Free
Education  |   April 2013
Postoperative Respiratory Muscle Dysfunction: Pathophysiology and Preventive Strategies
Author Affiliations & Notes
  • Nobuo Sasaki, M.D.
    Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Staff Critical Care Physician, Department of Emergency and Critical Care Medicine, Showa General Hospital, Tokyo, Japan. Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital. Director of Research, Critical Care Division, Massachusetts General Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts, and Universitaet Duisburg Essen, Germany.
  • Matthew J. Meyer, M.D.
    Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Staff Critical Care Physician, Department of Emergency and Critical Care Medicine, Showa General Hospital, Tokyo, Japan. Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital. Director of Research, Critical Care Division, Massachusetts General Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts, and Universitaet Duisburg Essen, Germany.
  • Matthias Eikermann, M.D., Ph.D.
    Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Staff Critical Care Physician, Department of Emergency and Critical Care Medicine, Showa General Hospital, Tokyo, Japan. Research Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital. Director of Research, Critical Care Division, Massachusetts General Hospital, and Associate Professor, Harvard Medical School, Boston, Massachusetts, and Universitaet Duisburg Essen, Germany.
  • Received from the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Submitted for publication August 31, 2012. Accepted for publication November 21, 2012. Support was provided solely from institutional and/or departmental sources.
    Received from the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Submitted for publication August 31, 2012. Accepted for publication November 21, 2012. Support was provided solely from institutional and/or departmental sources.×
  • Presented at the American Society of Anesthesiologists Annual Meeting, October 2012.
    Presented at the American Society of Anesthesiologists Annual Meeting, October 2012.×
  • This article is accompanied by an Editorial View. Please see: Gropper MA: Postoperative respiratory muscle dysfunction: Only the strong survive. Anesthesiology 2013; 118:00–00.
    This article is accompanied by an Editorial View. Please see: Gropper MA: Postoperative respiratory muscle dysfunction: Only the strong survive. Anesthesiology 2013; 118:00–00.×
  • Address correspondence to Dr. Eikermann: Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Gray-Bigelow 444, 55 Fruit Street, Boston, Massachusetts 02114. meikermann@partners.org. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.
Article Information
Education / Review Article / Airway Management / Respiratory System
Education   |   April 2013
Postoperative Respiratory Muscle Dysfunction: Pathophysiology and Preventive Strategies
Anesthesiology 04 2013, Vol.118, 961-978. doi:10.1097/ALN.0b013e318288834f
Anesthesiology 04 2013, Vol.118, 961-978. doi:10.1097/ALN.0b013e318288834f
Abstract

Postoperative pulmonary complications are responsible for significant increases in hospital cost as well as patient morbidity and mortality; respiratory muscle dysfunction represents a contributing factor. Upper airway dilator muscles functionally resist the upper airway collapsing forces created by the respiratory pump muscles. Standard perioperative medications (anesthetics, sedatives, opioids, and neuromuscular blocking agents), interventions (patient positioning, mechanical ventilation, and surgical trauma), and diseases (lung hyperinflation, obesity, and obstructive sleep apnea) have differential effects on the respiratory muscle subgroups. These effects on the upper airway dilators and respiratory pump muscles impair their coordination and function and can result in respiratory failure. Perioperative management strategies can help decrease the incidence of postoperative respiratory muscle dysfunction. Such strategies include minimally invasive procedures rather than open surgery, early and optimal mobilizing of respiratory muscles while on mechanical ventilation, judicious use of respiratory depressant anesthetics and neuromuscular blocking agents, and noninvasive ventilation when possible.

Postoperative pulmonary complications are responsible for increases in hospital cost and patient morbidity and mortality. The authors review the role respiratory muscle function, and dysfunction, contribute to the pathophysiology and prevention of postoperative pulmonary complications.

POSTOPERATIVE pulmonary complications (PPC), defined as new onset or exacerbation of respiratory failure following surgery, occur frequently1–3  and are associated with increased rates of short- and long-term mortality,4  as well as increased cost.5  A thorough understanding of the clinical effects of PPC is hindered by inconsistency in the definition of PPC among researchers. The diagnoses classically considered PPC include atelectasis, bronchospasm, pneumonia, pulmonary edema, and respiratory failure.6  Respiratory failure itself is not clearly defined, although the most common criterion is failure to be extubated within 48 h of surgery.6  Adding complexity to assessing the impact of PPC are recent studies which support expanding the definition to include acute upper airway obstruction,7–9  complications from obstructive sleep apnea (OSA),10  chemical pneumonitis,11  and hypoxemia due to abdominal compartment syndrome.12,13 
Estimating the incidence of PPC and respiratory failure is complicated for many reasons including the imprecise definitions; however, recent studies attempted exactly this by defining respiratory failure as unplanned reintubation and postoperative mechanical ventilation.3,14 
For this small subset of the post-surgical population, the probability of PPC affecting their longevity is great. In 2005, National Surgical Quality Improvement Program data were queried and for patients who were unable to wean from mechanical ventilation after major surgery, the 30-day mortality was 29% (12 times greater than those not experiencing PPC).4  In another cohort study, postoperative reintubation was associated with a 90-fold increase in mortality.14 
Along with the huge mortality burden of PPC, there is a significant financial consideration. A 2004 study analyzing hospital cost at the University of Michigan identified PPC as the most expensive of the major postoperative complications. Moreover, when compared to the median hospital cost of $5,015 for surgical patients without PPC, the $62,704 hospital expense for a surgical patient with a pulmonary complication was 12 times greater.5 
One underappreciated factor in the development of PPC and respiratory failure is respiratory muscle dysfunction. Upper airway muscles play a vital role in maintaining the anatomic structure of the pharynx and laryngotracheal complex and ensure upper airway patency. Respiratory pump muscles create negative, and occasionally positive, pressure to ventilate and oxygenate. Research shows that even partial respiratory muscle paralysis may lead to more PPC.8,15  In the upper airway, partial paralysis can lead to obstruction16  and increased aspiration risk,17  whereas respiratory pump muscle failure leads to weak cough18  and increased incidence of pneumonia.19  Finally, a 2-week long, preoperative inspiratory muscle training program reduced the incidence of PPC, further demonstrating the importance of respiratory muscle fitness in the prevention of PPC20  and subsequent respiratory failure.
The aim of this article was two-fold: (1) to review the current concepts of postoperative pathophysiology as it pertains to respiratory muscle dysfunction, and (2) to discuss strategies to avoid respiratory muscle dysfunction during the perioperative period and critical illness.
Anatomy and Physiology
The muscles involved in respiration are morphologically and functionally skeletal muscles and can be classified by their anatomic function into two groups: (1) upper airway dilators and (2) respiratory pump muscles. Upper airway dilator muscles counterbalance the negative inspiratory pressure generated by the pump muscle to permit airflow during inspiration. Respiratory pump muscles are the collection of muscles responsible for generating inspiratory and expiratory forces in the thorax.
Upper Airway Patency
Patency of the upper airway is maintained by balancing collapsing and dilating forces (fig. 1). The primary upper airway collapsing forces are (1) negative intraluminal pressure generated by the respiratory pump during inspiration and (2) compressive extra-luminal forces from the surrounding tissues. These collapsing forces are opposed by the actions of the upper airway dilator muscles to maintain the airway.
Fig. 1.
Perioperative relationship of upper airway patency and respiratory pump activation. (A) Schematic of the respiratory system under normal physiology. Upper airway dilator muscles counterbalance the collapsing forces imposed on the upper airway by extra-luminal pressures and negative inspiratory pressure generated by the respiratory pump muscles. The green balloon (labeled “dilating forces”) represents the forces generated by the upper airway dilator muscles which resist the anatomic and physiologic forces promoting collapse of the upper airway (represented by the orange counterweight labeled “collapsing forces”). (B) Respiratory system in the perioperative period. The “needle” represents the multitude of iatrogenic factors listed in the nearby orange box that can cause upper airway dilator muscle dysfunction. The lowest orange counterweight represents perioperative factors leading to increased respiratory pump muscle contractions. In the perioperative period, a patient’s physiology and anatomy are affected so that upper airway dilating forces are diminished and can no longer create enough force to resist the increased collapsing forces, thus leading to upper airway collapse. PORC = postoperative residual curarization.
Image Not Available
Fig. 1.
Perioperative relationship of upper airway patency and respiratory pump activation. (A) Schematic of the respiratory system under normal physiology. Upper airway dilator muscles counterbalance the collapsing forces imposed on the upper airway by extra-luminal pressures and negative inspiratory pressure generated by the respiratory pump muscles. The green balloon (labeled “dilating forces”) represents the forces generated by the upper airway dilator muscles which resist the anatomic and physiologic forces promoting collapse of the upper airway (represented by the orange counterweight labeled “collapsing forces”). (B) Respiratory system in the perioperative period. The “needle” represents the multitude of iatrogenic factors listed in the nearby orange box that can cause upper airway dilator muscle dysfunction. The lowest orange counterweight represents perioperative factors leading to increased respiratory pump muscle contractions. In the perioperative period, a patient’s physiology and anatomy are affected so that upper airway dilating forces are diminished and can no longer create enough force to resist the increased collapsing forces, thus leading to upper airway collapse. PORC = postoperative residual curarization.
×
Upper Airway Dilator Muscles.
The actions of the upper airway dilator muscles keep the airway patent. There are many muscles involved in dilating the upper airway; however, the most extensively studied muscles of the upper airway dilators are the genioglossus and the tensor palatine, and experimentally these serve as surrogates for the others. Neurologically, the genioglossus receives a variety of inputs, including phasic (inspiratory) and tonic (non-inspiratory) drive which are distributed differentially across the hypoglossal motoneuron pool.21  In response to negative pharyngeal pressure created by the respiratory pump during inspiration, the genioglossus reflexively stabilizes the upper airway in both humans22  and rats.23  This reflex is likely a product of signaling from inspiratory modulated motor units. Whereas the genioglossus responds to phasic input on top of its tonic (non-respiratory) activation, the tensor palatine is considered a tonic muscle with consistent tone throughout the respiratory cycle.24 
Extra-luminal Pressure.
The soft tissues of the pharynx are enclosed and stabilized by bony structures such as the mandible and the spine, and complete collapse of the pharyngeal airway ordinarily requires extra-luminal forces such as hematoma, edema, or peri-pharyngeal masses. Pharyngeal manifestation of obesity compresses the airway.25  Craniofacial abnormalities can further increase the collapsing effects of excessive pharyngeal extra-luminal soft tissue in obese patients and lead to increased pharyngeal collapsibility and OSA26 : a disorder involving intermittent nocturnal upper airway collapse. Thus, the extra-luminal soft tissue, and size and shape of the bony enclosure are determinants of the extra-luminal pressure that needs to be antagonized by the upper airway dilator muscle contraction during inspiration in order to avoid an upper airway obstruction-related apnea.26 
Body Position.
The effects of body position on upper airway patency have been extensively studied by Isono et al.27,28  The upper airway is more vulnerable to collapse in the supine position than the lateral and sitting positions. Evidence for the lateral position is considerable and frequently based upon research involving subjects with OSA. In sleeping subjects with OSA, fewer obstructive events were reported in the lateral position than supine.29  In anesthetized and paralyzed subjects with OSA, the patency of the passive pharynx was better maintained in the lateral and sitting positions than in the supine.27,28  These improvements in airway patency caused by the lateral position are explained by a less obstructive orientation of the pharyngeal soft tissues.
Respiratory Timing.
The length of the respiratory cycle (Ttot) and variation in its component parts of inspiration (TI) and expiration can affect upper airway patency. Inspiratory duty cycle, also referred to as effective inspiratory time, is the ratio of inspiration to the total respiratory cycle (TI/Ttot), and this can be directly associated with airflow. In fact, increased inspiratory duty cycle can actually compensate for partial airway obstruction.30 
Effects of End-expiratory Lung Volume.
A less intuitive component of upper airway patency is lung volume. Higher end-expiratory lung volumes are associated with a decrease in upper airway resistance to airflow in awake healthy humans,31  and an increase in upper airway lumen dimensions in subjects with and without OSA.32  The mechanism for the interaction between upper airway patency and lung volume is thought to lie in the generation of longitudinal traction forces in the trachea.33,34  Upon inspiration, the lung inflates and effectively forces the carina into a more caudal position, thus creating stretching forces on the fixed trachea.34  These forces are transferred to the upper airway walls through assorted soft tissue connections, resulting in improved upper airway dilatation.33  Effectively, tracheal traction allows the respiratory pump muscles to contribute to upper airway patency.
Effects of Fluid Homeostasis on Upper Airway Patency.
Fluid overload can affect upper airway patency. In awake, healthy volunteers, the inflation of antishock trousers displaced so much fluid from the lower extremities that neck circumference increased, the pharynx narrowed,35  and the upper airway had a lower threshold for collapse.36  This concept is reinforced in studies of subjects with lower extremity venous insufficiency37  and congestive heart failure.38  These studies have shown that nocturnal redistribution of fluid from the lower extremities into the neck increases upper airway collapsibility37  and the severity of central and OSAs.38  Future studies in perioperative medicine will show if perioperative fluid restriction helps decrease the vulnerability of the upper airway to collapse.
Respiratory Pump Muscle Activation
The respiratory pump generates the motorized action driving inspiration and expiration. It is the force that broadens the thoracic cavity and creates negative intrathoracic pressure to draw a breath in, and, when needed, positive intrathoracic pressure to exhale rapidly.
Inspiratory Pump Muscles.
Inspiratory pump muscles are an anatomically diverse group, with the best studied being the diaphragm and those of the thoracic wall. The most important inspiratory muscle in healthy humans is the diaphragm, which accounts for 60–70% of lung volume change during simple respiration.39  It is a thin, flat, musculotendinous structure subdivided into the crural diaphragm (originating at the lumbar vertebrae) and the costal diaphragm (originating at the inner surfaces of the lower six ribs); these two divisions function as one during respiration. During inspiration, the volume of the thoracic cavity increases as a result of contraction of the diaphragm and the external intercostal muscles. The lungs expand secondarily to the increased negative intrathoracic pressure generated by these phasic actions of the inspiratory pump muscles.
Inspiratory tone is present in muscles acting on the rib cage and helps to maintain negative intrathoracic pressure.40  There is also inspiratory tone in the diaphragm and its likely purpose is to prevent abdominal viscera mechanically from compressing the lungs.41  The combination of an effective inspiratory tonicity of both the diaphragm and rib cage muscles acting upon the rib cage effectively increases functional residual capacity (FRC) by about 0.8 l.42 
Body Position.
Body posture has significant influence on the contribution of respiratory pump muscles to inspiration and lung function. When the torso is upright, the diaphragm is lower in the chest, and the chest circumference changes little compared to that in supine;43  consequently, FRC is about 20% greater upright than supine in humans.44  In the upright position, displacement of the rib cage accounts for approximately 60% of resting tidal volume and in this setting, thoracic wall muscles contribute greatly. In the supine position, rib cage displacement accounts for less than half of the upright tidal volume, and abdominal and diaphragmatic movement contributes significantly more.45  Thus, supine position following surgery renders a patient particularly vulnerable to diaphragmatic dysfunction induced by perioperative medical interventions.
Expiratory Pump Muscles.
The expiratory pump muscles include the internal intercostal, rectus abdominis, external oblique, internal oblique, and transverse abdominis muscles. Expiration at rest is usually passive, relying on the elasticity of the lungs and thorax to return to their equilibrium position. During high breathing effort (i.e., exercise, sepsis, and dysfunctional pulmonary status), the expiratory muscles contract to increase the speed of exhalation, increasing inspiratory duty cycle, in preparation for the next inhalation. Expiratory pump muscles are used in everyday life for speaking, coughing, and airway secretion clearance.
Perioperative Pathophysiology, Treatments, and Interventions Contributing to Respiratory Muscle Dysfunction
Perioperative patients are a subset of the general population where respiratory muscle dysfunction occurs frequently and is often due to predictable causes (fig. 2).
Fig. 2.
Pathophysiology of postoperative respiratory failure emphasizing respiratory muscle dysfunction. Perioperative respiratory muscle dysfunction results from a multitude of factors, including preoperative comorbidities and perioperative interventions, each individually affecting upper airway dilator muscles, respiratory pump muscles, or both. Whereas a single factor rarely translates into respiratory failure, a combination of factors can cause pulmonary complications leading to respiratory failure. In the setting of respiratory failure requiring mechanical ventilation, ventilator-induced diaphragmatic dysfunction (VIDD) further compounds respiratory pump muscle dysfunction and contributes to increased morbidity and mortality. OSA = obstructive sleep apnea.
Image Not Available
Fig. 2.
Pathophysiology of postoperative respiratory failure emphasizing respiratory muscle dysfunction. Perioperative respiratory muscle dysfunction results from a multitude of factors, including preoperative comorbidities and perioperative interventions, each individually affecting upper airway dilator muscles, respiratory pump muscles, or both. Whereas a single factor rarely translates into respiratory failure, a combination of factors can cause pulmonary complications leading to respiratory failure. In the setting of respiratory failure requiring mechanical ventilation, ventilator-induced diaphragmatic dysfunction (VIDD) further compounds respiratory pump muscle dysfunction and contributes to increased morbidity and mortality. OSA = obstructive sleep apnea.
×
Surgery and Trauma
Surgery can be characterized as intentional penetrating trauma that can cause respiratory failure. Procedures on the foregut, the hepatopancreatobiliary region, and the aorta have the strongest association with respiratory failure46 ; length of surgery is also associated with greater incidence of PPC.47,48  Surgery impairs respiratory pump muscles through a variety of different avenues, leading to increased atelectasis and decreased FRC and decreased vital capacity.49,50  Moreover, the effects are not merely transient but can last from a day to a week,51,52  to upward of a year with phrenic nerve damage.53 
There are many mechanisms through which surgery can induce respiratory failure. Some of these reasons are straightforward: functional disruption (cutting, tearing, and retracting) of respiratory muscles (intercostals or rectus abdominis),54–56  postoperative pain leading to voluntary restrictions on respirations,57,58  and phrenic nerve injury resulting in direct diaphragmatic dysfunction.53  Following abdominal or thoracic surgery, patients typically experience a restrictive pattern respiratory abnormality due to impaired respiratory pump muscle function within the first postoperative day. When affected by this restrictive pathology, a patient breathes at reduced lung volumes and FRC diminishes. When FRC decreases below the lung volume where small airway closure generally occurs, entitled closing capacity, regions with low ventilation/perfusion ratios develop, leading to impaired gas exchange and possibly gas trapping and atelectasis.59 
Other mechanisms underlying respiratory failure are physiologically more complex. It is well documented that diaphragmatic dysfunction occurs postoperatively,51,60  but the exact mechanism is less certain. In rats, localized, postoperative inflammation has been shown to weaken diaphragm action within hours after exposure.61  Another likely contributor to diaphragmatic dysfunction is the neural inhibitory response to surgical stimulation. In canines, surgical manipulation of the gallbladder has been associated with quick and profound reduction in function of the diaphragm; the rapid time-course of the effect suggests reflex inhibition via vagal afferents.62 
In addition, surgery-associated conditions such as peritonitis, systemic inflammatory response syndrome, abdominal trauma, exploratory laparotomies, and fluid shifts following large resuscitations can cause respiratory failure by increasing the intraabdominal pressure, which leads to intraabdominal hypertension (intraabdominal pressure > 12 mmHg) and, in its extreme, abdominal compartment syndrome (intraabdominal pressure > 20 mmHg).63  The external application of abdominal binders may also contribute to increased intraabdominal pressure.64  The increase in intraabdominal pressure can decrease chest wall compliance and diaphragmatic excursion65  which combine to affect respiratory mechanics and increase overall work of breathing for respiratory pump muscles.
Another contributor to respiratory failure is direct chest trauma and rib fractures. One of 13 patients with rib fractures from blunt trauma will have a flail chest, a condition with a 10–20% mortality rate.66  With a flail chest, the negative intrathoracic pressure of inspiration generated by the contraction of the diaphragm and other respiratory muscles draws the flail segment inward, the opposite direction needed to inspire gas, resulting in increased work of breathing and an increase in oxygen consumption.67 
Respiratory Arousal
Respiratory muscle function is under both voluntary and involuntary control. Respiratory arousal, as defined by Berry et al.,68  is arousal from sleep due to cumulative and progressive increases in stimuli related to breathing (hypoxia, hypercapnia, and respiratory effort). For our review focused on perioperative medicine, we broaden the definition of the term “respiratory arousal” to include awakening from sleep and other drug-induced or endogenous impairments of consciousness, as well as any neurally mediated restoration of sufficient upper airway and respiratory pump muscle tone independent of patient state of wakefulness.
Three primary inputs contribute to respiratory arousal: (1) peripheral and central chemoreceptors sensitive to partial pressures of oxygen and carbon dioxide,69  (2) sensors in the upper airway responsive to negative pressure generated by the respiratory pump,22,23  and (3) cortical stimulation directly related to state of consciousness or “wakefulness.”70  For a visual representation of respiratory arousal, see figure 3.
Fig. 3.
