CH.20: Postoperative care Pg. 367-368 Respiratory Problem

Respiratory Problems in the PACU

Etiology

In the immediate postanesthesia period, common causes of airway compromise include obstruction, hypoxemia, and hypoventilation. High-risk patients include those who:

  1. Have had general anesthesia

  2. Are older than 55 years of age

  3. Have a history of tobacco use

  4. Have preexisting lung problems and/or sleep-disordered breathing

  5. Are obese and/or have an unusual body habitus (e.g., large or short neck)

  6. Have co-morbidities (e.g., kidney problems, diabetes, hypertension)

  7. Have undergone airway, thoracic, or abdominal surgeryPulmonary complications pose the greatest risk to patients in the postanesthesia and immediate postoperative period. High-risk patients should be monitored in PACU or a critical unit.

Common Respiratory Issues:

  • Airway Obstruction: Often caused by the patient’s tongue blocking the airway, more pronounced in supine position and after surgery when the patient is extremely sleepy.

  • Hypoxemia: Characterized by a PaO2 less than 60 mm Hg leading to a spectrum of signs from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia. Pulse oximetry shows low O2 saturation (<90%).

  • Atelectasis: The most common post-surgery cause of hypoxemia, caused by bronchial obstruction due to retained secretions, decreased respiratory excursion, or general anesthesia. It occurs when mucus blocks bronchioles or when there isn’t enough alveolar surfactant.

  • Other causes of hypoxemia include pulmonary edema, pulmonary embolism, aspiration, and bronchospasm.

Initial PACU Assessment

Airway• Patency• Oral or nasal airway• Laryngeal mask airway• Endotracheal tube with ventilator settings

Breathing• Respiratory rate and quality• Auscultate breath sounds• Pulse oximetry• Capnography or other technology-supported monitoring• Supplemental O2

Circulation• ECG monitoring: rate and rhythm• BP: noninvasive or arterial line• Hemodynamic pressure readings (if applicable)• Temperature• Capillary refill• Color, temperature, moisture of skin• Apical and peripheral pulses

Neurologic• Level of consciousness• Orientation• Sensory and motor status• Pupil size and reaction

Surgical Site• Dressings and visible incisions• Drains: type, patency, and drainage• IV assessment: location and condition of sites, solutions infusing

Genitourinary• Urine output

strointestinal• Nausea, vomiting• Intake (fluids, irrigations)• Output (vomitus)• Bowel sounds

Pain• Incision• Other

Patient Safety Needs• Patient position• Fall risk assessment

Risks of Aspiration

Patients are at risk for aspiration of gastric contents during intubation or after surgery due to anesthesia depressing protective airway reflexes, potentially resulting in laryngospasm, pneumonia, and pulmonary edema.

Bronchospasm

Occurs from increased bronchial smooth muscle tone causing airway edema and secretions. Symptoms include wheezing, dyspnea, hypoxemia, and tachypnea.It may be caused by aspiration, intubation, suctioning, or allergies. More common in patients with smoking history, asthma, and COPD.

Signs of Inadequate Oxygenation

  • Cardiovascular System: Increased or decreased BP, HR, dysrhythmias, delayed capillary refill, decreased O2 saturation, weak peripheral pulses.

  • Central Nervous System: Agitation, confusion, muscle twitching, restlessness, seizures.

  • Renal System: Urine output <0.5 mL/kg/hr.

  • Respiratory System: Increased to absent respiratory effort, use of accessory muscles, abnormal breath sounds, abnormal ABG values.

  • Skin: Cool, flushed, or moist skin; cyanosis.

Hypoventilation

Common in the PACU, appearing as decreased respiratory rate, hypoxemia, and hypercapnia. Can result from anesthesia or opioid use, or poor respiratory muscle tone.

Safety Alert: Assess for decreased respiratory rate when administering opioids. Use a sedation assessment scale to ensure patient safety and initiate emergency management if hypoventilation occurs.

Respiratory Problems in the Clinical Unit

Common Causes

  • Atelectasis and Pneumonia: Particularly prevalent in patients with co-morbidities such as Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease (COPD), and heart failure, especially following abdominal or thoracic surgery.

Contributing Factors

  • Mucous Plugs and Surfactant Production: Development of mucous plugs and decreased surfactant production is directly related to several factors:

    • Hypoventilation

    • Ineffective coughing

    • History of tobacco use

    • Immobility and bed rest

  • Increased Bronchial Secretions: Occur due to irritation from:

    • Heavy smoking

    • COPD

    • Pulmonary infection

    • Dry mucous membranes from intubation, inhalation anesthesia, and dehydration.

Consequences

  • Without timely intervention, atelectasis can progress to pneumonia.