Association Between Rating of Respiratory Distress and Vital Signs, Severity of Illness, Intubation, and Mortality in Acutely Ill Subjects

Abstract

BACKGROUND: When deciding whether mechanical ventilation is indicated, physicians integrate their findings on physical examination in a gestalt known as respiratory distress. Despite its importance, this gestalt is poorly understood. This study aims to describe the association between the rating of the severity of respiratory distress and vital signs, severity of illness, use of mechanical ventilation, and death. A prospective observational study with 1,134 consecutive subjects with uncertain triage evaluated by a critical care consult team was carried out in a public inner city teaching hospital. METHODS: After the initial evaluation of each patient, a critical care physician rated the level of respiratory distress. We recorded vital signs, diagnosis, and laboratory results and calculated the Acute Physiology and Chronic Health Evaluation (APACHE) II score. We recorded if mechanical ventilation was initiated by 72 h and if the subject died during the hospitalization. RESULTS: The most common diagnoses were respiratory illnesses. Higher distress levels were associated with higher breathing frequency (20, 22, 27, and 30 breaths/min, P < .001) and heart rate (96, 101, 109, and 116 beats/min, P < .001) and lower S pO 2 (97, 95, 93, and 92%, P < .001). These variables explain only a small portion of the variance of distress. Distress correlated weakly with the APACHE II score (r ‫؍‬ 0.22, P ‫؍‬ .001). Blood pressure, temperature, Glasgow coma scale score, and laboratory data were unrelated to the levels of distress. However, higher levels of distress correlated with intubation rates (5, 13, 27, and 41%, P < .001). The area under the receiver operating characteristic curve for respiratory distress predicting intubation (0.72) was larger than that for breathing frequency (0.65). Distress was an independent predictor of intubation but not of death. CONCLUSIONS: A physician's rating of respiratory distress is independently predictive of intubation in 72 h. Vital signs explain only a small proportion of variance in distress; the other observations contributing to a physician's rating of distress must be determined.

Targeted-Volume Noninvasive Ventilation Reduces Extubation Failure in Postextubated Medical Intensive Care Unit Patients: A Randomized Controlled Trial

“…However, we hypothesized that the targeted-volume NIV might be more suitable than conventional targeted-pressure NIV due to more steady TV. In this study, respiratory rate and heart rate during postextubation were significantly lower in targeted-volume NIV group compared to oxygen mask group which may indicate reduction in work of breathing from respiratory muscle resting[ 9 25 ] [ Figure 4 ]. On the other hand, excessive TV may result in an excessive leakage, causing suboptimal benefit of NIV and may lead to NIV failure.…”

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

“…[8,15,16] Although both are manifestations of increased work of breathing,[17,18] we selected distress because physicians rely on their observations of patients in determining the need for respiratory support and do so independent of patients’ ability to express dyspnea or its severity. [2,19] This choice was reasonable also because the rating of respiratory distress by physicians predicts the need for mechanical ventilation,[4] and because it is as reproducible as dyspnea. [8,20]…”

“…It cannot be easily measured at the bedside and physicians have to rely on their examination of the signs of increased breathing effort or on their gestalt of a patient’s effort—commonly referred to as respiratory distress. [2,4]…”

Broadcasting Not Properly: Using B‐type Natriuretic Peptide Interval Likelihood Ratios and the Results of Other Emergency Department Tests to Diagnose Acute Heart Failure in Dyspneic Patients

“…On the other hand, while individual examination findings may be unhelpful in diagnosing AHF, those first 2 minutes in the examination room are critical to the evaluation of the patient. In general, we are skeptical of intuitive decision‐making, but the experienced clinician is often able to distinguish the severely from the moderately ill based on a brief in‐person evaluation, often without even using a stethoscope …”