1. Perioperative Respiratory Safety
Prevention and Treatment
Will Shakespeare MD
Medical Director of Anesthesiology

2. Parker’s story

4. PreScreen PreOp Preparation Disease Optimization Asthma Smoking
Sleep Apnea
Respiratory Infection
PreOp
Disease Optimization
Asthma
Smoking
Sleep Apnea
Respiratory Infection
Education

5. Periop Respiratory Physiology
Thoracic and upper-abdominal surgery are associated with a reduction in lung volumes in a restrictive pattern
●Vital capacity (VC) is reduced by 50 to 60 percent and may remain decreased for up to one week.
●Functional residual capacity (FRC) is reduced by about 30 percent.
Diaphragmatic dysfuntion
pain/Splinting-shallow breaths=Atelectasis
Anesthetic agents and postoperative opioids both depress the respiratory drive. Inhibition of cough and impairment of mucociliary clearance of respiratory secretions are factors that contribute to the risk of postoperative

6. Respiratory risk ARISCAT STUDY 7:
2010 low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery.
Anesthesiology Dec;113(6): doi: /ALN.0b013e3181fc6e0a

7. ARISCAT STUDY
Anesthesiology Dec;113(6):

8. Asthma
 Despite early reports indicating that patients with asthma had higher than expected rates of postoperative pulmonary complications, more recent studies have found no link for patients with well-controlled asthma.
Uptodate

9. Smoking increased risk for postoperative pulmonary complications
smoking cessation at least four weeks prior to surgery reduces the risk of postoperative complications, and longer periods of smoking cessation may be even better
In a 2014 meta-analysis of 107 cohort and case-control studies, preoperative smoking was associated with
an increased risk of postoperative complications,
Greater than 20 pack-year smoking history have a higher incidence of postoperative pulmonary complications
Uptodate

10. Sleep Apnea
Patients with OSA have a two- to fourfold higher risk for perioperative complications compared with patients without OSA
Most common complications desaturation, respiratory failure
Also:
difficulty with airway management
cardiovascular complications
postoperative delirium
higher resource utilization.
Uptodate

11. Respiratory infection
Children with active URIs have more minor postoperative respiratory events such as oxygen desaturation, but no apparent increase in major morbidity or long-term sequelae
Uptodate

13. Intraop
Difficult Airway

16. Postop
Laryngospasm
NPPE
OSA

17. Laryngospasm
glottic closure reflex due to stimulation of the superior laryngeal nerve
Chin lift or jaw thrust are not effective.
Treatment :
remove the irritant (eg, by suctioning blood or secretions)
positive pressure ventilation
jaw thrust maneuver
If bag-mask ventilation is not successful, a small dose of succinylcholine (0.1 mg/kg IV) is administered to relax the cords.
Uptodate

18. Negative Pressure Pulmonary Edema
Airway obstruction during laryngospasm, pharyngeal obstruction, or biting that clamps off the endotracheal tube
Treatment
supportive with supplemental O2
Diuretics if appropriate
CPAP or Reintubation as needed
Uptodate

20. Post Discharge
Home O2
Admit
Monitoring

22. OSA Education
While CMS regulations state that education is to happen prior to discharge, It is most time effective and impactful to have education occur in the pre-operative evaluation with family present. Emphasis should be on the following points:
Use NIPPV (CPAP, BiPAP) sleeping device if not contra-indicated.
For the first 24 hours have a responsible adult with you especially while you are sedated/sleeping.
Sleep in semi-reclined position or on your side. Do not sleep flat on your back.
Take narcotic (opioid) medication 2 hours before lying down even if you are sleeping during the day.
Do not take sleeping aids. If you are taking a prescribed sedative do not take a narcotic (opioid) pain medication before sleeping.
Take narcotic (opioid) pain medication only for severe pain unrelieved by non-narcotic pain medications.
Ruth Zimmer MD

23. INTRA-OPERATIVE CONSIDERATIONS
* Light sedation.
* Regional when possible.
* Short acting sedative/narcotic medications.
* General anesthesia with a secure airway is better than deep sedation w/o a
secure airway.
* Consider CPAP with moderate to heavy sedation.
* Awake extubation if conditions warrant.
* Full (documented) reversal of NMB.
* Recovery in a position other than supine if possible.
* Patients with OSA have increased sensitivity to narcotics. This can be especially
pronounced in patients who are narcotic naive. Consider this with post-operative
and intra-operative narcotic use. Especially in teenagers and young adults who
may be sent home on oral narcotics.
START LOW AND GO SLOW.
Ruth Zimmer MD

24. POST-OPERATIVE CONSIDERATIONS
* Regional anesthesia will decrease the need for systemic opioids.
* Consider the benefits vs. risks of neuraxial opioids
* Use of NIPPV/CPAP if feasible
* If patient controlled systemic opioids are to be used avoid
background/baseline infusions
* Supplemental O2 should be used for all OSA patients until
baseline sats on RA can be maintained.
* Patients should remain under observation until they are able to maintain
oxygenation without stimulation, either on RA or with supplemental O2.
This applies to inpatients as well as outpatients.
* If patients are unable to maintain oxygenation consider telemetry or a
monitored bed. If patients are to be discharged home make sure there is
adequate supervision/ consider inpatient admission.
* REM-rebound occurs 3-4 post-operatively. OSA patients are at increased risk at this
time due to the increase in REM sleep. Obstruction in OSA most commonly occurs
during REM.
Ruth Zimmer MD

26. Ruth Zimmer MD

30. Case Studies
Shoulder Scope- Home Oxygen Therapy Shoulder Scope- Sleep Apnea Lumbar Fusion-Sleep Apnea

31. Admit for overnight Oxygen supplementation and monitoring
Diagnosed OSA (STOP BANG 5+), anemia, URI in last month, Trauma, >2hrs
Admit for overnight Oxygen supplementation and monitoring
Chronic Home Oxygen use back at baseline Oxygen Requirement
Room Air Sats < 90%
In SDS
Discharge home on oxygen
Low Risk: Pass 60 min test

32. Peak Respiratory Depression Time

34. Anesthesia/Nursing Partnership
Recognize high-risk patients in pre-screen
Collaborate in opioid-sparing surgery
Sync messages on conservative teaching for use of opioids at home
Identify patients in PACU/SDS who are high risk for apnea.
Communicate to anesthesia
Be the final message prior to discharge from SDS

35. Thank You!!!