I N T EG R A T I V E L I T E R A T U R E R E V IE W S A N D M E T A - A N A L Y S E S

The role of nurses in preventing adverse events related to respiratory

dysfunction: literature review
Julie Considine BN MN RN RM FRCNA
PhD Candidate, School of Nursing, Deakin University, Burwood; and Clinical Nurse Educator, Emergency Department, The
Northern Hospital, Epping, Victoria, Australia

Accepted for publication 10 May 2004

Correspondence: CONSIDINE J. (2005) Journal of Advanced Nursing 49(6), 624–633

Julie Considine, The role of nurses in preventing adverse events related to respiratory dysfunction:
c/o Emergency Department, literature review
The Northern Hospital,
Aims. This paper reports a literature review examining the relationship between
185 Cooper Street,
specific clinical indicators of respiratory dysfunction and adverse events, and
Epping 3076,
Victoria,
exploring the role of nurses in preventing adverse events related to respiratory
Australia. dysfunction.
E-mail: julie.considine@nh.org.au Background. Adverse events in hospital are associated with poor patient outcomes
such as increased mortality and permanent disability. Many of these adverse events
are preventable and are preceded by a period during which the patient exhibits
clearly abnormal physiological signs. The role of nurses in preserving physiological
safety by early recognition and correction of physiological abnormality is a key
factor in preventing adverse events.
Methods. A search of the Medline and CINAHL databases was conducted using the
following terms: predictors of poor outcome, adverse events, mortality, cardiac
arrest, emergency, oxygen, supplemental oxygen, oxygen therapy, oxygen satura-
tion, oxygen delivery, assessment, patient assessment, physical assessment, dys-
pnoea, hypoxia, hypoxaemia, respiratory assessment, respiratory dysfunction,
shortness of breath and pulse oximetry. The papers reviewed were research papers
that demonstrated a relationship between adverse events and various clinical indi-
cators of respiratory dysfunction.
Results. Respiratory dysfunction is a known clinical antecedent of adverse events
such as cardiac arrest, need for medical emergency team activation and unplanned
intensive care unit admission. The presence of respiratory dysfunction prior to an
adverse event is associated with increased mortality. The specific clinical indicators
involved are alterations in respiratory rate, and the presence of dyspnoea, hypox-
aemia and acidosis.
Conclusions. The way in which nurses assess, document and use clinical indicators
of respiratory dysfunction is influential in identifying patients at risk of an adverse
event and preventing adverse events related to respiratory dysfunction. If such
adverse events are to be prevented, nurses must not only be able to recognise and
interpret signs of respiratory dysfunction, but must also take responsibility for ini-
tiating and evaluating interventions aimed at correcting respiratory dysfunction.

Keywords: adverse events, risk management, acute nursing, assessment, respiratory

dysfunction, literature review

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2005 Blackwell Publishing Ltd

Integrative literature reviews and meta-analyses
Introduction
As many as 16Æ6% of hospital inpatients in Australia are
affected by adverse events during their stays (Wilson et al.
1995). An adverse event is an ‘an unintentional injury or
complication resulting in disability, death or prolonged
hospital stay that is a result of health care management’
rather than the patient’s underlying disease (Wilson et al.
1995, p. 459). Outcomes following adverse events are poor
and patients who suffer an adverse event while in hospital
are more likely to die or experience permanent disability
(Wilson et al. 1995, Buist et al. 1999). The ‘preventability’ of
in-hospital adverse events is well-documented (Sax &
Charlson 1987, Bedell et al. 1991, Hourihan et al. 1995,
Wilson et al. 1995, Buist et al. 2002) and the notion that
adverse events occur suddenly and without warning has been
challenged. It is now evident that the majority of adverse
events are preceded by a period during which the patient
exhibits clearly abnormal physiological signs (Franklin et al.
1986, Sax & Charlson 1987, Schein et al. 1990, Franklin &
Matthew 1994, Hourihan et al. 1995, Buist et al. 2002). The
literature supports the notion that early recognition and
correction of physiological abnormality can improve patient
outcomes by reducing the incidence of adverse events,
particularly cardiac arrest (Schein et al. 1990, Franklin &
Matthew 1994, McQuillan et al. 1998, Buist et al. 1999,
2002). This has important implications for the role of nurses
in adverse event prevention (Considine & Botti 2004),
particularly in preserving physiological safety by accurate
assessment and early recognition and correction of abnorm-
ality (Considine & Botti 2004).
Examination of the literature related to physiological
abnormality as a risk factor for adverse events reveals a
strong relationship between adverse events and respiratory
dysfunction. Respiratory dysfunction is now well-documen-
ted as a clinical antecedent of adverse events. For the
purposes of this paper, respiratory dysfunction refers to the
presence of problems such as hypoxaemia, dyspnoea,
tachypnoea or bradypnoea (Hourihan et al. 1995, Buist
et al. 1999, McGloin et al. 1999, Buist & Moore 2000).
Nurses are in a pivotal position to influence the relationship
between respiratory dysfunction and adverse events. They are
responsible for the ongoing assessment of patients’ physiolo-
gical status. The ability of nurses to identify respiratory
dysfunction accurately and correct it is essential if adverse
events related to respiratory dysfunction are to be prevented
(Considine & Botti 2004).
This paper examines the association between respiratory
dysfunction and adverse events by reviewing the literature
and presenting key research findings. The relationship

