parcka parleys - university of utah
TRANSCRIPT
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Opioid-Induced Respiratory Failure (OIRD) Are There Early Warning Signs
Robert J Farney MDClinical Professor of Medicine
University of Utah School of Medicine
robertjfarneygmailcom
Parcka Parleys18 Aug 2020
Drug Overdose Deaths in the United States 1999-2016 H Hedegaard NCHS Data Brief No 294 December 2017
Fentanyl
OxycodoneHydrocodoneHydromorphone
Main Teaching Points1 Opioids suppress all aspects of respiration including drive
(RR and VT) and pattern
2 Respiratory effects occur mainly during sleep or non-awake states
3 Sub-population with enhanced sensitivity and without known risk factors
4 Quantified ataxic breathing patterns can aid early recognition of opioid induced respiratory depression (OIRD)
Sleep-disordered breathing in stable methadone programme patients a pilot study
H Teichtahl Addiction 200196395-403
5 minutes
35 year old female Chronic fatigue and poor sleepStaging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
6 AM5 AM4 AM3 AM2 AM1 AM12 AM11 PM
SaO2
90
100
70
Hydrocodone 2nd dose
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
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-
![Page 2: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/2.jpg)
Drug Overdose Deaths in the United States 1999-2016 H Hedegaard NCHS Data Brief No 294 December 2017
Fentanyl
OxycodoneHydrocodoneHydromorphone
Main Teaching Points1 Opioids suppress all aspects of respiration including drive
(RR and VT) and pattern
2 Respiratory effects occur mainly during sleep or non-awake states
3 Sub-population with enhanced sensitivity and without known risk factors
4 Quantified ataxic breathing patterns can aid early recognition of opioid induced respiratory depression (OIRD)
Sleep-disordered breathing in stable methadone programme patients a pilot study
H Teichtahl Addiction 200196395-403
5 minutes
35 year old female Chronic fatigue and poor sleepStaging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
6 AM5 AM4 AM3 AM2 AM1 AM12 AM11 PM
SaO2
90
100
70
Hydrocodone 2nd dose
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
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- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
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- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 3: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/3.jpg)
Main Teaching Points1 Opioids suppress all aspects of respiration including drive
(RR and VT) and pattern
2 Respiratory effects occur mainly during sleep or non-awake states
3 Sub-population with enhanced sensitivity and without known risk factors
4 Quantified ataxic breathing patterns can aid early recognition of opioid induced respiratory depression (OIRD)
Sleep-disordered breathing in stable methadone programme patients a pilot study
H Teichtahl Addiction 200196395-403
5 minutes
35 year old female Chronic fatigue and poor sleepStaging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
6 AM5 AM4 AM3 AM2 AM1 AM12 AM11 PM
SaO2
90
100
70
Hydrocodone 2nd dose
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
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- Slide Number 59
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- Slide Number 63
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- Slide Number 67
- Slide Number 68
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- Slide Number 70
-
![Page 4: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/4.jpg)
Sleep-disordered breathing in stable methadone programme patients a pilot study
H Teichtahl Addiction 200196395-403
5 minutes
35 year old female Chronic fatigue and poor sleepStaging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
6 AM5 AM4 AM3 AM2 AM1 AM12 AM11 PM
SaO2
90
100
70
Hydrocodone 2nd dose
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
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- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 5: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/5.jpg)
35 year old female Chronic fatigue and poor sleepStaging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
6 AM5 AM4 AM3 AM2 AM1 AM12 AM11 PM
SaO2
90
100
70
Hydrocodone 2nd dose
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 6: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/6.jpg)
Tracheal sound
Airflow
Thorax
Abdomen
Oximetry
600 seconds
Recurrent extremely prolonged obstructive ldquohypopneasrdquo only during NREM sleep
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
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- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
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- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 7: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/7.jpg)
Reversal of prolonged obstructive ldquohypopneardquo during NREM sleep
Airflow
Thorax
Abdomen
Oximetry
Inspiratory airflow flattening
60 seconds
Inspiratory airflow flattening
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
77 7679 89
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 8: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/8.jpg)
Oximetry
Abdomen
Thorax
Airflow
NREM SLEEP REM SLEEP
CPAP = 16 cm H2O
300 seconds
CENTRAL APNEAS during NREM sleep Unresponsive to nasal CPAP
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
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- Slide Number 24
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- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
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- Slide Number 40
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- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
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- Slide Number 55
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-
![Page 9: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/9.jpg)
Airflow
Thorax
Abdomen
Oximetry
Tracheal sound
300 secondsAtaxic breathing and severe hypoxia during NREM
Sleep-Disordered Breathing Associated with Long-term Opioid Therapy
RJ Farney Walker JM Cloward TV Rhondeau S Chest 2003123632-639
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
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- Slide Number 67
- Slide Number 68
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- Slide Number 70
-
![Page 10: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/10.jpg)
Camille Biot (19 Dec 1850)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 11: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/11.jpg)
Contribution a lrsquoegravetude de phegravenomegravenerespiratoire de Cheyne-Stokes
MC Biot Lyon Megraved 1876 23 517-528 561-567
ldquoBiotrsquosrdquo breathing in a 16 year old male with tuberculous meningitis
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
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- Slide Number 23
- Slide Number 24
- Slide Number 25
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- Slide Number 27
- Slide Number 28