Effects of respiratory arousal on upper airway dilator and respiratory pump muscles. Respiratory arousal is composed of three primary inputs: central respiratory pattern generator processing peripheral and central chemoreceptor afferents, reflex responsiveness to the magnitude of negative pressure in the airway generated by the respiratory pump muscles, and strength of the “wakefulness” drive. Inhibitory modulators are shown: anesthetics, opioids, and impaired consciousness of endogenous etiology. Blue arrows: excitatory; Red arrows: inhibitory; MNs = motor neurons.
Image Not Available
Fig. 3.
Effects of respiratory arousal on upper airway dilator and respiratory pump muscles. Respiratory arousal is composed of three primary inputs: central respiratory pattern generator processing peripheral and central chemoreceptor afferents, reflex responsiveness to the magnitude of negative pressure in the airway generated by the respiratory pump muscles, and strength of the “wakefulness” drive. Inhibitory modulators are shown: anesthetics, opioids, and impaired consciousness of endogenous etiology. Blue arrows: excitatory; Red arrows: inhibitory; MNs = motor neurons.
×
Any of the three respiratory arousal inputs can restore respiratory muscle tone if the magnitude is great enough. Cortical awakening from sleep, identified by electroencephalogram signs of wakefulness, is an adequate stimulus for ventilation. Importantly, obstructive apneas, such as upper airway collapse in OSA, can be terminated by increased drive to the respiratory muscles not involving cortical arousal.71  For example, hypercarbia resulting from sustained hypopnea69  and elevated upper airway negative pressure22,23  can independently restore tone to the respiratory muscles.
The magnitude of respiratory arousal provided to the respiratory muscles is dependent upon the summation of stimuli in the central respiratory pattern generator output, including peripheral and central chemoresponsiveness, reflex responsiveness to the negative airway pressure, and strength of the “wakefulness” drive. During the perioperative period, respiratory arousal is dampened by sedation, anesthesia, opioids, and endogenous impairment of consciousness. Consequently, the total level of stimulation to respiratory muscles decreases and the upper airway is more vulnerable to collapse and respiratory failure.
Impaired Respiratory Arousal by Endogenous Impairment of Consciousness.
The wakefulness drive to the respiratory muscles can be reduced or eliminated by a variety of perioperative pathologies. Postoperative delirium is a common complication in patients aged more than 65 yr72  and has been associated with failure to wean from the ventilator.73  Stroke is an unfortunate intraoperative complication, with a relatively high incidence following cardiac surgery.74  Strokes directly harm neuronal tissue and can afflict multiple sites, which may affect neuronal transmission of respiratory arousal, thereby causing respiratory muscle weakness that translates to a high incidence of respiratory failure.75  Hypoglycemia,76  hypothyroidism,77  and adrenal insufficiency78  also affect respiratory arousal and can be considered risk factors for respiratory failure in critically ill patients. Thus, endogenous conditions can impair respiratory arousal and are possible contributors to perioperative muscle dysfunction.
Impairment of Respiratory Arousal by Anesthetics, Opioids, and Rapid Eye Movement Sleep Rebound.
Anesthetics, sedatives, and opioids are known respiratory depressants and decrease motor drive to the upper airway dilator and respiratory pump muscles; functionally, they impair respiratory arousal by a variety of mechanisms including reducing chemoresponsiveness to hypoxia and hypercarbia,79–81  suppressing the reflexive responsiveness to negative upper airway pressure,82  and depressing the magnitude of wakefulness. In addition, anesthetics (similar to normal sleep) typically disturb the balance between upper airway dilator muscle and respiratory pump muscle activation upon initiation of unconsciousness.83,84 
Anesthetic and Sedative Effects on Respiratory Muscles.
The effects of anesthetics upon respiratory function are dependent upon a variety of factors, including agent, dose, subject’s consciousness, and specific muscle group. Upper airway muscles are generally more affected by sleep, anesthetics, and sedatives than respiratory pump muscles. In 1984, the seminal paper written by Nishino et al.85  described differential effects of anesthetics and sedatives on neural input to upper airway (hypoglossal nerve) and respiratory pump muscles (phrenic nerve) in ventilated, vagotomized cats. Anesthetic and sedative medicines from four classes were tested: volatile (halothane), barbiturate (thiopental), dissociative (ketamine), and benzodiazepine (diazepam). All showed a similar effect on respiratory muscles: decreased stimulation in both nerves. However, whereas halothane, thiopental, and diazepam significantly reduced neural input to upper airway muscles relative to that of the already dampened respiratory pump muscles, ketamine did not. Ketamine reduced the neural input to both the upper airway and respiratory muscles equally, but it reduced the neural input to the upper airway muscles less relative to the other classes of anesthetics.85 
Recent animal research suggests that ketamine has no inhibitory effect upon genioglossus activity, but increases genioglossus muscle activity relative to wakefulness, slow wave, and rapid eye movement (REM) sleep.86  Over a wide dose range, ketamine anesthesia maintains activity in the arousal areas of forebrain,87  and it likely stimulates respiration by uncoupling the link between loss of consciousness and upper airway dilator muscle hypotonia.86  Thus, ketamine, unlike other anesthetics, preserves a high level of upper airway dilator muscle activity ordinarily only found with consciousness87 ; this phenomenon may be in part linked to ketamine’s dose-dependent increase in duty cycle.86  Based on the preclinical data as well as the long-term experience with ketamine as a drug that preserves respiratory function during anesthesia, it may prove to be a safe pharmacological choice for patients with upper airway comorbidities undergoing procedural sedation.
Additional evidence for compound- and muscle-specific effects of anesthetics comes from preclinical studies. In both pentobarbital84,88  and isoflurane,89  anesthetics that initially reduce upper airway muscle activity during the transition from wakefulness to unconsciousness dose dependently promote genioglossus phasic activity relative to the initial reduction. The neural pathways mediating the dose-dependent activating effect of some anesthetics are not fully understood, but considering isoflurane’s genioglossus stimulating effect is abolished in vagotomized rats, the vagus nerve is hypothesized to be the afferent limb.89  Whereas isoflurane in a certain dose range may stimulate both upper airway dilator and respiratory muscles, barbiturates studied in the same model induced a different effect on these respiratory muscles. Pentobarbital increased genioglossus activity, while causing a dose-dependent decrease in diaphragmatic activity.84 
Of all anesthetics studied, it appears that propofol has the greatest debilitating effect on the drive to both upper airway dilator and respiratory pump muscles. Compared to an equianesthetic dose of isoflurane, propofol elicited only one third the amount of phasic genioglossus activity in rats, and similarly depressed the drive to the pump muscles,90  effects that could be reversed by conditions that increase the ventilatory drive (i.e., hypoxia and hypercarbia).89 
The majority of controlled studies evaluating the effects of anesthetics on the upper airway have been performed on animals. However, the preclinical results lend themselves to well-planned translational studies, which could lead to quality initiatives and the prevention of postoperative respiratory failure. One such study examined airway protection at subhypnotic doses of anesthetics and found that all anesthetics tested compromised pharyngeal function. Furthermore, propofol had the greatest effect upon pharyngeal contraction pattern,91  a finding that agrees with the animal study.89  Another clinical trial92  suggests that ketamine has similar protective effects on ventilatory drive as that observed in preclinical trials.87 
Opioid Effects on Respiratory Muscles.
Opioids are the most common postoperative analgesic prescribed,93  and they have a notable adverse effect profile including respiratory depression via upper airway dilator94,95  and respiratory pump muscles96,97  dysfunction. In animal models, opioids impair upper airway muscle function in a dose-dependent fashion.
This effect has been shown through reduced genioglossus activity in rats,94,98,99  decreased vagal motor neuron activity in laryngeal abductors, and increased vagal motor neuron activity in laryngeal adductors.100  These opioid-induced changes result in increased upper airway resistance and possibly vocal cord closure and pharyngeal airflow obstruction.100  It is of clinical importance to note that patients with OSA may be more sensitive to the analgesic effects of opioids and should have doses adjusted accordingly.101,102 
The effect of opioids on muscle function extends to those of the respiratory pump including muscles of the thorax and the diaphragm. Chest wall rigidity following opioid administration was first described in 1953,103  and while usually associated with rapid injection, multiple agents, and large doses, it has also occurred when opioids were administered in a conservative fashion.104  Opioid analgesia has also been shown to increase abdominal muscle activity,105  and this persistent expiratory muscle activity produces a rapid decrease in end-expiratory lung volume and FRC, contributing to a higher degree of atelectasis.106  This opioid-induced expiratory muscle recruitment appears not to be related to airway obstruction.107  Even the diaphragm is affected. In spontaneously ventilating rats, high-dose opioids led to diaphragm dysfunction and a reduction in phasic activity, leading to reduced tidal volume and minute ventilation;96  similar effects have been seen in felines.100 
REM Rebound Effect on Respiratory Muscles.
Both surgery and anesthetics can affect sleep structure. Sleep following surgery is typically fragmented, reduced, and lacking in REM sleep.108,109  The absence of REM sleep leads to a REM sleep deficit, and this deficit can only be repaid by increasing REM sleep relative to non-REM stages in subsequent nights.110  Consequently, REM sleep returns abruptly a few nights after surgery in greater intensity and quantity than usual.111 
During REM sleep, there is persistent voluntary muscle hypotonia, and electromyogram activity is at its lowest level of any stage of sleep.112  Accordingly, the neural drive to the upper airway dilators is decreased and this relative hypotonia predisposes the patient to airway instability, leading to episodic hypoxemia.113  In addition to the anatomic changes in the upper airway, REM affects respiratory physiology including reducing both the hypoxic ventilatory drive and the hypercarbic ventilatory response.112  Thus, the postoperative return of REM sleep, labeled REM rebound, results in an even greater number of episodes of hypoxemia secondary to impaired respiratory arousal.114 
However, not all surgeries and not all anesthetics have this effect. For surgery, the severity of the procedure performed affects loss of REM sleep115  and implicitly the incidence of REM rebound. This concept holds true with minimally invasive surgery, as a laparoscopic cholecystectomy appears to have less effect upon postoperative REM quality and quantity than major abdominal surgery.116 
As for anesthesia, different anesthetics and lengths of exposure have different effects upon REM sleep. For example, whereas 6 h of either isoflurane, sevoflurane, or halothane anesthesia caused both a REM deficit and REM rebound in mice,117  3 h of isoflurane general anesthesia in nonsurgical volunteers had no effect upon REM.118  Benzodiazepines as a class reduce REM sleep and are known to cause REM rebound upon discontinuation.119  On the opposite end of the spectrum is propofol which in preclinical trials appears to cause neither REM deficit120  nor REM rebound.121 
Accordingly, choice of anesthetic may help reduce occurrences of postoperative apnea both in the near term from immediate effects of anesthetics on the upper airway dilators and in the days into recovery by reducing or eliminating REM rebound.109 
Neuromuscular Blocking Agents (Postoperative Residual Curarization)
Pharmacologic muscle relaxation through neuromuscular blocking agents (NMBA) is helpful to optimize surgical conditions. Following completion of the procedure, patients often have this chemical paralysis reversed, but postoperative residual curarization frequently persists.122  There is strong evidence that postoperative residual curarization not only results in physiologic impairment,16,17,123,124  but also places patients at increased perioperative risk8,124,125  and may increase costs.126  Additionally, even patients whose “train of four” ratio is just less than unity still show significant distortion in their upper airway anatomy and function.123 
It is well documented in preclinical and clinical trials that upper airway dilators are disproportionately sensitive to the effects of NMBA than the diaphragm,123,127,128  and, similar to sleep,129  the retropalatal region is the most collapsible part in the upper airway.123  In healthy volunteers, even minimal neuromuscular blockade is associated with impairment of upper airway dilator muscle function, resulting in increased upper airway closing pressures and greater risk of collapse.123,124  Even the use of modern intermediate-acting NMBA predicts an increased risk of postoperative desaturation as well as reintubation requiring unplanned admission to an intensive care unit.14  Interestingly, increased upper airway closing pressures were also seen in healthy volunteers, who, after fully recovering from pharmacological paralysis, were administered reversal agents (neostigmine and glycopyrrolate),130  and neostigmine reversal was also associated with increased postoperative respiratory complications.14  These studies suggest that acetylcholinesterase inhibitor-based reversal agents can trigger the very symptomatology they are intended to prevent.14,130 
Increased upper airway collapsibility may predispose patients to respiratory failure, particularly when coupled with other airway comorbidities such as obesity or increased airway secretions.8,15  Additionally, postoperative residual curarization may cause negative pressure pulmonary edema secondary to excessive negative intrathoracic pressures generated by respiratory pump muscles contracting in the setting of upper airway obstruction.131  Postoperative residual curarization may also lead to respiratory failure via increased aspiration risk secondary to impaired swallow reflexes.17 
Accordingly, it is important to titrate NMBA carefully by using quantitative neuromuscular transmission monitoring. In addition, future goals for reducing the respiratory risks of non-depolarizing NMBA include the development and use of shorter-acting NMBA and new reversal agents that directly halt the effects of NMBA such that skeletal muscle strength can be fully restored at the end of the case.
Systemic Inflammation
Systemic inflammation, whether a preoperative condition, a product of trauma,132  or the surgery alone,133  can have a serious effect upon the respiratory system. Traditionally, inflammation is associated with increased ventilatory effort due to increased metabolic demands, and direct cytotoxic effects upon the respiratory system.
Imbalance between Energy Supplies and Oxygen Consumption.
Systemic inflammation places a patient into a catabolic state and a patient’s metabolic demands markedly increase,134  resulting in downstream effects of increased respiratory drive, increased respiratory pump work, and increased oxygen consumption. Both an animal model135  and an observational study136  have shown that severe, systemic inflammation can lead to body oxygen demand outstripping oxygen stores and leading to depressed performance of respiratory pump muscles and respiratory failure. Furthermore, the resulting lactate acidosis may also directly affect diaphragmatic contractility.137 
Cytotoxic Effects of Inflammatory Mediators.
In the setting of systemic inflammation, inflammatory mediators nitric oxide and tumor necrosis factor-α have been linked to respiratory muscle weakness, which contributes to severe sepsis-associated respiratory failure.138–141 
Mechanical Ventilation
Approximately 20–30% of patients have trouble weaning from prolonged mechanical ventilation142  and this leads to increased healthcare costs.143  Failure of respiratory pump muscles is a contributing factor to weaning delays.144,145  Furthermore, controlled mechanical ventilation immobilizes the diaphragm and directly harms diaphragm function,146–148  causing ventilator-induced diaphragmatic dysfunction and adding to the conditions perpetuating the respiratory failure.
Controlled ventilation is associated with the rapid onset of proteolysis in the diaphragm, leading to atrophy and diaphragm dysfunction in preclinical146,149  and clinical studies.147,148  Only 18 h of controlled ventilation resulted in diaphragm atrophy and contractile dysfunction in both laboratory animals146  and humans.147  Additionally, length of time on controlled ventilation is positively correlated with diaphragmatic thinning150  as well as injury and atrophy.148  Controlled ventilation appears to be a dose-dependent contributor to respiratory pump muscle dysfunction and may be responsible for delayed weaning from mechanical ventilation.
The addition of NMBA to controlled ventilation, in an attempt to reduce work of breathing and transpulmonary pressure (PL), and improve ventilatory synchrony, can further harm respiratory muscles making a risk–benefit assessment critical before prescribing NMBA in the setting of acute respiratory distress syndrome. The use of NMBA has been associated with intensive care unit-acquired weakness151–154 —a condition linked to delayed weaning of mechanical ventilation.155  The paralytic effects of NMBA persist long after their final dosing, with paralysis continuing from 6 h to 7 days in 44% of a group of critically ill patients treated with vecuronium.156  Additionally, NMBA may compound the diaphragmatic damage done by mechanical ventilation; in rats, rocuronium with controlled ventilation has been linked to even greater diaphragmatic dysfunction than mechanical ventilation with placebo.157 
Finally, NMBA block muscle function and eliminate volitional mobility. Physical mobilization historically has been associated with improved respiratory function.158  Recent studies focusing on early mobilization have linked it to fewer ventilator days159  and shorter intensive care unit and hospital lengths of stay.160  Moreover, comprehensive early pulmonary rehabilitation consisting of inspiratory muscle training combined with early mobilization improved the 6-min walk distance, a fundamental measure of rehabilitation.161  Early mobilization and pulmonary rehabilitation are likely cost-effective methods of improving respiratory outcomes. Recent data suggest that these data gathered in the medical intensive care units translate also to perioperative patients.162 
Preoperative Respiratory Morbidity
Respiratory muscle function can be affected in the postoperative period by patients’ comorbid conditions unrelated to the operation.
Age.
Aging is an important preoperative predictor of the development of PPC163  as it leads to reduced elastic recoil of the lung,164  reduced chest wall compliance,165  and decreased diaphragmatic strength.166  These anatomic changes can impair gas exchange and increase work of breathing, thus leading to vulnerability to respiratory muscle fatigue, and impaired upper airway patency.167  Furthermore, elderly patients are more sensitive to respiratory depressants168  because of both decreased responsiveness to hypercarbia and hypoxemia,169  and decreased metabolic clearance of anesthetics and opioids.168  In combination, the anatomic and physiologic changes brought about by aging predispose the aged to respiratory muscle dysfunction in the perioperative setting.
Obesity.
Over one third of the American adult population and one fifth of our children qualify as obese: obesity is an omnipresent health problem.170  Obesity affects both upper airway dilator and respiratory pump muscles. In the upper airway, obesity is associated with increased adipose around the pharyngeal airway which can overcome upper airway dilator muscles’ efforts at maintaining patency.171  This increased pharyngeal soft tissue in obese subjects predisposes the upper airway to collapse,172  whereas in nonobese subjects, even during complete muscle paralysis through NMBA, the upper airway still requires -4 cm H2O to collapse.173  The excess truncal and abdominal adipose tissue found in obese subjects impedes the respiratory pump muscles by increasing the work required to expand the thorax during inspiration, thus leading to lower flow and volume.174  Obese subjects also have an increased work of breathing compared with nonobese controls as demonstrated by a 16% reduction in oxygen consumption when obese subjects were placed on mechanical ventilation compared to no change with nonobese subjects.175 
Obstructive Sleep Apnea.
Body weight and obesity are strongly associated with OSA.176  OSA is an increasingly common chronic disease in developed and rapidly developing nations, with a prevalence estimate of 3–7% in men and 1–4% in women;177  this gender discrepancy may partially be related to women’s more robust respiratory arousal elicited by negative pressures in the upper airway.178  Along with obesity and male gender, OSA risk factors include aging,167  smoking and alcohol consumption, craniofacial anatomy, and sundry heritable factors.177 
In patients with OSA, upper airway obstruction during the perioperative period can result from alterations in either the passive structural pharyngeal properties or impaired respiratory arousal. During inspiration and expiration, the genioglossus muscle has significantly more activity in subjects with OSA than in control subjects.179  However, the onset of sleep changes the control of the upper airway muscles. Specifically, the negative-pressure reflex resulting in increased upper airway contraction is substantially reduced during non-REM sleep and even further reduced during REM sleep.180,181  Additionally, the “wakefulness” input to these muscles is lessened during sleep,70  leaving the upper airway particularly vulnerable to collapse. Continuous positive airway pressure (CPAP) is the definitive standard treatment for OSA patients during sleep,182  and CPAP has the potential to improve perioperative conditions as well183  (fig. 4). Furthermore, usage of CPAP in the postoperative period may allow more patients with OSA to have ambulatory surgery rather than requiring overnight admission for respiratory observation.184,185 
Fig. 4.
Representative polysomnography recordings of an obese patient before and immediately after bariatric surgery. Respiratory recordings obtained through polysomnography in an obese patient. The first frame shows severe desaturations during sleep at patient’s baseline prior to surgery resulting from a combination of obstructive and central events. In the second frame, immediately following surgery, patient was placed on 30% oxygen in the postanesthesia care unit and continues to have sleep-disordered breathing with mostly central apneas and desaturations. In the third block, again, immediately following surgery, patient was placed on 30% oxygen with continuous positive airway pressure (CPAP) at 10 cm H2O and there were no more apnea or desaturation events. Flow = respiratory flow; Thorax = thoracic respiratory effort; Abdomen = abdominal respiratory effort; Sum = respiratory effort of thorax and abdomen; SpO2 = oxygen saturation; N1 = non-rapid eye movement (REM) sleep stage 1; red bar indicates obstructive apnea; blue bar indicates mixed apnea; pink bar indicates obstructive hypopnea; gray bar indicates desaturation; PACU = postanesthesia care unit.
Image Not Available
Fig. 4.
Representative polysomnography recordings of an obese patient before and immediately after bariatric surgery. Respiratory recordings obtained through polysomnography in an obese patient. The first frame shows severe desaturations during sleep at patient’s baseline prior to surgery resulting from a combination of obstructive and central events. In the second frame, immediately following surgery, patient was placed on 30% oxygen in the postanesthesia care unit and continues to have sleep-disordered breathing with mostly central apneas and desaturations. In the third block, again, immediately following surgery, patient was placed on 30% oxygen with continuous positive airway pressure (CPAP) at 10 cm H2O and there were no more apnea or desaturation events. Flow = respiratory flow; Thorax = thoracic respiratory effort; Abdomen = abdominal respiratory effort; Sum = respiratory effort of thorax and abdomen; SpO2 = oxygen saturation; N1 = non-rapid eye movement (REM) sleep stage 1; red bar indicates obstructive apnea; blue bar indicates mixed apnea; pink bar indicates obstructive hypopnea; gray bar indicates desaturation; PACU = postanesthesia care unit.