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
Preventing adverse events related to respiratory dysfunction
between specific clinical indicators of respiratory dysfunction
and adverse events will be explored in detail. The role of
nurses in preventing adverse events related to respiratory
dysfunction and, in particular, their ability to identify
respiratory dysfunction and intervene appropriately will also
be considered.
Search methods
A search of Medline and CINAHL databases was conducted
using the following search terms: predictors of poor outcome,
adverse events, mortality, cardiac arrest, emergency, oxygen,
supplemental oxygen, oxygen therapy, oxygen saturation,
oxygen delivery, assessment, patient assessment, physical
assessment, dyspnoea, hypoxia, hypoxaemia, respiratory
assessment, respiratory dysfunction, shortness of breath and
pulse oximetry. The resulting review is not a systematic
review. The papers reviewed were chosen for their relevance
to adverse events related to respiratory dysfunction. All the
papers examined are research papers that demonstrate a
relationship between adverse events and various clinical
indicators of respiratory dysfunction.
Results and discussion
The relationship between respiratory dysfunction and
adverse events
Analysis of the literature on respiratory dysfunction and the
occurrence of adverse events reveals two major issues:
respiratory dysfunction is a known precursor to adverse
events, and the presence of respiratory dysfunction prior to
an adverse event has a significant negative effect on mortality.
The following section examines these issues and summarises
key research findings.
Respiratory dysfunction as a precursor to adverse events
The relationship between respiratory dysfunction and adverse
events, particularly in situations such as cardiac arrest, acti-
vation of the medical emergency team (MET) and unplanned
intensive care unit (ICU) admission, is well-documented and
is summarized in Table 1. Schein et al. (1990) found that,
prior to cardiac arrest, 53% of patients had documented
respiratory dysfunction. One third (37Æ2%) of patients who
had physiological abnormality prior to cardiac arrest suffered
from respiratory dysfunction, making it the most common
type of physiological abnormality preceding cardiac arrest
(Schein et al. 1990).
The MET is an organized and strategic hospital response
by medical and nursing personnel with skills in and
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J. Considine

Table 1 Summary of research relating to respiratory dysfunction as a precursor to adverse events

Study Sample Results

Rubins and Moskowitz (1988)
Schein et al. (1990)
Ridley and Purdie (1992)
Lee et al. (1995)
Hourihan et al. (1995)
Crispin and Daffurn (1998)
McGloin et al. (1999)
Buist and Moore (2000)
295 ICU patients, 37 with AEs 25% (73/295) patients admitted to ICU and 20% (6/30)
readmitted to ICU had respiratory insufficiency
Respiratory insufficiency was the most common reason
for ICU admission
53% (8/15) of patients readmitted to ICU required ventilation
64 cardiac arrests 53% (34/64) patients had documented deterioration of
respiratory function in the 8 hours preceding arrest
20% (13/64) patients had an isolated deterioration in
respiratory function in the 8 hours preceding arrest
763 patients discharged 34% (256/763) patients were admitted to ICU with respiratory failure
from ICU Respiratory failure was the most common reason for ICU admission
522 medical emergency team 36% (n ¼ 92/253) of calls in response to specific condition
(MET) calls criteria were for compromise to airway and breathing
Of these, 44% (40/92) were for acute respiratory failure
265 MET calls requiring 39% (103/265) of interventions were respiratory interventions
intervention Most common respiratory intervention was administration of
O2 > 10 L/minute via mask (34%, 35/103)
168 MET calls 31% (25/79) of patients with physiological abnormality in
the 24 hours preceding a MET call had respiratory dysfunction
35% of patients who required a MET call for airway or breathing
problems died
22% MET calls were for airway/breathing problems (37/168)
Airway/breathing problems were second only to cardiac arrest
(25%, 42/168) as the most common reason for MET calls
89 unexpected ICU 48% (47/89) of patients unexpectedly admitted to ICU were
admissions admitted for respiratory dysfunction
83% (10/12) of patients with unrecognised physiological
abnormalities prior to ICU admission had respiratory abnormalities
100% (19/19) of patients who had inappropriate treatment of
physiological abnormality prior to ICU admission had respiratory
abnormalities
2202 AEs 57% (915/2202) of AEs related to physiological abnormality
involved respiratory dysfunction