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- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
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- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
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- Slide Number 50
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- Slide Number 55
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- Slide Number 70
-
![Page 12: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/12.jpg)
Opioid Non-Opioid pAtaxic Breathing 70 5 lt0001
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
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- Slide Number 63
- Slide Number 64
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- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 13: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/13.jpg)
32 yo female morphine dose equivalent 375 mg BMI 22 kgm2
32 yo female no opioids BMI 23 kgm2
120 seconds Stage 2 NREM
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 14: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/14.jpg)
Opioid Effects on RespirationPathophysiologic
Opioids can suppress all aspects of respiration Drive and Pattern
ClinicalCentral apneas
Obstructive apneasHypopneas
Ataxic breathing BradypneaHypoxemia
PhysiologicBreathing frequencyTidal Volume
and Pattern Chemoresponsiveness to CO2 and O2
Upper airway patencyChest amp abdominal wall compliance
Arousal response
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
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- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 15: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/15.jpg)
All commercially available narcotics are μ-opioid receptor agonists and reduce neuronal activity of
both pain and respiratory neurons
Mu-opioid receptors are widely distributed throughout the central and peripheral nervous systems
cortex brain stem and carotid body
Opioid Effects on RespirationPhysiologic
Key targets preBoumltzinger complex in ventral-lateral medulla amp Koumllliker-Fuse pontine neurons
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
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- Slide Number 17
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- Slide Number 19
- Slide Number 20
- Slide Number 21
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- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
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- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
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- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
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- Slide Number 54
- Slide Number 55
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-
![Page 16: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/16.jpg)
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Holy Grail
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 17: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/17.jpg)
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
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- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
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- Slide Number 40
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- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
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- Slide Number 49
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- Slide Number 54
- Slide Number 55
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-
![Page 18: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/18.jpg)
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 19: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/19.jpg)
Normal breathing requires preBoumltzinger complex neurokinin-1 receptor-expressing neurons
PA Gray Nat Neurosci 20014(9)927-930
1 Rats with bilateral but not unilateral destruction of NK1R neurons developed severe ataxic breathing pattern 4-5 days after injection
2 Ataxic patterns characterized by shortened respiratory periods and an irregular sequence of inspiratory efforts of near normal amplitude interspersed with prolonged apneas or very low amplitude inspiration
3 Arterial blood gas profile showed respiratory depression pH 726 PaCO2 56 mmHg and PaO2 77 mmHg
4 Compared to control rats that showed increased respiratory rate and increased inspiratory amplitude for gt 15 minutes to severe hypoxia (44 O2956 N2) injected rats developed apneas of increasing and eventually fatal duration
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 20: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/20.jpg)
High RR
Low RR
Sleep Awake
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
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- Slide Number 46
- Slide Number 47
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- Slide Number 49
- Slide Number 50
- Slide Number 51
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- Slide Number 54
- Slide Number 55
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- Slide Number 57
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- Slide Number 59
- Slide Number 60
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-
![Page 21: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/21.jpg)
PreBoumltzinger Complex Neurokinin-1REceptor-Expressing Neurons Mediate Opioid-Induced Respiratory Depression
G Montandon J of Neuroscience 201131(4)1292-1301
Opioids at the PreBoumltzinger complex depress breathing and cause persistent apnea
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 22: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/22.jpg)
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 23: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/23.jpg)
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 24: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/24.jpg)
Definition of Opioid Induced Respiratory DepressionPrimary Clinical Measurements
1Respiratory Rate (lt 8-10 bpm)
2Oximetry (SpO2 lt 90-92)
3End-Tidal CO2 (ETCO2 gt 50 mmHg)
4Mental Status (Sedated)
How do you assess these parameters in a sleeping patient on oxygen
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 25: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/25.jpg)
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 26: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/26.jpg)
Why is the Respiratory Rate unreliable for detection opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 27: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/27.jpg)
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 10min
4 minutes
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 28: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/28.jpg)
PTAF
Thermistor
Thorax
Abdomen
Oximetry
Severe Ataxic Breathing Pattern Secondary to Opioids
60 seconds
RR = 7min
4 minutes
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 29: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/29.jpg)
Why is the Respiratory Rate unreliable for detection of opioid induced respiratory depression
