We thank Hortmann et al. for their supplementary and positive assessment of the respiratory rate as a risk marker for emergency patients at risk. They have obviously also experienced that knowledge/ awareness of this fact is still insufficiently put into clinical practice. Since the respiratory rate is a component in different established prognostic instruments used in acutely ill patients (among others, of the emergency severity index (ESI) or confusion, respiratory rate, blood pressure (CRB)-65 index), a valid measurement of the respiratory rate is vital for using these instruments.
The systematic use of validated instruments for the structured support of medical triage decisions, such as the colleagues in Nuremberg’s and Basel’s emergency department successfully practise, has as its vital prerequisite that the respiratory rate is measured reliably. Hortmann et al. have shown impressively how the successful implementation of such an instrument (the ESI, in this case) in the context of a structured multidimensional healthcare concept can make a crucial contribution to improving the quality of healthcare. We can only congratulate our colleagues on their reported results in CAP (1).
If the risk assessment is complemented by appropriate subsequent clinical actions that are adapted to the individual risk (for example, intensive monitoring, rapid treatment, discharge, admission), patients will benefit. However, as Professor von Wichert points out in his letter to the editor, patients will not benefit from the assessment alone—something we addressed in the discussion section in our article: “Thus, abnormal respiratory rates should be further investigated while these patients require close monitoring (e.g. on display devices).” Current guidelines explicitly recommend the use of the CRB-65 index, and thus the respiratory rate, for the purposes of risk assessment and decision support (for example, inpatient admission, intensive monitoring) and thus is of immediate benefit for patients (2, 3). It would have exceeded the scope and objectives of our original article to explain the pathophysiology of respiratory rate regulation. We therefore confined ourselves to mentioning hypercapnia, hypoxia, and metabolic acidosis as factors that—among others—can lead to an increase in the respiratory rate.
Easy to use automated methods for measuring the respiratory rate can improve acceptance in everyday clinical practice. There are currently different developments in new measuring techniques that—as long as they yield valid results in a cost effective fashion—could be used in emergency medicine in the future. In addition to the approaches mentioned by Hortmann et al., these could also include procedures for analyzing acoustic phenomena of respiration (4).
On behalf of the authors:
PD Dr. med. Richard Strauß
Medizinische Klinik 1
Conflict of interest statement
Dr Strauß has received fees for consultancy from Swedish Orphan Biovitrum, Biotest and Pfizer. He has received reimbursements for congress participation fees from Bayer Vital, Pfizer and Infetcopharm. He has received reimbursement for travel and accommodation expenses and fees for the preparation of scientific meetings from Bayer Vital, Pfizer, Infectopharm, and MSD.
The remaining authors declare that no conflict of interest exists.
|1.||Hortmann M, Heppner HJ, Popp S, et al.: Reduction of mortality in community-acquired pneumonia after implementing standardized care bundles in the emergency department. Eur J Emerg Med 2014; 21: 429-35. CrossRef CrossRef MEDLINE|
|2.||Hoffken G, Lorenz J, Kern W, et al.: Epidemiology, diagnosis, antimicrobial therapy and management of community-acquired pneumonia and lower respiratory tract infections in adults. Guidelines of the Paul-Ehrlich-Society for Chemotherapy, the German Respiratory Society, the German Society for Infectiology and the Competence Network CAPNETZ Germany. Pneumologie 2009; 63: e1–68. MEDLINE|
|3.||Woodhead M, Blasi F, Ewig S, et al.: Guidelines for the management of adult lower respiratory tract infections—full version. Clin Microbiol Infect 2011; 17: e1–59. CrossRef CrossRef|
|4.||Sahgal N: Monitoring and analysis of lung sounds remotely. Int J Chron Obstruct Pulmon Dis 2011; 6: 407–12. CrossRef MEDLINE PubMed Central|
|5.||Strauß R, Ewig S, Richter K, König T, Heller G, Bauer TT: The prognostic significance of respiratory rate in patients with pneumonia—a retrospective analysis of data from 705 928 hospitalized patients in Germany from 2010–2012. Dtsch Arztebl Int 2014; 111: 503–8. VOLLTEXT|