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Postoperative apnea, respiratory strategies, and pathogenesis mechanisms: a review

Journal of Anesthesia volume 27, pages 423–432 (2013)Cite this article

Abstract

Recovery from anesthesia is ideally routine and uneventful. After extubation, the recovering postoperative patient ought to breathe without supportive care or additional oxygenation. It has been demonstrated in previous studies that postoperative pulmonary complications are clinically relevant in terms of mortality, morbidity, and length of hospital stay. Compromised postoperative ventilation can be described as the condition in which the postoperative patient does not have satisfactory spontaneous ventilation support and adequate oxygenation. Causes of impaired ventilation, oxygenation, and airway maintenance can be mechanical, hemodynamic, and pharmacologic. This review describes prevalence and differential diagnosis, including co-morbidities of postoperative apnea. The physiological mechanisms of breathing and prolonged postoperative apnea are also reviewed; these mechanisms include influences from the brainstem, the cerebral cortex, and chemoreceptors in the carotid and aortic body. Causes of prolonged postoperative apnea and management are also discussed.

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References

  1. Committee on Fetus and Newborn, American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003;111(4 Pt 1):914–7.

    Google Scholar 

  2. Peutrell JM. Heniotomy in the ex-premie. In: Stoddart PA, Lauder GR, editors. Problems in anaestesia paediatric anaesthesia. London: Taylor & Francis; 2004. p. 19–27.

    Chapter  Google Scholar 

  3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230–5.

    PubMed  Article  CAS  Google Scholar 

  4. West JB. Respiratory physiology: the essentials. 6th ed. Lippincott, Williams and Wilkins: Philadelphia; 1999.

    Google Scholar 

  5. Stella G. On the mechanism of production, and the physiological significance of “apneusis”. J Physiol. 1938;93(1):10–23.

    PubMed  CAS  Google Scholar 

  6. Nattie E, Li A. Central chemoreception is a complex system function that involves multiple brain stem sites. J Appl Physiol. 2009;106(4):1464–6.

    PubMed  Article  CAS  Google Scholar 

  7. Derenne JP, Macklem PT, Roussos C. The respiratory muscles: mechanics, control, and pathophysiology. Am Rev Respir Dis. 1978;118(1):119–33.

    PubMed  CAS  Google Scholar 

  8. Wise RA, Robotham JL, Summer WR. Effects of spontaneous ventilation on the circulation. Lung. 1981;159(4):175–86.

    PubMed  Article  CAS  Google Scholar 

  9. Knill RL, Gelb AW. Ventilatory responses to hypoxia and hypercapnia during halothane sedation and anesthesia in man. Anesthesiology. 1978;49(4):244–51.

    PubMed  Article  CAS  Google Scholar 

  10. Eger EI. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001;93(4):947–53.

    PubMed  Article  CAS  Google Scholar 

  11. Fowler M, Speiss B. Post anesthesia recovery. In: Barash P, Cullen B, Stoelting RK, Cahalan MK, Stock MC, editors. Handbook of clinical anesthesia. 6th ed. Philadelphia: Lippincott, Williams and Wilkins; 2009. p. 1423–39.

  12. Pattinson KT. Opioids and the control of respiration. Br J Anaesth. 2008;100(6):747–58.

    PubMed  Article  CAS  Google Scholar 

  13. Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology. 2010;112(1):226–38.

    PubMed  Article  Google Scholar 

  14. Herbstreit F, Peters J, Eikermann M. Impaired upper airway integrity by residual neuromuscular blockade: increased airway collapsibility and blunted genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2009;110(6):1253–60.

    PubMed  Article  Google Scholar 

  15. Heier T, Caldwell JE. Impact of hypothermia on the response to neuromuscular blocking drugs. Anesthesiology. 2006;104(5):1070–80.

    PubMed  Article  Google Scholar 

  16. Lee CJ, Lim SH, Shin CM, Kim YJ, Choe YK, Cheong SH, Lee KM, Lee JH, Kim YH, Lee SH, Bae JS. Lambert-Eaton myasthenic syndrome as a cause of persistent neuromuscular weakness after a mediastinoscopic biopsy—a case report. Korean J Anesthesiol. 2010;59(1):45–8.

