Acute Pulmonary Insufficiency

When discussing persistence of greater than expected oxygenation problems beyond 48 hours in a post op extubated patient I inquire about whether or not the diagnosis of Acute Pulmonary Insufficiency is applicable with physicians and they simply state they have never heard of the term and or have never seen the definition of it.  Physician’s often use the term ‘Insufficiency’ loosely in there documentation except in the case of Acute Pulmonary Insufficiency. We often see documentation of adrenal insufficiency, arterial insufficiency, acute coronary insufficiency, pancreatic insufficiency, acute renal insufficiency, acute respiratory insufficiency, vertebro- basilar insufficiency etc. 

Let us split the hairs between failure and insufficiency. Merriam Webster dictionary defines failure as “a state of inability to perform a normal function” where the word perform is defined as: to carry out an action. In practice Respiratory Failure is defined as: the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory failure is defined as a P/F ratio < 300, a PaO2 value of less than 60 mm Hg while breathing room air or a PaCO2 of more than 50 mm Hg.

Respiratory is defined as: of or relating to respiration which is movement of gases (as oxygen and carbon dioxide) into and out of the lungs. 

Merriam defines insufficiency as” inability of an organ or body part to function normally” where function is defined as any group related actions contributing to a larger action. Pulmonary is defined as: of, relating to, affecting, or occurring in the lung. 

So what could cause the lungs not to function normally (be insufficient) in the post op patient? Why the prolonged oxygen therapy without a diagnosis? Well we all learned this stuff years ago in med school. The most common causes of course are atelectasis and lung edema. But many other issues exist as well. Reduced tidal volume of up to 50% depending the location of the incision (thorax, upper abdomen).Reduced lung expansion from post op pain, supine position, abdominal distention, sedatives and narcotics. Increased ventilation rate secondary to anxiety leads to loss of normal periodic hyperinflation. Compromised airway defenses secondary to loss of normal cough reflex, decreased ciliary activity and accumulation of secretions. Problems related to laparoscopic surgery include diaphragmatic splinting from pneumoperitoneum. Another issue is the (SIRS) systemic inflammatory state from the trauma of surgery itself in which circulating inflammatory mediators cause edema in the lung parenchyma. Variables predictive of postoperative pulmonary insufficiency include active cigarette smoking, baseline COPD, and cardiac, renal, or bleeding complications. 

CMS has provided an ICD 10 CM code to capture the condition but it needs to be documented as “Acute Pulmonary Insufficiency” for the code to be assigned. The code for Acute Pulmonary Insufficiency was created to capture the cost of treating those patients requiring greater than expected LOS or use of oxygen for hypoxia post operatively. J95.1 Acute Pulmonary Insufficiency (coder will use this code in thoracic surgery cases) J95.2 Acute Pulmonary Insufficiency MCC (coder will use this code in non-thoracic surgery cases).

So if you’re surgical patient is not progressing as expected due to the inability of 1 or both lungs to function normally consider the diagnosis of acute pulmonary insufficiency in your documentation to explain this delay in discharge.

Comments

  • Pulmonary Insufficiency is a real condition and it is sited in several medical textbooks.
    In Clinical Anesthesia, 5th Edition Copyright ©2006 Lippincott Williams & Wilkins Pg 434 Microaggregates have been implicated in the pathogenesis of pulmonary insufficiency and the development of ARDS, which often follows large volume transfusions (defined as >10 to 12 units in 24 hrs). Pg 1918 despite advantages in cardiac surgery and perfusion technology, the deleterious effects of CPB are well documented. These include stroke and neurocognitive defects, renal failure, pulmonary insufficiency, coagulopathy, and activation of a systemic inflammatory response.
      
    In Johns Hopkins Textbook of Cardiothoracic Surgery 2014 Pg 68 Lesions that replace functional lung parenchyma can also cause pulmonary insufficiency. Pg 120 Predictably, pulmonary insufficiency was an issue and 21 percent of patients required at least one reintubation, tracheostomy was necessary in 8.2, and 5. 1 percent could not be weaned Pg 122 Cardiac dysrhythmias, pneumonia, and pulmonary insufficiency constitute the most common causes of morbidity, just as with LVRS.

    In 2013 Principles and Practice of Cardiothoracic Surgery Copyright © 2013 InTech Pg 62 Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to prevent pulmonary insufficiency. Postoperative pulmonary insufficiency occurs because of infection, inability to clear secretions or edema around day 2 or 3, to prevent these from happening attention should be given to physiotherapy, bronchodilators, restriction of intravenous fluids and tracheal toilet. Chest physiotherapy includes deep breathing and coughing exercises and incentive spirometry. Pulmonary insufficiency is more common in patients have low FEV1.

