Evaluation of respiratory volume monitoring (RVM) to detect respiratory compromise in advance of pulse oximetry and help minimize false desaturation alarms

Galvagno, Samuel M.; Duke, Peggy G.; Eversole, Daniel; George, Edward

doi:10.1097/ta.0000000000001152

Cited by 18 publications

(10 citation statements)

References 23 publications

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“…The data suggest that the RVM can provide more clinically useful information than capnography during procedural sedation. These results are in-line with the findings that the RVM provides an indication of respiratory depression in advance of changes in pulse oximetry in patients following orthopedic procedures [31] and can also be used to identify and quantify respiratory depression following the administration of midazolam peri-operatively [32]. Furthermore, Holley et al demonstrated the superiority of MV moniting over monitoring RR alone during procedural sedation for upper endoscopic procedures [33].…”

Section: Discussionsupporting

confidence: 76%

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation

Mehta

Williams

Harvey³

et al. 2017

PLoS ONE

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BackgroundMonitoring respiratory status using end tidal CO2 (EtCO2), which reliably reflects arterial PaCO2 in intubated patients under general anesthesia, has often proven both inaccurate and inadequate when monitoring non-intubated and spontaneously breathing patients. This is particularly important in patients undergoing procedural sedation (e.g., endoscopy, colonoscopy). This can be undertaken in the operating theater, but is also often delivered outside the operating room by non-anesthesia providers. In this study we evaluated the ability for conventional EtCO2 monitoring to reflect changes in ventilation in non-intubated surgical patients undergoing monitored anesthesia care and compared and contrasted these findings to both intubated patients under general anesthesia and spontaneously breathing volunteers.MethodsMinute Ventilation (MV), tidal volume (TV), and respiratory rate (RR) were continuously collected from an impedance-based Respiratory Volume Monitor (RVM) simultaneously with capnography data in 160 patients from three patient groups: non-intubated surgical patients managed using spinal anesthesia and Procedural Sedation (n = 58); intubated surgical patients under General Anesthesia (n = 54); and spontaneously breathing Awake Volunteers (n = 48). EtCO2 instrument sensitivity was calculated for each patient as the slope of a Deming regression between corresponding measurements of EtCO2 and MV and expressed as angle from the x-axis (θ). All data are presented as mean ± SD unless otherwise indicated.ResultsWhile, as expected, EtCO2 and MV measurements were negatively correlated in most patients, we found gross systematic differences across the three cohorts. In the General Anesthesia patients, small changes in MV resulted in large changes in EtCO2 (high sensitivity, θ = -83.6 ± 9.9°). In contrast, in the Awake Volunteers patients, large changes in MV resulted in insignificant changes in EtCO2 (low sensitivity, θ = -24.7 ± 19.7°, p < 0.0001 vs General Anesthesia). In the Procedural Sedation patients, EtCO2 sensitivity showed a bimodal distribution, with an approximately even split between patients showing high EtCO2 instrument sensitivity, similar to those under General Anesthesia, and patients with low EtCO2 instrument sensitivity, similar to the Awake Volunteers.ConclusionsWhen monitoring non-intubated patients undergoing procedural sedation, EtCO2 often provides inadequate instrument sensitivity when detecting changes in ventilation. This suggests that augmenting standard patient care with EtCO2 monitoring is a less than optimal solution for detecting changes in respiratory status in non-intubated patients. Instead, adding direct monitoring of MV with an RVM may be preferable for continuous assessment of adequacy of ventilation in non-intubated patients.

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Section: Discussionsupporting

confidence: 76%

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation

Mehta

Williams

Harvey³

et al. 2017

PLoS ONE

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“…Minute ventilation is measured using a respiratory volume monitor. Clinical studies indicate that monitoring minute ventilation is effective, comfortable for the patient, and in some cases more effective in detecting OIRD than measuring respiratory rate, oxygen saturation, or end tidal CO 2 (Ebert, Middleton, & Makhija, 2017;Galvagno, Duke, Eversole, & George, 2016;Holley et al, 2016;Mehta, Cattano, Brayanov, & George, 2017;Voscopoulos, Theos, Tillmann Hein, & George, 2017;Voscopoulos et al, 2014). See Table 8 for additional information on minute ventilation.…”