1 RR obtained by physical examination is notoriously inaccurate (eg poor technique patient arousal)
2 Most technologies are not validated for detecting slow respiratory rates
3 Automated methods are insensitive to respiratory patterns (eg apneas) resulting in inaccurate RR
4 RR does not equate to adequate ventilation
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 30: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/30.jpg)
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 31: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/31.jpg)
Opioids suppress multiple components of respiration that can be measured and respiratory depression probably precedes acute cardiorespiratory arrest
So what are the problems What could possibly go wrong
1 How should we monitor patients2 How should respiratory depression be defined3 Does any measurement or set of observations predict
the onset of respiratory depression4 Are there warning signs that actually predict
cardiorespiratory arrest
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 32: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/32.jpg)
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
41 year old female (BMI 367 kgm2) underwent right hip arthroplasty
Post-Operative Day 30800 Alert 010 pain
1100 Asleep but easily arousable 010 pain
Epidural bupivacaine and fentanyl continued
1200 Found unresponsive ldquoKussmall respirationrdquoRR 18minRapid breathing (RR 20-30 breaths)Apnea (20-40 seconds)
Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 33: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/33.jpg)
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
66 year old male (BMI 363 kgm2) underwent right hip arthroplasty
Post-Operative Day 20900 AlertOriented RR 20min
Oxygen discontinued
1345 Oximetry on room air SpO2 86Nasal oxygen resumed SpO2 98
Post-Operative Day 30630 ldquoChecked by Orthopedic servicerdquo
0700 Seen by nurses and orthopedic physiciansldquoHe was sleepingrdquo and not disturbedRR 14min HR 120min BP 10550 mmHg
0725 Found unresponsive Resuscitation efforts unsuccessful
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 34: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/34.jpg)
Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea
AM Ostermeier Anesth Analg 199785452-460
47 year old male (BMI 275 kgm2) underwent ventral hernia repair
Post-Operative Day 20600 ldquoSlight unimportant changes in vital signsrdquo since 1200 (MN)
ldquoNo painrdquoRR 14min BP 11050 HR 78 bpm
Continuous epidural bupivacaine and fentanyl without dose activation by the patient
0700 Found ldquobreathless with cool skin and cyanotic He was asystolic and advanced cardiac life support was givenrdquo
ldquoDied laterrdquo
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
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- Slide Number 48
- Slide Number 49
- Slide Number 50
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-
![Page 35: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/35.jpg)
Cardiopulmonary Arrest
Risk Factors + Opioids
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
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- Slide Number 59
- Slide Number 60
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- Slide Number 70
-
![Page 36: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/36.jpg)
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Cardiopulmonary Arrest
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 37: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/37.jpg)
Risk Factors + Opioids
Respiratory Depression
RRVT
Ataxia
Hypoxia
Hypoventilation
Hypercapnic acidosis
Cardiopulmonary Arrest
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
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- Slide Number 23
- Slide Number 24
- Slide Number 25
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- Slide Number 27
- Slide Number 28
- Slide Number 29
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- Slide Number 31
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- Slide Number 36
- Slide Number 37
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- Slide Number 49
- Slide Number 50
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- Slide Number 54
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-
![Page 38: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/38.jpg)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Severe Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
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- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
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- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
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- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
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- Slide Number 59
- Slide Number 60
- Slide Number 61
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- Slide Number 68
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- Slide Number 70
-
![Page 39: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/39.jpg)
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
Moderate Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
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![Page 40: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/40.jpg)
Airflow (Thermistor)
Airflow (PTAF)
Thorax
Abdomen
SpO2
300 s
Sleep disordered breathing in patients receiving therapy with buprenorphinenaloxone
RJ Farney Eur Respir J 2013 42394-403
Mild Sleep ApneaHypopnea with ataxia (Biotrsquos Respiration)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
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-
![Page 41: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/41.jpg)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
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- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 42: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/42.jpg)
Effect-site target controlled infusions of low dose Propofol and escalating doses of Remifentanil administered to 26 normal volunteers
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
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1 Stabilization
0 10 up to 20
2 Monitoring 4 Ventilation Prompting Protocol
30 35 36
5 Quiet 6 OAAS
Time (min)
Protocol at each target effect site concentration pair
Aim 1 Aim 2
Classify Airway Events
Randomized nurse or computer prompts first
Possible repeated computer prompts
3 OAAS BP
NIBP
If no airway events proceed to next drug step
7 RB
Change Drug
Drug Equal
1 Steady state drug reached2 Subject not talking or perturbed3 No intervention4 At least 30 breaths
Observer Assessment of Alertness Score (1-5)The quick brown fox jumps over the lazy dogSpeech Facial Expression Eyes
Take a deep breath
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
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- Slide Number 13
- Slide Number 14
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- Slide Number 23
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- Slide Number 28
