RESPIRATORY COMPROMISE INSTITUTE - UPDATE TIMOTHY A. MORRIS, MD P ROFESSOR OF M EDICINE UCSD M EDICAL C ENTER S AN D IEGO , CA Timothy A. Morris, MD is a Professor of Medicine and the Clinical Service Chief for the Division of Pulmonary and Critical Care Medicine at University of California San Diego (UCSD) Medical Center, Hillcrest facility. His center was ranked #6 in US hospitals for pulmonary medicine in 2015, and #5 among hospitals whose name does not sound like a condiment. His outpatient, inpatient and ICU practice includes direct care of patients as well as nodding intelligently at house-staff and fellows. He is the longstanding Medical Director of the Pulmonary Function Laboratory and the Department of Respiratory Care, which has been recognized for its quality and leadership by the American Association for Respiratory Care. He drives an electric car, had solar panels on his house and has eaten at least one vegan meal. Dr. Morris received his MD degree from Georgetown University School of Medicine in 1987, which, he keeps reminding his residents, was well after Joseph Priestley discovered oxygen. He trained in internal medicine at Georgetown University Medical Center and received the Dudley P. Jackson Award as the Outstanding Resident for Excellence in Teaching . He did his fellowship in Pulmonary and Critical Care Medicine at UCSD, during which time he was awarded the American Lung Association of California Research Fellowship Grant and the ACCP Young Investigator Award . As a faculty member, he has received thirteen annual Outstanding Teaching Awards from the UCSD Department of Medicine. He is the lead editor of the educational textbook, the Manual of Clinical Problems in Pulmonary Medicine . He served as President of the California Thoracic Society and as a member of numerous steering committees of the ACCP networks. The California Thoracic Society gave him their annual “ Outstanding Clinician Award ” in 2008. Dr. Morris’ NIH-funded research is in the area of pulmonary embolism. He is an author of the current ACCP Consensus Guidelines on therapy for pulmonary embolism. He was a two-time recipient of the Distinguished Scholar in Thrombosis Award , American College of Chest Physicians for 2003-2007. He received the First Place Award for Best Research Abstract presented at CHEST by the American College of Chest Physicians in 2006. In 2009, he was awarded the “ Certificate of Achievement from as the Clinical Expert in Pulmonary Embolism ” by The American Thoracic Society and The CHEST Foundation: Award in Venous Thromboembolism by The American College of Chest Physicians. He also received the “ Very Tall Pulmonary Doctor ” certificate, the “ Most Interesting Head Injury Story ” award, the coveted “ Most Italicized Words in a Paragraph Award ” and the “ Nobody Ever Reads This Far Into a Biography ” award. Dr. Morris has two children, both of whom are in college. He constantly embarrasses them.
OBJECTIVES: Participants should be better able to: 1. Understand the definition of respiratory compromise and the impact of respiratory compromise on outcomes of hospitalized patients; 2. Understand the different mechanisms by which patients may progress from stability to respiratory compromise to respiratory failure; 3. Define five categories of respiratory compromise and understand the mechanisms of deterioration within each category. T H U R S D A Y , M A R C H 3 , 2 0 1 6 1 0 :3 0 A M
3/8/2016 Respiratory Compromise Timothy A. Morris, MD FCCP President, National Association for Medical Direction of Respiratory Care Clinical Service Chief, Division of Pulmonary, Critical Care Medicine and Sleep Medical Director of Respiratory Care and Pulmonary Function Laboratory University of California, San Diego Dr. Morris has declared no conflicts of interest related to the content of his presentation. 1
3/8/2016 Conflicts of Interest • None 1. What percentage of in-hospital deaths are associated with respiratory conditions? A. 0-5% B. >5% - 10% C. >10% - 15% D. >15% - 20% E. >20% - 25% F. >25% 2
3/8/2016 1. What percentage of in-hospital deaths are associated with respiratory conditions? A. 0-5% 48% B. >5% - 10% C. >10% - 15% 27% 18% D. >1>20% - 25% 6% 0% 0% E. >20% - 25% A. B. C. D. E. F. F. >25% 2. The in-hospital mortality of patients admitted with COPD is? A. 0-5% B. >5% - 10% C. >10% - 15% D. >15% - 20% E. >20% - 25% F. >25% 3
