Caring for people with complex pulmonary illness

Acute respiratory failure and ARDS

Acute respiratory distress syndrome (ARDS) is one cause of severe respiratory failure. Injury and inflammation in the lungs can make it difficult to get enough oxygen into the blood. Treatment supports breathing while the team addresses the underlying illness. Pneumonia and sepsis were prominent causes in the research discussed in the original pulmonary paper.

The historical brief cited estimates of about 190,000 Americans affected annually, mortality around 35–40%, and sepsis or pneumonia associated with 40–60% of diagnoses in the cited literature. The estimates came from different studies and periods. Severity, other illnesses and the population studied all affect interpretation. They do not predict an individual patient’s survival.

Why the paper anticipated higher demand

One driver was severe COVID-19. The paper cited early observational groups in Wuhan in which 42–67% of selected hospitalized or critically ill patients developed ARDS and more than 81% of the people who died in a cited cohort had ARDS. Those data describe selected early-pandemic groups. They cannot be applied to all people with a COVID-19 infection.

Another driver was the interaction between aging and chronic disease. The paper cited an estimate that 64% of adults age 65 or older had two or more chronic conditions and a projection that roughly one in five Americans would be 65 or older by 2030. For a particular referral, record the actual diagnoses, their current effect on breathing, prior functional status and the treatments the person still needs.

What happens after the ICU?

People with severe lung injury may need prolonged ventilation or respiratory rehabilitation. Ventilator support is adjusted to the person’s condition. The team also treats infection, manages fluid and nutrition needs, protects skin and watches for complications of immobility. A breathing trial is one part of that plan.

The original paper cited one study of respiratory therapist-led weaning protocols that reported shorter ventilation, reduced mortality and lower costs in its study population. Another found an association between earlier appropriate LTACH transfer and a higher probability of weaning among people on prolonged ventilation. Study design, case selection and care setting matter when interpreting those results.

Organize a respiratory care plan

• Review the referral for the person’s airway, ventilator or oxygen needs, settings, time on support, recent trial results, coexisting illness and precautions.
• Ask the physician and respiratory team which problem is limiting progress and what clinical change would make another trial appropriate. Confirm how nursing and rehabilitation staff will support the plan.
• Incorporate safe early movement when appropriate. Coordinate the airway, lines, support staff and timing before sitting, standing or transferring.
• Include daily attention to oral care, comfort and skin integrity, especially around devices or areas under pressure. Ask how the person will communicate discomfort.
• Teach patients and families about the planned assessment, ways to take part and important changes to report. Ask how patient experience and clinical outcomes are reviewed.

The source described a historical respiratory-failure program, ventilator rounds, performance tracking, early mobility and pursuit of disease-specific certification. For a Lakeview referral, ask Admissions to review the exact ventilator and monitoring needs of the person under consideration.

Breathing with less support

A ventilator gives breathing support while clinicians treat an illness or injury. Some people still need it after the ICU. The team looks at the underlying illness, the need for oxygen, strength, airway secretions and ability to protect the airway. A spontaneous breathing trial lets clinicians observe what happens with less machine support when it is safe to try.

A person who needs a tracheostomy may need humidification, suctioning, skin care, communication support and a plan for secretions. Ask whether the next goal is a longer breathing trial, a change in the type of support or time to recover before trying again. Progress can vary from one day to the next.

The clinician directing breathing care, respiratory therapist, nurse, pharmacist, dietitian and rehabilitation staff bring different information to rounds. Breathing and mobility sessions must fit around rest, procedures and nutrition. Ask what happened during the last trial, what led the team to stop, and what they are watching before the next trial.

Reading behind the original brief

Talk with Lakeview

Call Lakeview Admissions at (262) 534-8509 to discuss a referral. For clinical records, use the referral fax at (262) 534-8507.