    In 2012 Cardiac Surgery in the Adult Lawrence H. Cohn, MD Pg 267 Even mild residual neuromuscular blockade contributes to pulmonary insufficiency by compromising mechanics of breathing and decreasing negative inspiratory force, vital capacity, tidal volume, and the ability to generate an effective cough.

    In 2011 Springer : CT Surgery in the Elderly Pg 392 Multivariate analyses by Williams et al., who studied a group of 300 octogenarians who underwent isolated coronary artery bypass, revealed that preoperative renal dysfunction (creatinine >2.0 mg/dL), pulmonary insufficiency, and postoperative sternal wound infection were strong predictors of hospital mortality.

    In 20013 Trauma 7th edition pg 485 In patients without a pneumothorax or with a pleural symphysis, insertion of a large-bore needle into the lung in an intubated patient can contribute to fatal systemic air embolism and also cause a pulmonary hematoma with subsequent pulmonary insufficiency.  These conditions are the basis for the traditional A-irway, B-reathing, C-irculation of resuscitation. Infection, sepsis, pulmonary insufficiency, and other functional impairents may occur secondarily, and any or all contribute to the decision to operate and when. Pg 1035Assessing specific pulmonary mechanics can significantly aid in diagnosing and treating a patient’s sudden or progressive pulmonary insufficiency.Pg1040 TCPV is useful in patients with progressive pulmonary insufficiency or ARDS, while also meeting acute respiratory distress syndrome network (ARDSNet) criteria so long as the set driving pressure and PIPs are below 30 cm H 2O pg1113 Since pulmonary function generally shows little improvement with fluid restriction during the initial 24 hours of a massive septic insult, the pulmonary insufficiency appears to result from the sepsis, per se, rather than a PV overload.

    In 2012 Textbook of Critical Care Pg 75 TRALI presents with dyspnea and bilateral pulmonary edema during or within up to 6 hours of a transfusion, with no other risk factors to explain its development. It must be distinguished from pulmonary insufficiency due to circulatory overload, where the central venous pressure and pulmonary artery wedge pressure would be elevated. Pg 701 ECMO is generally used in the adult population for periods of 1 to 10 days when there is marked concomitant pulmonary insufficiency and cardiac failure. The use of ECMO in the adult population for reasons other than primary cardiac failure with secondary pulmonary insufficiency has limited advantages over conventional therapies Pg 704 The hallmarks of cardiogenic shock are low cardiac output, hypotension, peripheral vasoconstriction, cold extremities, poor urine output, and altered mental status. As the pathophysiologic state progresses, pulmonary insufficiency and pulmonary edema ensue. Pg 705 The mode of mechanical support used for cardiogenic shock is determined by a number of factors. The first is the degree of pulmonary insufficiency. If there is pulmonary failure with a very large alveolar-to-arterial oxygen gradient on maximal ventilatory support, ECMO support is indicated. A small percentage of ECMO patients in this setting will recover, some will require VAD placement as a bridge to transplantation, fewer still will bridge to VAD and then to recovery. If the degree of pulmonary insufficiency is limited to pulmonary edema that is likely to recover with adequate cardiac output, patients should undergo VAD placement directly.

    In 2008 Critical Care current diagnosis and treatment Pg 740 The current treatment of inhalation injury is primarily supportive because no specific agent has been identified that minimizes the severity of the insult. The aim of treatment, therefore, is to correct the underlying pulmonary insufficiency while minimizing further iatrogenic pulmonary insults. The amount of intervention required is guided by the severity of pulmonary insufficiency. Pg749Inhalation of aerosolized chemicals may produce pulmonary injury and systemic toxicity, thus requiring accurate diagnosis and aggressive treatment. Varying degrees of pulmonary insufficiency may be agent-specific and manifested by severe airway edema formation, mucosal sloughing, and bronchospasm. Systemic toxicity through pulmonary absorption may occur; thus the causative agents must be clearly identified to ensure appropriate diagnostic and treatment strategies. The degree of pulmonary support required is determined by the severity of pulmonary insufficiency.

    In 2014 Common Problems in Acute Care Surgery, Chapter 8 Page 109 and 2009 Comprehensive Vascular and Endovascular Surgery Chapter 33, Page 569 pulmonary insufficiency is mentioned throughout these chapters.
  • We are being asked by a consultant company to begin querying for acute pulmonary insufficiency following surgery on pts who are requiring O2 and have a GMLOS longer than expected without an obvious reason why but are still on O2.  Are others querying for this diagnosis?
  • Has anyone established clinical criteria for the diagnosis of Acute Pulmonary Insufficiency or created a policy that they are willing to share?
  • Has anyone established the condition pulmonary insufficiency found in many textbooks , including trauma and anesthesia with the ICD coding of pulmonary insufficiency and coding guidelines of such?

    We are tossing this one back and forth and have not formulated an exact plan on how to go about it...


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