AE, adverse event; ICU, intensive care unit; MET, medical emergency team.

knowledge about advanced life support. The aim of the MET
is to improve patient outcomes through risk reduction,
primarily by promoting early recognition of physiological
abnormality and providing rapid initiation of emergency
treatment in patients with physiological deterioration (Buist
et al. 2002). The MET can be activated by any member of the
nursing or medical staff in response to specific criteria. These
usually consist of defined physiological abnormalities, specific
conditions and/or heightened levels of concern about the
clinical status of a patient (Daffurn et al. 1994, Lee et al.
1995, Crispin & Daffurn 1998, Buist & Moore 2000, Buist
et al. 2002). Of those patients who were shown to have
physiological abnormality prior to the MET call, one-third
(31%) to one half (57%) had respiratory dysfunction
(Crispin & Daffurn 1998, Buist & Moore 2000). Compro-
mise to airway and/or breathing was cited as the alerting
factor in 22–36% of MET activations that occurred when
criteria relating to specific conditions were met (Lee et al.
1995, Crispin & Daffurn 1998).
Many researchers regard unplanned admission or read-
mission to ICU as an adverse event in its own right (Rubins &
Moskowitz 1988, McQuillan et al. 1998, Buist et al. 1999,
McGloin et al. 1999). This implies that the need for ICU care
is a direct reflection of severe illness and a high risk of
mortality. In several studies, respiratory dysfunction has been
shown to be the most common reason for ICU admission
(Rubins & Moskowitz 1988, Ridley & Purdie 1992)
accounting for up to half (48%) of unexpected admissions
to ICU (McGloin et al. 1999). One-fifth (20%) of patients
requiring unexpected readmission to ICU were readmitted
because of respiratory dysfunction and, of these, 53%
required mechanical ventilation (Rubins & Moskowitz
1988). The unexpected nature of ICU readmission coupled
with a need for mechanical ventilation indicates a

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Integrative literature reviews and meta-analyses
life-threatening degree of respiratory dysfunction. This raises
questions about the timing of identification of respiratory
dysfunction and the appropriateness of early interventions.
Few studies have examined the timing and appropriateness
of interventions in relation to respiratory dysfunction and
adverse events. McGloin et al. (1999) examined recognition
of physiological abnormalities and appropriateness of inter-
ventions prior to ICU readmission and found that respiratory
dysfunction was present in 83% of patients who had
unrecognised physiological abnormalities and 100% of
patients who had inappropriate treatment of physiological
abnormality. Analysis of MET interventions by Hourihan
et al. (1995) found that, of the MET calls that required
intervention, over one-third (39%) required respiratory
interventions. These included the administration of high flow
supplemental oxygen (>10 L/minute via mask), intermittent
positive pressure ventilation, intubation and continuous
positive airway pressure. It is notable, however, that the
administration of high flow oxygen by mask was the most
common respiratory intervention initiated by the MET. An
important question related to these findings is: If nurses were
concerned enough about a patient to activate the MET, why
did they not initiate interventions such as oxygen adminis-
tration? The finding that nurses do not always initiate oxygen
administration suggests that they have difficulty in identifying
respiratory dysfunction and/or do not manage respiratory
dysfunction appropriately.
Effect of respiratory dysfunction prior to adverse events
on mortality
The presence of respiratory dysfunction before an adverse
event has been shown to have a significant impact on post-
event mortality, increasing the likelihood of cardiac arrest by
18Æ5% (P < 0Æ001) (Sax & Charlson 1987). This is an
important association, as patient outcomes once cardiac ar-
rest has occurred are often negative. Despite advances in
resuscitation over recent decades, survival rates following
in-hospital cardiac arrest have not improved. Only 43% of
patients survive initial resuscitation and approximately 13%
of patients survive and are discharged from hospital
(Camarata et al. 1971, Bedell et al. 1983, Suljaga Pechtel
et al. 1984, George et al. 1989, Bedell et al. 1991, Franklin &
Matthew 1994, Buist et al. 1999). In another study, 35% of
patients who required MET activation for an airway or
breathing problem died (Crispin & Daffurn 1998). When
patients with respiratory dysfunction have an in-hospital
adverse event they are at significant risk of death.
Patients who require ICU-level care for respiratory
dysfunction have also been shown to be at significant risk
of death. Admission to ICU with respiratory pathology has

