Healthcare Service Improvement Team
Primary and secondary
prevention of
chronic respiratory failure
Author:
Date:
Norma Prosser, Dr Mary Webb, Public Health Specialists
3 September 2010
Version:
1
Publication/ Distribution:

Public (Internet)
Review Date:
A review of this document is not planned by Public Health
Wales NHS Trust
Purpose and Summary of Document:
This is an evidence-based summary of effective interventions for primary
and secondary prevention of chronic respiratory failure. It has been
produced to assist local health boards to implement Designed for people
with chronic conditions, Service development and commissioning directives,
Chronic respiratory conditions, and should be read in conjunction with that
publication.
Smoking cessation, influenza and pneumococcal vaccination in accordance
with national guidance, monitoring and continued medical management of
those with chronic lung disease have been identified as prevention
interventions.
Work Plan reference: HS04
Public Health Wales
Primary and secondary prevention of
chronic respiratory failure
CONTENTS
1
BACKGROUND ......................................................................... 3
2
CHRONIC RESPIRATORY FAILURE .......................................... 3
2.1 Introduction ......................................................................... 3
2.2 Search methodology ............................................................. 4
2.3 Prevalence ........................................................................... 4
2.4 Hospital admissions .............................................................. 5
3
PRIMARY PREVENTION INTERVENTIONS ............................... 6
4
SECONDARY PREVENTION INTERVENTIONS ........................... 7
5
FURTHER INFORMATION ........................................................ 7
6
REFERENCES ........................................................................... 7
© 2010 Public Health Wales NHS Trust.
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to Public Health Wales NHS Trust to be stated.
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1
Primary and secondary prevention of
chronic respiratory failure
Background
This document has been produced to assist local health boards to
implement the Welsh Assembly Government’s, Designed for people with
chronic conditions, Service development and commissioning directives,
Chronic respiratory conditions1, and should be read in conjunction with
that publication.
A key action identified in chapter 2: Prevention – reducing the risks (p.
22) of the publication is evidence-based primary and secondary
prevention1.
To supplement the evidence–base, and provide an overview of the topic,
information with regard to prevalence (where available); hospital
admissions (where information is available from Patient Episode Database
Wales - PEDW); and links to additional information resources have been
included. The links to the additional information resources is included to
indicate where further details, or management and treatment guidance
can be sought.
The information contained in this document is not exhaustive.
2
Chronic respiratory failure
2.1
Introduction
Respiratory failure refers to inadequate gas exchange between the lungs
and the blood that result in arterial oxygen and/or carbon dioxide levels
not being maintained within their normal ranges. A drop in blood
oxygenation is known as hypoxemia. A rise in arterial carbon dioxide
levels is hypercapnia2. Hypoxemia and hypercapnia may be either acute or
chronic3.
Acute respiratory failure is characterized by life-threatening derangements
in arterial blood gases and acid-base status. The manifestations of chronic
respiratory failure are less dramatic and may not be as readily apparent3.
Acute hypercapnic respiratory failure develops over minutes to hours.
Chronic respiratory failure develops over several days or longer, allowing
time for renal compensation and an increase in bicarbonate
concentration3.
The distinction between acute and chronic hypoxemic respiratory failure
cannot readily be made on the basis of arterial blood gases. The clinical
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Public Health Wales
Primary and secondary prevention of
chronic respiratory failure
markers of chronic hypoxemia, such as polycythemia or cor pulmonale,
suggest a long-standing disorder3.
2.2
Search methodology
Search terms used: primary prevention, secondary prevention, chronic
respiratory failure.
Search terms were kept broad to maximise retrieval of literature and
search limits set to retrieve papers published between January 2003 to
January 2010.
Electronic databases: Medline; Embase; Cochrane Database of Systematic
Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central
Register of Controlled Trials and British Nursing Index.
Meta search engines: Turning Research Into Practice (TRIP); Google
Scholar; SUMsearch.