×
Obstructive Respiratory Pathology.
Asthma and chronic obstructive pulmonary disease are two common respiratory pathologies and have been diagnosed in approximately 13 and 6% of American adults, respectively.186  Both chronic obstructive pulmonary disease and asthma can lead to a pathologic increase in FRC termed hyperinflation. Hyperinflation prevents optimal generation of negative intrathoracic pressure through a variety of mechanisms—most affecting diaphragmatic function,187–190  which may be an important pathophysiologic mechanism in the predisposition of chronic obstructive pulmonary disease patients to develop perioperative respiratory failure.191 
Smoking.
Active smoking is an independent risk factor for PPC.192  Smoking increases airway hypersensitivity to chemical stimulants including desflurane,193  retards pulmonary immune system defenses against infection,194,195  and increases respiratory mucus production.196  Together these changes further reduce a patient’s physiological reserve to respond to perioperative respiratory challenges.
Strategies to Prevent Postoperative Respiratory Failure
Postoperative hypoxemia complicates 30–50% of abdominal surgeries, and up to 8–10% of these patients require reintubation and mechanical ventilation.197  Statistics such as these inspire research to predict which patients may need reintubation based on a variety of perioperative risk factors. The ideal algorithm for predicting the likelihood of reintubation would be based on preoperative characteristics198  so patients could be triaged to appropriate postsurgical level of care. Furthermore, intraoperative events could be considered alongside a validated pretest probability, and only high-risk patients would be conservatively sent to higher care and higher cost units. Perioperative characteristics that have been associated with respiratory failure, and could be considered for an algorithm, include the following: American Society of Anesthesiologists physical status score, comorbid disorders, dependent functional status, emergency case, and type of surgery.3,6,46,198 
Although predicting the likelihood of reintubation assists in the proper allocation of resources, preventing reintubation is the genuine goal and can be done by maintaining patients’ respiratory muscle function. A summary of preventative strategies for preserving respiratory muscle function can be found in table 1.
Table 1.
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure×
Image Not Available
Table 1.
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure×
×
The effort to improve postoperative respiratory muscle function and avoid respiratory failure begins with surgical and anesthetic planning: minimally invasive techniques56,116,199  and regional anesthesia for pain aggravated by breathing200  should be utilized when indicated. Regional anesthesia for postoperative pain control can result in improved pulmonary function. First, regional anesthesia can provide better overall pain control than intravenous administration of opioids201  and potentially allow for deeper breaths and earlier ambulation. Additionally, regional anesthesia improves diaphragm muscle activity, likely by blocking nerves associated with an inhibitory reflex,202  and increases FRC, through the caudal motion of the diaphragm and a decrease in the intrathoracic blood volume.203  In total, these improvements in pain control and postoperative lung function may translate to decreased incidence of PPC.204 
Furthermore, long-acting paralytics must be avoided,15  and both paralytics8,124,125  and reversal agents127  must be precisely dosed and monitored by quantitative neuromuscular transmission monitoring.
In the setting of decreased efficiency of respiratory muscle contractions, such as flail chest, intraabdominal hypertension, and bronchial hyperreactivity, consider basing treatment on the property of the conditions; for example, open reduction with internal fixation and regional anesthesia for flail chest,200,205  fluid restriction and decompression for intraabdominal hypertension,65,206,207  and rigorous bronchodilator treatment and noninvasive ventilation for bronchial hyperreactivity.208,209  During periods of systemic inflammation with increased respiratory effort, identify and treat the underlying cause early.210  Following any procedure, multimodal analgesic strategies to decrease opioid-induced respiratory muscle weakness should be employed.211 
For obese patients with the diagnosis of OSA, and probably those without,212  postoperative CPAP may reduce the risk of pulmonary complications.183  Substituting CPAP and other forms of noninvasive mechanical ventilation may also be beneficial for patients with postoperative hypoxia or hypoventilation not requiring airway protection.208,213 
When a patient is maintained on mechanical ventilation postoperatively or develops acute respiratory distress syndrome, it is important to minimize the immobilizing effect of mechanical ventilation on the respiratory muscles147,157  and encourage passive mobilization as an initial step in pulmonary rehabilitation161  (fig. 5). Therefore, spontaneous breathing efforts should be trialed while keeping the transpulmonary pressure (PL) in mind.214  PL is defined as the difference between airway plateau pressure (PPlat) and pleural pressure (PPL), and it varies with respiratory pump effort when PPlat is constant.215  Most importantly, increases in PL from high respiratory effort and aggressive spontaneous breathing can result in barotrauma.216,217 
Fig. 5.
Effects of respiratory pump muscle activity on the outcome of critically ill patients requiring mechanical ventilation. Acute respiratory distress syndrome (ARDS) typically is associated with an increased work of breathing due to poor respiratory system compliance and systemic inflammation. The associated increases in transpulmonary pressures (PL) may be sufficient to induce lung injury. Lung protective ventilation with low tidal volume is the standard of care in patients with ARDS. Temporary pharmacologic immobilization (opioids, sedatives, anesthetics, and rarely neuromuscular blocking agents) may be required to reduce or abolish breathing efforts, but even short-term (48 h) immobilization can lead to muscle atrophy. Thus, both muscle immobilization and excessive activation can lead to increased morbidity and mortality. The pulmonary health of the patient depends on seeking a fine balance between immobilization and activation.
Image Not Available
Fig. 5.
Effects of respiratory pump muscle activity on the outcome of critically ill patients requiring mechanical ventilation. Acute respiratory distress syndrome (ARDS) typically is associated with an increased work of breathing due to poor respiratory system compliance and systemic inflammation. The associated increases in transpulmonary pressures (PL) may be sufficient to induce lung injury. Lung protective ventilation with low tidal volume is the standard of care in patients with ARDS. Temporary pharmacologic immobilization (opioids, sedatives, anesthetics, and rarely neuromuscular blocking agents) may be required to reduce or abolish breathing efforts, but even short-term (48 h) immobilization can lead to muscle atrophy. Thus, both muscle immobilization and excessive activation can lead to increased morbidity and mortality. The pulmonary health of the patient depends on seeking a fine balance between immobilization and activation.
×
One approach to managing PL is utilizing controlled ventilation and prescribing NMBA216,218 ; however, it is important to avoid immobilizing the diaphragm unnecessarily,157  especially when initial attempts to control PL can be made through titration and selection of sedatives and analgesics. Furthermore, partial support ventilatory modes that permit spontaneous breathing should be utilized as they reduce diaphragmatic harm in preclinical trials219–221  and improve ventilation perfusion matching in clinical studies.222,223 
Conclusion
Proper respiratory muscle dysfunction is a key determinant of postoperative respiratory failure. Careful attention should be paid to the effect of perioperative interventions on respiratory muscles, particularly in patients at risk of postoperative respiratory failure. The type of surgical procedure, the anesthesia plan, the postoperative pain management, and the mechanical ventilation strategy can all incrementally push a patient toward or away from upper airway collapse or respiratory pump dysfunction: both of which increase the likelihood of postoperative respiratory failure.
References
1.Money, SR, Rice, K, Crockett, D, Becker, M, Abdoh, A, Wisselink, W, Kazmier, F, Hollier, L Risk of respiratory failure after repair of thoracoabdominal aortic aneurysms.. Am J Surg. (1994). 168 152–5 [Article] [PubMed]
1.Money, SR, Rice, K, Crockett, D, Becker, M, Abdoh, A, Wisselink, W, Kazmier, F, Hollier, L Risk of respiratory failure after repair of thoracoabdominal aortic aneurysms.. Am J Surg. (1994). 168 152–5 [Article] [PubMed]×
2.Filsoufi, F, Rahmanian, PB, Castillo, JG, Chikwe, J, Adams, DH Predictors and early and late outcomes of respiratory failure in contemporary cardiac surgery.. Chest. (2008). 133 713–21 [Article] [PubMed]
2.Filsoufi, F, Rahmanian, PB, Castillo, JG, Chikwe, J, Adams, DH Predictors and early and late outcomes of respiratory failure in contemporary cardiac surgery.. Chest. (2008). 133 713–21 [Article] [PubMed]×
3.Johnson, RG, Arozullah, AM, Neumayer, L, Henderson, WG, Hosokawa, P, Khuri, SF Multivariable predictors of postoperative respiratory failure after general and vascular surgery: Results from the patient safety in surgery study.. J Am Coll Surg. (2007). 204 1188–98 [Article] [PubMed]
3.Johnson, RG, Arozullah, AM, Neumayer, L, Henderson, WG, Hosokawa, P, Khuri, SF Multivariable predictors of postoperative respiratory failure after general and vascular surgery: Results from the patient safety in surgery study.. J Am Coll Surg. (2007). 204 1188–98 [Article] [PubMed]×
4.Khuri, SF, Henderson, WG, DePalma, RG, Mosca, C, Healey, NA, Kumbhani, DJ Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.. Ann Surg. (2005). 242 326–41; discussion 341–3 [PubMed]
4.Khuri, SF, Henderson, WG, DePalma, RG, Mosca, C, Healey, NA, Kumbhani, DJ Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.. Ann Surg. (2005). 242 326–41; discussion 341–3 [PubMed]×
5.Dimick, JB, Chen, SL, Taheri, PA, Henderson, WG, Khuri, SF, Campbell, DAJr Hospital costs associated with surgical complications: A report from the private-sector National Surgical Quality Improvement Program.. J Am Coll Surg. (2004). 199 531–7 [Article] [PubMed]
5.Dimick, JB, Chen, SL, Taheri, PA, Henderson, WG, Khuri, SF, Campbell, DAJr Hospital costs associated with surgical complications: A report from the private-sector National Surgical Quality Improvement Program.. J Am Coll Surg. (2004). 199 531–7 [Article] [PubMed]×
6.Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program.. Ann Surg. (2000). 232 242–53 [Article] [PubMed]
6.Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program.. Ann Surg. (2000). 232 242–53 [Article] [PubMed]×
7.Eikermann, M, Blobner, M, Groeben, H, Rex, C, Grote, T, Neuhäuser, M, Beiderlinden, M, Peters, J Postoperative upper airway obstruction after recovery of the train of four ratio of the adductor pollicis muscle from neuromuscular blockade.. Anesth Analg. (2006). 102 937–42 [Article] [PubMed]
7.Eikermann, M, Blobner, M, Groeben, H, Rex, C, Grote, T, Neuhäuser, M, Beiderlinden, M, Peters, J Postoperative upper airway obstruction after recovery of the train of four ratio of the adductor pollicis muscle from neuromuscular blockade.. Anesth Analg. (2006). 102 937–42 [Article] [PubMed]×
8.Murphy, GS, Szokol, JW, Marymont, JH, Greenberg, SB, Avram, MJ, Vender, JS Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.. Anesth Analg. (2008). 107 130–7 [Article] [PubMed]
8.Murphy, GS, Szokol, JW, Marymont, JH, Greenberg, SB, Avram, MJ, Vender, JS Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.. Anesth Analg. (2008). 107 130–7 [Article] [PubMed]×
9.Cook, TM, Woodall, N, Frerk, C Fourth National Audit Project, Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.. Br J Anaesth. (2011). 106 617–31 [Article] [PubMed]
9.Cook, TM, Woodall, N, Frerk, C Fourth National Audit Project, Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.. Br J Anaesth. (2011). 106 617–31 [Article] [PubMed]×
10.Bolden, N, Smith, CE, Auckley, D, Makarski, J, Avula, R Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia.. Anesth Analg. (2007). 105 1869–70 [Article] [PubMed]
10.Bolden, N, Smith, CE, Auckley, D, Makarski, J, Avula, R Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia.. Anesth Analg. (2007). 105 1869–70 [Article] [PubMed]×
11.Warner, MA, Warner, ME, Weber, JG Clinical significance of pulmonary aspiration during the perioperative period.. Anesthesiology. (1993). 78 56–62 [Article] [PubMed]
11.Warner, MA, Warner, ME, Weber, JG Clinical significance of pulmonary aspiration during the perioperative period.. Anesthesiology. (1993). 78 56–62 [Article] [PubMed]×
12.Hong, JJ, Cohn, SM, Perez, JM, Dolich, MO, Brown, M, McKenney, MG Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome.. Br J Surg. (2002). 89 591–6 [Article] [PubMed]
12.Hong, JJ, Cohn, SM, Perez, JM, Dolich, MO, Brown, M, McKenney, MG Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome.. Br J Surg. (2002). 89 591–6 [Article] [PubMed]×
13.Runck, H, Schumann, S, Tacke, S, Haberstroh, J, Guttmann, J Effects of intra-abdominal pressure on respiratory system mechanics in mechanically ventilated rats.. Respir Physiol Neurobiol. (2012). 180 204–10 [Article] [PubMed]
13.Runck, H, Schumann, S, Tacke, S, Haberstroh, J, Guttmann, J Effects of intra-abdominal pressure on respiratory system mechanics in mechanically ventilated rats.. Respir Physiol Neurobiol. (2012). 180 204–10 [Article] [PubMed]×
14.Grosse-Sundrup, M, Henneman, JP, Sandberg, WS, Bateman, BT, Uribe, JV, Nguyen, NT, Ehrenfeld, JM, Martinez, EA, Kurth, T, Eikermann, M Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: Prospective propensity score matched cohort study.. BMJ. (2012). 345 e6329 [Article] [PubMed]
14.Grosse-Sundrup, M, Henneman, JP, Sandberg, WS, Bateman, BT, Uribe, JV, Nguyen, NT, Ehrenfeld, JM, Martinez, EA, Kurth, T, Eikermann, M Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: Prospective propensity score matched cohort study.. BMJ. (2012). 345 e6329 [Article] [PubMed]×
15.Berg, H, Roed, J, Viby-Mogensen, J, Mortensen, CR, Engbaek, J, Skovgaard, LT, Krintel, JJ Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.. Acta Anaesthesiol Scand. (1997). 41 1095–103 [Article] [PubMed]
15.Berg, H, Roed, J, Viby-Mogensen, J, Mortensen, CR, Engbaek, J, Skovgaard, LT, Krintel, JJ Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.. Acta Anaesthesiol Scand. (1997). 41 1095–103 [Article] [PubMed]×
16.Eikermann, M, Groeben, H, Hüsing, J, Peters, J Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade.. Anesthesiology. (2003). 98 1333–7 [Article] [PubMed]
16.Eikermann, M, Groeben, H, Hüsing, J, Peters, J Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade.. Anesthesiology. (2003). 98 1333–7 [Article] [PubMed]×
17.Sundman, E, Witt, H, Olsson, R, Ekberg, O, Kuylenstierna, R, Eriksson, LI The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: Pharyngeal videoradiography and simultaneous manometry after atracurium.. Anesthesiology. (2000). 92 977–84 [Article] [PubMed]
17.Sundman, E, Witt, H, Olsson, R, Ekberg, O, Kuylenstierna, R, Eriksson, LI The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: Pharyngeal videoradiography and simultaneous manometry after atracurium.. Anesthesiology. (2000). 92 977–84 [Article] [PubMed]×
18.McCool, FD Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines.. Chest. (2006). 129 48S–53S [Article] [PubMed]
18.McCool, FD Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines.. Chest. (2006). 129 48S–53S [Article] [PubMed]×
19.Bach, JR Amyotrophic lateral sclerosis: Prolongation of life by noninvasive respiratory AIDS.. Chest. (2002). 122 92–8 [Article] [PubMed]
19.Bach, JR Amyotrophic lateral sclerosis: Prolongation of life by noninvasive respiratory AIDS.. Chest. (2002). 122 92–8 [Article] [PubMed]×
20.Hulzebos, EH, Helders, PJ, Favié, NJ, De Bie, RA, Brutel de la Riviere, A, Van Meeteren, NL Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: A randomized clinical trial.. JAMA. (2006). 296 1851–7 [Article] [PubMed]
20.Hulzebos, EH, Helders, PJ, Favié, NJ, De Bie, RA, Brutel de la Riviere, A, Van Meeteren, NL Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: A randomized clinical trial.. JAMA. (2006). 296 1851–7 [Article] [PubMed]×
21.Butler, JE Drive to the human respiratory muscles.. Respir Physiol Neurobiol. (2007). 159 115–26 [Article] [PubMed]
21.Butler, JE Drive to the human respiratory muscles.. Respir Physiol Neurobiol. (2007). 159 115–26 [Article] [PubMed]×
22.Pierce, R, White, D, Malhotra, A, Edwards, JK, Kleverlaan, D, Palmer, L, Trinder, J Upper airway collapsibility, dilator muscle activation and resistance in sleep apnoea.. Eur Respir J. (2007). 30 345–53 [Article] [PubMed]
22.Pierce, R, White, D, Malhotra, A, Edwards, JK, Kleverlaan, D, Palmer, L, Trinder, J Upper airway collapsibility, dilator muscle activation and resistance in sleep apnoea.. Eur Respir J. (2007). 30 345–53 [Article] [PubMed]×
23.Chamberlin, NL, Eikermann, M, Fassbender, P, White, DP, Malhotra, A Genioglossus premotoneurons and the negative pressure reflex in rats.. J Physiol (Lond). (2007). 579 515–26 [Article] [PubMed]
23.Chamberlin, NL, Eikermann, M, Fassbender, P, White, DP, Malhotra, A Genioglossus premotoneurons and the negative pressure reflex in rats.. J Physiol (Lond). (2007). 579 515–26 [Article] [PubMed]×
24.Nicholas, CL, Jordan, AS, Heckel, L, Worsnop, C, Bei, B, Saboisky, JP, Eckert, DJ, White, DP, Malhotra, A, Trinder, J Discharge patterns of human tensor palatini motor units during sleep onset.. Sleep. (2012). 35 699–707 [PubMed]
24.Nicholas, CL, Jordan, AS, Heckel, L, Worsnop, C, Bei, B, Saboisky, JP, Eckert, DJ, White, DP, Malhotra, A, Trinder, J Discharge patterns of human tensor palatini motor units during sleep onset.. Sleep. (2012). 35 699–707 [PubMed]×
25.Isono, S, Tanaka, A, Tagaito, Y, Sho, Y, Nishino, T Pharyngeal patency in response to advancement of the mandible in obese anesthetized persons.. Anesthesiology. (1997). 87 1055–62 [Article] [PubMed]
25.Isono, S, Tanaka, A, Tagaito, Y, Sho, Y, Nishino, T Pharyngeal patency in response to advancement of the mandible in obese anesthetized persons.. Anesthesiology. (1997). 87 1055–62 [Article] [PubMed]×