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
Preventing adverse events related to respiratory dysfunction
been associated with mortality rates as high as 34% (Ridley
& Purdie 1992) and respiratory failure is cited to be the cause
of death in 19% of patients who die following ICU discharge
(Ridley & Purdie 1992). Pneumonia has been demonstrated
by numerous studies to have a strong association with
adverse events, including cardiac arrest and death. Bedell
et al. (1983) found that pneumonia was an independent
predictor of in-hospital mortality and that all patients who
had pneumonia prior to cardiac arrest died. It was the most
common clinical diagnosis in patients who suffered cardiac
arrest (Schein et al. 1990) and the second most common
cause of death in patients who died unexpectedly (McGloin
et al. 1999). Management of oxygenation has also been
implicated as a factor in pneumonia-related mortality, with
inadequate airway or oxygen management cited as factors in
22% of preventable deaths (Dubois & Brook 1988). The
studies that have examined the effect of respiratory dysfunc-
tion prior to adverse events on subsequent mortality are
summarized in Table 2.
These findings raise two fundamental questions about
nurses’ perception of patient risk of an adverse event. Patients
with respiratory illnesses such as pneumonia, exacerbation of
chronic obstructive airways disease and asthma are familiar to
most nurses working in acute care medical settings. Do nurses
working in areas where these illnesses are common perceive
these patients as being at high risk of adverse event or consider
that they will be at high risk of death should an adverse event
occur? If these risks were more apparent, would the result be
more frequent physiological assessment and more aggressive
intervention for respiratory abnormalities?
Clinical indicators of respiratory dysfunction and adverse
events
Nurses’ ability to recognize and treat respiratory dysfunction
as a key factor in adverse event prevention is based on the
premises that: (1) respiratory dysfunction is a known
precursor, and (2) its presence prior to an adverse event has
a negative effect on survival. This raises questions about the
relationship between observable clinical indicators of respir-
atory dysfunction and adverse events. The indicators that
have been examined in the adverse event literature are
alteration in respiratory rate, and presence of dyspnoea,
hypoxaemia and acidosis. The following section examines the
relationship of these indicators of respiratory dysfunction to
adverse events and summarises key research findings.
Alteration in respiratory rate
Alteration in respiratory rate (bradypnoea or tachypnoea)
has been shown to be an influential factor in adverse events
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Table 2 Summary of research relating to the effect on subsequent mortality of respiratory dysfunction prior to an adverse event

Study Sample Results

Bedell et al. (1983)
Dubois and Brook (1988)
Ridley and Purdie (1992)
Schein et al. (1990)
McGloin et al. (1999)
Crispin and Daffurn (1998)
294 patients with cardiac arrest
182 patients who died from
pneumonia, AMI or stroke
763 patients discharged from ICU
64 cardiac arrests
16 unexpected deaths
168 MET calls
Pneumonia was an independently significant predictor of mortality
after cardiac arrest (P < 0Æ05)
20% (58/294) of patients had pneumonia prior to cardiac arrest
and all of these patients died (n ¼ 58)
Pneumonia had the highest mortality rate at 53% (70/132),
followed by AMI (44%, 62/140) and stroke (48%, 50/105)
22% of preventable deaths from pneumonia involved
inadequate airway or oxygen management
34% of patients admitted to ICU with respiratory failure died
Of the patients who died following ICU discharge, 19% (30/158)
died from respiratory failure.
Respiratory failure was second only to malignancy as the most
common ICU admission diagnosis in patients who died
following ICU discharge
20% (13/64) of patients who had cardiac arrest had pneumonia
Pneumonia was the most common clinical diagnosis
19% (3/16) of patients died from pneumonia
Pneumonia was second to cardiac events as the most common
cause of death
Patients who required a MET call for airway or breathing
problems had a 35% mortality rate

AMI, acute myocardial infarction; MET, emergency medical team; ICU, intensive care unit.

