What is the management of respiratory depression?

Management of Respiratory Depression

Reversal agents should be administered to all patients experiencing significant respiratory depression, with appropriate resuscitation initiated in cases of severe respiratory depression. 1

Immediate Management Steps

• Administer supplemental oxygen to patients with altered level of consciousness, respiratory depression, or hypoxemia 1
• Maintain intravenous access in all patients with respiratory depression, especially if recurring episodes are anticipated 1
• Administer naloxone for significant opioid-induced respiratory depression regardless of oxygen saturation levels, as clinical presentation is more important than oxygen saturation numbers alone 2
• For adults with opioid-induced respiratory depression, administer naloxone 0.4 mg to 2 mg intravenously, which may be repeated at 2-3 minute intervals if respiratory function does not improve 2, 3
• For children with opioid-induced respiratory depression, administer naloxone 0.01 mg/kg body weight intravenously initially, with subsequent dose of 0.1 mg/kg if needed 3
• For postoperative opioid-induced depression in adults, titrate naloxone in smaller increments of 0.1 to 0.2 mg intravenously at 2-3 minute intervals to achieve adequate ventilation and alertness without significant pain 3
• For postoperative opioid-induced depression in children, administer naloxone in increments of 0.005 mg to 0.01 mg intravenously at 2-3 minute intervals 3
• Consider noninvasive positive-pressure ventilation if frequent or severe airway obstruction or hypoxemia occurs during monitoring 1, 4

Monitoring After Reversal

• Continue supplemental oxygen until the patient is alert with no respiratory depression or hypoxemia 1
• Monitor patients for at least 2 hours after naloxone administration, with longer observation periods for patients on long-acting opioids 2
• Be prepared for possible recurrence of respiratory depression as naloxone's duration of action may be shorter than that of many opioids 2
• Monitor adequacy of ventilation through respiratory rate, depth of respiration, and pattern of breathing 4
• Use continuous pulse oximetry to detect hypoxemia early 4
• Consider end-tidal CO2 monitoring (capnography) which can detect respiratory depression earlier than clinical signs or pulse oximetry alone 4, 5
• Regularly assess alertness and sedation level using a standardized scoring system 4

Prevention Strategies

• Identify patients at increased risk of respiratory depression including those with sleep apnea, obesity, unstable medical conditions, concomitant use of other opioids or sedatives, and extremes of age 1
• Use the lowest efficacious dose of opioids to minimize the risk of respiratory depression 1
• Cautiously administer parenteral opioids or hypnotics in the presence of neuraxial opioids 1
• Increase monitoring intensity and duration for high-risk patients 1, 6
• When clinically suitable, consider single-injection neuraxial fentanyl or sufentanil as safer alternatives to single-injection neuraxial morphine 1
• Continuous epidural opioids are preferred to parenteral opioids for anesthesia and analgesia to reduce the risk of respiratory depression 1

Common Pitfalls and Caveats

• Avoid administering too large a dose of naloxone which may result in significant reversal of analgesia and increase in blood pressure 3
• Too rapid reversal may induce nausea, vomiting, sweating, or circulatory stress 3
• Routine use of supplemental oxygen may hinder detection of atelectasis, transient apnea, and hypoventilation 1
• Naloxone may precipitate acute withdrawal syndrome in opioid-dependent patients, which can be minimized by using the lowest effective dose 2
• Recognize that patients experiencing opioid-related adverse events have 55% longer hospital stays, 47% higher costs, and 3.4 times higher risk of inpatient mortality 5
• Be aware that respiratory depression is often preventable with proper monitoring and early intervention 7, 5