UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Respiratory problems in the post-anesthesia care unit (PACU)

Authors
Edward A Bittner, MD, PhD, FCCP, FCCM
Edward George, MD, PhD
Section Editor
Natalie F Holt, MD, MPH
Deputy Editors
Nancy A Nussmeier, MD, FAHA
Geraldine Finlay, MD

INTRODUCTION

Respiratory complications are the second most common problem requiring treatment in the immediate postoperative period, after nausea and vomiting [1,2]. Etiologies are varied and can be due to abnormalities in the upper airway, lower airway, or lung parenchyma, as well as abnormalities of peripheral nerves and muscles that control breathing. Appropriate monitoring, early diagnosis, and timely management are critical since even potentially fatal respiratory compromise is usually reversible.

This topic will review monitoring, assessment, and management of respiratory problems in adults admitted to the post-anesthesia care unit (PACU). Evaluation of preoperative pulmonary risk, strategies to reduce postoperative pulmonary complications, and management of these complications after PACU discharge are presented separately.

(See "Evaluation of preoperative pulmonary risk".)

(See "Strategies to reduce postoperative pulmonary complications in adults".)

(See "Overview of the management of postoperative pulmonary complications".)

                              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Tue May 31 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992; 74:503.
  2. Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002; 57:1060.
  3. Apfelbaum JL, Silverstein JH, Chung FF, et al. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2013; 118:291.
  4. Smetana GW. Postoperative pulmonary complications: an update on risk assessment and reduction. Cleve Clin J Med 2009; 76 Suppl 4:S60.
  5. Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunction: pathophysiology and preventive strategies. Anesthesiology 2013; 118:961.
  6. Guay J, Choi P, Suresh S, et al. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014; :CD010108.
  7. Hausman MS Jr, Jewell ES, Engoren M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 2015; 120:1405.
  8. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120.
  9. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010; 111:129.
  10. Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329.
  11. Fortier LP, McKeen D, Turner K, et al. The RECITE Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade. Anesth Analg 2015; 121:366.
  12. Stewart PA, Liang SS, Li QS, et al. The Impact of Residual Neuromuscular Blockade, Oversedation, and Hypothermia on Adverse Respiratory Events in a Postanesthetic Care Unit: A Prospective Study of Prevalence, Predictors, and Outcomes. Anesth Analg 2016; 123:859.
  13. Weingarten TN, Herasevich V, McGlinch MC, et al. Predictors of Delayed Postoperative Respiratory Depression Assessed from Naloxone Administration. Anesth Analg 2015; 121:422.
  14. Hanning CD, Alexander-Williams JM. Pulse oximetry: a practical review. BMJ 1995; 311:367.
  15. Glossop AJ, Shephard N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth 2012; 109:305.
  16. Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients: a systematic review. Intensive Care Med 2011; 37:918.
  17. Faria DA, da Silva EM, Atallah ÁN, Vital FM. Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery. Cochrane Database Syst Rev 2015; :CD009134.
  18. Ireland CJ, Chapman TM, Mathew SF, et al. Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery. Cochrane Database Syst Rev 2014; :CD008930.
  19. Huerta S, DeShields S, Shpiner R, et al. Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg 2002; 6:354.
  20. Michelet P, D'Journo XB, Seinaye F, et al. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg 2009; 96:54.
  21. Abad-Gurumeta A, Ripollés-Melchor J, Casans-Francés R, et al. A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade. Anaesthesia 2015; 70:1441.
  22. Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia: laryngospasm. Qual Saf Health Care 2005; 14:e3.
  23. Wittekamp BH, van Mook WN, Tjan DH, et al. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care 2009; 13:233.
  24. Kriner EJ, Shafazand S, Colice GL. The endotracheal tube cuff-leak test as a predictor for postextubation stridor. Respir Care 2005; 50:1632.
  25. Zhou T, Zhang HP, Chen WW, et al. Cuff-leak test for predicting postextubation airway complications: a systematic review. J Evid Based Med 2011; 4:242.
  26. Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg 2013; 116:368.
  27. Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001; 11:861.
  28. Boyd M, Chatterjee A, Chiles C, Chin R Jr. Tracheobronchial foreign body aspiration in adults. South Med J 2009; 102:171.
  29. Mise K, Jurcev Savicevic A, Pavlov N, Jankovic S. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc 2009; 23:1360.
  30. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 2007; 117:1864.
  31. Sue RD, Susanto I. Long-term complications of artificial airways. Clin Chest Med 2003; 24:457.
  32. Weber S. Traumatic complications of airway management. Anesthesiol Clin North America 2002; 20:503.
  33. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007; 40:1109.
  34. Sanapala A, Nagaraju M, Rao LN, Nalluri K. Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy. Anesth Essays Res 2015; 9:251.
  35. Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002; 27:949.
  36. Bittner EA. Silent pain in the neck. http://webmm.ahrq.gov/case.aspx?caseID=235 (Accessed on May 20, 2014).
  37. Berroa F, Lafuente A, Javaloyes G, et al. The incidence of perioperative hypersensitivity reactions: a single-center, prospective, cohort study. Anesth Analg 2015; 121:117.
  38. Gurrieri C, Weingarten TN, Martin DP, et al. Allergic reactions during anesthesia at a large United States referral center. Anesth Analg 2011; 113:1202.
  39. Krodel DJ, Bittner EA, Abdulnour R, et al. Case scenario: acute postoperative negative pressure pulmonary edema. Anesthesiology 2010; 113:200.
  40. Janda M, Scheeren TW, Nöldge-Schomburg GF. Management of pulmonary aspiration. Best Pract Res Clin Anaesthesiol 2006; 20:409.
  41. Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78:56.
  42. Beck-Schimmer B, Bonvini JM. Bronchoaspiration: incidence, consequences and management. Eur J Anaesthesiol 2011; 28:78.
  43. Marik PE. Pulmonary aspiration syndromes. Curr Opin Pulm Med 2011; 17:148.
  44. Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry: 2011. Respir Care 2011; 56:1600.
  45. Hedenstierna G, Edmark L. The effects of anesthesia and muscle paralysis on the respiratory system. Intensive Care Med 2005; 31:1327.
  46. Fu ES, Downs JB, Schweiger JW, et al. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest 2004; 126:1552.
  47. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. J Clin Anesth 2005; 17:537.
  48. Cashman JN, Dolin SJ. Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data. Br J Anaesth 2004; 93:212.
  49. Overdyk FJ, Carter R, Maddox RR, et al. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg 2007; 105:412.
  50. Sun Z, Sessler DI, Dalton JE, et al. Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study. Anesth Analg 2015; 121:709.
  51. Fuchs-Buder T, Meistelman C, Alla F, et al. Antagonism of low degrees of atracurium-induced neuromuscular blockade: dose-effect relationship for neostigmine. Anesthesiology 2010; 112:34.
  52. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology 2010; 112:1013.
  53. Hunter JM. Antagonising neuromuscular block at the end of surgery. BMJ 2012; 345:e6666.
  54. Thilen SR, Hansen BE, Ramaiah R, et al. Intraoperative neuromuscular monitoring site and residual paralysis. Anesthesiology 2012; 117:964.
  55. Videira RL, Vieira JE. What rules of thumb do clinicians use to decide whether to antagonize nondepolarizing neuromuscular blocking drugs? Anesth Analg 2011; 113:1192.
  56. Geldner G, Niskanen M, Laurila P, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67:991.
  57. Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth 2015; 115:743.
  58. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.