Table 3 Summary of research relating to alteration in respiratory rate and adverse events

Study Sample Results

Rubins and Moskowitz (1988)
Lee et al. (1995)
Hourihan et al. (1995)
Crispin and Daffurn (1998)
McGloin et al. (1999)
Buist and Moore (2000)
295 ICU patients discharged Patients who suffered an AE following ICU discharge had significantly
from ICU higher respiratory rates (RR) on ICU discharge than those who did
not suffer an AE (mean RR: 30 vs. 26 breaths/minute) (P ¼ 0Æ002)
347 MET calls* 27% (94/347) of patients had altered respiratory rates
Of these, 78% (73/94) of patients were tachypnoeic and 22% (21/94)
of patients were bradypnoeic
213 MET calls* 18% (39/213) of patients had altered respiratory rates
Of these, 85% (33/39) of patients were tachypnoeic and 15% (6/94) of
patients were bradypnoeic
126 MET calls* 29% MET calls were for airway/breathing problems (37/126)
89 unexpected ICU admissions 60% (6/10) of patients who had unrecognised physiological
abnormalities prior to ICU admission had tachypnoea
32% (6/19) of patients who had inappropriate treatment of physiological
abnormality prior to ICU admission had tachypnoea
915 AEs related to respiratory 11% (99/915) had altered respiratory rates
dysfunction Of these, 89% (88/99) of patients were tachypnoeic and 11% (11/99) of
patients were bradypnoeic

AE, adverse event; ICU, intensive care unit; MET, medical emergency team.
*For physiological abnormality.

(Table 3). Studies of patients who required activation of
the MET have shown that up to 29% of patients had al-
tered respiratory rates (Hourihan et al. 1995, Lee et al.
1995, Buist & Moore 2000). Of these patients, the over-
whelming majority (78–89%) were tachypnoeic (Hourihan
et al. 1995, Lee et al. 1995, Buist & Moore 2000). Patients
who suffered an adverse event following ICU discharge had
a significantly higher mean respiratory rate at discharge
from ICU than patients whose post-ICU course was un-
affected by an adverse event (30 breaths per minute vs. 26
breaths per minute, P ¼ 0Æ002) (Rubins & Moskowitz
1988).

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These results are important as, although it is non-specific,
tachypnoea is well-recognized as a sign of acute illness
(Rubins & Moskowitz 1988) and hypoxia (Ryerson & Block
1983, Crocco et al. 1987, Wesmiller & Hoffman 1989,
Crocco & Francis 1991, Kester & Stoller 1992, Gaull 1993,
Palmer 1993, Grap et al. 1994). Responsibility for ongoing
assessment of respiratory rate lies with nurses. They measure
and document respiratory rate when they perform a physio-
logical assessment. As most nursing observation charts
require the documentation of respiratory rate, these data
are usually readily available at the bedside. However,
respiratory rate data are only valuable as an alerting factor
for risk of adverse event if assessment is performed at
appropriate intervals and the data are studied to identify
trends such as increasing tachypnoea. In addition, they need
to be studied alongside other physiological data. These
processes are dependent on the clinical judgements of nurses.
Dyspnoea
The presence of dyspnoea or shortness of breath is also a
clinical indicator of respiratory dysfunction and has also been
identified as a significant preceding factor for adverse events
(see Table 4). Patients admitted to hospital with acute dys-
pnoea are more likely to have an adverse event than patients
admitted for other reasons. In a study by Sax and Charlson
(1987), the rate of cardiac arrest in patients admitted with
acute dyspnoea was 22%, which is dramatically higher than
the 3Æ5% cardiac arrest rate in patients admitted for other
reasons (P < 0Æ001). As discussed previously, this is sig-
nificant, given the inherently high mortality associated with
cardiac arrest (Camarata et al. 1971, Bedell et al. 1983,
Suljaga Pechtel et al. 1984, George et al. 1989, Bedell et al.
1991, Franklin & Matthew 1994, Buist et al. 1999). Almost
one-third (29%) of patients admitted to hospital with acute
dyspnoea related to a chronic respiratory illness suffered an
adverse event, and adverse events occurred in 60% of
patients admitted with acute dyspnoea who suffered a
deterioration in their condition (Sax & Charlson 1987). Of
patients who had a complaint documented in the 24 hours
preceding an MET call, 37% complained of shortness of
breath (Crispin & Daffurn 1998), and dyspnoea was the
alerting factor in 41% of MET calls made by nursing staff
because of non-specific concerns about a patient (Hourihan
et al. 1995).
The fact that dyspnoea was shown to be an influential
factor in nurses’ activation of the MET suggests that they
recognize it as a negative sign and/or symptom. The import-
ance of dyspnoea in physiological assessment by nurses,
however, remains unclear. Data suggesting the presence of
dyspnoea may not be as readily available as other patient
data, such as respiratory rate. The presence of dyspnoea may
be identified by objective data, such as use of accessory
muscles and respiratory effort, or by subjective data, such as
patient complaints of shortness of breath. Documentation of
dyspnoea is somewhat subjective, as nurses have to describe
degree of accessory muscle use or patient complaints of
shortness of breath. Any description of level or degree
involves a judgement about physiological abnormality, and is
open to interpretation by other staff when they read the
assessment findings. Anecdotal evidence also suggests that