26.Watanabe, T, Isono, S, Tanaka, A, Tanzawa, H, Nishino, T Contribution of body habitus and craniofacial characteristics to segmental closing pressures of the passive pharynx in patients with sleep-disordered breathing.. Am J Respir Crit Care Med. (2002). 165 260–5 [Article] [PubMed]
26.Watanabe, T, Isono, S, Tanaka, A, Tanzawa, H, Nishino, T Contribution of body habitus and craniofacial characteristics to segmental closing pressures of the passive pharynx in patients with sleep-disordered breathing.. Am J Respir Crit Care Med. (2002). 165 260–5 [Article] [PubMed]×
27.Isono, S, Tanaka, A, Nishino, T Lateral position decreases collapsibility of the passive pharynx in patients with obstructive sleep apnea.. Anesthesiology. (2002). 97 780–5 [Article] [PubMed]
27.Isono, S, Tanaka, A, Nishino, T Lateral position decreases collapsibility of the passive pharynx in patients with obstructive sleep apnea.. Anesthesiology. (2002). 97 780–5 [Article] [PubMed]×
28.Tagaito, Y, Isono, S, Tanaka, A, Ishikawa, T, Nishino, T Sitting posture decreases collapsibility of the passive pharynx in anesthetized paralyzed patients with obstructive sleep apnea.. Anesthesiology. (2010). 113 812–8 [Article] [PubMed]
28.Tagaito, Y, Isono, S, Tanaka, A, Ishikawa, T, Nishino, T Sitting posture decreases collapsibility of the passive pharynx in anesthetized paralyzed patients with obstructive sleep apnea.. Anesthesiology. (2010). 113 812–8 [Article] [PubMed]×
29.Itasaka, Y, Miyazaki, S, Ishikawa, K, Togawa, K The influence of sleep position and obesity on sleep apnea.. Psychiatry Clin Neurosci. (2000). 54 340–1 [Article] [PubMed]
29.Itasaka, Y, Miyazaki, S, Ishikawa, K, Togawa, K The influence of sleep position and obesity on sleep apnea.. Psychiatry Clin Neurosci. (2000). 54 340–1 [Article] [PubMed]×
30.Schneider, H, Krishnan, V, Pichard, LE, Patil, SP, Smith, PL, Schwartz, AR Inspiratory duty cycle responses to flow limitation predict nocturnal hypoventilation.. Eur Respir J. (2009). 33 1068–76 [Article] [PubMed]
30.Schneider, H, Krishnan, V, Pichard, LE, Patil, SP, Smith, PL, Schwartz, AR Inspiratory duty cycle responses to flow limitation predict nocturnal hypoventilation.. Eur Respir J. (2009). 33 1068–76 [Article] [PubMed]×
31.Sériès, F, Marc, I Influence of lung volume dependence of upper airway resistance during continuous negative airway pressure.. J Appl Physiol. (1994). 77 840–4 [PubMed]
31.Sériès, F, Marc, I Influence of lung volume dependence of upper airway resistance during continuous negative airway pressure.. J Appl Physiol. (1994). 77 840–4 [PubMed]×
32.Hoffstein, V, Zamel, N, Phillipson, EA Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea.. Am Rev Respir Dis. (1984). 130 175–8 [PubMed]
32.Hoffstein, V, Zamel, N, Phillipson, EA Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea.. Am Rev Respir Dis. (1984). 130 175–8 [PubMed]×
33.Van de Graaff, WB Thoracic influence on upper airway patency.. J Appl Physiol. (1988). 65 2124–31 [PubMed]
33.Van de Graaff, WB Thoracic influence on upper airway patency.. J Appl Physiol. (1988). 65 2124–31 [PubMed]×
34.Van de Graaff, WB Thoracic traction on the trachea: Mechanisms and magnitude.. J Appl Physiol. (1991). 70 1328–36 [PubMed]
34.Van de Graaff, WB Thoracic traction on the trachea: Mechanisms and magnitude.. J Appl Physiol. (1991). 70 1328–36 [PubMed]×
35.Shiota, S, Ryan, CM, Chiu, KL, Ruttanaumpawan, P, Haight, J, Arzt, M, Floras, JS, Chan, C, Bradley, TD Alterations in upper airway cross-sectional area in response to lower body positive pressure in healthy subjects.. Thorax. (2007). 62 868–72 [Article] [PubMed]
35.Shiota, S, Ryan, CM, Chiu, KL, Ruttanaumpawan, P, Haight, J, Arzt, M, Floras, JS, Chan, C, Bradley, TD Alterations in upper airway cross-sectional area in response to lower body positive pressure in healthy subjects.. Thorax. (2007). 62 868–72 [Article] [PubMed]×
36.Su, MC, Chiu, KL, Ruttanaumpawan, P, Shiota, S, Yumino, D, Redolfi, S, Haight, JS, Bradley, TD Lower body positive pressure increases upper airway collapsibility in healthy subjects.. Respir Physiol Neurobiol. (2008). 161 306–12 [Article] [PubMed]
36.Su, MC, Chiu, KL, Ruttanaumpawan, P, Shiota, S, Yumino, D, Redolfi, S, Haight, JS, Bradley, TD Lower body positive pressure increases upper airway collapsibility in healthy subjects.. Respir Physiol Neurobiol. (2008). 161 306–12 [Article] [PubMed]×
37.Redolfi, S, Arnulf, I, Pottier, M, Lajou, J, Koskas, I, Bradley, TD, Similowski, T Attenuation of obstructive sleep apnea by compression stockings in subjects with venous insufficiency.. Am J Respir Crit Care Med. (2011). 184 1062–6 [Article] [PubMed]
37.Redolfi, S, Arnulf, I, Pottier, M, Lajou, J, Koskas, I, Bradley, TD, Similowski, T Attenuation of obstructive sleep apnea by compression stockings in subjects with venous insufficiency.. Am J Respir Crit Care Med. (2011). 184 1062–6 [Article] [PubMed]×
38.Yumino, D, Redolfi, S, Ruttanaumpawan, P, Su, MC, Smith, S, Newton, GE, Mak, S, Bradley, TD Nocturnal rostral fluid shift: A unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure.. Circulation. (2010). 121 1598–605 [Article] [PubMed]
38.Yumino, D, Redolfi, S, Ruttanaumpawan, P, Su, MC, Smith, S, Newton, GE, Mak, S, Bradley, TD Nocturnal rostral fluid shift: A unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure.. Circulation. (2010). 121 1598–605 [Article] [PubMed]×
39.Mead, J, Loring, SH Analysis of volume displacement and length changes of the diaphragm during breathing.. J Appl Physiol. (1982). 53 750–5 [PubMed]
39.Mead, J, Loring, SH Analysis of volume displacement and length changes of the diaphragm during breathing.. J Appl Physiol. (1982). 53 750–5 [PubMed]×
40.Muller, NL, Francis, PW, Gurwitz, D, Levison, H, Bryan, AC Mechanism of hemoglobin desaturation during rapid-eye-movement sleep in normal subjects and in patients with cystic fibrosis.. Am Rev Respir Dis. (1980). 121 463–9 [PubMed]
40.Muller, NL, Francis, PW, Gurwitz, D, Levison, H, Bryan, AC Mechanism of hemoglobin desaturation during rapid-eye-movement sleep in normal subjects and in patients with cystic fibrosis.. Am Rev Respir Dis. (1980). 121 463–9 [PubMed]×
41.Muller, N, Volgyesi, G, Becker, L, Bryan, MH, Bryan, AC Diaphragmatic muscle tone.. J Appl Physiol. (1979). 47 279–84 [PubMed]
41.Muller, N, Volgyesi, G, Becker, L, Bryan, MH, Bryan, AC Diaphragmatic muscle tone.. J Appl Physiol. (1979). 47 279–84 [PubMed]×
42.de Troyer, A, Bastenier, J, Delhez, L Function of respiratory muscles during partial curarization in humans.. J Appl Physiol. (1980). 49 1049–56 [PubMed]
42.de Troyer, A, Bastenier, J, Delhez, L Function of respiratory muscles during partial curarization in humans.. J Appl Physiol. (1980). 49 1049–56 [PubMed]×
43.Wade, OL Movements of the thoracic cage and diaphragm in respiration.. J Physiol (Lond). (1954). 124 193–212 [PubMed]
43.Wade, OL Movements of the thoracic cage and diaphragm in respiration.. J Physiol (Lond). (1954). 124 193–212 [PubMed]×
44.Sasaki, H, Hida, W, Takishima, T Influence of body position on dynamic compliance in young subjects.. J Appl Physiol. (1977). 42 706–10 [PubMed]
44.Sasaki, H, Hida, W, Takishima, T Influence of body position on dynamic compliance in young subjects.. J Appl Physiol. (1977). 42 706–10 [PubMed]×
45.Sharp, JT, Goldberg, NB, Druz, WS, Danon, J Relative contributions of rib cage and abdomen to breathing in normal subjects.. J Appl Physiol. (1975). 39 608–18 [PubMed]
45.Sharp, JT, Goldberg, NB, Druz, WS, Danon, J Relative contributions of rib cage and abdomen to breathing in normal subjects.. J Appl Physiol. (1975). 39 608–18 [PubMed]×
46.Gupta, H, Gupta, PK, Fang, X, Miller, WJ, Cemaj, S, Forse, RA, Morrow, LE Development and validation of a risk calculator predicting postoperative respiratory failure.. Chest. (2011). 140 1207–15 [Article] [PubMed]
46.Gupta, H, Gupta, PK, Fang, X, Miller, WJ, Cemaj, S, Forse, RA, Morrow, LE Development and validation of a risk calculator predicting postoperative respiratory failure.. Chest. (2011). 140 1207–15 [Article] [PubMed]×
47.McAlister, FA, Khan, NA, Straus, SE, Papaioakim, M, Fisher, BW, Majumdar, SR, Gajic, O, Daniel, M, Tomlinson, G Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery.. Am J Respir Crit Care Med. (2003). 167 741–4 [Article] [PubMed]
47.McAlister, FA, Khan, NA, Straus, SE, Papaioakim, M, Fisher, BW, Majumdar, SR, Gajic, O, Daniel, M, Tomlinson, G Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery.. Am J Respir Crit Care Med. (2003). 167 741–4 [Article] [PubMed]×
48.Mitchell, CK, Smoger, SH, Pfeifer, MP, Vogel, RL, Pandit, MK, Donnelly, PJ, Garrison, RN, Rothschild, MA Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery.. Arch Surg. (1998). 133 194–8 [Article] [PubMed]
48.Mitchell, CK, Smoger, SH, Pfeifer, MP, Vogel, RL, Pandit, MK, Donnelly, PJ, Garrison, RN, Rothschild, MA Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery.. Arch Surg. (1998). 133 194–8 [Article] [PubMed]×
49.Ali, J, Weisel, RD, Layug, AB, Kripke, BJ, Hechtman, HB Consequences of postoperative alterations in respiratory mechanics.. Am J Surg. (1974). 128 376–82 [Article] [PubMed]
49.Ali, J, Weisel, RD, Layug, AB, Kripke, BJ, Hechtman, HB Consequences of postoperative alterations in respiratory mechanics.. Am J Surg. (1974). 128 376–82 [Article] [PubMed]×
50.Meyers, JR, Lembeck, L, O’Kane, H, Baue, AE Changes in functional residual capacity of the lung after operation.. Arch Surg. (1975). 110 576–83 [Article] [PubMed]
50.Meyers, JR, Lembeck, L, O’Kane, H, Baue, AE Changes in functional residual capacity of the lung after operation.. Arch Surg. (1975). 110 576–83 [Article] [PubMed]×
51.Ford, GT, Whitelaw, WA, Rosenal, TW, Cruse, PJ, Guenter, CA Diaphragm function after upper abdominal surgery in humans.. Am Rev Respir Dis. (1983). 127 431–6 [PubMed]
51.Ford, GT, Whitelaw, WA, Rosenal, TW, Cruse, PJ, Guenter, CA Diaphragm function after upper abdominal surgery in humans.. Am Rev Respir Dis. (1983). 127 431–6 [PubMed]×
52.Simonneau, G, Vivien, A, Sartene, R, Kunstlinger, F, Samii, K, Noviant, Y, Duroux, P Diaphragm dysfunction induced by upper abdominal surgery. Role of postoperative pain.. Am Rev Respir Dis. (1983). 128 899–903 [PubMed]
52.Simonneau, G, Vivien, A, Sartene, R, Kunstlinger, F, Samii, K, Noviant, Y, Duroux, P Diaphragm dysfunction induced by upper abdominal surgery. Role of postoperative pain.. Am Rev Respir Dis. (1983). 128 899–903 [PubMed]×
53.Merino-Ramirez, MA, Juan, G, Ramón, M, Cortijo, J, Rubio, E, Montero, A, Morcillo, EJ Electrophysiologic evaluation of phrenic nerve and diaphragm function after coronary bypass surgery: Prospective study of diabetes and other risk factors.. J Thorac Cardiovasc Surg. (2006). 132 530–6, 536.e1–2 [Article] [PubMed]
53.Merino-Ramirez, MA, Juan, G, Ramón, M, Cortijo, J, Rubio, E, Montero, A, Morcillo, EJ Electrophysiologic evaluation of phrenic nerve and diaphragm function after coronary bypass surgery: Prospective study of diabetes and other risk factors.. J Thorac Cardiovasc Surg. (2006). 132 530–6, 536.e1–2 [Article] [PubMed]×
54.Lindell, P, Hedenstierna, G Ventilation efficiency after different incisions for cholecystectomy.. Acta Chir Scand. (1976). 142 561–5 [PubMed]
54.Lindell, P, Hedenstierna, G Ventilation efficiency after different incisions for cholecystectomy.. Acta Chir Scand. (1976). 142 561–5 [PubMed]×
55.Elman, A, Langonnet, F, Dixsaut, G, Hay, JM, Guignard, J, Dazza, F, Maillard, JN Respiratory function is impaired less by transverse than by median vertical supraumbilical incisions.. Intensive Care Med. (1981). 7 235–9 [Article] [PubMed]
55.Elman, A, Langonnet, F, Dixsaut, G, Hay, JM, Guignard, J, Dazza, F, Maillard, JN Respiratory function is impaired less by transverse than by median vertical supraumbilical incisions.. Intensive Care Med. (1981). 7 235–9 [Article] [PubMed]×
56.Rademaker, BM, Ringers, J, Odoom, JA, de Wit, LT, Kalkman, CJ, Oosting, J Pulmonary function and stress response after laparoscopic cholecystectomy: Comparison with subcostal incision and influence of thoracic epidural analgesia.. Anesth Analg. (1992). 75 381–5 [Article] [PubMed]
56.Rademaker, BM, Ringers, J, Odoom, JA, de Wit, LT, Kalkman, CJ, Oosting, J Pulmonary function and stress response after laparoscopic cholecystectomy: Comparison with subcostal incision and influence of thoracic epidural analgesia.. Anesth Analg. (1992). 75 381–5 [Article] [PubMed]×
57.Toledo-Pereyra, LH, DeMeester, TR Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function.. Ann Thorac Surg. (1979). 27 203–5 [Article] [PubMed]
57.Toledo-Pereyra, LH, DeMeester, TR Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function.. Ann Thorac Surg. (1979). 27 203–5 [Article] [PubMed]×
58.Ali, J, Yaffe, CS, Serrette, C The effect of transcutaneous electric nerve stimulation on postoperative pain and pulmonary function.. Surgery. (1981). 89 507–12 [PubMed]
58.Ali, J, Yaffe, CS, Serrette, C The effect of transcutaneous electric nerve stimulation on postoperative pain and pulmonary function.. Surgery. (1981). 89 507–12 [PubMed]×
59.Craig, DB Postoperative recovery of pulmonary function.. Anesth Analg. (1981). 60 46–52 [PubMed]
59.Craig, DB Postoperative recovery of pulmonary function.. Anesth Analg. (1981). 60 46–52 [PubMed]×
60.Berdah, SV, Picaud, R, Jammes, Y Surface diaphragmatic electromyogram changes after laparotomy.. Clin Physiol Funct Imaging. (2002). 22 157–60 [Article] [PubMed]
60.Berdah, SV, Picaud, R, Jammes, Y Surface diaphragmatic electromyogram changes after laparotomy.. Clin Physiol Funct Imaging. (2002). 22 157–60 [Article] [PubMed]×
61.Krause, KM, Moody, MR, Andrade, FH, Taylor, AA, Miller, CC3rd, Kobzik, L, Reid, MB Peritonitis causes diaphragm weakness in rats.. Am J Respir Crit Care Med. (1998). 157 1277–82 [Article] [PubMed]
61.Krause, KM, Moody, MR, Andrade, FH, Taylor, AA, Miller, CC3rd, Kobzik, L, Reid, MB Peritonitis causes diaphragm weakness in rats.. Am J Respir Crit Care Med. (1998). 157 1277–82 [Article] [PubMed]×
62.Ford, GT, Grant, DA, Rideout, KS, Davison, JS, Whitelaw, WA Inhibition of breathing associated with gallbladder stimulation in dogs.. J Appl Physiol. (1988). 65 72–9 [PubMed]
62.Ford, GT, Grant, DA, Rideout, KS, Davison, JS, Whitelaw, WA Inhibition of breathing associated with gallbladder stimulation in dogs.. J Appl Physiol. (1988). 65 72–9 [PubMed]×
63.Malbrain, ML, Chiumello, D, Pelosi, P, Wilmer, A, Brienza, N, Malcangi, V, Bihari, D, Innes, R, Cohen, J, Singer, P, Japiassu, A, Kurtop, E, De Keulenaer, BL, Daelemans, R, Del Turco, M, Cosimini, P, Ranieri, M, Jacquet, L, Laterre, PF, Gattinoni, L Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study.. Intensive Care Med. (2004). 30 822–9 [Article] [PubMed]
63.Malbrain, ML, Chiumello, D, Pelosi, P, Wilmer, A, Brienza, N, Malcangi, V, Bihari, D, Innes, R, Cohen, J, Singer, P, Japiassu, A, Kurtop, E, De Keulenaer, BL, Daelemans, R, Del Turco, M, Cosimini, P, Ranieri, M, Jacquet, L, Laterre, PF, Gattinoni, L Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study.. Intensive Care Med. (2004). 30 822–9 [Article] [PubMed]×
64.Hall, AB, Northern, D Effect of abdominal binders on pulmonary mechanics with implications for the military surgical population.. J Surg Educ. (2012). 69 34–6 [Article] [PubMed]
64.Hall, AB, Northern, D Effect of abdominal binders on pulmonary mechanics with implications for the military surgical population.. J Surg Educ. (2012). 69 34–6 [Article] [PubMed]×
65.Mutoh, T, Lamm, WJ, Embree, LJ, Hildebrandt, J, Albert, RK Volume infusion produces abdominal distension, lung compression, and chest wall stiffening in pigs.. J Appl Physiol. (1992). 72 575–82 [Article] [PubMed]
65.Mutoh, T, Lamm, WJ, Embree, LJ, Hildebrandt, J, Albert, RK Volume infusion produces abdominal distension, lung compression, and chest wall stiffening in pigs.. J Appl Physiol. (1992). 72 575–82 [Article] [PubMed]×
66.Ciraulo, DL, Elliott, D, Mitchell, KA, Rodriguez, A Flail chest as a marker for significant injuries.. J Am Coll Surg. (1994). 178 466–70 [PubMed]
66.Ciraulo, DL, Elliott, D, Mitchell, KA, Rodriguez, A Flail chest as a marker for significant injuries.. J Am Coll Surg. (1994). 178 466–70 [PubMed]×
67.Duff, JH, Goldstein, M, McLean, AP, Agrawal, SN, Munro, DD, Gutelius, JR Flail chest: A clinical review and physiological study.. J Trauma. (1968). 8 63–74 [Article] [PubMed]
67.Duff, JH, Goldstein, M, McLean, AP, Agrawal, SN, Munro, DD, Gutelius, JR Flail chest: A clinical review and physiological study.. J Trauma. (1968). 8 63–74 [Article] [PubMed]×
68.Berry, RB, Gleeson, K Respiratory arousal from sleep: Mechanisms and significance.. Sleep. (1997). 20 654–75 [PubMed]
68.Berry, RB, Gleeson, K Respiratory arousal from sleep: Mechanisms and significance.. Sleep. (1997). 20 654–75 [PubMed]×
69.Pattinson, KT Opioids and the control of respiration.. Br J Anaesth. (2008). 100 747–58 [Article] [PubMed]
69.Pattinson, KT Opioids and the control of respiration.. Br J Anaesth. (2008). 100 747–58 [Article] [PubMed]×
70.Lo, YL, Jordan, AS, Malhotra, A, Wellman, A, Heinzer, RA, Eikermann, M, Schory, K, Dover, L, White, DP Influence of wakefulness on pharyngeal airway muscle activity.. Thorax. (2007). 62 799–805 [Article] [PubMed]
70.Lo, YL, Jordan, AS, Malhotra, A, Wellman, A, Heinzer, RA, Eikermann, M, Schory, K, Dover, L, White, DP Influence of wakefulness on pharyngeal airway muscle activity.. Thorax. (2007). 62 799–805 [Article] [PubMed]×
71.Jordan, AS, Eckert, DJ, Wellman, A, Trinder, JA, Malhotra, A, White, DP Termination of respiratory events with and without cortical arousal in obstructive sleep apnea.. Am J Respir Crit Care Med. (2011). 184 1183–91 [Article] [PubMed]
71.Jordan, AS, Eckert, DJ, Wellman, A, Trinder, JA, Malhotra, A, White, DP Termination of respiratory events with and without cortical arousal in obstructive sleep apnea.. Am J Respir Crit Care Med. (2011). 184 1183–91 [Article] [PubMed]×
72.Mackensen, GB, Gelb, AW Postoperative cognitive deficits: More questions than answers.. Eur J Anaesthesiol. (2004). 21 85–8 [Article] [PubMed]
72.Mackensen, GB, Gelb, AW Postoperative cognitive deficits: More questions than answers.. Eur J Anaesthesiol. (2004). 21 85–8 [Article] [PubMed]×
73.Stransky, M, Schmidt, C, Ganslmeier, P, Grossmann, E, Haneya, A, Moritz, S, Raffer, M, Schmid, C, Graf, BM, Trabold, B Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation.. J Cardiothorac Vasc Anesth. (2011). 25 968–74 [Article] [PubMed]
73.Stransky, M, Schmidt, C, Ganslmeier, P, Grossmann, E, Haneya, A, Moritz, S, Raffer, M, Schmid, C, Graf, BM, Trabold, B Hypoactive delirium after cardiac surgery as an independent risk factor for prolonged mechanical ventilation.. J Cardiothorac Vasc Anesth. (2011). 25 968–74 [Article] [PubMed]×
