Q&A: Chronic respiratory failure criteria

Q: Our team had a question regarding the criteria for chronic respiratory failure. The ACDIS Pocket Guide states the criteria “typically requires continuous oxygen support,” so do patients just need to be on continuous oxygen to meet it?

A: Acute respiratory failure describes short-term respiratory dysfunction. Acute onset generally is sudden, related to an acute illness or disruption in respiratory function. This is a medical emergency, requiring treatment of the underlying etiology to reverse the decline of respiratory dysfunction. Chronic respiratory failure, in comparison, describes an ongoing condition resulting from chronic disease in which the inability to effectively exchange carbon dioxide and oxygen results in chronically low oxygen levels or chronically high carbon dioxide levels. Usually, the underlying etiology is chronic lung disease, such as chronic obstructive pulmonary disease, chronic bronchitis, or idiopathic interstitial pneumonia. It will require ongoing treatment and often worsens over time.

The treatment is not to “cure” the underlying etiology but to manage its progression and effectively manage the symptoms and complications. These symptoms and complications generally develop slowly over a long period of time as the chronic disease contributes to a decline in respiratory function.

Most providers agree that the diagnosis of chronic respiratory failure requires continuous oxygen support. Home oxygen is a significant clinical indicator. The goal is to maintain a room air SpO2 of 91%. It is often accompanied by compensatory metabolic acidosis (an elevated HCO3 with a normal PH). When determining an exacerbation or acute-on-chronic failure, one must understand the patient’s already compromised baseline function. If the baseline is not known, it can be retrospectively compared once the acute illness is resolved and added treatments have been discontinued.

Your question, I believe, is focusing on the word “typically” as related to the need of oxygen supplementation. In writing the definition for the ACDIS Pocket Guide, I choose to use this word as there are varying definitions related to the diagnostic criteria and treatments applied to chronic respiratory failure. Many feel that dependence upon oxygen supplementation is required, others focus on the use of medications to manage the contributing condition and allow for more efficient gas exchange. Such medications may include corticosteroids, anticholinergic inhalers, and medications assisting with more efficient cardiac function for example.

I suggest you work within your organization, such as with your pulmonologists and medical staff, to develop organizational criteria that offer support for the presence of chronic respiratory failure and promote consistency within your organization.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, ACDIS interim director and CDI education director, answered this question. Contact her at lprescott@acdis.org. Get your copy of the 2023 ACDIS Pocket Guide here.