The Physician Advisor’s Corner: Documenting Acute and Chronic Respiratory Failure

Premier Pulse     April 2018 Apr 1, 2018

1114925682By Robert Morrison, MD, associate chief medical officer, Miami Valley Hospital, Premier Health physician advisor

Acute Respiratory Failure

Acute respiratory failure is one of those diagnoses that can cause confusion. Here are some pearls to help you document it well:

The established criteria for acute respiratory failure are (all you need is one!):

  • Room Air pO2 less than 60
  • Room Air O2 Sat less than 91 percent
  • pCO2 greater than 50 and pH less than 7.35
  • pO2/FiO2 less than 300
  • pO2 decrease, or pCO2 increase of 10mmHg from baseline

Any of the above will qualify the patient for having acute respiratory failure. Remember that when you document acute respiratory failure based on these criteria, you must specify whether it is hypoxic or hypercarbic – or both – and outline how you made the diagnosis. For example, note that, “This is acute hypoxic respiratory failure as manifested by (insert at least one of the above criteria).” And remember to always link the respiratory failure to the etiology of the failure. For example, document that “…due to a right lower lobe pneumonia….”

Also describe in your notes the respiratory distress that your patient is experiencing. Use tachypnea and bradypnea; describe accessory muscle use; describe lung sounds; describe the patient’s mental status (severely lethargic with slurred speech); write that “the patient is unable to finish a sentence,” if that is the case, or that “he is in extremis and highly anxious,” etc. Consider whether the patient’s life would have been in imminent jeopardy without intervention, and say so in your notes. Paint the picture with words so that no one will question your clinical judgment or treatment plan.

The guideline FIO2 cutoff for acute respiratory failure is 6 liters by nasal cannula or more (which is an FiO2 of 50 percent or higher) to substantiate treatment and call it acute respiratory failure.

Always link the acute respiratory failure to the etiology by noting, for example, that “due to his RLL pneumonia with a large right-sided pleural effusion,” or “due to progressive, end-stage COPD,” etc.

If you feel a patient should be in the hospital, do not hesitate to admit the patient and care for him or her in the hospital even if he or she doesn’t fit the criteria – that is clinical decision-making. But make sure to document your decision in detail, saying, for example, that “the patient is in severe respiratory distress due to status asthmaticus, and despite a pO2 of 62 on room air, it is my clinical judgment that this represents acute respiratory failure requiring aggressive critical care.”

Chronic Respiratory Failure

Chronic respiratory failure should be considered if the patient has any of the following predisposing chronic conditions:

  • Pulmonary disease – COPD, cystic fibrosis, pulmonary fibrosis
  • Neurologic or neuromuscular diseases – spinal cord injuries, ALS, muscular dystrophy
  • Obesity hypoventilation syndrome (Pickwickian syndrome)

Treatments that should trigger consideration of a diagnosis of chronic respiratory failure are:

  • Home oxygen therapy
  • Tracheostomy
  • Mechanical or non-invasive ventilation

Document the type of chronic respiratory failure (hypoxic or hypercarbic) and link the diagnosis to the etiology.

Acute on chronic respiratory failure happens when a patient who was in compensated respiratory failure has an acute insult, manifested by:

  • pO2 decreases by 10; or
  • pCO2 increases by 10

(10 is the magic number)

Caveats of Documentation

All providers must be consistent – everybody needs to call it the same thing. Ideally, the pulmonologist will set the example, and the hospitalist will follow the lead, or vice versa.

  • Be precise with the type, acuity, and etiology.
  • Put the MENTATION back into documentation. Describe your clinical judgment.
  • THINK WITH INK!!

Happy documenting, and thanks for everything you do for our patients.

Dr. Bob Morrison, MD 

Dr. Morrison is the associate chief medical officer at Miami Valley Hospital and is a physician advisor for Premier Health. He can be reached at (937) 208 -2315 or (937) 203-6215, or by email. 

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