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Respiratory Rates: Why Bother?
Introduction
Blood transfusions are an important part of modern health care but are not a benign
treatment. Haemovigilance reports from the New Zealand Blood Service (NZBS
2013) show that blood transfusions are associated with a small number of adverse
events ranging from mild febrile reactions to serious events such as allergic
reactions, haemolytic reactions, Transfusion Related Acute Lung Injury (TRALI) and
Transfusion Associated Circulatory Overload (TACO). In 2013 there was a report of a
death due to TACO.
Recording a full set of vital signs at least daily is considered a basic standard in most
hospitals especially during blood transfusions. However there is evidence that
recordings are poorly performed (Hillman et al 2005). A full set of vital signs including
temperature, pulse, respiration rate and blood pressure (T, P, R and BP) should be
performed as a baseline, at 15 minutes and be repeated at the conclusion of each
transfusion. (Australian and New Zealand Society of Blood Transfusion -2011).
Further observations will be dependent upon the status of the patient, as well as
individual hospital policies- many of which mandate more frequent observations in
line with early warning score (EWS) principles.
Despite this policy, an observational audit carried out in eight New Zealand hospitals
by the NZBS (2009) showed that of the four vital signs, respiration rate (RR) was
often omitted with only 67% of baseline RR recorded; this dropped to 56% at
completion of the transfusion. This is also confirmed from information obtained from
transfusion reaction reports where only 63% of RR in 2010 were recorded, although
this has risen to 83% in 2014. Hogan (2006) noted that RR was recorded less than
50% of the time when an EWS system was introduced into one hospital.
The importance of respiratory rate
Ventilation is a product of RR and tidal volume which is in turn controlled by
chemoreceptors in the central nervous system and peripheral vascular system.
Arterial partial pressures of oxygen (PaO2) and of carbon dioxide (PaCO2) drives the
rate of respiration with the level of carbon dioxide being the most important. Any
disease that causes a change in the pH of the circulation (sepsis, trauma) will create
a change in the RR; therefore this measure is a good surrogate marker for changes
occurring in several body systems. An increased RR is a good predictor of potential
serious adverse events (Cretikos et al 2008). The importance of RR is also confirmed
by Goldhill et al (2005) when they documented that inpatients with a RR above 25
bpm had a mortality rate of 21%.
Education
Several authors have stated that a lack of understanding by both junior medical and
nursing staff of the importance of RR may be the reason behind reduced respiratory
monitoring. One author also mentioned that standard education textbooks may not
help in this aspect by confirming the relative lower importance of RR compared to
blood pressures, temperature and pulse which are often done assiduously (Cook and
Smith 2004). The availability of pulse oximetry at the bedside has been useful for
monitoring but they have some limitations with erroneous results from reduced
perfusion the most obvious drawback. The use of pulse oximetry should be seen as
complimentary to RR rather than in place of (Cretikos et al2008: Hogan 2006). It may
be due to the ease of use of pulse oximetry that RRs are omitted. Hogan reported
that nurses didn’t record RR for three reasons; lack of knowledge, time and lack of
equipment. One nurse reported that respiration wasn’t recorded because “Dinamaps
don’t do it”. Mok et al (2015) suggested that although electronic measures of vital
signs have been very useful a disadvantage is reducing patient-nurse interaction
resulting in decreased RR recordings. A recent article in the journal Transfusion
reported on vital sign variations during blood transfusions. Neither respiratory rate
nor pulse oximetry were recorded. Following personal communication with the author
it was discovered that clinical staff at his hospital did not routinely monitor respiratory
rates but no reason was given (Gehrie 2015). Obtaining a respiratory rate does
require a nurse to actually watch the breaths of a patient which in itself can alter the
breathing rate. This was a point that some nurses raised when asked why they didn’t
record respiratory rates (Hogan 2006).
No single vital sign can be used to identify a decline in a patient’s condition but it
appears that RR is the most useful predictor of deterioration. Despite this nurses
overlook the importance of this vital sign for a variety of reasons. EWS systems
which are in use in most New Zealand hospitals have been a proven tool for assisting
in identifying at risk patients early, but they will only be as useful as the person who
uses it. Ongoing education is required to remind nursing staff of the importance of
including RR while monitoring patients, particularly when undergoing invasive
procedures which includes blood transfusions.
References:
1. Australian and New Zealand Society of Blood Transfusion (2011).
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http://www.anzsbt.org.au/publications/documents/ANZSBT_Guidelines_Admi
nistration_Blood_Products_2ndEd_Dec_Plain_Tables.pdf
Cook, C. & Smith, G. (2004) Do textbooks of clinical examination contain
information regarding the assessment of critically ill patients? Resuscitation
2004. Vol 60. 129-136.
Cretikos, M.A., Bellomo, R., Hillman, K., Chen, J., Finfer, S. & Flabouris, A.
(2008) Respiratory Rate: the neglected vital sign. MJA. Vol 188;11 June.
Hillman, K., Chen, J. & Cretikos, M. (2005). MERIT study investigators.
Introduction of the medical emergency team (MET) system: a cluster
randomised controlled trial. Lancet; 365. 2091-2097.
Hogan, J.(2006). Why don’t nurses monitor the respiratory rates of patients?
British Journal of Nursing. Vol15: 9. 489-492.
Gehrie, E.A., Hendrickson, J.E. & Tormey, C.A. (2015). Variation in vital signs
resulting from blood component administration in adults. Transfusion. Vol 55.
August.1866-1871.
Goldhill, D.R., McNarry, A.F., Mandersloot, G., & McGinley, A. (2005) A
physiologically-based early warning score for ward patients: The association
between score and outcome. Anaesthesia Vol 60: 547-553.
Mok, W.Q., Wang, W.W. & Liaw, S.Y. (2015) Vital signs monitoring to detect
patient deterioration: An integrative literature review. International Journal of
Nursing Practice. 21 (suppl 2) 91-98.
New Zealand Blood Service (2013) National Haemovigilance Programme
Annual Report.
http://intranet/clinical%20documents/Haemovigilance/Haemovigilance%20An
nual%20Report%202013.pdf