3/8/2016 2. The in-hospital mortality of patients admitted with COPD is? A. 0-5% 31% B. >5% - 10% 19% 19% 19% C. >10% - 15% 12% D. >15% - 20% 0% E. >20% - 25% A. B. C. D. E. F. F. >25% 3. Among in-hospital patients with pneumococcal pneumonia, which of the following is true: A. HCAP has less than half the 30 day mortality of CAP B. HCAP has about the same 30 day mortality as CAP C. HCAP has more than twice the 30 day mortality of CAP 4
3/8/2016 3. Among in-hospital patients with pneumococcal pneumonia, which of the following is true: A. HCAP has less than half 86% the 30 day mortality of CAP B. HCAP has about the same 14% 30 day mortality as CAP 0% A. B. C. C. HCAP has more than twice the 30 day mortality of CAP 4. Among in-hospital patients with pneumococcal pneumonia, which of the following is true: A. HCAP has less than half the ICU admission rate of CAP B. HCAP has about the same ICU admission rate as CAP C. HCAP has more than twice the ICU admission rate of CAP 5
3/8/2016 4. Among in-hospital patients with pneumococcal pneumonia, which of the following is true: A. HCAP has less than half the 79% ICU admission rate of CAP B. HCAP has about the same 21% ICU admission rate as CAP 0% A. B. C. C. HCAP has more than twice the ICU admission rate of CAP 5. Pulse oximetry would be least likely to give an early warning sign of respiratory deterioration in which type of patient? A. Obese post-op patient on an opiate infusion B. Bacterial pneumonia C. Status asthmaticus D. Congestive heart failure E. Acute pulmonary embolism 6
3/8/2016 5. Pulse oximetry would be least likely to give an early warning sign of respiratory deterioration in which type of patient? 53% A. Obese post-op patient on an opiate infusion B. Bacterial pneumonia 17% 13% 10% C. Status asthmaticus 7% D. Congestive heart failure A. B. C. D. E. E. Acute pulmonary embolism 6. Telemetry EKG would be least likely to give an early warning sign of respiratory deterioration in which type of patient? A. Obese post-op patient on an opiate infusion B. Bacterial pneumonia C. Status asthmaticus D. Congestive heart failure E. Acute pulmonary embolism 7
3/8/2016 6. Telemetry EKG would be least likely to give an early warning sign of respiratory deterioration in which type of patient? 30% 30% A. Obese post-op patient on an 20% opiate infusion 10% 10% B. Bacterial pneumonia C. Status asthmaticus D. Congestive heart failure A. B. C. D. E. E. Acute pulmonary embolism 7. Vital signs q 6 h would be least likely to give an early warning sign of respiratory deterioration in which type of patient? A. Obese post-op patient on an opiate infusion B. Bacterial pneumonia C. Status asthmaticus D. Congestive heart failure E. Acute pulmonary embolism 8
3/8/2016 7. Vital signs q 6 h would be least likely to give an early warning sign of respiratory deterioration in which type of patient? A. Obese post-op patient on an 43% opiate infusion B. Bacterial pneumonia C. Status asthmaticus 19% 19% 11% D. Congestive heart failure 8% E. Acute pulmonary embolism A. B. C. D. E. Respiratory Compromise • A state in which there is a high likelihood of decompensation into respiratory failure or death, but for which specific interventions (enhanced monitoring or therapies) might prevent or mitigate decompensation. 9
3/8/2016 Why define “respiratory compromise”? • Respiratory illness is just another reason for hospitalization • The care of patients who are worsening is obvious • Existing “rescue systems” are already adequate – ICU – Rapid response teams • My hospital won’t benefit by focusing on respiratory patients at risk of respiratory failure Why define “respiratory compromise”? • Respiratory illness is just another reason for hospitalization • The care of patients who are worsening is obvious • Existing “rescue systems” are already adequate – ICU – Rapid response teams • My hospital won’t benefit by focusing on respiratory patients at risk of respiratory failure 10
3/8/2016 In-hospital deaths 1. Le Guen M and Tobin A. Epidemiology of in-hospital mortality in acute patients admitted to a tertiary level hospital. Internal medicine journal. 2016. Survival of COPD patients in resp failure admitted to ICU 24.5% in-hospital mortality 1. Ai-Ping, et al. In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study. Journal/Chest. 128(2)518-524 11
3/8/2016 Pulmonary embolism as a cause of inpatient death Baglin et al. J Clin Path 1997 HCAP vs CAP 1. Rello J, Lujan M, Gallego M, Valles J, Belmonte Y, Fontanals D, Diaz E and Lisboa T. Why mortality is increased in health-care- associated pneumonia: lessons from pneumococcal bacteremic pneumonia. Chest. 2010;137:1138-44. 12
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