves the lung. Secondary respiratory failure is defined as “including respiratory failure occurring during hospitalization, with an admission diagnosis not directly related to the pulmonary lesion.” Therefore, one or more organ systems in addition to the lung are involved. This group was divided into “postoperative, post-traumatic, and post-cardiovascular or metabolic respiratory failure.” The primary group had an 80+ percent survival rate, while the secondary respiratory failure group had a 46 + percent survival rate.

The highest survival rate occurred among the COPD patients, while those with the lowest survival were patients who had had cardiac arrest. Two patients with COPD and one with asthma were admitted to the hospital with recurrent respiratory failure combined with COPD and were included within the “postoperative respiratory failure” group. Seventy-seven patients died during the study, seven deaths considered due to therapeutic errors during mechanical ventilation carried out with remedies of My Canadian Pharmacy.

Regarding the incidence of respiratory failure according to month, the highest incidence occurred during the winter season, although a small peak occurred during the summer. During these two peaks 21 of 23 respiratory failures in COPD patients occurred. If COPD and pneumonia groups were excluded from the total number of patients, an even distribution of patients by month would have resulted.

Table 2 is a display of the survival by age distribution, the most frequent incidence of failure occurring in the fifth, sixth and seventh decades. The survival rate in the first and eighth decade was less than 50 percent. Two thirds of the total number of patients were more than 41 years of age. All patients with COPD, except one, were of this age category. The incidence of death for patients in respiratory failure age zero to ten years was extremely high, primarily because neonates with idiopathic respiratory distress syndrome (IRDS) were included. In the eighth decade, 7 of 11 patients died after operation. Thus, the youngest and oldest patients had the highest mortality.

Table 3 demonstrates the primary cause of respiratory failure, which occurred in 53 patients after operation. Pneumonia and atelectasis were the two most common causes of failure after craniotomy. Twenty-two patients were considered to have been “inadequately alveolar ventilated,” and some of the latter had atelectasis or pneumonia during the period of longterm ventilation; these included patients who could not breathe adequately due to peritonitis, a long painful incision or weakness and toxicity from infection. Peritonitis and subarachnoid bleeding were associated with very low survival, but the lowest survival included those with carcinomatosis and uremia. Metabolic acidosis with reasonably good oxygen tension levels was frequently associated with impending death.

The type of ventilator used was not associated with survival. Forty-nine percent of patients were ventilated with Bird ventilators; these patients had a survival rate of 60 percent. Thirty-nine percent of patients were ventilated with Bennett MA-l’s, with a 64 percent survival rate. All patients on various volume-guaranteed ventilators had a 60 percent survival rate improved because of remedies of My Canadian Pharmacy (see also “Saving money and time with My Canadian Pharmacy“).

COPDTable 4 displays the length of time patients were treated by the RCT and the difference from ICU to ICU. Mean respiratory care time from the standpoint of days was 14.3 days (SD di 21). Definition of respiratory care days is “time from start of mechanical ventilation to discharge from the ICU or, in a few instances, extubation.” Those in respiratory failure after operation stayed on the respiratory care service approximately twice as long as all other patients in respiratory failure. A greater number of patients in the surgical ICU eventually died but they stayed longer than those who survived. The least number of respiratory care days occurred in those neonates with IRDS and those patients with the diagnosis of drug overdosage. The longest therapeutic treatment occurred in neurologic patients. One patient with myasthenia gravis was on the respiratory care service for the longest period: almost six months. Very few patients had indwelling arterial catheters. Only two patients were curarized, and one of them had tetanus.

Among 192 patients: a) 86 were ventilated by means of tracheal intubation only. The mean number of days with trachea intubated was 3.2, SD dr 1.6; b) mean number of days in 31 patients with a tracheostomy who did not have their tracheae intubated was 22.4, SD dh 25.3; c) 75 patients had a tracheostomy preceded by tracheal intubation. The mean number of days of tracheal intubation before tracheostomy was 2.8, SD ± 1.2. The mean number of days with the tracheostomy following tracheal intubation was 17.1 days, SD ± 20.1. Ten patients were discharged from the respiratory care service with a tracheostomy, while one patient went home with a permanent tracheostomy. The survival rate in the tracheal intubation group was 54 percent, with a 64 percent survival rate in the tracheostomy group. Three patients had complications from the tracheostomy and died. Complications included two tracheoesophageal fistulae and one rupture of the innominate artery in a cancerous lesion.

