Acute Respiratory Failure/Organ Dysfunction

proddy@clarionhospital.org

We have had some interesting conversation  recently amongst our medical staff and CDI regarding Acute Respiratory Failure.  Often we are finding that a patient has a P/F ratio of < 300 or even <250 requiring oxygen, thus meeting the gold standard for diagnosis of Respiratory failure, however they are often managed on 3L NC oxygen.  I know I read somewhere, perhaps on one of these threads, that if the patient requires less than 4 or 5L of O2, it is vulnerable to audit and denials to use a diagnosis of Acute Respiratory Failure.  This week we had a pt with pneumonia, a SOFA score of 2 due to a P/F ratio <300, but no documented life-threatening organ dysfunction (yes we have adopted Sepsis 3 criteria).  I queried  for additional clinical indicators to support/validate the diagnosis of Sepsis as well as any associated organ dysfunction.   Because the patient never required more than 3L O2, and our recent discussions, the attending removed the diagnosis of Sepsis as there was no organ dysfunction.    Anyone one else having similar issues (whether using  Sepsis 3 critieria or not), how are you and your attending  handling situations like this?

evanspx@sutterhealth.org

Excellent question:  One thing that occurs to me is that a patient may qualify for severe sepsis if SOFA scores of  at least 2 or greater are present, and the changes in the SOFA are stated as due to the sepsis. 

 It is interesting to hear the MD removed the diagnosis of Sepsis because by the definition cited by Sepsis 3, 'dysfunction'  due to sepsis (SOFA was 2) is present?   Overt and acute organ failures are not required to achieve SOFA scores that may meet Sepsis 3 criteria. 

Certainly, we all recognize  the precise definition for ARF can be elusive and varies amongst  clinicians.

Here is 'a' definition that some have adopted, and it seems more restrictive than other versions we have all found and used as reference.  I post this particular definition because it does state that 'at least" 4L/min is required in order to meet  criteria.  This particular version does not mention the P/F ratio.

I think the bigger issue here is that, in your case, 'organ dysfunction' in the setting of sepsis is apparently present as a SOFA score of at least 2 was met; this has met Sepsis 3 definition, as such.

source; Maryland Hospital Association

A
-Altered mental status -Tachypnea or lowered respiratory rate -Dyspnea or increased work of breathing -Hemodynamic instability
And
B*
-SpO2 < 92% or a dependence on at least 4L/min of O2 through nasal cannula to prevent SpO2 from dropping below 92% and further decompensation -Acute respiratory acidosis: either a pH<7.35 from an arterial sample or a pH<7.3 from a venous sample
And
C	Intervention
-The unanticipated need for an intervention to support ventilation and/or gas exchange that is physiologically required to prevent decompensation; These interventions may include the use of a mechanical ventilator, BiPAP, or CPAP; These interventions may also include the use of milder support interventions such as oxygen delivered via high flow therapy, non-rebreather mask or nasal cannula delivering at least 4L/min provided that the milder intervention is required for at least 2 hours or longer Paul Evans, RHIA, CCDS

proddy@clarionhospital.org

I guess there is opportunity for more education for myself and perhaps the attending in this case.  Thanks Paul for your quick response.  Although we certainly want to avoid audits and denials, we should be careful to not tailor our documentation or approach medicine that way. I think we get too caught up in criteria sometimes. 

evanspx@sutterhealth.org

My individual belief in regards to ‘sepsis’, being this is so problematic, is to see if organ dysfunctions are present.  If so, and not due to some other process, and potentially due to sepsis, I will query so that any dysfunction due to sepsis is clearly stated as such.  I do this with the mindset that dysfunctions, not just acute failures, may help define the condition.  I think this strategy is helpful with sepsis 2, and technically,  the dysfunctions that can impact the SOFA scores are actually required to be charted so that Sepsis can be coded if Sepsis 3 is adopted.  Hope this is not confusing?

proddy@clarionhospital.org

not confusing at all, thanks Paul!

afrady@blr.com

Late to the party but a couple clarifications.

1) Under Sepsis 3 (or even Mods ((muldti-organ dysfunction syndrome)), "failure" is not required, the threshold is "dysfunction due to infection".  Dr. James Kennedy has a blog on this some where, i believe Pinson may also have written on this.   Under Sep 3, 2+ organ dysfunctions subsequent to a dysregulated host response is criteria threshold.  The actual diagnosis of sepsis however still has to be clincially validated by the MD, making sure other possible exacerbating factors and the patient's pre-exsisting baseline are carefully considered.   

2) The absolute threshold (PF value) or treatment (3L vs 4L) is less important than the patient's baseline.
In a person with very health lungs, anything less than 400 is already considered abnormal and hypoxic.  On the other hand, in a patient with end stage severe COPD, my red flag doesn't go up until it is closer to 250ish.

4L/NC for a 90 year old with end stage COPD is potentially just an exacerbation of his COPD (possibly not even failure) where as a 14 year old soccer player accustomed to running 7 or 8 miles 5 or 6 times a week without even getting winded...now needing even 2L to oxygenate properly may indeed be in respiratory failure and in serious decline.  

Anyone who tells you that only absolute values matter without looking at the patient's pre-existing status and baseline medical information does not understand clinical truth or the thought process that an actual physician has to apply.

There may be an implied "of course this is for elderly patient's as they are the majority" in that 4L/NC requirement, but i prefer it be stated each time and not implied, otherwise it gets inappropriately applied to other patient populations.  

Relevant to another discussion, failure to totally wean may from NC 02  after 4 or so days may be some what expected (and nebulous) to upcode to "post operative respiratory insufficiency" for one patient population, but COMPLETELY appropriate for a different patient population. 

Critical thinking is now required.