74.Hogue, CWJr, Murphy, SF, Schechtman, KB, Dávila-Román, VG Risk factors for early or delayed stroke after cardiac surgery.. Circulation. (1999). 100 642–7 [Article] [PubMed]
74.Hogue, CWJr, Murphy, SF, Schechtman, KB, Dávila-Román, VG Risk factors for early or delayed stroke after cardiac surgery.. Circulation. (1999). 100 642–7 [Article] [PubMed]×
75.Knapik, P, Ciesla, D, Borowik, D, Czempik, P, Knapik, T Prolonged ventilation post cardiac surgery–tips and pitfalls of the prediction game.. J Cardiothorac Surg. (2011). 6 158 [Article] [PubMed]
75.Knapik, P, Ciesla, D, Borowik, D, Czempik, P, Knapik, T Prolonged ventilation post cardiac surgery–tips and pitfalls of the prediction game.. J Cardiothorac Surg. (2011). 6 158 [Article] [PubMed]×
76.Baig, MA, Ali, S, Rasheed, J, Bergman, M, Privman, V Severe hypoglycemia in a nondiabetic patient leading to acute respiratory failure.. J Natl Med Assoc. (2006). 98 1362–4 [PubMed]
76.Baig, MA, Ali, S, Rasheed, J, Bergman, M, Privman, V Severe hypoglycemia in a nondiabetic patient leading to acute respiratory failure.. J Natl Med Assoc. (2006). 98 1362–4 [PubMed]×
77.Boyd, DW, Brewis, RA, Gleeson, MH Myxoedema coma.. Postgrad Med J. (1969). 45 342–4 [Article] [PubMed]
77.Boyd, DW, Brewis, RA, Gleeson, MH Myxoedema coma.. Postgrad Med J. (1969). 45 342–4 [Article] [PubMed]×
78.de Lind van Wijngaarden, RF, Joosten, KF, van den Berg, S, Otten, BJ, de Jong, FH, Sweep, CG, de Weerd, AW, Hokken-Koelega, AC The relationship between central adrenal insufficiency and sleep-related breathing disorders in children with Prader-Willi syndrome.. J Clin Endocrinol Metab. (2009). 94 2387–93 [Article] [PubMed]
78.de Lind van Wijngaarden, RF, Joosten, KF, van den Berg, S, Otten, BJ, de Jong, FH, Sweep, CG, de Weerd, AW, Hokken-Koelega, AC The relationship between central adrenal insufficiency and sleep-related breathing disorders in children with Prader-Willi syndrome.. J Clin Endocrinol Metab. (2009). 94 2387–93 [Article] [PubMed]×
79.Hwang, JC, St John, WM, Bartlett, DJr Respiratory-related hypoglossal nerve activity: Influence of anesthetics.. J Appl Physiol. (1983). 55 785–92 [PubMed]
79.Hwang, JC, St John, WM, Bartlett, DJr Respiratory-related hypoglossal nerve activity: Influence of anesthetics.. J Appl Physiol. (1983). 55 785–92 [PubMed]×
80.Zhang, Z, Zhuang, J, Zhang, C, Xu, F Activation of opioid μ-receptors in the commissural subdivision of the nucleus tractus solitarius abolishes the ventilatory response to hypoxia in anesthetized rats.. Anesthesiology. (2011). 115 353–63 [Article] [PubMed]
80.Zhang, Z, Zhuang, J, Zhang, C, Xu, F Activation of opioid μ-receptors in the commissural subdivision of the nucleus tractus solitarius abolishes the ventilatory response to hypoxia in anesthetized rats.. Anesthesiology. (2011). 115 353–63 [Article] [PubMed]×
81.Zhang, Z, Xu, F, Zhang, C, Liang, X Activation of opioid mu receptors in caudal medullary raphe region inhibits the ventilatory response to hypercapnia in anesthetized rats.. Anesthesiology. (2007). 107 288–97 [Article] [PubMed]
81.Zhang, Z, Xu, F, Zhang, C, Liang, X Activation of opioid mu receptors in caudal medullary raphe region inhibits the ventilatory response to hypercapnia in anesthetized rats.. Anesthesiology. (2007). 107 288–97 [Article] [PubMed]×
82.Eastwood, PR, Szollosi, I, Platt, PR, Hillman, DR Collapsibility of the upper airway during anesthesia with isoflurane.. Anesthesiology. (2002). 97 786–93 [Article] [PubMed]
82.Eastwood, PR, Szollosi, I, Platt, PR, Hillman, DR Collapsibility of the upper airway during anesthesia with isoflurane.. Anesthesiology. (2002). 97 786–93 [Article] [PubMed]×
83.Drummond, GB Influence of thiopentone on upper airway muscles.. Br J Anaesth. (1989). 63 12–21 [Article] [PubMed]
83.Drummond, GB Influence of thiopentone on upper airway muscles.. Br J Anaesth. (1989). 63 12–21 [Article] [PubMed]×
84.Eikermann, M, Fassbender, P, Zaremba, S, Jordan, AS, Rosow, C, Malhotra, A, Chamberlin, NL Pentobarbital dose-dependently increases respiratory genioglossus muscle activity while impairing diaphragmatic function in anesthetized rats.. Anesthesiology. (2009). 110 1327–34 [Article] [PubMed]
84.Eikermann, M, Fassbender, P, Zaremba, S, Jordan, AS, Rosow, C, Malhotra, A, Chamberlin, NL Pentobarbital dose-dependently increases respiratory genioglossus muscle activity while impairing diaphragmatic function in anesthetized rats.. Anesthesiology. (2009). 110 1327–34 [Article] [PubMed]×
85.Nishino, T, Shirahata, M, Yonezawa, T, Honda, Y Comparison of changes in the hypoglossal and the phrenic nerve activity in response to increasing depth of anesthesia in cats.. Anesthesiology. (1984). 60 19–24 [Article] [PubMed]
85.Nishino, T, Shirahata, M, Yonezawa, T, Honda, Y Comparison of changes in the hypoglossal and the phrenic nerve activity in response to increasing depth of anesthesia in cats.. Anesthesiology. (1984). 60 19–24 [Article] [PubMed]×
86.Eikermann, M, Grosse-Sundrup, M, Zaremba, S, Henry, ME, Bittner, EA, Hoffmann, U, Chamberlin, NL Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction.. Anesthesiology. (2012). 116 35–46 [Article] [PubMed]
86.Eikermann, M, Grosse-Sundrup, M, Zaremba, S, Henry, ME, Bittner, EA, Hoffmann, U, Chamberlin, NL Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction.. Anesthesiology. (2012). 116 35–46 [Article] [PubMed]×
87.Lu, J, Nelson, LE, Franks, N, Maze, M, Chamberlin, NL, Saper, CB Role of endogenous sleep-wake and analgesic systems in anesthesia.. J Comp Neurol. (2008). 508 648–62 [Article] [PubMed]
87.Lu, J, Nelson, LE, Franks, N, Maze, M, Chamberlin, NL, Saper, CB Role of endogenous sleep-wake and analgesic systems in anesthesia.. J Comp Neurol. (2008). 508 648–62 [Article] [PubMed]×
88.Eikermann, M, Eckert, DJ, Chamberlin, NL, Jordan, AS, Zaremba, S, Smith, S, Rosow, C, Malhotra, A Effects of pentobarbital on upper airway patency during sleep.. Eur Respir J. (2010). 36 569–76 [Article] [PubMed]
88.Eikermann, M, Eckert, DJ, Chamberlin, NL, Jordan, AS, Zaremba, S, Smith, S, Rosow, C, Malhotra, A Effects of pentobarbital on upper airway patency during sleep.. Eur Respir J. (2010). 36 569–76 [Article] [PubMed]×
89.Eikermann, M, Malhotra, A, Fassbender, P, Zaremba, S, Jordan, AS, Gautam, S, White, DP, Chamberlin, NL Differential effects of isoflurane and propofol on upper airway dilator muscle activity and breathing.. Anesthesiology. (2008). 108 897–906 [Article] [PubMed]
89.Eikermann, M, Malhotra, A, Fassbender, P, Zaremba, S, Jordan, AS, Gautam, S, White, DP, Chamberlin, NL Differential effects of isoflurane and propofol on upper airway dilator muscle activity and breathing.. Anesthesiology. (2008). 108 897–906 [Article] [PubMed]×
90.Eastwood, PR, Platt, PR, Shepherd, K, Maddison, K, Hillman, DR Collapsibility of the upper airway at different concentrations of propofol anesthesia.. Anesthesiology. (2005). 103 470–7 [Article] [PubMed]
90.Eastwood, PR, Platt, PR, Shepherd, K, Maddison, K, Hillman, DR Collapsibility of the upper airway at different concentrations of propofol anesthesia.. Anesthesiology. (2005). 103 470–7 [Article] [PubMed]×
91.Sundman, E, Witt, H, Sandin, R, Kuylenstierna, R, Bodén, K, Ekberg, O, Eriksson, LI Pharyngeal function and airway protection during subhypnotic concentrations of propofol, isoflurane, and sevoflurane: Volunteers examined by pharyngeal videoradiography and simultaneous manometry.. Anesthesiology. (2001). 95 1125–32 [Article] [PubMed]
91.Sundman, E, Witt, H, Sandin, R, Kuylenstierna, R, Bodén, K, Ekberg, O, Eriksson, LI Pharyngeal function and airway protection during subhypnotic concentrations of propofol, isoflurane, and sevoflurane: Volunteers examined by pharyngeal videoradiography and simultaneous manometry.. Anesthesiology. (2001). 95 1125–32 [Article] [PubMed]×
92.Drummond, GB Comparison of sedation with midazolam and ketamine: Effects on airway muscle activity.. Br J Anaesth. (1996). 76 663–7 [Article] [PubMed]
92.Drummond, GB Comparison of sedation with midazolam and ketamine: Effects on airway muscle activity.. Br J Anaesth. (1996). 76 663–7 [Article] [PubMed]×
93.Dahan, A, Aarts, L, Smith, TW Incidence, reversal, and prevention of opioid-induced respiratory depression.. Anesthesiology. (2010). 112 226–38 [Article] [PubMed]
93.Dahan, A, Aarts, L, Smith, TW Incidence, reversal, and prevention of opioid-induced respiratory depression.. Anesthesiology. (2010). 112 226–38 [Article] [PubMed]×
94.Hajiha, M, DuBord, MA, Liu, H, Horner, RL Opioid receptor mechanisms at the hypoglossal motor pool and effects on tongue muscle activity in vivo.. J Physiol. (2009). 587 2677–92 [Article] [PubMed]
94.Hajiha, M, DuBord, MA, Liu, H, Horner, RL Opioid receptor mechanisms at the hypoglossal motor pool and effects on tongue muscle activity in vivo.. J Physiol. (2009). 587 2677–92 [Article] [PubMed]×
95.Overdyk, FJ Postoperative opioids remain a serious patient safety threat.. Anesthesiology. (2010). 113 259–60; author reply 260–1 [Article] [PubMed]
95.Overdyk, FJ Postoperative opioids remain a serious patient safety threat.. Anesthesiology. (2010). 113 259–60; author reply 260–1 [Article] [PubMed]×
96.Campbell, C, Weinger, MB, Quinn, M Alterations in diaphragm EMG activity during opiate-induced respiratory depression.. Respir Physiol. (1995). 100 107–17 [Article] [PubMed]
96.Campbell, C, Weinger, MB, Quinn, M Alterations in diaphragm EMG activity during opiate-induced respiratory depression.. Respir Physiol. (1995). 100 107–17 [Article] [PubMed]×
97.Horrow, JC, Abrams, JT, Van Riper, DF, Lambson, DL, Storella, RJ Ventilatory compliance after three sufentanil-pancuronium induction sequences.. Anesthesiology. (1991). 75 969–74 [Article] [PubMed]
97.Horrow, JC, Abrams, JT, Van Riper, DF, Lambson, DL, Storella, RJ Ventilatory compliance after three sufentanil-pancuronium induction sequences.. Anesthesiology. (1991). 75 969–74 [Article] [PubMed]×
98.Skulsky, EM, Osman, NI, Baghdoyan, HA, Lydic, R Microdialysis delivery of morphine to the hypoglossal nucleus of Wistar rat increases hypoglossal acetylcholine release.. Sleep. (2007). 30 566–73 [PubMed]
98.Skulsky, EM, Osman, NI, Baghdoyan, HA, Lydic, R Microdialysis delivery of morphine to the hypoglossal nucleus of Wistar rat increases hypoglossal acetylcholine release.. Sleep. (2007). 30 566–73 [PubMed]×
99.Liu, X, Sood, S, Liu, H, Horner, RL Opposing muscarinic and nicotinic modulation of hypoglossal motor output to genioglossus muscle in rats in vivo.. J Physiol (Lond). (2005). 565 965–80 [Article] [PubMed]
99.Liu, X, Sood, S, Liu, H, Horner, RL Opposing muscarinic and nicotinic modulation of hypoglossal motor output to genioglossus muscle in rats in vivo.. J Physiol (Lond). (2005). 565 965–80 [Article] [PubMed]×
100.Lalley, PM Mu-opioid receptor agonist effects on medullary respiratory neurons in the cat: Evidence for involvement in certain types of ventilatory disturbances.. Am J Physiol Regul Integr Comp Physiol. (2003). 285 R1287–304 [PubMed]
100.Lalley, PM Mu-opioid receptor agonist effects on medullary respiratory neurons in the cat: Evidence for involvement in certain types of ventilatory disturbances.. Am J Physiol Regul Integr Comp Physiol. (2003). 285 R1287–304 [PubMed]×
101.Brown, KA, Laferrière, A, Moss, IR Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia.. Anesthesiology. (2004). 100 806–10; discussion 5A [Article] [PubMed]
101.Brown, KA, Laferrière, A, Moss, IR Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia.. Anesthesiology. (2004). 100 806–10; discussion 5A [Article] [PubMed]×
102.Brown, KA, Laferrière, A, Lakheeram, I, Moss, IR Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates.. Anesthesiology. (2006). 105 665–9 [Article] [PubMed]
102.Brown, KA, Laferrière, A, Lakheeram, I, Moss, IR Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates.. Anesthesiology. (2006). 105 665–9 [Article] [PubMed]×
103.Hamilton, WK, Cullen, SC Effect of levallorphan tartrate upon opiate induced respiratory depression.. Anesthesiology. (1953). 14 550–4 [Article] [PubMed]
103.Hamilton, WK, Cullen, SC Effect of levallorphan tartrate upon opiate induced respiratory depression.. Anesthesiology. (1953). 14 550–4 [Article] [PubMed]×
104.Vaughn, RL, Bennett, CR Fentanyl chest wall rigidity syndrome–a case report.. Anesth Prog. (1981). 28 50–1 [PubMed]
104.Vaughn, RL, Bennett, CR Fentanyl chest wall rigidity syndrome–a case report.. Anesth Prog. (1981). 28 50–1 [PubMed]×
105.Drummond, GB, Duncan, MK Abdominal pressure during laparoscopy: Effects of fentanyl.. Br J Anaesth. (2002). 88 384–8 [Article] [PubMed]
105.Drummond, GB, Duncan, MK Abdominal pressure during laparoscopy: Effects of fentanyl.. Br J Anaesth. (2002). 88 384–8 [Article] [PubMed]×
106.Chawla, G, Drummond, GB Fentanyl decreases end-expiratory lung volume in patients anaesthetized with sevoflurane.. Br J Anaesth. (2008). 100 411–4 [Article] [PubMed]
106.Chawla, G, Drummond, GB Fentanyl decreases end-expiratory lung volume in patients anaesthetized with sevoflurane.. Br J Anaesth. (2008). 100 411–4 [Article] [PubMed]×
107.Wu, A, Drummond, GB Respiratory muscle activity and respiratory obstruction after abdominal surgery.. Br J Anaesth. (2006). 96 510–5 [Article] [PubMed]
107.Wu, A, Drummond, GB Respiratory muscle activity and respiratory obstruction after abdominal surgery.. Br J Anaesth. (2006). 96 510–5 [Article] [PubMed]×
108.Aurell, J, Elmqvist, D Sleep in the surgical intensive care unit: Continuous polygraphic recording of sleep in nine patients receiving postoperative care.. Br Med J (Clin Res Ed). (1985). 290 1029–32 [Article] [PubMed]
108.Aurell, J, Elmqvist, D Sleep in the surgical intensive care unit: Continuous polygraphic recording of sleep in nine patients receiving postoperative care.. Br Med J (Clin Res Ed). (1985). 290 1029–32 [Article] [PubMed]×
109.Kaw, R, Michota, F, Jaffer, A, Ghamande, S, Auckley, D, Golish, J Unrecognized sleep apnea in the surgical patient: Implications for the perioperative setting.. Chest. (2006). 129 198–205 [Article] [PubMed]
109.Kaw, R, Michota, F, Jaffer, A, Ghamande, S, Auckley, D, Golish, J Unrecognized sleep apnea in the surgical patient: Implications for the perioperative setting.. Chest. (2006). 129 198–205 [Article] [PubMed]×
110.Borbély, AA, Tobler, I, Hanagasioglu, M Effect of sleep deprivation on sleep and EEG power spectra in the rat.. Behav Brain Res. (1984). 14 171–82 [Article] [PubMed]
110.Borbély, AA, Tobler, I, Hanagasioglu, M Effect of sleep deprivation on sleep and EEG power spectra in the rat.. Behav Brain Res. (1984). 14 171–82 [Article] [PubMed]×
111.Knill, RL, Moote, CA, Skinner, MI, Rose, EA Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week.. Anesthesiology. (1990). 73 52–61 [Article] [PubMed]
111.Knill, RL, Moote, CA, Skinner, MI, Rose, EA Anesthesia with abdominal surgery leads to intense REM sleep during the first postoperative week.. Anesthesiology. (1990). 73 52–61 [Article] [PubMed]×
112.Roth, T, Roehrs, T Sleep organization and regulation.. Neurology. (2000). 545 Suppl 1 S2–7 [PubMed]
112.Roth, T, Roehrs, T Sleep organization and regulation.. Neurology. (2000). 545 Suppl 1 S2–7 [PubMed]×
113.Cherniack, NS Respiratory dysrhythmias during sleep.. N Engl J Med. (1981). 305 325–30 [Article] [PubMed]
113.Cherniack, NS Respiratory dysrhythmias during sleep.. N Engl J Med. (1981). 305 325–30 [Article] [PubMed]×
114.Rosenberg, J, Wildschiødtz, G, Pedersen, MH, von Jessen, F, Kehlet, H Late postoperative nocturnal episodic hypoxaemia and associated sleep pattern.. Br J Anaesth. (1994). 72 145–50 [Article] [PubMed]
114.Rosenberg, J, Wildschiødtz, G, Pedersen, MH, von Jessen, F, Kehlet, H Late postoperative nocturnal episodic hypoxaemia and associated sleep pattern.. Br J Anaesth. (1994). 72 145–50 [Article] [PubMed]×
115.Ellis, BW, Dudley, HA Some aspects of sleep research in surgical stress.. J Psychosom Res. (1976). 20 303–8 [Article] [PubMed]
115.Ellis, BW, Dudley, HA Some aspects of sleep research in surgical stress.. J Psychosom Res. (1976). 20 303–8 [Article] [PubMed]×
116.Rosenberg-Adamsen, S, Skarbye, M, Wildschiødtz, G, Kehlet, H, Rosenberg, J Sleep after laparoscopic cholecystectomy.. Br J Anaesth. (1996). 77 572–5 [Article] [PubMed]
116.Rosenberg-Adamsen, S, Skarbye, M, Wildschiødtz, G, Kehlet, H, Rosenberg, J Sleep after laparoscopic cholecystectomy.. Br J Anaesth. (1996). 77 572–5 [Article] [PubMed]×
117.Pick, J, Chen, Y, Moore, JT, Sun, Y, Wyner, AJ, Friedman, EB, Kelz, MB Rapid eye movement sleep debt accrues in mice exposed to volatile anesthetics.. Anesthesiology. (2011). 115 702–12 [Article] [PubMed]
117.Pick, J, Chen, Y, Moore, JT, Sun, Y, Wyner, AJ, Friedman, EB, Kelz, MB Rapid eye movement sleep debt accrues in mice exposed to volatile anesthetics.. Anesthesiology. (2011). 115 702–12 [Article] [PubMed]×
118.Moote, CA, Knill, RL Isoflurane anesthesia causes a transient alteration in nocturnal sleep.. Anesthesiology. (1988). 69 327–31 [Article] [PubMed]
118.Moote, CA, Knill, RL Isoflurane anesthesia causes a transient alteration in nocturnal sleep.. Anesthesiology. (1988). 69 327–31 [Article] [PubMed]×
119.Eisen, J, MacFarlane, J, Shapiro, CM ABC of sleep disorders. Psychotropic drugs and sleep.. BMJ. (1993). 306 1331–4 [Article] [PubMed]
119.Eisen, J, MacFarlane, J, Shapiro, CM ABC of sleep disorders. Psychotropic drugs and sleep.. BMJ. (1993). 306 1331–4 [Article] [PubMed]×
120.Tung, A, Lynch, JP, Mendelson, WB Prolonged sedation with propofol in the rat does not result in sleep deprivation.. Anesth Analg. (2001). 92 1232–6 [Article] [PubMed]
120.Tung, A, Lynch, JP, Mendelson, WB Prolonged sedation with propofol in the rat does not result in sleep deprivation.. Anesth Analg. (2001). 92 1232–6 [Article] [PubMed]×
121.Tung, A, Bergmann, BM, Herrera, S, Cao, D, Mendelson, WB Recovery from sleep deprivation occurs during propofol anesthesia.. Anesthesiology. (2004). 100 1419–26 [Article] [PubMed]
121.Tung, A, Bergmann, BM, Herrera, S, Cao, D, Mendelson, WB Recovery from sleep deprivation occurs during propofol anesthesia.. Anesthesiology. (2004). 100 1419–26 [Article] [PubMed]×
122.Cammu, G, De Witte, J, De Veylder, J, Byttebier, G, Vandeput, D, Foubert, L, Vandenbroucke, G, Deloof, T Postoperative residual paralysis in outpatients versus inpatients.. Anesth Analg. (2006). 102 426–9 [Article] [PubMed]
122.Cammu, G, De Witte, J, De Veylder, J, Byttebier, G, Vandeput, D, Foubert, L, Vandenbroucke, G, Deloof, T Postoperative residual paralysis in outpatients versus inpatients.. Anesth Analg. (2006). 102 426–9 [Article] [PubMed]×