Websites: NHS Evidence; International Network of Agencies for Health
Technology Assessment (INAHTA); National Institute for Health and
Clinical Excellence (NICE); National Horizon Scanning Centre and Map of
Medicine; UpToDate.
2.3
Prevalence
Respiratory failure is a syndrome rather than a single disease process, and
the overall frequency of respiratory failure is not well known3.
The mortality rate associated with respiratory failure varies according to
the etiology. For acute respiratory distress syndrome, the mortality rate is
approximately 45% in most studies. This percentage has not changed
over the years3.
Respiratory failure can arise from an abnormality in any of the
components of the respiratory system and may be associated with a
variety of clinical manifestations, including the airways, alveoli, central
nervous system, peripheral nervous system, respiratory muscles, and
chest wall. Patients who have hypoperfusion secondary to cardiogenic,
hypovolemic, or septic shock often present with respiratory failure3.
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2.4
Primary and secondary prevention of
chronic respiratory failure
Hospital admissions
Figure 1: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of chronic respiratory failure (ICD-10, J98) by Unitary Authority
Number of people admitted to hospital with a principal diagnosis of chronic respiratory failure
2008
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Unitary Authority
Figure 2: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of chronic respiratory failure (ICD-10, J98) by Local Health
Board
Number of people admitted to hospital with a principal diagnosis of chronic respiratory failure
2008
120
Admissions
100
80
60
40
20
0
Betsi Cadw aladar
University
Pow ys
Hyw el Dda
Abertaw e Bro
Morganw w g
Cardiff and Vale
University
Cw m Taf
Aneurin Bevan
Local Health Board
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Primary and secondary prevention of
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Table 1: Persons admitted to hospital in Wales in 2008 with a principal
diagnosis of chronic respiratory failure (ICD-10, J98)
Local Health Board
Betsi Cadwaladr University
Unitary Authority
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Powys
Ceredigion
Pembrokeshire
Carmarthenshire
Swansea
Neath Port Talbot
Bridgend
Vale of Glamorgan
Cardiff
Rhondda Cynon Taff
Merthyr Tydfil
Caerphilly
Blaenau Gwent
Torfaen
Monmouthshire
Newport
Powys
Hywel Dda
Abertawe Bro Morgannwg
Cardiff and Vale University
Cwm Taf
Aneurin Bevan
Total
Admission
s
12
25
11
7
15
5
19
17
12
32
15
19
16
38
47
8
36
18
10
15
18
395
Source: PEDW
Note: - data not shown due to small counts (less than five admissions)
3
Primary prevention interventions
Primary prevention is based on risk awareness of relevant medical
conditions or trauma, and control or correction of underlying illnesses or
injuries4.
There is evidence that the administration of influenza and pneumococcal
vaccinations to patients at risk of respiratory failure e.g. patients with
asthma or chronic obstructive pulmonary disease (COPD) can help prevent
respiratory failure in vulnerable groups. However, there is controversy
regarding whether influenza vaccination of general populations,
particularly the elderly, is effective in preventing pneumonia4.
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Primary and secondary prevention of
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Smoking cessation for all patients with lung disease limits the progression
of pulmonary dysfunction and subsequent development of respiratory
failure4.
4
Secondary prevention interventions
Monitoring and continued medical management of patients with relevant
chronic lung disease e.g. asthma, helps limit acute exacerbations and
reduces the risk of respiratory failure5.
Chronic respiratory failure (CRF) is most frequently caused by COPD and
short periods of daytime intermittent positive pressure breathing should
not be used6. Non invasive ventilation (NIV) is used to treat patients with
CRF and a commissioning policy for NIV services exists in Wales7. Bi-level
non-invasive positive pressure ventilation may be a useful adjunct for a
subset of patients with severe stable chronic obstructive pulmonary
disease8.
Some patients with neurological disease or spinal cord injury develop
respiratory failure and become dependent on mechanical ventilation.