Table 4 Summary of research relating to dyspnoea and adverse events

Study Sample Results

Sax and Charlson (1987)
Lee et al. (1995)
Hourihan et al. (1995)
Crispin and Daffurn (1998)
554 patients Patients admitted with acute dyspnoea were more likely to have a cardiac
arrest than those admitted for other reasons [22% (5/22) vs. 3Æ5% (15/444),
P < 0Æ001]
29% (4/14) of patients admitted with acute dyspnoea related to chronic
pulmonary disease had an AE
60% (3/5) of patients admitted with acute dyspnoea and who suffered a
deterioration in condition had a cardiac arrest
522 MET calls 36% (n ¼ 92/253) of calls in response to specific condition criteria were for
compromise to airway and breathing.
Of these, 44% (40/92) were for acute respiratory failure
Of the patients who had a physiological abnormality (but did not have a
cardiac arrest), 20% (73/347) were tachypnoeic and 6% (21/374) were
bradypnoeic
294 MET calls Of MET calls made because the nursing staff were ‘worried’, 41% had
dyspnoea as the alerting factor (9/22)
168 MET calls 37% (16/43) of patients who had a documented complaint in the 24 hours
preceding a MET call complained of dyspnoea

AE, adverse event; MET, medical emergency team.

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 629
J. Considine
most nursing observation charts do not allow for the
documentation of dyspnoea, and that if this is documented
it will be in the patient notes. This information may not,
therefore, be available at the bedside. This also makes the
identification of a trend towards increasing dyspnoea diffi-
cult. As dyspnoea is a relatively common and subjective
complaint, the issues previously discussed with regard to
perceived risk of adverse events are also applicable.
Hypoxaemia
The presence of hypoxaemia prior to adverse events has been
shown to have a major effect on mortality. Studies by
Camarata et al. (1971) and Suljaga Pechtel et al. (1984)
examined arterial blood gas findings and patient outcomes
following cardiac arrest. Although these studies were con-
ducted 13 years apart their findings are remarkably similar.
The results of both studies show that hypoxaemia and failure
to correct significant hypoxaemia are prominent factors in
failed resuscitations (Suljaga Pechtel et al. 1984). Acute
anoxia was a factor in 40% of cardiac arrests that were
considered ‘unexpected’ by virtue of the absence of acidosis
(pH >7Æ37) (Camarata et al. 1971). Hypoxaemia (defined as
a partial pressure of oxygen of <50 mmHg or 6Æ7 kPa) was
demonstrated in 59% of patients who experienced cardiac
arrest (Suljaga Pechtel et al. 1984), and only 42Æ3% of
patients who were hypoxaemic at the time of cardiac arrest
were successfully resuscitated. This is much lower than the
successful resuscitation rate of 63Æ9% in patients who were
not hypoxaemic (P < 0Æ05) (Suljaga Pechtel et al. 1984).
Correction of hypoxaemia during the course of resuscitation
had a major effect on patient mortality. Almost two-thirds
Table 5 Summary of research relating to hypoxaemia and adverse events
Study Sample
Camarata et al. (1971) 193 cardiac arrests in
132 patients
Suljaga Pechtel et al. (1984) 207 cardiac arrests
McGloin et al. (1999) 89 unexpected ICU
admissions
Buist and Moore (2000) 2202 AEs
AE, adverse event; ICU, intensive care unit.
630
(63Æ9%) of patients in whom acidosis was corrected were
successfully resuscitated, compared with only 20Æ9% of
patients whose pH remained below 7Æ2 (P ¼ 0Æ05).
When examining the relationship between hypoxaemia and
other adverse events, hypoxaemia has been shown to be the
most common reason for MET activation, leading to 37% of
all MET calls (Buist & Moore 2000). Research also shows
that a many patients have unrecognized or inappropriately
treated hypoxaemia prior to an adverse event. In a group of
patients who had unrecognized physiological abnormalities
prior to ICU admission, 40% were hypoxaemic, as were 52%
of patients who had inappropriate treatment of physiological
abnormality prior to ICU admission (McGloin et al. 1999).
The studies that have examined the relationship between
hypoxaemia and adverse events are summarized in Table 5.
These results have significant implications for the role of
nurses in preventing adverse events through early identifica-
tion and correction of hypoxaemia. Pulse oximetry is now
used as a routine part of patient assessment in most clinical
environments (Grap 1998) and is a valuable adjunct to
clinical assessment in the detection of hypoxaemia. Routine
use of pulse oximetry by nurses to measure oxygen saturation
has the potential to impact positively on health outcomes by
facilitating early detection of hypoxaemia (Albin et al. 1992).
Fundamental to the use of this technology is that nurses
recognize its limitations (Rutherford 1989b, Smart & Mark
1992) and consider other factors that influence oxygenation
such as adequacy of ventilation, plasma oxygen transport,
haemoglobin levels, cardiac output, oxygen delivery to the
tissues and cellular utilization of oxygen (Rutherford 1989b,
Goodfellow 1997, Tittle & Flynn 1997, Grap 1998). Nurses
Results
40% (13/33) of patients in whom arrest was judged to be ‘unexpected’
(pH > 7Æ37) were acutely anoxic
59% (123/207) of patients had significant hypoxaemia (PO2 < 50 mmHg)
Patients with initial PO2 > 50 mmHg were more likely to be successfully
resuscitated (58Æ3% vs. 42Æ3%, P < 0Æ05)
Patients with initial PO2 < 50 mmHg and a second PO2 > initial PO2
(correction of hypoxaemia) had increased likelihood of successful
resuscitation (63Æ9% vs. 20Æ9%, P < 0Æ05)
40% (4/10) of patients who had unrecognised physiological abnormalities
prior to ICU admission were hypoxaemic
52% (10/19) of patients who had inappropriate treatment of physiological
abnormality prior to ICU admission were hypoxaemic
37% (816/2202) of AEs were related to hypoxaemia (SpO2 < 90%) and
this was the most common AE
86% (705/816) of cases of hypoxaemia resolved with intervention