123.Eikermann, M, Vogt, FM, Herbstreit, F, Vahid-Dastgerdi, M, Zenge, MO, Ochterbeck, C, de Greiff, A, Peters, J The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade.. Am J Respir Crit Care Med. (2007). 175 9–15 [Article] [PubMed]
123.Eikermann, M, Vogt, FM, Herbstreit, F, Vahid-Dastgerdi, M, Zenge, MO, Ochterbeck, C, de Greiff, A, Peters, J The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade.. Am J Respir Crit Care Med. (2007). 175 9–15 [Article] [PubMed]×
124.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 1253–60 [Article] [PubMed]
124.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 1253–60 [Article] [PubMed]×
125.Murphy, GS, Szokol, JW, Marymont, JH, Greenberg, SB, Avram, MJ, Vender, JS, Nisman, M Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit.. Anesthesiology. (2008). 109 389–98 [Article] [PubMed]
125.Murphy, GS, Szokol, JW, Marymont, JH, Greenberg, SB, Avram, MJ, Vender, JS, Nisman, M Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit.. Anesthesiology. (2008). 109 389–98 [Article] [PubMed]×
126.Butterly, A, Bittner, EA, George, E, Sandberg, WS, Eikermann, M, Schmidt, U Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge.. Br J Anaesth. (2010). 105 304–9 [Article] [PubMed]
126.Butterly, A, Bittner, EA, George, E, Sandberg, WS, Eikermann, M, Schmidt, U Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge.. Br J Anaesth. (2010). 105 304–9 [Article] [PubMed]×
127.Eikermann, M, Fassbender, P, Malhotra, A, Takahashi, M, Kubo, S, Jordan, AS, Gautam, S, White, DP, Chamberlin, NL Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossus and diaphragm muscle function.. Anesthesiology. (2007). 107 621–9 [Article] [PubMed]
127.Eikermann, M, Fassbender, P, Malhotra, A, Takahashi, M, Kubo, S, Jordan, AS, Gautam, S, White, DP, Chamberlin, NL Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossus and diaphragm muscle function.. Anesthesiology. (2007). 107 621–9 [Article] [PubMed]×
128.Nguyen-Huu, T, Molgó, J, Servent, D, Duvaldestin, P Resistance to D-tubocurarine of the rat diaphragm as compared to a limb muscle: Influence of quantal transmitter release and nicotinic acetylcholine receptors.. Anesthesiology. (2009). 110 1011–5 [Article] [PubMed]
128.Nguyen-Huu, T, Molgó, J, Servent, D, Duvaldestin, P Resistance to D-tubocurarine of the rat diaphragm as compared to a limb muscle: Influence of quantal transmitter release and nicotinic acetylcholine receptors.. Anesthesiology. (2009). 110 1011–5 [Article] [PubMed]×
129.Trudo, FJ, Gefter, WB, Welch, KC, Gupta, KB, Maislin, G, Schwab, RJ State-related changes in upper airway caliber and surrounding soft-tissue structures in normal subjects.. Am J Respir Crit Care Med. (1998). 158 1259–70 [Article] [PubMed]
129.Trudo, FJ, Gefter, WB, Welch, KC, Gupta, KB, Maislin, G, Schwab, RJ State-related changes in upper airway caliber and surrounding soft-tissue structures in normal subjects.. Am J Respir Crit Care Med. (1998). 158 1259–70 [Article] [PubMed]×
130.Herbstreit, F, Zigrahn, D, Ochterbeck, C, Peters, J, Eikermann, M Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure.. Anesthesiology. (2010). 113 1280–8 [Article] [PubMed]
130.Herbstreit, F, Zigrahn, D, Ochterbeck, C, Peters, J, Eikermann, M Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure.. Anesthesiology. (2010). 113 1280–8 [Article] [PubMed]×
131.Krodel, DJ, Bittner, EA, Abdulnour, RE, Brown, RH, Eikermann, M Negative pressure pulmonary edema following bronchospasm.. Chest. (2011). 140 1351–4 [Article] [PubMed]
131.Krodel, DJ, Bittner, EA, Abdulnour, RE, Brown, RH, Eikermann, M Negative pressure pulmonary edema following bronchospasm.. Chest. (2011). 140 1351–4 [Article] [PubMed]×
132.Ayala, A, Wang, P, Ba, ZF, Perrin, MM, Ertel, W, Chaudry, IH Differential alterations in plasma IL-6 and TNF levels after trauma and hemorrhage.. Am J Physiol. (1991). 260 R167–71 [PubMed]
132.Ayala, A, Wang, P, Ba, ZF, Perrin, MM, Ertel, W, Chaudry, IH Differential alterations in plasma IL-6 and TNF levels after trauma and hemorrhage.. Am J Physiol. (1991). 260 R167–71 [PubMed]×
133.Pullicino, EA, Carli, F, Poole, S, Rafferty, B, Malik, ST, Elia, M The relationship between the circulating concentrations of interleukin 6 (IL-6), tumor necrosis factor (TNF) and the acute phase response to elective surgery and accidental injury.. Lymphokine Res. (1990). 9 231–8 [PubMed]
133.Pullicino, EA, Carli, F, Poole, S, Rafferty, B, Malik, ST, Elia, M The relationship between the circulating concentrations of interleukin 6 (IL-6), tumor necrosis factor (TNF) and the acute phase response to elective surgery and accidental injury.. Lymphokine Res. (1990). 9 231–8 [PubMed]×
134.Plank, LD, Connolly, AB, Hill, GL Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis.. Ann Surg. (1998). 228 146–58 [Article] [PubMed]
134.Plank, LD, Connolly, AB, Hill, GL Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis.. Ann Surg. (1998). 228 146–58 [Article] [PubMed]×
135.Leon, A, Boczkowski, J, Dureuil, B, Desmonts, JM, Aubier, M Effects of endotoxic shock on diaphragmatic function in mechanically ventilated rats.. J Appl Physiol. (1992). 72 1466–72 [PubMed]
135.Leon, A, Boczkowski, J, Dureuil, B, Desmonts, JM, Aubier, M Effects of endotoxic shock on diaphragmatic function in mechanically ventilated rats.. J Appl Physiol. (1992). 72 1466–72 [PubMed]×
136.Burke, JF, Pontoppidan, H, Welch, CE High output respiratory failure: an important cause of death ascribed to peritonitis or ileus.. Ann Surg. (1963). 158 581–95 [Article] [PubMed]
136.Burke, JF, Pontoppidan, H, Welch, CE High output respiratory failure: an important cause of death ascribed to peritonitis or ileus.. Ann Surg. (1963). 158 581–95 [Article] [PubMed]×
137.Jammes, Y, Balzamo, E Changes in afferent and efferent phrenic activities with electrically induced diaphragmatic fatigue.. J Appl Physiol. (1992). 73 894–902 [PubMed]
137.Jammes, Y, Balzamo, E Changes in afferent and efferent phrenic activities with electrically induced diaphragmatic fatigue.. J Appl Physiol. (1992). 73 894–902 [PubMed]×
138.Reid, MB, Lännergren, J, Westerblad, H Respiratory and limb muscle weakness induced by tumor necrosis factor-alpha: Involvement of muscle myofilaments.. Am J Respir Crit Care Med. (2002). 166 479–84 [Article] [PubMed]
138.Reid, MB, Lännergren, J, Westerblad, H Respiratory and limb muscle weakness induced by tumor necrosis factor-alpha: Involvement of muscle myofilaments.. Am J Respir Crit Care Med. (2002). 166 479–84 [Article] [PubMed]×
139.Spooner, CE, Markowitz, NP, Saravolatz, LD The role of tumor necrosis factor in sepsis.. Clin Immunol Immunopathol. (1992). 62 S11–7 [Article] [PubMed]
139.Spooner, CE, Markowitz, NP, Saravolatz, LD The role of tumor necrosis factor in sepsis.. Clin Immunol Immunopathol. (1992). 62 S11–7 [Article] [PubMed]×
140.Boczkowski, J, Lanone, S, Ungureanu-Longrois, D, Danialou, G, Fournier, T, Aubier, M Induction of diaphragmatic nitric oxide synthase after endotoxin administration in rats: Role on diaphragmatic contractile dysfunction.. J Clin Invest. (1996). 98 1550–9 [Article] [PubMed]
140.Boczkowski, J, Lanone, S, Ungureanu-Longrois, D, Danialou, G, Fournier, T, Aubier, M Induction of diaphragmatic nitric oxide synthase after endotoxin administration in rats: Role on diaphragmatic contractile dysfunction.. J Clin Invest. (1996). 98 1550–9 [Article] [PubMed]×
141.Lanone, S, Mebazaa, A, Heymes, C, Henin, D, Poderoso, JJ, Panis, Y, Zedda, C, Billiar, T, Payen, D, Aubier, M, Boczkowski, J Muscular contractile failure in septic patients: Role of the inducible nitric oxide synthase pathway.. Am J Respir Crit Care Med. (2000). 162 2308–15 [Article] [PubMed]
141.Lanone, S, Mebazaa, A, Heymes, C, Henin, D, Poderoso, JJ, Panis, Y, Zedda, C, Billiar, T, Payen, D, Aubier, M, Boczkowski, J Muscular contractile failure in septic patients: Role of the inducible nitric oxide synthase pathway.. Am J Respir Crit Care Med. (2000). 162 2308–15 [Article] [PubMed]×
142.Esteban, A, Frutos, F, Tobin, MJ, Alía, I, Solsona, JF, Valverdú, I, Fernández, R, de la Cal, MA, Benito, S, Tomás, R A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group.. N Engl J Med. (1995). 332 345–50 [Article] [PubMed]
142.Esteban, A, Frutos, F, Tobin, MJ, Alía, I, Solsona, JF, Valverdú, I, Fernández, R, de la Cal, MA, Benito, S, Tomás, R A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group.. N Engl J Med. (1995). 332 345–50 [Article] [PubMed]×
143.Dasta, JF, McLaughlin, TP, Mody, SH, Piech, CT Daily cost of an intensive care unit day: The contribution of mechanical ventilation.. Crit Care Med. (2005). 33 1266–71 [Article] [PubMed]
143.Dasta, JF, McLaughlin, TP, Mody, SH, Piech, CT Daily cost of an intensive care unit day: The contribution of mechanical ventilation.. Crit Care Med. (2005). 33 1266–71 [Article] [PubMed]×
144.Zakynthinos, SG, Vassilakopoulos, T, Roussos, C The load of inspiratory muscles in patients needing mechanical ventilation.. Am J Respir Crit Care Med. (1995). 152 1248–55 [Article] [PubMed]
144.Zakynthinos, SG, Vassilakopoulos, T, Roussos, C The load of inspiratory muscles in patients needing mechanical ventilation.. Am J Respir Crit Care Med. (1995). 152 1248–55 [Article] [PubMed]×
145.Vassilakopoulos, T, Zakynthinos, S, Roussos, C The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success.. Am J Respir Crit Care Med. (1998). 158 378–85 [Article] [PubMed]
145.Vassilakopoulos, T, Zakynthinos, S, Roussos, C The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success.. Am J Respir Crit Care Med. (1998). 158 378–85 [Article] [PubMed]×
146.Shanely, RA, Zergeroglu, MA, Lennon, SL, Sugiura, T, Yimlamai, T, Enns, D, Belcastro, A, Powers, SK Mechanical ventilation-induced diaphragmatic atrophy is associated with oxidative injury and increased proteolytic activity.. Am J Respir Crit Care Med. (2002). 166 1369–74 [Article] [PubMed]
146.Shanely, RA, Zergeroglu, MA, Lennon, SL, Sugiura, T, Yimlamai, T, Enns, D, Belcastro, A, Powers, SK Mechanical ventilation-induced diaphragmatic atrophy is associated with oxidative injury and increased proteolytic activity.. Am J Respir Crit Care Med. (2002). 166 1369–74 [Article] [PubMed]×
147.Levine, S, Nguyen, T, Taylor, N, Friscia, ME, Budak, MT, Rothenberg, P, Zhu, J, Sachdeva, R, Sonnad, S, Kaiser, LR, Rubinstein, NA, Powers, SK, Shrager, JB Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.. N Engl J Med. (2008). 358 1327–35 [Article] [PubMed]
147.Levine, S, Nguyen, T, Taylor, N, Friscia, ME, Budak, MT, Rothenberg, P, Zhu, J, Sachdeva, R, Sonnad, S, Kaiser, LR, Rubinstein, NA, Powers, SK, Shrager, JB Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.. N Engl J Med. (2008). 358 1327–35 [Article] [PubMed]×
148.Jaber, S, Petrof, BJ, Jung, B, Chanques, G, Berthet, JP, Rabuel, C, Bouyabrine, H, Courouble, P, Koechlin-Ramonatxo, C, Sebbane, M, Similowski, T, Scheuermann, V, Mebazaa, A, Capdevila, X, Mornet, D, Mercier, J, Lacampagne, A, Philips, A, Matecki, S Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans.. Am J Respir Crit Care Med. (2011). 183 364–71 [Article] [PubMed]
148.Jaber, S, Petrof, BJ, Jung, B, Chanques, G, Berthet, JP, Rabuel, C, Bouyabrine, H, Courouble, P, Koechlin-Ramonatxo, C, Sebbane, M, Similowski, T, Scheuermann, V, Mebazaa, A, Capdevila, X, Mornet, D, Mercier, J, Lacampagne, A, Philips, A, Matecki, S Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans.. Am J Respir Crit Care Med. (2011). 183 364–71 [Article] [PubMed]×
149.Mrozek, S, Jung, B, Petrof, BJ, Pauly, M, Roberge, S, Lacampagne, A, Cassan, C, Thireau, J, Molinari, N, Futier, E, Scheuermann, V, Constantin, JM, Matecki, S, Jaber, S Rapid onset of specific diaphragm weakness in a healthy murine model of ventilator-induced diaphragmatic dysfunction.. Anesthesiology. (2012). 117 560–7 [Article] [PubMed]
149.Mrozek, S, Jung, B, Petrof, BJ, Pauly, M, Roberge, S, Lacampagne, A, Cassan, C, Thireau, J, Molinari, N, Futier, E, Scheuermann, V, Constantin, JM, Matecki, S, Jaber, S Rapid onset of specific diaphragm weakness in a healthy murine model of ventilator-induced diaphragmatic dysfunction.. Anesthesiology. (2012). 117 560–7 [Article] [PubMed]×
150.Grosu, HB, Lee, YI, Lee, J, Eden, E, Eikermann, M, Rose, K Diaphragm muscle thinning in mechanically ventilated patients.. Chest. (2012). 142 1455–60 [Article] [PubMed]
150.Grosu, HB, Lee, YI, Lee, J, Eden, E, Eikermann, M, Rose, K Diaphragm muscle thinning in mechanically ventilated patients.. Chest. (2012). 142 1455–60 [Article] [PubMed]×
151.Behbehani, NA, Al-Mane, F, D’yachkova, Y, Paré, P, FitzGerald, JM Myopathy following mechanical ventilation for acute severe asthma: The role of muscle relaxants and corticosteroids.. Chest. (1999). 115 1627–31 [Article] [PubMed]
151.Behbehani, NA, Al-Mane, F, D’yachkova, Y, Paré, P, FitzGerald, JM Myopathy following mechanical ventilation for acute severe asthma: The role of muscle relaxants and corticosteroids.. Chest. (1999). 115 1627–31 [Article] [PubMed]×
152.Adnet, F, Dhissi, G, Borron, SW, Galinski, M, Rayeh, F, Cupa, M, Pourriat, JL, Lapostolle, F Complication profiles of adult asthmatics requiring paralysis during mechanical ventilation.. Intensive Care Med. (2001). 27 1729–36 [Article] [PubMed]
152.Adnet, F, Dhissi, G, Borron, SW, Galinski, M, Rayeh, F, Cupa, M, Pourriat, JL, Lapostolle, F Complication profiles of adult asthmatics requiring paralysis during mechanical ventilation.. Intensive Care Med. (2001). 27 1729–36 [Article] [PubMed]×
153.Leatherman, JW, Fluegel, WL, David, WS, Davies, SF, Iber, C Muscle weakness in mechanically ventilated patients with severe asthma.. Am J Respir Crit Care Med. (1996). 153 1686–90 [Article] [PubMed]
153.Leatherman, JW, Fluegel, WL, David, WS, Davies, SF, Iber, C Muscle weakness in mechanically ventilated patients with severe asthma.. Am J Respir Crit Care Med. (1996). 153 1686–90 [Article] [PubMed]×
154.Douglass, JA, Tuxen, DV, Horne, M, Scheinkestel, CD, Weinmann, M, Czarny, D, Bowes, G Myopathy in severe asthma.. Am Rev Respir Dis. (1992). 146 517–9 [Article] [PubMed]
154.Douglass, JA, Tuxen, DV, Horne, M, Scheinkestel, CD, Weinmann, M, Czarny, D, Bowes, G Myopathy in severe asthma.. Am Rev Respir Dis. (1992). 146 517–9 [Article] [PubMed]×
155.Garnacho-Montero, J, Amaya-Villar, R, García-Garmendía, JL, Madrazo-Osuna, J, Ortiz-Leyba, C Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients.. Crit Care Med. (2005). 33 349–54 [Article] [PubMed]
155.Garnacho-Montero, J, Amaya-Villar, R, García-Garmendía, JL, Madrazo-Osuna, J, Ortiz-Leyba, C Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients.. Crit Care Med. (2005). 33 349–54 [Article] [PubMed]×
156.Segredo, V, Caldwell, JE, Matthay, MA, Sharma, ML, Gruenke, LD, Miller, RD Persistent paralysis in critically ill patients after long-term administration of vecuronium.. N Engl J Med. (1992). 327 524–8 [Article] [PubMed]
156.Segredo, V, Caldwell, JE, Matthay, MA, Sharma, ML, Gruenke, LD, Miller, RD Persistent paralysis in critically ill patients after long-term administration of vecuronium.. N Engl J Med. (1992). 327 524–8 [Article] [PubMed]×
157.Testelmans, D, Maes, K, Wouters, P, Gosselin, N, Deruisseau, K, Powers, S, Sciot, R, Decramer, M, Gayan-Ramirez, G Rocuronium exacerbates mechanical ventilation-induced diaphragm dysfunction in rats.. Crit Care Med. (2006). 34 3018–23 [PubMed]
157.Testelmans, D, Maes, K, Wouters, P, Gosselin, N, Deruisseau, K, Powers, S, Sciot, R, Decramer, M, Gayan-Ramirez, G Rocuronium exacerbates mechanical ventilation-induced diaphragm dysfunction in rats.. Crit Care Med. (2006). 34 3018–23 [PubMed]×
158.Scheidegger, D, Bentz, L, Piolino, G, Pusterla, C, Gigon, JP Influence of early mobilisation of pulmonary function in surgical patients.. Eur J Intensive Care Med. (1976). 2 35–40 [Article] [PubMed]
158.Scheidegger, D, Bentz, L, Piolino, G, Pusterla, C, Gigon, JP Influence of early mobilisation of pulmonary function in surgical patients.. Eur J Intensive Care Med. (1976). 2 35–40 [Article] [PubMed]×
159.Schweickert, WD, Pohlman, MC, Pohlman, AS, Nigos, C, Pawlik, AJ, Esbrook, CL, Spears, L, Miller, M, Franczyk, M, Deprizio, D, Schmidt, GA, Bowman, A, Barr, R, McCallister, KE, Hall, JB, Kress, JP Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial.. Lancet. (2009). 373 1874–82 [Article] [PubMed]
159.Schweickert, WD, Pohlman, MC, Pohlman, AS, Nigos, C, Pawlik, AJ, Esbrook, CL, Spears, L, Miller, M, Franczyk, M, Deprizio, D, Schmidt, GA, Bowman, A, Barr, R, McCallister, KE, Hall, JB, Kress, JP Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial.. Lancet. (2009). 373 1874–82 [Article] [PubMed]×
160.Morris, PE, Goad, A, Thompson, C, Taylor, K, Harry, B, Passmore, L, Ross, A, Anderson, L, Baker, S, Sanchez, M, Penley, L, Howard, A, Dixon, L, Leach, S, Small, R, Hite, RD, Haponik, E Early intensive care unit mobility therapy in the treatment of acute respiratory failure.. Crit Care Med. (2008). 36 2238–43 [Article] [PubMed]
160.Morris, PE, Goad, A, Thompson, C, Taylor, K, Harry, B, Passmore, L, Ross, A, Anderson, L, Baker, S, Sanchez, M, Penley, L, Howard, A, Dixon, L, Leach, S, Small, R, Hite, RD, Haponik, E Early intensive care unit mobility therapy in the treatment of acute respiratory failure.. Crit Care Med. (2008). 36 2238–43 [Article] [PubMed]×
161.Nava, S Rehabilitation of patients admitted to a respiratory intensive care unit.. Arch Phys Med Rehabil. (1998). 79 849–54 [Article] [PubMed]
161.Nava, S Rehabilitation of patients admitted to a respiratory intensive care unit.. Arch Phys Med Rehabil. (1998). 79 849–54 [Article] [PubMed]×
162.Kasotakis, G, Schmidt, U, Perry, D, Grosse-Sundrup, M, Benjamin, J, Ryan, C, Tully, S, Hirschberg, R, Waak, K, Velmahos, G, Bittner, EA, Zafonte, R, Cobb, JP, Eikermann, M The surgical intensive care unit optimal mobility score predicts mortality and length of stay.. Crit Care Med. (2012). 40 1122–8 [Article] [PubMed]
162.Kasotakis, G, Schmidt, U, Perry, D, Grosse-Sundrup, M, Benjamin, J, Ryan, C, Tully, S, Hirschberg, R, Waak, K, Velmahos, G, Bittner, EA, Zafonte, R, Cobb, JP, Eikermann, M The surgical intensive care unit optimal mobility score predicts mortality and length of stay.. Crit Care Med. (2012). 40 1122–8 [Article] [PubMed]×
163.Qaseem, A, Snow, V, Fitterman, N, Hornbake, ER, Lawrence, VA, Smetana, GW, Weiss, K, Owens, DK, Aronson, M, Barry, P, Casey, DEJr, Cross, JTJr, Fitterman, N, Sherif, KD, Weiss, KB Clinical Efficacy Assessment Subcommittee of the American College of Physicians, Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians.. Ann Intern Med. (2006). 144 575–80 [Article] [PubMed]