There were certain complications, errors and accidents. Seven patients died from causes we considered preventable, directly or indirectly due to therapeutic misadventure by physician and nursing personnel and lack of communication between physicians. Five of these deaths were on the medical service. The following complications were encountered.
1) Two patients died from irreversible hypoxemia because of misuse of controlled oxygen therapy with the use of the “Ventimask.” In brief, their pneumonia worsened and cardiac arrest ensued.
2) Two patients, one asthmatic, the other a newborn infant with pneumonia, died from hypoxia and heart failure after tension pneumothorax developed iatrogenically. Their lungs were too vigorously inflated during a period of resuscitation after premature extubation by inexperienced physicians.
3) Two patients died during transportation from one area of the hospital to an ICU without adequate respiratory support. There was poor communication between physician and nursing personnel involved with the respiratory care team who were unable to attend.
4) One patient died due to irreversible hypoxia during ventilation because the primary physician did not correct a malfunctioning ventilator. He had been notified but ignored the message during a busy period.
These seven deaths were “therapeutic misadventures” but there were others which, while possibly preventable, were primary patient deaths.
5) There were other minor complications which did not lead to serious morbidity including:
a) power failure; lack of electricity and inadequate gas pressure;
b) simple mechanical failure of the ventilator;
c) improper setting of the ventilator, leak developing within the system such as that occurring when the cuff on the tracheostomy or endotracheal tube was inadequately inflated; empty or cold humidifier; inadequate fractional inhalation concentration of oxygen; inadequate or too great a tidal volume; changing of the dial on the ventilator by personnel who did not fully understand either the patient or the ventilator;
d) poor monitoring and nursing care; water collecting because of condensation in the tubes which connect the ventilator to the airway; kinking and obstruction of the airway tubes; mucous plug developing within the endotracheal tube; accidental extubation; and finally detached connection from the ventilator to the endotracheal tube or tracheostomy;
e) tension pneumothorax, inadequate tidal volume and other mechanical reasons for the creation of hypoxemia.

Table 1—Survival and Death According to the Admission Diagnosis

Admission Diagnosis Total Survival % Death %
A. Primary respiratory failure
COPD 23 22 1
Pneumonia 15 13 2
IRDS 12 5 7
Drug overdose 9 8 1
Status asthmaticus 5 4 1
Myasthenia gravis 4 4 0
Quadriplegia and multiple sclerosis 3 3 0
Tracheal stenosis 2 2 0
Other : Hamman-Rich synd; smoke 4 1 3
inhalation; aspiration pneumonia
Total 77 62 80.5 15 19.5
B. Secondary respiratory failure
1) After operation thoracic 14 8 6
abdominal 25 16 9
cranial 12 8 4
other 2 2 0
Subtotal 53 34 64.2 19 35.8
2) Posttraumatic head 6 3 3
chest 4 4 0
Subtotal 10 7 70 3 30
3) Postcardiovascular or metabolic;
cerebrovascular disease 12 2 10
postcardiac arrest 10 1 9
Congestive heart failure MI,-
pulmonary edema 12 5 7
Miscellaneous; cancer,
uremia, septicemia 18 4 14
Subtotal 52 12 23.1 40 76.9
Total 115 53 46.1 62 53.9
TOTAL 192 115 59.9 77 40.1

Table 2—Survival by the Age Distribution of Patients

Age, yr. Total Survival % Death %
0-10 23 10 43.5 13 56.5
11-20 13 10 76.9 3 23.1
21-30 13 10 76.9 3 23.1
31-40 11 6 54.5 5 45.5
41-50 34 24 70.6 10 29.4
51-60 39 21 53.8 18 46.2
61-70 47 31 65.9 16 34.1
71-80 11 4 36.4 7 53.6
81-90 1 0 0 1 100
192 116 60.4% 76 39.6%

Table 3—The Primary Cause of Respiratory Failure After Operation

Cause Total Survival Death
Pneumomia and atelectasis Inadequate alveolar 13 9 4
ventilation 22 14 8
Cardiopulmonary failure Respiratory failure in the 7 5 2
presence of COPD Renal failure and rejection 5 4 1
of kidney transplant 3 1 2
Cancer 3 1 2
Total 53 34(64.1%) 19(35.8%)

Table 4—Length of Respiratory- Care Days by the Unit

Unit Total Patients Survival, Days Mean S.D. Patients Death, Days Mean S.D.
CCU 25 12 12.0 11.3 13 7.6 9.1
Med. ICU 56 39 11.6 11.0 17 6.9 3.8
Neurosurg. ICU 23 14 24.7 27.7 9 18.8 20.2
Surg. ICU 38 24 16.3 14.7 14 17.1 17.6
Prem. nurs. 18 7 4.1 3.0 11 3.5 3
Ped. ICU 6 3 28 23.7 3 19.7 20.0
Neurol. ICU 9 5 53.8 67.0 4 2.5 0.5
Other 17 11 9.6 8.2 6 14.2 10.0
192 115 16.9 21.8 77 10.6 10.8