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
Integrative literature reviews and meta-analyses Preventing adverse events related to respiratory dysfunction

Table 6 Summary of research relating to acidosis and adverse events

Study Sample Results

Camarata et al. (1971)
Suljaga Pechtel et al. (1984)
193 cardiac arrests 74% (98/132) of patients were acidotic (pH < 7Æ35) prior to arrest
in 132 patients Of these, 66Æ3% (65/98) of patients had respiratory acidosis (pH < 7Æ35
and a PCO2 > 41 mmHg) and this was the most common cause of
prearrest acidosis
1% (1/99) of patients known to be acidotic prior to arrest survived to
hospital discharge
207 cardiac 39% (81/207) of patients had significant acidosis (pH < 7Æ2)
arrests Patients with initial pH > 7Æ2 mmHg were more likely to be successfully
resuscitated (55% vs. 39%, P < 0Æ05)
Patients with a second pH > than the initial pH (correction of acidosis)
had increased likelihood of successful resuscitation (67% vs. 26%, P ¼ 0Æ05)

AE, adverse event.

are in a pivotal position to enable timely and appropriate

correction of hypoxaemia by the initiation of interventions
such as the administration of supplemental oxygen using
delivery devices and flow rates appropriate to the patient’s
clinical condition.
Acidosis
The presence of acidosis prior to adverse events has also been
shown to have a major effect on mortality (see Table 6).
Again, studies by Camarata et al. (1971) and Suljaga Pechtel
et al. (1984) both show that acidosis is a preceding factor in
many cardiac arrests, and that patients with documented
acidosis prior to, or shortly after, cardiac arrest have poorer
outcomes than patients who are not in an acidotic state
(Camarata et al. 1971, Suljaga Pechtel et al. 1984). Only
39% of patients who were acidotic (pH <7Æ2) at the time of
cardiac arrest were successfully resuscitated compared with a
successful resuscitation rate of 55% in patients who were not
acidotic (P < 0Æ05) (Suljaga Pechtel et al. 1984). Correction
of acidosis during the course of resuscitation had a major
effect on patient mortality. Two-thirds (67%) of patients in
whom acidosis was corrected were successfully resuscitated,
compared with only 26% of patients whose pH remained
below 7Æ2 (P ¼ 0Æ05).
These findings are important, as the presence of acidosis
can, in many cases, be directly related to prolonged,
untreated respiratory dysfunction. Two-thirds (66%) of the
acidotic states identified by Camarata et al. (1971) were
deemed to be the result of respiratory dysfunction. Respir-
atory acidosis occurs when the partial pressure of carbon
dioxide is elevated, and is often the result of hypoventilation
(McCance & Huether 2002). The clinical indicators of
respiratory acidosis include altered state of consciousness,
and tachypnoea progressing to bradypnoea (McCance &
Huether 2002). These signs are readily detectable by nurses.
Limitations
This review was limited in that the papers reviewed were
accessed from medical and nursing literature, were written in
English and were research papers that demonstrated a
relationship between adverse events and various clinical
indicators of respiratory dysfunction. All the papers reviewed
were from studies carried out in the United States, the United
Kingdom or Australia and, while it may be argued that there
are significant variations in health care practices in these
countries, the fact that many of the findings are similar
indicates that there must be some commonalities.
Conclusions
In summary, the presence of respiratory dysfunction is a
known precursor to adverse events and the presence of
respiratory dysfunction prior to adverse events is associated
with increased mortality. Alteration in respiratory rate, and
presence of dyspnoea, hypoxaemia and acidosis are clinical
indicators of respiratory dysfunction, and important factors
in the identification of respiratory dysfunction and assess-
ment of risk of adverse events. The significance of early
recognition and treatment of respiratory dysfunction (Lee
et al. 1995, Buist & Moore 2000) is made clear by the
considerable increase in mortality rates if physiological
abnormality is allowed to progress to cardiac arrest
(Hourihan et al. 1995). Nurses have a pivotal role in the