Section: Oxygen Saturationmentioning

confidence: 99%

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions

Jungquist

Quinlan-Colwell

Vallerand

et al. 2020

Pain Management Nursing

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a b s t r a c tObjectives: This report presents up-to-date evidence and expert consensus-based revisions to the ASPMN 2011 guidelines that inform interprofessional clinical decision-making for hospitalized adults receiving opioid analgesics. Design: Systematic review of the literature. Methods: A 14-member expert panel was charged with reviewing and grading the strength of scientific evidence published in peer reviewed journals and revising the ASPMN 2011 existing guidelines. Panel members formulated recommendations based on the strength of evidence and reached consensus through discussion, reappraisal of evidence, and voting by majority when necessary. The American Society of Anesthesiologists evidence categories for grading and classifying the strength of the evidence were used. Recommendations were subjected to a critical review by ASPMN members as well as external reviews. Results: The 2011 guidelines were found to still be relevant to clinical practice, but new evidence substantiated refinement and more specific recommendations for electronic monitoring. The revised guidelines present risk factors divided into three categories: patient-specific, treatment-related, and environment of care. Specific recommendations for the use of electronic monitoring are delineated. Conclusions: All hospitalized patients that are administered opioids for acute pain are at risk of opioid induced advancing sedation and respiratory depression, but some patients are at high risk and require extra vigilance to prevent adverse events. All patients must be assessed for level of risk. Adaptations to the plan of care and monitoring strategies should be driven by iterative re-assessments according to level of risk.

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“…The RVM is a noninvasive impedance-based monitor that provides continuous real-time measurements of V E , V T , and breathing frequency. [10][11][12][13][14][15] The impedance signal was recorded via an electrode PadSet, which was placed on the patient with electrodes at the sternal notch, xiphoid, and the mid-axillary line at the level of the xiphoid. 16 The RVM automatically calculated V E , V T , and breathing frequency from the impedance signal with an average error of ϳ10% for V E and V T , and ϳ2% for breathing frequency relative to a spirometer.…”

Section: Equipmentmentioning

confidence: 99%

“…The threshold for a low V E alarm was set to 40% of predicted V E sustained for 2 min as described in the literature. 12,13,17 Because previous studies have demonstrated that breathing frequency alone is a poor indicator of respiratory sufficiency, missing Ͼ80% of low V E measurements, 18,19 low breathing frequency alarms were not enabled. Importantly, many patients with obstructive sleep apnea have prolonged apneas followed by large "rescue breaths" but maintain an adequate V E , so low breathing frequency alarms can lead to multiple nuisance alarms in patients with overall adequate ventilation.…”

Section: Equipmentmentioning

confidence: 99%

“…While previous research demonstrated that RVM can potentially lower the incidence of false alarms in the post-anesthesia care unit (PACU) compared to pulse oximetry, 12 the actual alarm rate of RVM has not been evaluated. Therefore, we sought to evaluate the use of RVM in the perioperative setting at multiple centers to characterize the clinical use of the RVM during the perioperative period in the PACU, including alarm rates of RVM along with corresponding interventions by clinical staff.…”

Section: Introductionmentioning

confidence: 99%

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Respiratory Volume Monitoring in the Perioperative Setting Across Multiple Centers

et al. 2020

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BACKGROUND: The prevalence of nuisance (technical) alarms is the leading cause of alarm fatigue resulting in decreased awareness and a reduction in effective care. The Joint Commission identified in their National Patient Safety goals alarm fatigue as a major safety issue. The introduction of noninvasive respiratory volume monitoring (RVM) has implications for effective perioperative respiratory status management. We evaluated this within the Kaiser Permanente health system. METHODS: This observational study was conducted at 4 hospitals in the Kaiser Permanente system. Standard data from RVM, pulse oximetry, and capnography were collected postoperatively in the post-anesthesia care unit (PACU) and/or on the general hospital floor. Devicespecific alarm types, rates, and respective actions were recorded and analyzed by non-study staff. RESULTS: RVM was applied to 247 subjects (143 females, body mass index 32.3 ؎ 8.7 kg/m 2 , age 60.9 ؎ 13.9 y) providing 2,321 h. RVM alarms occurred 605 times (0.25 alarms/h); 64% were actionable and addressed, 17% were not addressed, 13% were self-resolved, and only 6% were nuisance. In a subgroup, RVM completed all 127 h of monitoring, whereas oximetry with capnography only completed 51 h with 12.9 alarms/h (73% nuisance). The overall RVM alarm rate was significantly lower than with either pulse oximeters or capnography monitors. We saw a nearly 1,000-fold reduction in nuisance alarms compared to capnography and a 20-50-fold reduction in nuisance alarms compared to pulse oximetry. CONCLUSIONS: Our study indicates that alarm fatigue due to nuisance alarms continues to be a clinical challenge in perioperative settings. Among the 3 common technologies for respiratory function monitoring, RVM had the lowest rate of overall technical alarms and the highest rate of compliance. Furthermore, with early interventions, none of the subjects monitored with RVM suffered any negative outcomes.

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Evaluation of respiratory volume monitoring (RVM) to detect respiratory compromise in advance of pulse oximetry and help minimize false desaturation alarms

Abstract: Diagnostic study, level II.

Cited by 18 publications

References 23 publications

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions

Respiratory Volume Monitoring in the Perioperative Setting Across Multiple Centers

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