163.Qaseem, A, Snow, V, Fitterman, N, Hornbake, ER, Lawrence, VA, Smetana, GW, Weiss, K, Owens, DK, Aronson, M, Barry, P, Casey, DEJr, Cross, JTJr, Fitterman, N, Sherif, KD, Weiss, KB Clinical Efficacy Assessment Subcommittee of the American College of Physicians, Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians.. Ann Intern Med. (2006). 144 575–80 [Article] [PubMed]×
164.Turner, JM, Mead, J, Wohl, ME Elasticity of human lungs in relation to age.. J Appl Physiol. (1968). 25 664–71 [PubMed]
164.Turner, JM, Mead, J, Wohl, ME Elasticity of human lungs in relation to age.. J Appl Physiol. (1968). 25 664–71 [PubMed]×
165.Sprung, J, Gajic, O, Warner, DO Review article: Age related alterations in respiratory function - anesthetic considerations.. Can J Anaesth. (2006). 53 1244–57 [Article] [PubMed]
165.Sprung, J, Gajic, O, Warner, DO Review article: Age related alterations in respiratory function - anesthetic considerations.. Can J Anaesth. (2006). 53 1244–57 [Article] [PubMed]×
166.Tolep, K, Higgins, N, Muza, S, Criner, G, Kelsen, SG Comparison of diaphragm strength between healthy adult elderly and young men.. Am J Respir Crit Care Med. (1995). 152 677–82 [Article] [PubMed]
166.Tolep, K, Higgins, N, Muza, S, Criner, G, Kelsen, SG Comparison of diaphragm strength between healthy adult elderly and young men.. Am J Respir Crit Care Med. (1995). 152 677–82 [Article] [PubMed]×
167.Eikermann, M, Jordan, AS, Chamberlin, NL, Gautam, S, Wellman, A, Lo, YL, White, DP, Malhotra, A The influence of aging on pharyngeal collapsibility during sleep.. Chest. (2007). 131 1702–9 [Article] [PubMed]
167.Eikermann, M, Jordan, AS, Chamberlin, NL, Gautam, S, Wellman, A, Lo, YL, White, DP, Malhotra, A The influence of aging on pharyngeal collapsibility during sleep.. Chest. (2007). 131 1702–9 [Article] [PubMed]×
168.Turnheim, K When drug therapy gets old: Pharmacokinetics and pharmacodynamics in the elderly.. Exp Gerontol. (2003). 38 843–53 [Article] [PubMed]
168.Turnheim, K When drug therapy gets old: Pharmacokinetics and pharmacodynamics in the elderly.. Exp Gerontol. (2003). 38 843–53 [Article] [PubMed]×
169.Kronenberg, RS, Drage, CW Attenuation of the ventilatory and heart rate responses to hypoxia and hypercapnia with aging in normal men.. J Clin Invest. (1973). 52 1812–9 [Article] [PubMed]
169.Kronenberg, RS, Drage, CW Attenuation of the ventilatory and heart rate responses to hypoxia and hypercapnia with aging in normal men.. J Clin Invest. (1973). 52 1812–9 [Article] [PubMed]×
170.Ogden, CL, Carroll, MD, Kit, BK, Flegal, KM Prevalence of obesity in the United States, 2009–2010.. NCHS Data Brief. (2012).  1–8
170.Ogden, CL, Carroll, MD, Kit, BK, Flegal, KM Prevalence of obesity in the United States, 2009–2010.. NCHS Data Brief. (2012).  1–8×
171.Isono, S Obstructive sleep apnea of obese adults: Pathophysiology and perioperative airway management.. Anesthesiology. (2009). 110 908–21 [Article] [PubMed]
171.Isono, S Obstructive sleep apnea of obese adults: Pathophysiology and perioperative airway management.. Anesthesiology. (2009). 110 908–21 [Article] [PubMed]×
172.Welch, KC, Foster, GD, Ritter, CT, Wadden, TA, Arens, R, Maislin, G, Schwab, RJ A novel volumetric magnetic resonance imaging paradigm to study upper airway anatomy.. Sleep. (2002). 25 532–42 [PubMed]
172.Welch, KC, Foster, GD, Ritter, CT, Wadden, TA, Arens, R, Maislin, G, Schwab, RJ A novel volumetric magnetic resonance imaging paradigm to study upper airway anatomy.. Sleep. (2002). 25 532–42 [PubMed]×
173.Isono, S, Remmers, JE, Tanaka, A, Sho, Y, Sato, J, Nishino, T Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects.. J Appl Physiol. (1997). 82 1319–26 [PubMed]
173.Isono, S, Remmers, JE, Tanaka, A, Sho, Y, Sato, J, Nishino, T Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects.. J Appl Physiol. (1997). 82 1319–26 [PubMed]×
174.Ladosky, W, Botelho, MA, Albuquerque, JPJr Chest mechanics in morbidly obese non-hypoventilated patients.. Respir Med. (2001). 95 281–6 [Article] [PubMed]
174.Ladosky, W, Botelho, MA, Albuquerque, JPJr Chest mechanics in morbidly obese non-hypoventilated patients.. Respir Med. (2001). 95 281–6 [Article] [PubMed]×
175.Kress, JP, Pohlman, AS, Alverdy, J, Hall, JB The impact of morbid obesity on oxygen cost of breathing (VO(2RESP)) at rest.. Am J Respir Crit Care Med. (1999). 160 883–6 [Article] [PubMed]
175.Kress, JP, Pohlman, AS, Alverdy, J, Hall, JB The impact of morbid obesity on oxygen cost of breathing (VO(2RESP)) at rest.. Am J Respir Crit Care Med. (1999). 160 883–6 [Article] [PubMed]×
176.Shinohara, E, Kihara, S, Yamashita, S, Yamane, M, Nishida, M, Arai, T, Kotani, K, Nakamura, T, Takemura, K, Matsuzawa, Y Visceral fat accumulation as an important risk factor for obstructive sleep apnoea syndrome in obese subjects.. J Intern Med. (1997). 241 11–8 [Article] [PubMed]
176.Shinohara, E, Kihara, S, Yamashita, S, Yamane, M, Nishida, M, Arai, T, Kotani, K, Nakamura, T, Takemura, K, Matsuzawa, Y Visceral fat accumulation as an important risk factor for obstructive sleep apnoea syndrome in obese subjects.. J Intern Med. (1997). 241 11–8 [Article] [PubMed]×
177.Punjabi, NM The epidemiology of adult obstructive sleep apnea.. Proc Am Thorac Soc. (2008). 5 136–43 [Article] [PubMed]
177.Punjabi, NM The epidemiology of adult obstructive sleep apnea.. Proc Am Thorac Soc. (2008). 5 136–43 [Article] [PubMed]×
178.Ayuse, T, Hoshino, Y, Kurata, S, Ayuse, T, Schneider, H, Kirkness, JP, Patil, SP, Schwartz, AR, Oi, K The effect of gender on compensatory neuromuscular response to upper airway obstruction in normal subjects under midazolam general anesthesia.. Anesth Analg. (2009). 109 1209–18 [Article] [PubMed]
178.Ayuse, T, Hoshino, Y, Kurata, S, Ayuse, T, Schneider, H, Kirkness, JP, Patil, SP, Schwartz, AR, Oi, K The effect of gender on compensatory neuromuscular response to upper airway obstruction in normal subjects under midazolam general anesthesia.. Anesth Analg. (2009). 109 1209–18 [Article] [PubMed]×
179.Mezzanotte, WS, Tangel, DJ, White, DP Waking genioglossal electromyogram in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism).. J Clin Invest. (1992). 89 1571–9 [Article] [PubMed]
179.Mezzanotte, WS, Tangel, DJ, White, DP Waking genioglossal electromyogram in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism).. J Clin Invest. (1992). 89 1571–9 [Article] [PubMed]×
180.Horner, RL, Innes, JA, Morrell, MJ, Shea, SA, Guz, A The effect of sleep on reflex genioglossus muscle activation by stimuli of negative airway pressure in humans.. J Physiol (Lond). (1994). 476 141–51 [PubMed]
180.Horner, RL, Innes, JA, Morrell, MJ, Shea, SA, Guz, A The effect of sleep on reflex genioglossus muscle activation by stimuli of negative airway pressure in humans.. J Physiol (Lond). (1994). 476 141–51 [PubMed]×
181.Wheatley, JR, Tangel, DJ, Mezzanotte, WS, White, DP Influence of sleep on response to negative airway pressure of tensor palatini muscle and retropalatal airway.. J Appl Physiol. (1993). 75 2117–24 [PubMed]
181.Wheatley, JR, Tangel, DJ, Mezzanotte, WS, White, DP Influence of sleep on response to negative airway pressure of tensor palatini muscle and retropalatal airway.. J Appl Physiol. (1993). 75 2117–24 [PubMed]×
182.Park, JG, Ramar, K, Olson, EJ Updates on definition, consequences, and management of obstructive sleep apnea.. Mayo Clin Proc. (2011). 86 549–54; quiz 554–5 [Article] [PubMed]
182.Park, JG, Ramar, K, Olson, EJ Updates on definition, consequences, and management of obstructive sleep apnea.. Mayo Clin Proc. (2011). 86 549–54; quiz 554–5 [Article] [PubMed]×
183.Rennotte, MT, Baele, P, Aubert, G, Rodenstein, DO Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery.. Chest. (1995). 107 367–74 [Article] [PubMed]
183.Rennotte, MT, Baele, P, Aubert, G, Rodenstein, DO Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery.. Chest. (1995). 107 367–74 [Article] [PubMed]×
184.Joshi, GP, Ankichetty, SP, Gan, TJ, Chung, F Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.. Anesth Analg. (2012). 115 1060–8 [Article] [PubMed]
184.Joshi, GP, Ankichetty, SP, Gan, TJ, Chung, F Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.. Anesth Analg. (2012). 115 1060–8 [Article] [PubMed]×
185.Gross, JB, Bachenberg, KL, Benumof, JL, Caplan, RA, Connis, RT, Coté, CJ, Nickinovich, DG, Prachand, V, Ward, DS, Weaver, EM, Ydens, L, Yu, S American Society of Anesthesiologists Task Force on Perioperative Management, Practice guidelines for the perioperative management of patients with obstructive sleep apnea: A report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.. Anesthesiology. (2006). 104 1081–93; quiz 1117–8 [Article] [PubMed]
185.Gross, JB, Bachenberg, KL, Benumof, JL, Caplan, RA, Connis, RT, Coté, CJ, Nickinovich, DG, Prachand, V, Ward, DS, Weaver, EM, Ydens, L, Yu, S American Society of Anesthesiologists Task Force on Perioperative Management, Practice guidelines for the perioperative management of patients with obstructive sleep apnea: A report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.. Anesthesiology. (2006). 104 1081–93; quiz 1117–8 [Article] [PubMed]×
186.Schiller, JS, Lucas, JW, Ward, BW, Peregoy, JA Summary health statistics for U.S. adults: National Health Interview Survey, 2010.. Vital Health Stat. (2012). 10 1–207
186.Schiller, JS, Lucas, JW, Ward, BW, Peregoy, JA Summary health statistics for U.S. adults: National Health Interview Survey, 2010.. Vital Health Stat. (2012). 10 1–207×
187.Cassart, M, Pettiaux, N, Gevenois, PA, Paiva, M, Estenne, M Effect of chronic hyperinflation on diaphragm length and surface area.. Am J Respir Crit Care Med. (1997). 156 504–8 [Article] [PubMed]
187.Cassart, M, Pettiaux, N, Gevenois, PA, Paiva, M, Estenne, M Effect of chronic hyperinflation on diaphragm length and surface area.. Am J Respir Crit Care Med. (1997). 156 504–8 [Article] [PubMed]×
188.McKenzie, DK, Gorman, RB, Tolman, J, Pride, NB, Gandevia, SC Estimation of diaphragm length in patients with severe chronic obstructive pulmonary disease.. Respir Physiol. (2000). 123 225–34 [Article] [PubMed]
188.McKenzie, DK, Gorman, RB, Tolman, J, Pride, NB, Gandevia, SC Estimation of diaphragm length in patients with severe chronic obstructive pulmonary disease.. Respir Physiol. (2000). 123 225–34 [Article] [PubMed]×
189.Zocchi, L, Garzaniti, N, Newman, S, Macklem, PT Effect of hyperinflation and equalization of abdominal pressure on diaphragmatic action.. J Appl Physiol. (1987). 62 1655–64 [Article] [PubMed]
189.Zocchi, L, Garzaniti, N, Newman, S, Macklem, PT Effect of hyperinflation and equalization of abdominal pressure on diaphragmatic action.. J Appl Physiol. (1987). 62 1655–64 [Article] [PubMed]×
190.Brancatisano, A, Engel, LA, Loring, SH Lung volume and effectiveness of inspiratory muscles.. J Appl Physiol. (1993). 74 688–94 [PubMed]
190.Brancatisano, A, Engel, LA, Loring, SH Lung volume and effectiveness of inspiratory muscles.. J Appl Physiol. (1993). 74 688–94 [PubMed]×
191.Sheer, AJ, Heckman, JE, Schneider, EB, Wu, AW, Segal, JB, Feinberg, R, Lidor, AO Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.. Dis Colon Rectum. (2011). 54 1430–7 [Article] [PubMed]
191.Sheer, AJ, Heckman, JE, Schneider, EB, Wu, AW, Segal, JB, Feinberg, R, Lidor, AO Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.. Dis Colon Rectum. (2011). 54 1430–7 [Article] [PubMed]×
192.Hawn, MT, Houston, TK, Campagna, EJ, Graham, LA, Singh, J, Bishop, M, Henderson, WG The attributable risk of smoking on surgical complications.. Ann Surg. (2011). 254 914–20 [Article] [PubMed]
192.Hawn, MT, Houston, TK, Campagna, EJ, Graham, LA, Singh, J, Bishop, M, Henderson, WG The attributable risk of smoking on surgical complications.. Ann Surg. (2011). 254 914–20 [Article] [PubMed]×
193.Wilkes, AR, Hall, JE, Wright, E, Grundler, S The effect of humidification and smoking habit on the incidence of adverse airway events during deepening of anaesthesia with desflurane.. Anaesthesia. (2000). 55 685–9 [Article] [PubMed]
193.Wilkes, AR, Hall, JE, Wright, E, Grundler, S The effect of humidification and smoking habit on the incidence of adverse airway events during deepening of anaesthesia with desflurane.. Anaesthesia. (2000). 55 685–9 [Article] [PubMed]×
194.Konrad, FX, Schreiber, T, Brecht-Kraus, D, Georgieff, M Bronchial mucus transport in chronic smokers and nonsmokers during general anesthesia.. J Clin Anesth. (1993). 5 375–80 [Article] [PubMed]
194.Konrad, FX, Schreiber, T, Brecht-Kraus, D, Georgieff, M Bronchial mucus transport in chronic smokers and nonsmokers during general anesthesia.. J Clin Anesth. (1993). 5 375–80 [Article] [PubMed]×
195.Kotani, N, Hashimoto, H, Sessler, DI, Yoshida, H, Kimura, N, Okawa, H, Muraoka, M, Matsuki, A Smoking decreases alveolar macrophage function during anesthesia and surgery.. Anesthesiology. (2000). 92 1268–77 [Article] [PubMed]
195.Kotani, N, Hashimoto, H, Sessler, DI, Yoshida, H, Kimura, N, Okawa, H, Muraoka, M, Matsuki, A Smoking decreases alveolar macrophage function during anesthesia and surgery.. Anesthesiology. (2000). 92 1268–77 [Article] [PubMed]×
196.Maestrelli, P, Saetta, M, Mapp, CE, Fabbri, LM Remodeling in response to infection and injury. Airway inflammation and hypersecretion of mucus in smoking subjects with chronic obstructive pulmonary disease.. Am J Respir Crit Care Med. (2001). 164 S76–80 [Article] [PubMed]
196.Maestrelli, P, Saetta, M, Mapp, CE, Fabbri, LM Remodeling in response to infection and injury. Airway inflammation and hypersecretion of mucus in smoking subjects with chronic obstructive pulmonary disease.. Am J Respir Crit Care Med. (2001). 164 S76–80 [Article] [PubMed]×
197.Squadrone, V, Coha, M, Cerutti, E, Schellino, MM, Biolino, P, Occella, P, Belloni, G, Vilianis, G, Fiore, G, Cavallo, F, Ranieri, VM Piedmont Intensive Care Units Network (PICUN), Continuous positive airway pressure for treatment of postoperative hypoxemia: A randomized controlled trial.. JAMA. (2005). 293 589–95 [Article] [PubMed]
197.Squadrone, V, Coha, M, Cerutti, E, Schellino, MM, Biolino, P, Occella, P, Belloni, G, Vilianis, G, Fiore, G, Cavallo, F, Ranieri, VM Piedmont Intensive Care Units Network (PICUN), Continuous positive airway pressure for treatment of postoperative hypoxemia: A randomized controlled trial.. JAMA. (2005). 293 589–95 [Article] [PubMed]×
198.Ramachandran, SK, Nafiu, OO, Ghaferi, A, Tremper, KK, Shanks, A, Kheterpal, S Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery.. Anesthesiology. (2011). 115 44–53 [Article] [PubMed]
198.Ramachandran, SK, Nafiu, OO, Ghaferi, A, Tremper, KK, Shanks, A, Kheterpal, S Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery.. Anesthesiology. (2011). 115 44–53 [Article] [PubMed]×
199.Ohtani, H, Tamamori, Y, Noguchi, K, Azuma, T, Fujimoto, S, Oba, H, Aoki, T, Minami, M, Hirakawa, K Meta-analysis of laparoscopy-assisted and open distal gastrectomy for gastric cancer.. J Surg Res. (2011). 171 479–85 [Article] [PubMed]
199.Ohtani, H, Tamamori, Y, Noguchi, K, Azuma, T, Fujimoto, S, Oba, H, Aoki, T, Minami, M, Hirakawa, K Meta-analysis of laparoscopy-assisted and open distal gastrectomy for gastric cancer.. J Surg Res. (2011). 171 479–85 [Article] [PubMed]×
200.Wisner, DH A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: Effect of epidural analgesia.. J Trauma. (1990). 30 799–804; discussion 804–5 [Article] [PubMed]
200.Wisner, DH A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: Effect of epidural analgesia.. J Trauma. (1990). 30 799–804; discussion 804–5 [Article] [PubMed]×
201.Wu, CL, Cohen, SR, Richman, JM, Rowlingson, AJ, Courpas, GE, Cheung, K, Lin, EE, Liu, SS Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: A meta-analysis.. Anesthesiology. (2005). 103 1079–88; quiz 1109–10 [Article] [PubMed]
201.Wu, CL, Cohen, SR, Richman, JM, Rowlingson, AJ, Courpas, GE, Cheung, K, Lin, EE, Liu, SS Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: A meta-analysis.. Anesthesiology. (2005). 103 1079–88; quiz 1109–10 [Article] [PubMed]×
202.Pansard, JL, Mankikian, B, Bertrand, M, Kieffer, E, Clergue, F, Viars, P Effects of thoracic extradural block on diaphragmatic electrical activity and contractility after upper abdominal surgery.. Anesthesiology. (1993). 78 63–71 [Article] [PubMed]
202.Pansard, JL, Mankikian, B, Bertrand, M, Kieffer, E, Clergue, F, Viars, P Effects of thoracic extradural block on diaphragmatic electrical activity and contractility after upper abdominal surgery.. Anesthesiology. (1993). 78 63–71 [Article] [PubMed]×
203.Warner, DO, Warner, MA, Ritman, EL Human chest wall function during epidural anesthesia.. Anesthesiology. (1996). 85 761–73 [Article] [PubMed]
203.Warner, DO, Warner, MA, Ritman, EL Human chest wall function during epidural anesthesia.. Anesthesiology. (1996). 85 761–73 [Article] [PubMed]×
204.Ballantyne, JC, Carr, DB, deFerranti, S, Suarez, T, Lau, J, Chalmers, TC, Angelillo, IF, Mosteller, F The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials.. Anesth Analg. (1998). 86 598–612 [PubMed]
204.Ballantyne, JC, Carr, DB, deFerranti, S, Suarez, T, Lau, J, Chalmers, TC, Angelillo, IF, Mosteller, F The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials.. Anesth Analg. (1998). 86 598–612 [PubMed]×
205.Bhatnagar, A, Mayberry, J, Nirula, R Rib fracture fixation for flail chest: What is the benefit?. J Am Coll Surg. (2012). 215 201–5 [Article] [PubMed]
205.Bhatnagar, A, Mayberry, J, Nirula, R Rib fracture fixation for flail chest: What is the benefit?. J Am Coll Surg. (2012). 215 201–5 [Article] [PubMed]×
206.Ranieri, VM, Brienza, N, Santostasi, S, Puntillo, F, Mascia, L, Vitale, N, Giuliani, R, Memeo, V, Bruno, F, Fiore, T, Brienza, A, Slutsky, AS Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: Role of abdominal distension.. Am J Respir Crit Care Med. (1997). 156 1082–91 [Article] [PubMed]
206.Ranieri, VM, Brienza, N, Santostasi, S, Puntillo, F, Mascia, L, Vitale, N, Giuliani, R, Memeo, V, Bruno, F, Fiore, T, Brienza, A, Slutsky, AS Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: Role of abdominal distension.. Am J Respir Crit Care Med. (1997). 156 1082–91 [Article] [PubMed]×
207.Cheatham, ML, Malbrain, ML, Kirkpatrick, A, Sugrue, M, Parr, M, De Waele, J, Balogh, Z, Leppäniemi, A, Olvera, C, Ivatury, R, D’Amours, S, Wendon, J, Hillman, K, Wilmer, A Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations.. Intensive Care Med. (2007). 33 951–62 [Article] [PubMed]
207.Cheatham, ML, Malbrain, ML, Kirkpatrick, A, Sugrue, M, Parr, M, De Waele, J, Balogh, Z, Leppäniemi, A, Olvera, C, Ivatury, R, D’Amours, S, Wendon, J, Hillman, K, Wilmer, A Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations.. Intensive Care Med. (2007). 33 951–62 [Article] [PubMed]×
208.Lightowler, JV, Wedzicha, JA, Elliott, MW, Ram, FS Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis.. BMJ. (2003). 326 185 [Article] [PubMed]
