DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

Abstract

BackgroundThe assessment of the work of breathing in the definitions of respiratory failure is vague and variable.ObjectiveIdentify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients.MethodsWe examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis.ResultsWe performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress.ConclusionMost of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.

Detection of strong inspiratory efforts from the analysis of central venous pressure swings: a preliminary clinical study

“…A clinical diagnosis of respiratory distress is usually based on the presence of tachypnea, tachycardia, and hypoxia. 34,35 In our study population, respiratory rate, heart rate, and arterial oxygenation were not associated with the strength of inspiration. This was true for other possible signs of increased work of breathing, such as anxiety and central venous oxygen desaturation.…”

Prevalence and prognosis of respiratory pendelluft phenomenon in mechanically ventilated ICU patients with acute respiratory failure: a retrospective cohort study

“…In our study population, pendelluft was more likely to occur in patients with spontaneous breathing, but there was no direct evaluation of breathing effort. Respiratory rate was an indirect indicator reflecting the breathing effort [ 19 , 20 ]. It was higher in patients with pendelluft but without statistical significance after multivariable regression.…”

“…A total of 200 patients (135 men and 65 women) were included, with a median age of 62 years and a median APACHE II score of 16 at 24 h of ICU admission. Patients received mechanical ventilation with a median PaO 2 /FiO 2 ratio of 200 (164, 246) mmHg, tidal volume of 428 (396, 501) mL, PEEP of 7 (5, 8) cmH 2 O, and respiratory rate of 17 (15,19) cycles/minute at the time point of EIT recording (Table 1). 94 (47%) of them had spontaneous breathing.…”

Analysis of Respiratory Kinematics: a method to characterize breaths from motion signals

“…Less experienced clinicians may simply miss red-flag signs or fail to recognize the risk they portend (26). Second, attempts to standardize terminology in narrative descriptions have not achieved wide adoption (27). Such an approach would require large scale continuous training of staff at every level of care.…”