    PubMed  Article  Google Scholar 

  17. Yao FS, Malhotra V. Yao and Artusio’s anesthesiology: problem-oriented patient management: New York, Lippincott-Raven; 2008.

  18. Lui F, Ng KF. Adjuvant analgesics in acute pain. Expert Opin Pharmacother. 2011;12(3):363–85.

    PubMed  Article  CAS  Google Scholar 

  19. Smetana GW. Postoperative pulmonary complications: an update on risk assessment and reduction. Clevel Clin J Med. 2009;76(Suppl 4):S60–5.

    Article  Google Scholar 

  20. Sankri-Tarbichi AG, Rowley JA, Badr MS. Expiratory pharyngeal narrowing during central hypocapnic hypopnea. Am J Respir Crit Care Med. 2009;179(4):313–9.

    PubMed  Article  Google Scholar 

  21. Meier S, Geiduschek J, Paganoni R, Fuehrmeyer F, Reber A. The effect of chin lift, jaw thrust, and continuous positive airway pressure on the size of the glottic opening and on stridor score in anesthetized, spontaneously breathing children. Anesth Analg. 2002;94(3):494–9. (table of contents).

    PubMed  Article  Google Scholar 

  22. Tung A. Indications for mechanical ventilation. Int Anesthesiol Clin. 1997;35(1):1–17.

    PubMed  Article  CAS  Google Scholar 

  23. Macklem PT. The physiology of small airways. Am J Respir Crit Care Med. 1998;157(5 Pt 2):S181–3.

    PubMed  Article  CAS  Google Scholar 

  24. Kim V, Rogers TJ, Criner GJ. New concepts in the pathobiology of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):478–85.

    PubMed  Article  CAS  Google Scholar 

  25. Gold MI, Helrich M. Pulmonary compliance during anesthesia. Anesthesiology. 1965;26:281–8.

    PubMed  Article  CAS  Google Scholar 

  26. Perilli V, Sollazzi L, Bozza P, Modesti C, Chierichini A, Tacchino RM, Ranieri R. The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91(6):1520–5.

    PubMed  Article  CAS  Google Scholar 

  27. Pelosi P, Gregoretti C. Perioperative management of obese patients. Best Pract Res Clin Anaesthesiol. 2010;24(2):211–25.

    PubMed  Article  Google Scholar 

  28. Hedenstierna G, Edmark L. Mechanisms of atelectasis in the perioperative period. Best Pract Res Clin Anaesthesiol. 2010;24(2):157–69.

    PubMed  Article  Google Scholar 

  29. Hedenstierna G. Oxygen and anesthesia: what lung do we deliver to the post-operative ward? Acta Anaesthesiol Scand. 2012;56(6):675–85.

    Google Scholar 

  30. Johnson D. Lung recruitment during general anesthesia. Can J Anaesth. 2001;51(7):649–53.

    Google Scholar 

  31. Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia care unit. Patient, surgical, and anesthetic factors. Anesthesiology. 1994;81(2):410–8.

    PubMed  Article  CAS  Google Scholar 

  32. Ferguson MK. Preoperative assessment of pulmonary risk. Chest. 1999;115(5 Suppl):58S–63S.

    PubMed  Article  CAS  Google Scholar 

  33. Keifer JC, Baghdoyan HA, Lydic R. Sleep disruption and increased apneas after pontine microinjection of morphine. Anesthesiology. 1992;77:973–82.

    PubMed  Article  CAS  Google Scholar 

  34. Wang D, Teichtahl H, Drummer O, Goodman C, Cherry G, Cunnington D, Kronborg I. Central sleep apnea in stable methadone maintenance treatment patients. Chest. 2005;128:1348–56.

    PubMed  Article  Google Scholar 

  35. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;20(9):705–6.

    PubMed  CAS  Google Scholar 

  36. Davies RJ, Stradling JR. The relationship between neck circumference, radiographic pharyngeal anatomy, and the obstructive sleep apnoea syndrome. Eur Respir J. 1990;3(5):509–14.

