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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). 2. 3. 4. 5. 6. 7. 8. 9. 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