208.Lightowler, JV, Wedzicha, JA, Elliott, MW, Ram, FS Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis.. BMJ. (2003). 326 185 [Article] [PubMed]×
209.Woods, BD, Sladen, RN Perioperative considerations for the patient with asthma and bronchospasm.. Br J Anaesth. (2009). 103 i57–65 [Article] [PubMed]
209.Woods, BD, Sladen, RN Perioperative considerations for the patient with asthma and bronchospasm.. Br J Anaesth. (2009). 103 i57–65 [Article] [PubMed]×
210.Kumar, A, Roberts, D, Wood, KE, Light, B, Parrillo, JE, Sharma, S, Suppes, R, Feinstein, D, Zanotti, S, Taiberg, L, Gurka, D, Kumar, A, Cheang, M Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.. Crit Care Med. (2006). 34 1589–96 [Article] [PubMed]
210.Kumar, A, Roberts, D, Wood, KE, Light, B, Parrillo, JE, Sharma, S, Suppes, R, Feinstein, D, Zanotti, S, Taiberg, L, Gurka, D, Kumar, A, Cheang, M Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.. Crit Care Med. (2006). 34 1589–96 [Article] [PubMed]×
211.Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.. Anesthesiology. (2004). 100 1573–81 [Article] [PubMed]
211.Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.. Anesthesiology. (2004). 100 1573–81 [Article] [PubMed]×
212.Ahmad, S, Nagle, A, McCarthy, RJ, Fitzgerald, PC, Sullivan, JT, Prystowsky, J Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery.. Anesth Analg. (2008). 107 138–43 [Article] [PubMed]
212.Ahmad, S, Nagle, A, McCarthy, RJ, Fitzgerald, PC, Sullivan, JT, Prystowsky, J Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery.. Anesth Analg. (2008). 107 138–43 [Article] [PubMed]×
213.Jaber, S, Delay, JM, Chanques, G, Sebbane, M, Jacquet, E, Souche, B, Perrigault, PF, Eledjam, JJ Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation.. Chest. (2005). 128 2688–95 [Article] [PubMed]
213.Jaber, S, Delay, JM, Chanques, G, Sebbane, M, Jacquet, E, Souche, B, Perrigault, PF, Eledjam, JJ Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation.. Chest. (2005). 128 2688–95 [Article] [PubMed]×
214.Marini, JJ Unproven clinical evidence in mechanical ventilation.. Curr Opin Crit Care. (2012). 18 1–7 [Article] [PubMed]
214.Marini, JJ Unproven clinical evidence in mechanical ventilation.. Curr Opin Crit Care. (2012). 18 1–7 [Article] [PubMed]×
215.Chiumello, D, Carlesso, E, Cadringher, P, Caironi, P, Valenza, F, Polli, F, Tallarini, F, Cozzi, P, Cressoni, M, Colombo, A, Marini, JJ, Gattinoni, L Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome.. Am J Respir Crit Care Med. (2008). 178 346–55 [Article] [PubMed]
215.Chiumello, D, Carlesso, E, Cadringher, P, Caironi, P, Valenza, F, Polli, F, Tallarini, F, Cozzi, P, Cressoni, M, Colombo, A, Marini, JJ, Gattinoni, L Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome.. Am J Respir Crit Care Med. (2008). 178 346–55 [Article] [PubMed]×
216.Papazian, L, Forel, JM, Gacouin, A, Penot-Ragon, C, Perrin, G, Loundou, A, Jaber, S, Arnal, JM, Perez, D, Seghboyan, JM, Constantin, JM, Courant, P, Lefrant, JY, Guérin, C, Prat, G, Morange, S, Roch, A ACURASYS Study Investigators, Neuromuscular blockers in early acute respiratory distress syndrome.. N Engl J Med. (2010). 363 1107–16 [Article] [PubMed]
216.Papazian, L, Forel, JM, Gacouin, A, Penot-Ragon, C, Perrin, G, Loundou, A, Jaber, S, Arnal, JM, Perez, D, Seghboyan, JM, Constantin, JM, Courant, P, Lefrant, JY, Guérin, C, Prat, G, Morange, S, Roch, A ACURASYS Study Investigators, Neuromuscular blockers in early acute respiratory distress syndrome.. N Engl J Med. (2010). 363 1107–16 [Article] [PubMed]×
217.Yoshida, T, Uchiyama, A, Matsuura, N, Mashimo, T, Fujino, Y Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: High transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury.. Crit Care Med. (2012). 40 1578–85 [Article] [PubMed]
217.Yoshida, T, Uchiyama, A, Matsuura, N, Mashimo, T, Fujino, Y Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: High transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury.. Crit Care Med. (2012). 40 1578–85 [Article] [PubMed]×
218.Murray, MJ, Cowen, J, DeBlock, H, Erstad, B, Gray, AWJr, Tescher, AN, McGee, WT, Prielipp, RC, Susla, G, Jacobi, J, Nasraway, SAJr, Lumb, PD Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians, Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.. Crit Care Med. (2002). 30 142–56 [Article] [PubMed]
218.Murray, MJ, Cowen, J, DeBlock, H, Erstad, B, Gray, AWJr, Tescher, AN, McGee, WT, Prielipp, RC, Susla, G, Jacobi, J, Nasraway, SAJr, Lumb, PD Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians, Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.. Crit Care Med. (2002). 30 142–56 [Article] [PubMed]×
219.Sassoon, CS, Zhu, E, Caiozzo, VJ Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction.. Am J Respir Crit Care Med. (2004). 170 626–32 [Article] [PubMed]
219.Sassoon, CS, Zhu, E, Caiozzo, VJ Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction.. Am J Respir Crit Care Med. (2004). 170 626–32 [Article] [PubMed]×
220.Gayan-Ramirez, G, Testelmans, D, Maes, K, Rácz, GZ, Cadot, P, Zádor, E, Wuytack, F, Decramer, M Intermittent spontaneous breathing protects the rat diaphragm from mechanical ventilation effects.. Crit Care Med. (2005). 33 2804–9 [Article] [PubMed]
220.Gayan-Ramirez, G, Testelmans, D, Maes, K, Rácz, GZ, Cadot, P, Zádor, E, Wuytack, F, Decramer, M Intermittent spontaneous breathing protects the rat diaphragm from mechanical ventilation effects.. Crit Care Med. (2005). 33 2804–9 [Article] [PubMed]×
221.Hudson, MB, Smuder, AJ, Nelson, WB, Bruells, CS, Levine, S, Powers, SK Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy.. Crit Care Med. (2012). 40 1254–60 [Article] [PubMed]
221.Hudson, MB, Smuder, AJ, Nelson, WB, Bruells, CS, Levine, S, Powers, SK Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy.. Crit Care Med. (2012). 40 1254–60 [Article] [PubMed]×
222.Wrigge, H, Zinserling, J, Neumann, P, Muders, T, Magnusson, A, Putensen, C, Hedenstierna, G Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: A randomized controlled computed tomography trial.. Crit Care. (2005). 9 R780–9 [Article] [PubMed]
222.Wrigge, H, Zinserling, J, Neumann, P, Muders, T, Magnusson, A, Putensen, C, Hedenstierna, G Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: A randomized controlled computed tomography trial.. Crit Care. (2005). 9 R780–9 [Article] [PubMed]×
223.Putensen, C, Mutz, NJ, Putensen-Himmer, G, Zinserling, J Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome.. Am J Respir Crit Care Med. (1999). 159 1241–8 [Article] [PubMed]
223.Putensen, C, Mutz, NJ, Putensen-Himmer, G, Zinserling, J Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome.. Am J Respir Crit Care Med. (1999). 159 1241–8 [Article] [PubMed]×
224.Kress, JP, Pohlman, AS, O’Connor, MF, Hall, JB Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.. N Engl J Med. (2000). 342 1471–7 [Article] [PubMed]
224.Kress, JP, Pohlman, AS, O’Connor, MF, Hall, JB Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.. N Engl J Med. (2000). 342 1471–7 [Article] [PubMed]×
225.Liu, SS, Wu, CL Effect of postoperative analgesia on major postoperative complications: A systematic update of the evidence.. Anesth Analg. (2007). 104 689–702 [Article] [PubMed]
225.Liu, SS, Wu, CL Effect of postoperative analgesia on major postoperative complications: A systematic update of the evidence.. Anesth Analg. (2007). 104 689–702 [Article] [PubMed]×
226.Hellström, A, Willman, A Promoting sleep by nursing interventions in health care settings: A systematic review.. Worldviews Evid Based Nurs. (2011). 8 128–42 [Article] [PubMed]
226.Hellström, A, Willman, A Promoting sleep by nursing interventions in health care settings: A systematic review.. Worldviews Evid Based Nurs. (2011). 8 128–42 [Article] [PubMed]×
227.Leray, V, Bourdin, G, Flandreau, G, Bayle, F, Wallet, F, Richard, JC, Guérin, C A case of pneumomediastinum in a patient with acute respiratory distress syndrome on pressure support ventilation.. Respir Care. (2010). 55 770–3 [PubMed]
227.Leray, V, Bourdin, G, Flandreau, G, Bayle, F, Wallet, F, Richard, JC, Guérin, C A case of pneumomediastinum in a patient with acute respiratory distress syndrome on pressure support ventilation.. Respir Care. (2010). 55 770–3 [PubMed]×
228.Lagneau, F, D’honneur, G, Plaud, B, Mantz, J, Gillart, T, Duvaldestin, P, Marty, J, Clyti, N, Pourriat, JL A comparison of two depths of prolonged neuromuscular blockade induced by cisatracurium in mechanically ventilated critically ill patients.. Intensive Care Med. (2002). 28 1735–41 [Article] [PubMed]
228.Lagneau, F, D’honneur, G, Plaud, B, Mantz, J, Gillart, T, Duvaldestin, P, Marty, J, Clyti, N, Pourriat, JL A comparison of two depths of prolonged neuromuscular blockade induced by cisatracurium in mechanically ventilated critically ill patients.. Intensive Care Med. (2002). 28 1735–41 [Article] [PubMed]×
Fig. 1.
Perioperative relationship of upper airway patency and respiratory pump activation. (A) Schematic of the respiratory system under normal physiology. Upper airway dilator muscles counterbalance the collapsing forces imposed on the upper airway by extra-luminal pressures and negative inspiratory pressure generated by the respiratory pump muscles. The green balloon (labeled “dilating forces”) represents the forces generated by the upper airway dilator muscles which resist the anatomic and physiologic forces promoting collapse of the upper airway (represented by the orange counterweight labeled “collapsing forces”). (B) Respiratory system in the perioperative period. The “needle” represents the multitude of iatrogenic factors listed in the nearby orange box that can cause upper airway dilator muscle dysfunction. The lowest orange counterweight represents perioperative factors leading to increased respiratory pump muscle contractions. In the perioperative period, a patient’s physiology and anatomy are affected so that upper airway dilating forces are diminished and can no longer create enough force to resist the increased collapsing forces, thus leading to upper airway collapse. PORC = postoperative residual curarization.
Image Not Available
Fig. 1.
Perioperative relationship of upper airway patency and respiratory pump activation. (A) Schematic of the respiratory system under normal physiology. Upper airway dilator muscles counterbalance the collapsing forces imposed on the upper airway by extra-luminal pressures and negative inspiratory pressure generated by the respiratory pump muscles. The green balloon (labeled “dilating forces”) represents the forces generated by the upper airway dilator muscles which resist the anatomic and physiologic forces promoting collapse of the upper airway (represented by the orange counterweight labeled “collapsing forces”). (B) Respiratory system in the perioperative period. The “needle” represents the multitude of iatrogenic factors listed in the nearby orange box that can cause upper airway dilator muscle dysfunction. The lowest orange counterweight represents perioperative factors leading to increased respiratory pump muscle contractions. In the perioperative period, a patient’s physiology and anatomy are affected so that upper airway dilating forces are diminished and can no longer create enough force to resist the increased collapsing forces, thus leading to upper airway collapse. PORC = postoperative residual curarization.
×
Fig. 2.
Pathophysiology of postoperative respiratory failure emphasizing respiratory muscle dysfunction. Perioperative respiratory muscle dysfunction results from a multitude of factors, including preoperative comorbidities and perioperative interventions, each individually affecting upper airway dilator muscles, respiratory pump muscles, or both. Whereas a single factor rarely translates into respiratory failure, a combination of factors can cause pulmonary complications leading to respiratory failure. In the setting of respiratory failure requiring mechanical ventilation, ventilator-induced diaphragmatic dysfunction (VIDD) further compounds respiratory pump muscle dysfunction and contributes to increased morbidity and mortality. OSA = obstructive sleep apnea.
Image Not Available
Fig. 2.
Pathophysiology of postoperative respiratory failure emphasizing respiratory muscle dysfunction. Perioperative respiratory muscle dysfunction results from a multitude of factors, including preoperative comorbidities and perioperative interventions, each individually affecting upper airway dilator muscles, respiratory pump muscles, or both. Whereas a single factor rarely translates into respiratory failure, a combination of factors can cause pulmonary complications leading to respiratory failure. In the setting of respiratory failure requiring mechanical ventilation, ventilator-induced diaphragmatic dysfunction (VIDD) further compounds respiratory pump muscle dysfunction and contributes to increased morbidity and mortality. OSA = obstructive sleep apnea.
×
Fig. 3.
Effects of respiratory arousal on upper airway dilator and respiratory pump muscles. Respiratory arousal is composed of three primary inputs: central respiratory pattern generator processing peripheral and central chemoreceptor afferents, reflex responsiveness to the magnitude of negative pressure in the airway generated by the respiratory pump muscles, and strength of the “wakefulness” drive. Inhibitory modulators are shown: anesthetics, opioids, and impaired consciousness of endogenous etiology. Blue arrows: excitatory; Red arrows: inhibitory; MNs = motor neurons.
Image Not Available
Fig. 3.
Effects of respiratory arousal on upper airway dilator and respiratory pump muscles. Respiratory arousal is composed of three primary inputs: central respiratory pattern generator processing peripheral and central chemoreceptor afferents, reflex responsiveness to the magnitude of negative pressure in the airway generated by the respiratory pump muscles, and strength of the “wakefulness” drive. Inhibitory modulators are shown: anesthetics, opioids, and impaired consciousness of endogenous etiology. Blue arrows: excitatory; Red arrows: inhibitory; MNs = motor neurons.
×
Fig. 4.
Representative polysomnography recordings of an obese patient before and immediately after bariatric surgery. Respiratory recordings obtained through polysomnography in an obese patient. The first frame shows severe desaturations during sleep at patient’s baseline prior to surgery resulting from a combination of obstructive and central events. In the second frame, immediately following surgery, patient was placed on 30% oxygen in the postanesthesia care unit and continues to have sleep-disordered breathing with mostly central apneas and desaturations. In the third block, again, immediately following surgery, patient was placed on 30% oxygen with continuous positive airway pressure (CPAP) at 10 cm H2O and there were no more apnea or desaturation events. Flow = respiratory flow; Thorax = thoracic respiratory effort; Abdomen = abdominal respiratory effort; Sum = respiratory effort of thorax and abdomen; SpO2 = oxygen saturation; N1 = non-rapid eye movement (REM) sleep stage 1; red bar indicates obstructive apnea; blue bar indicates mixed apnea; pink bar indicates obstructive hypopnea; gray bar indicates desaturation; PACU = postanesthesia care unit.
Image Not Available
Fig. 4.
Representative polysomnography recordings of an obese patient before and immediately after bariatric surgery. Respiratory recordings obtained through polysomnography in an obese patient. The first frame shows severe desaturations during sleep at patient’s baseline prior to surgery resulting from a combination of obstructive and central events. In the second frame, immediately following surgery, patient was placed on 30% oxygen in the postanesthesia care unit and continues to have sleep-disordered breathing with mostly central apneas and desaturations. In the third block, again, immediately following surgery, patient was placed on 30% oxygen with continuous positive airway pressure (CPAP) at 10 cm H2O and there were no more apnea or desaturation events. Flow = respiratory flow; Thorax = thoracic respiratory effort; Abdomen = abdominal respiratory effort; Sum = respiratory effort of thorax and abdomen; SpO2 = oxygen saturation; N1 = non-rapid eye movement (REM) sleep stage 1; red bar indicates obstructive apnea; blue bar indicates mixed apnea; pink bar indicates obstructive hypopnea; gray bar indicates desaturation; PACU = postanesthesia care unit.
×
Fig. 5.
Effects of respiratory pump muscle activity on the outcome of critically ill patients requiring mechanical ventilation. Acute respiratory distress syndrome (ARDS) typically is associated with an increased work of breathing due to poor respiratory system compliance and systemic inflammation. The associated increases in transpulmonary pressures (PL) may be sufficient to induce lung injury. Lung protective ventilation with low tidal volume is the standard of care in patients with ARDS. Temporary pharmacologic immobilization (opioids, sedatives, anesthetics, and rarely neuromuscular blocking agents) may be required to reduce or abolish breathing efforts, but even short-term (48 h) immobilization can lead to muscle atrophy. Thus, both muscle immobilization and excessive activation can lead to increased morbidity and mortality. The pulmonary health of the patient depends on seeking a fine balance between immobilization and activation.
Image Not Available
Fig. 5.
Effects of respiratory pump muscle activity on the outcome of critically ill patients requiring mechanical ventilation. Acute respiratory distress syndrome (ARDS) typically is associated with an increased work of breathing due to poor respiratory system compliance and systemic inflammation. The associated increases in transpulmonary pressures (PL) may be sufficient to induce lung injury. Lung protective ventilation with low tidal volume is the standard of care in patients with ARDS. Temporary pharmacologic immobilization (opioids, sedatives, anesthetics, and rarely neuromuscular blocking agents) may be required to reduce or abolish breathing efforts, but even short-term (48 h) immobilization can lead to muscle atrophy. Thus, both muscle immobilization and excessive activation can lead to increased morbidity and mortality. The pulmonary health of the patient depends on seeking a fine balance between immobilization and activation.
×
Table 1.
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure×
Image Not Available
Table 1.
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure
Avoiding Respiratory Muscle-related Postoperative Respiratory Failure×
×