    PubMed  CAS  Google Scholar 

  37. Stradling JR, Crosby JH. Predictors and prevalence of obstructive sleep apnoea and snoring in 1001 middle aged men. Thorax. 1991;46(2):85–90.

    PubMed  Article  CAS  Google Scholar 

  38. Connolly LA. Anesthetic management of obstructive sleep apnea patients. J Clin Anesth. 1991;3(6):461–9.

    PubMed  Article  CAS  Google Scholar 

  39. Keamy MF, Cadieux RJ, Kofke WA, Kales A. The occurrence of obstructive sleep apnea in a recovery room patient. Anesthesiology. 1987;66(2):232–4.

    PubMed  Article  Google Scholar 

  40. Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. Can J Anaesth. 1990;37(2):210–8.

    PubMed  Article  CAS  Google Scholar 

  41. Cademartiri F, Luccichenti G, Laganà F, Brevi B, Sesenna E, Pavone P. Effective clinical outcome of a mandibular distraction device using three-dimensional CT with volume rendering in Pierre-Robin sequence. Acta Biomed. 2004;75(2):122–5.

    PubMed  Google Scholar 

  42. Pang KP. Identifying patients who need close monitoring during and after upper airway surgery for obstructive sleep apnoea. J Laryngol Otol. 2006;120:655–60.

    PubMed  Article  CAS  Google Scholar 

  43. Savoia G, Alampi D, Amantea B, Ambrosio F, Arcioni R, Berti M, Bettelli G, Bertini L, Bosco M, Casati A, Castelletti I, Carassiti M, Carassiti M, Costantini A, Coluzzi F, Danelli G, Evangelista M, Finco G, Gatti A, Gravino E, Launo C, Loreto M, Mediati R, Mokini Z, Mondello E, Palermo S, Paoletti F, Paolicchi A, Petrini F, Piacevoli Q, Rizza A, Sabato AF, Santangelo E, Troglio E, Mattia C. Postoperative pain treatment SIAARTI recommendations 2010. Short version. Minerva Anestesiol. 2010;76(8):657–67.

    PubMed  CAS  Google Scholar 

  44. Levitzky MG. Pulmonary physiology. 8th ed. New York: McGraw-Hill (Lange Series), 2013 (in press).

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Conflict of interest

The authors have no relationships with pharmaceutical companies or products to disclose, nor do they discuss off-label or investigative products in this lesson.

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Affiliations

  1. Department of Anesthesiology, Louisiana State University School of Medicine, Louisiana State University Health Science Center, 1542 Tulane Ave, Room 656, New Orleans, LA, 70112, USA

    Alan D. Kaye, Rachel J. Kaye & Franklin Rivera Bueno

  2. Department of Anesthesiology, Emory University, Atlanta, GA, USA

    McKenzie Mayo Hollon

  3. Yale University School of Medicine, New Haven, CT, USA

    Nalini Vadivelu

  4. School of Liberal Arts and Sciences, University of Connecticut, Storrs, CT, USA

    Gopal Kodumudi

  5. Metropolitan Anesthesia Consultants, Dallas, TX, USA

    Amir R. Baluch

  6. Department of Pharmacology, Louisiana State University Health Science Center, New Orleans, LA, 70112, USA

    Alan D. Kaye

Authors
  1. Alan D. Kaye
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  2. McKenzie Mayo Hollon
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  3. Nalini Vadivelu
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  4. Gopal Kodumudi
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  5. Rachel J. Kaye
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  6. Franklin Rivera Bueno
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  7. Amir R. Baluch
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Correspondence to Alan D. Kaye.

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Kaye, A.D., Hollon, M.M., Vadivelu, N. et al. Postoperative apnea, respiratory strategies, and pathogenesis mechanisms: a review. J Anesth 27, 423–432 (2013). https://doi.org/10.1007/s00540-012-1517-0

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  • DOI: https://doi.org/10.1007/s00540-012-1517-0

Keywords

  • Postop apnea
  • Obesity
  • Medications
  • Brain mechanisms