reduction or prevention of adverse events that may occur as a
consequence of respiratory dysfunction. The recognition and
interpretation of respiratory dysfunction is fundamental, but
nurses must also take responsibility for the initiation and
ongoing evaluation of interventions aimed at correcting
respiratory dysfunction, particularly the administration of
supplemental oxygen.

2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633 631
J. Considine
What is already known about this topic
• Respiratory dysfunction is a known clinical antecedent
of adverse events.
• The presence of respiratory dysfunction prior to an
adverse event is associated with increased mortality.
What this paper adds
• Early recognition and correction of respiratory dys-
function by nurses can prevent adverse events and is a
key factor in improving patient outcomes.
• Nurses’ ability to assess the risk of adverse events has
important implications for their prevention.
• Nurses must take responsibility for ensuring patients’
physiological safety through accurate assessment, rig-
orous interpretation of assessment findings and timely
and appropriate interventions.
Nursing education should highlight the fact that the
assessment, documentation and interpretation of physiologi-
cal information are essential to nurses’ ability to identify
patients at risk of an adverse event, and to the prevention of
adverse events related to respiratory dysfunction. Nurses
need to acknowledge that the recognition of patients at high
risk of an adverse event is important, and to consider how
they can use this information to put pre-emptive measures in
place. For example, if it is known that patients admitted to
hospital with respiratory problems, patients with pneumonia
and those who exhibit signs of respiratory dysfunction, such
as tachypnoea, dyspnoea and hypoxaemia, are at high risk of
an adverse event (and high risk of subsequent death), then
these patients may benefit from more frequent physiological
assessment or more aggressive management to restore normal
respiratory function.
Nursing educators also have a responsibility to ensure that
nurses are prepared to act on the interpretation of their
assessment findings in a timely and appropriate manner. They
must be able to initiate and evaluate interventions commen-
surate with their scope of practice and to articulate the need
for assistance or for further interventions to other health care
professionals. Nurses must understand the pathophysiology
associated with signs of respiratory dysfunction, the physio-
logical response that interventions such as administration of
supplemental oxygen should elicit and the consequences of
the failure of the patient to respond to these interventions.
Organizational culture and policy should support nurses to
be effective in the assessment and management of their
patients. Levels of staffing and resources need to be based on
632
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 49(6), 624–633
considerations about whether patients are at high risk of
adverse events, rather than waiting for acute deterioration to
occur before acknowledging that additional nursing care is
needed.
Finally, further research that directly examines the effects
of nursing assessment and intervention on the physiological
status of patients and the incidence and severity of adverse
events is warranted. This is particularly important if nurses
are to demonstrate they have a key role in adverse event
prevention and argue for the authority to initiate interven-
tions aimed at correcting physiological abnormalities.
Acknowledgements
I would like to acknowledge Professor Mari Botti, School of
Nursing, Deakin University, and Professor Shane Thomas,
School of Public Health, LaTrobe University, for their
assistance in editing this manuscript for publication. The
paper was written as part of the requirements for a PhD in
Nursing at Deakin University that was supported by a Deakin
University Postgraduate Scholarship and the Royal College of
Nursing, Australia Annie M. Sage Scholarship for 2004. The
views expressed in this paper do not necessarily represent
those of Royal College of Nursing, Australia.
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