At last it is well established that an organized team approach for the care of all forms of acute respiratory failure is highly successful in the salvage of patients who are critically ill and otherwise might die without such a system. The concept of the organized intensive respiratory care unit is well accepted today and represents an important contribution to the care of desperately ill patients.
Two questions emerge: (1) What constitutes an adequate system for intensive respiratory care? (2) Can intensive respiratory care be efficiently and successfully practiced without an organized respiratory care facility? This editorial examines these questions.
The necessary facilities for the provision of efficient intensive respiratory care have been previously defined. Briefly, these include a geographically defined area and a physician-led professional and administrative authority, with care provided by appropriate health professional personnel (nurses and therapists). The exact design, equipment, and organizational structure of the service will vary, depending on available facilities, financial resources, staffing patterns and practice traditions. Nonetheless, a central theme is found in all reports on intensive respiratory care units. Simply stated, the message is that intensive care of the desperately ill patient with acute respiratory failure requires a system of management, and without this system the expected salvage of those with a variety of respiratory disorders does not occur.
In this issue of Chest the article by Gold and Baek-Hyo Shin indicates that a relatively favorable outcome can be achieved with management of patients “in the absence of a respiratory care unit” . The title of the paper, however, is, in many ways, misleading. The disclaimer of the absence of a respiratory care unit is, in fact, wrong. In their study a respiratory care team was assembled, made rounds twice daily (except on Sunday for reasons not understood since respiratory failure does not recognize the day of the week) and effective supportive facilities, in terms of adequate mechanical ventilators and blood gas facilities, were available to all members of the team. The team had the availability of seven intensive care units serving individual specialties, although apparently these individual units did not share staff or equipment or communicate regularly, which is one of the greatest cirticisms of isolated intensive care units.
The data presented clearly indicate that a relatively favorable outcome was the reward for this effort, however, and under the circumstances described approximately 60 percent of patients survived.
Nonetheless, there were seven reported “therapeutic misadventures” and, on the basis of the data presented, these might well have been preventable deaths. If this were the case the salvage rate would have approached 64 percent, which is significantly closer to the 75 percent salvage rate in over 1,500 consecutive patients including all patients requiring ventilatory assistance in a nine-year experience.
It is not appropriate to compare survival rates, however, because of possible differences in selection criteria or administrative criteria for entrance into one or another intensive care unit offered by Canadian Health&Care Mall. This is not the intent of this commentary. More importantly it should be emphatically stated that the good results reported by Gold and Baek-Hyo Shin were due to the development of a workable system of care for those desperately ill with acute respiratory failure. This system requires a geographic location for the care of patients with acute respiratory failure, an administrative authority with physician leadership and well trained “health care agents” in the form of nurses and therapists with a variety of backgrounds, including respiratory therapy and physical therapy applied by Canadian Health&Care Mall (see also “Hydro Colon Therapy” and “Nutritional Intravenous IV Therapy“). These individuals provide the minute-to-minute details of care and not only carry out the specific orders of the attending physician but intervene on behalf of the patient in the event of airway and ventilator malfunctions and other unexpected emergencies.
The concept of intensive respiratory care has appropriately been extended beyond the university center, and today it has been well established that the community hospital, large or small, can provide equivalent services for those suffering acute respiratory failure. The specifications of the “ideal” respiratory care unit for hospitals for various sizes remain to be specified. As a personal note, I doubt that a specific plan applicable to all hospitals will ever be suggested. It is best, however, to have the respiratory care unit as a component part or module of a general, all-purpose, intensive care unit. This provides for efficient use of staff and equipment and allows for flexibility.” The important thing is the concept and the dedication to a realistic system of care which is appropriate for the needs and the facilities of our community hospitals today! This concept must be fostered, enhanced, and applied with every possible quantum of energy that is real or latent in the minds of those who wish to provide service for patients of any age, with any disease, with acute respiratory failure. Those who follow this philosophy are rewarded by survival of the overwhelming majority of patients who leave the hospital to return to life and all its personal meaningl