Clinical paperRisk of cardiopulmonary arrest after acute respiratory compromise in hospitalized patients☆,☆☆
Introduction
During the course of their care, hospitalized patients with serious medical conditions such as shock, aspiration, pulmonary edema or stroke may develop unexpected acute respiratory compromise (ARC). Occurring throughout the hospital, these crises may require emergency rescue therapy such as bag-valve-mask ventilation or endotracheal intubation, among others.1, 2, 3 To provide prompt emergency care and to prevent progression to cardiopulmonary arrest (CPA), many hospitals have developed medical emergency response systems to care for these patients. However, only limited data describe the risk of CPA after ARC, the characteristics of patients progressing to CPA, or the subsequent clinical course of these patients. Enhanced understanding of these factors could help refine system plans for the emergent care provided to ARC victims.
In this study we determined the characteristics and clinical course of hospitalized patients developing ARC. Specifically, we identified the proportion of ARC patients progressing to CPA, the elapsed time from ARC recognition to CPA, the clinical factors associated with developing CPA, and subsequent survival to hospital discharge.
Section snippets
Methods
The University of Pittsburgh Institutional Review Board approved this study.
We identified adult (age ≥18 years) acute respiratory compromise (ARC) cases from patients enrolled in the National Registry of Cardiopulmonary Resuscitation (NRCPR). Initiated in 2000, NRCPR is an international quality improvement database of resuscitation events at hospitals in the United States, Canada, Germany, Brazil and Japan. Using standard data collection forms, participating facilities provide structured data
Results
There were 4358 adult ARC events. The mean patient age was 65.7 years (95% CI: 65.2, 66.2). The majority of patients were male (54.1%) (Table 1). Over one-fourth of ARC events occurred in general inpatient units. The remaining cases occurred in intensive care units, step down units, emergency departments and other hospital or healthcare units.
The ARC event ended with controlled ventilation in 3145 (72.2%; 95% CI: 70.8, 73.5%) and return of spontaneous ventilation in 487 (11.1%; 10.3, 12.1%);
Discussion
Even when receiving appropriate care, a portion of hospitalized patients may deteriorate acutely and unexpectedly, requiring rescue therapy for ensuing ARC. The early identification of these cases offers opportunities to initiate stabilizing airway, ventilatory, pharmacologic and other interventions. Hospitals have invested in medical emergency response teams to expedite emergency care and to prevent these patients from deteriorating to CPA. Despite these systems of rescue care, in this series
Conclusion
Approximately one in six patients experiencing initial ARC deteriorates to CPA. Most CPA occur within 10 min of ARC recognition. Improved ARC recognition, hospital emergency team response and airway management may potentially enhance care and outcomes for these critically ill patients.
Conflicts of interest
None.
Acknowledgements
We acknowledge Matthew D. Weaver, NREMT for his assistance with preparing the manuscript. Dr. Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Details of funding: Dr. Wang is supported by Clinical Scientist Development Award K08-HS013628 from the Agency for Healthcare Research and Quality, Rockville, MD, USA. This research was independent from the funders.
References (17)
- et al.
Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial
Lancet
(2001) - et al.
Long-term survival after successful inhospital cardiac arrest resuscitation
Am Heart J
(2007) - et al.
Naloxone
Ann Emerg Med
(1983) - et al.
Misplaced endotracheal tubes by paramedics in an urban emergency medical services system
Ann Emerg Med
(2001) - et al.
Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation
Ann Emerg Med
(2003) - et al.
Urgent tracheal intubation in general hospital units: an observational study
J Clin Anesth
(2007) - et al.
Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts
Ann Emerg Med
(2005) - et al.
Airway management in the emergency department: a one-year study of 610 tracheal intubations
Ann Emerg Med
(1998)
Cited by (0)
- ☆
A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.06.025.
- ☆☆
Resuscitation Science Symposium, American Heart Association Scientific Sessions 2007, November 2007, Orlando, Florida.