Prolonged ventilatory support may be provided by invasive (intubated)
mechanical ventilation or non-invasive ventilation. Diaphragmatic pacing
by phrenic nerve stimulation using implanted electrodes in the neck or
chest is an alternative for some patients with spinal cord injury or
neurological disease.
The National Institute of Clinical Excellence (NICE)9 recently reviewed the
evidence for intramuscular diaphragm stimulation, an alternative form of
diaphragmatic pacing that aims to achieve full or partial weaning from
mechanical ventilation. It concluded that current evidence on its efficacy is
inadequate and therefore this procedure should only be used with special
arrangements.
5
Further information
British Thoracic Society:
 Guidelines for the ventilatory management of hypercapnic
respiratory failure – due for publication 2011/12;
 Non-invasive ventilation in COPD; management of acute type 2
respiratory failure;
 Non-invasive ventilation in acute respiratory failure.
http://www.brit-thoracic.org.uk/
6
References
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Primary and secondary prevention of
chronic respiratory failure
1.
Welsh Assembly Government. Designed for people with chronic
conditions. Service development and commissioning directives.
Chronic respiratory conditions. Cardiff: WAG; 2007. Available at:
http://wales.gov.uk/dhss/publications/health/strategies/chronicrespir
atory/respiratorye.pdf;jsessionid=2T6fLNkJTBJcQ0ZzBLgcJfCjsXtmc0K
0JKQvB4X1JnQp1hHbqZsG!-330498905?lang=en [Accessed 11th Mar
2010]
2.
BMJ Group [Website]. BMJ Evidence Centre. Best Practice.
Respiratory failure – Summary Available at:
http://bestpractice.bmj.com/best-practice/monograph/853.html
[Accessed 18th May 2010]
3.
Kaynar AM, Sharma S. Respiratory failure. Emedicine Available at:
http://emedicine.medscape.com/article/167981-overview [Accessed
14th Apr 2010]
4.
BMJ Evidence Centre [Website]. Best Practice. Respiratory failure Primary prevention.
http://bestpractice.bmj.com/best-practice/monograph/853.html
[Accessed 14th Apr 2010]
5.
BMJ Evidence Centre [Website]. Best Practice. Respiratory failure Secondary prevention.
http://bestpractice.bmj.com/best-practice/monograph/853.html
[Accessed 14th Apr 2010]
6.
Bott J et al. Guidelines for the physiotherapy management of the
adult, medical, spontaneously breathing patient. Thorax 2009;
64(Suppl I): i1–i51. doi:10.1136/thx.2008.110726 Available at:
http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Physiotherapy/Physi
otherapyGuideline/PhysioFullGuideline.pdf [Accessed 14th Apr 2010]
7.
Health Commission Wales (Specialist Services). Non – invasive
ventilation for management of chronic Type ll respiratory failure commissioning policy. Cardiff: WAG; 2007. Available at:
http://cymru.gov.uk/dhss/publications/healthcommission/policies/non
invasive/ventilatione.pdf;jsessionid=YJJGLN4PKnvPwbrzhhQHYNWprjF
SfpzMxjbwwTvLyszfS5gyTGBy!-330498905?lang=en&ts=3 [Accessed
14th Apr 2010]
8.
Kolodziej MA et al. Systematic review of noninvasive positive pressure
ventilation in severe stable COPD. Eur Respir J 2007; 30: 293-306.
Available at:
http://www.erj.ersjournals.com/content/30/2/293.full.pdf+html
[Accessed 14th Apr 2010]
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9.
Primary and secondary prevention of
chronic respiratory failure
National Institute for Health and Clinical Excellence. Intramuscular
diaphragm stimulation for ventilator-dependent chronic respiratory
failure due to neurological disease. IPG307. London: NICE; 2009.
Available at: http://guidance.nice.org.uk/IPG307. [Accessed 14th Apr
2010]
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