Non-invasive respiratory volume monitoring identifies opioid-induced respiratory depression in an orthopedic surgery patient with diagnosed obstructive sleep apnea: a case report

Eamon Fleming, Christopher Voscopoulos, Edward George

Obstructive sleep apnea and opioid-induced respiratory depression can unpredictably threaten respiratory competence in the post-anesthesia care unit. Current respiratory monitoring relies heavily on respiratory rate and oxygen saturation, as well as subjective clinical assessment. These assessments have distinct limitations, and none provide a real-time, objective, quantitative direct measurement of respiratory status. A novel, non-invasive respiratory volume monitor uses bioimpedance to provide accurate, quantitative measurements of minute ventilation, tidal volume and respiratory rate continuously in real time, providing a direct measurement of ventilation. The case describes an orthopedic surgery patient (54-year-old Caucasian man, body mass index 33.7kg/m(2)) with diagnosed obstructive sleep apnea in whom the respiratory volume monitor data depicted persistent apneic behavior undetected by other monitoring. The monitor was able to detect a sudden reduction in minute ventilation after initial opioid administration in the post-anesthesia care unit. The patient had sustained low minute ventilation until discharge. Neither respiratory rate data from the hospital monitor nor oxygen saturation readings reflected the respiratory decompensation, remaining within normal limits even during sustained low minute ventilation. The events of this case illustrate the limitations of current respiratory rate monitoring and pulse oximetry in the evaluation of post-surgical respiratory status. Our patient displayed stable respiratory rate and no evidence of desaturation, despite sustained low minute ventilation, and he received opioids in the post-anesthesia care unit despite already compromised ventilation. Because the available monitoring did not indicate the patient's true respiratory status, he was treated with additional opioids, markedly increasing his risk for further respiratory decline.