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- Slide Number 31
- Slide Number 32
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![Page 44: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/44.jpg)
Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain
RJ Farney J Clin Sleep Med 20084(4)311-319
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
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- Slide Number 35
- Slide Number 36
- Slide Number 37
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- Slide Number 40
- Slide Number 41
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- Slide Number 43
- Slide Number 44
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- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
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- Slide Number 70
-
![Page 45: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/45.jpg)
Jules Henri Poincareacute29 Apr 1854 ndash 17 Jul 1912
Father of Chaos Theory
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 46: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/46.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 47: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/47.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560 560
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 48: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/48.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
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- Slide Number 40
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- Slide Number 43
- Slide Number 44
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- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
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- Slide Number 57
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0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
560
POINCAREacute PLOT OF RR INTERVALS
360
Acceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
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- Slide Number 14
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- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
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![Page 50: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/50.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
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- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 51: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/51.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
360 760
Deceleration
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 52: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/52.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 53: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/53.jpg)
0
100
200
300
400
500
600
700
800
900
1000
0 100 200 300 400 500 600 700 800 9001000RR-First (ms)
RR-Second (ms)
POINCAREacute PLOT OF RR INTERVALS
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 54: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/54.jpg)
Do Existing Measures of Poincaregrave Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 55: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/55.jpg)
Do Existing Measures of Poincareacute Plot Geometry Reflect Nonlinear Features of Heart Rate Variability
M Brennan IEEE Transactions on Biomedical Engineering 2001481342-1347
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 56: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/56.jpg)
Factor change in Tidal Volume
Interbreath Interval at t = i + 1 (sec)
Poincareacute Plot
Interbreath Interval at t = i (sec)
An automated algorithm incorporating Poincareacute analysis can quantify the severity of opioid-induced ataxic breathing
SC Ermer RJ Farney L M Brewer et al Anesthesia amp Analgesia In Press 2019
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 57: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/57.jpg)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 0
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 58: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/58.jpg)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 1
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 59: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/59.jpg)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 2
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 60: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/60.jpg)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 3
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 61: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/61.jpg)
1
15
25
3+
2
0 20 40 60
20
40
60
Factor change in Tidal Volume
Interbreath Interval at t = i (sec)
Poincareacute Plot
Ataxia Score 4
RIP Flow
Interbreath Interval at t = i + 1 (sec)
PTAF
Air Flow Waveform
Chest BlueAbdomen Red
(minutes)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 62: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/62.jpg)
Subject 23 gradually going off the cliff
OAAS 5OAAS 5 OAAS 5 OAAS 4OAAS 5 OAAS 5 OAAS 5 OAAS 4
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 63: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/63.jpg)
Subject 4 suddenly going off the cliff
OAAS 2 OAAS 4 OAAS 2 OAAS 4
OAAS 4OAAS 5
OAAS 2 OAAS 4 OAAS 2 OAAS 4 OAAS 4OAAS 5
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 64: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/64.jpg)
Fact
or c
hang
e in
Tid
al V
olum
e
Animated Poincareacute Plot of Progresssively Severe
Ataxic Breathing
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 65: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/65.jpg)
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min714
(N = 21)
239
48
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 66: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/66.jpg)
143 95
48 14348
333
48
143
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 8-10min
0 1 2 3 4
714
ATAXIA SCORE
(N = 21)
239
48
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 67: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/67.jpg)
2828 2883
28
222
114 56
278
2828
56
28
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 5-7min
0 1 2 3 4ATAXIA SCORE
(N = 36)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 68: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/68.jpg)
22 2 4 28 2
24 4
12 20 624
60
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate 0-4min
0 1 2 3 4ATAXIA SCORE
(N = 50)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Slide Number 37
- Slide Number 38
- Slide Number 39
- Slide Number 40
- Slide Number 41
- Slide Number 42
- Slide Number 43
- Slide Number 44
- Slide Number 45
- Slide Number 46
- Slide Number 47
- Slide Number 48
- Slide Number 49
- Slide Number 50
- Slide Number 51
- Slide Number 52
- Slide Number 53
- Slide Number 54
- Slide Number 55
- Slide Number 56
- Slide Number 57
- Slide Number 58
- Slide Number 59
- Slide Number 60
- Slide Number 61
- Slide Number 62
- Slide Number 63
- Slide Number 64
- Slide Number 65
- Slide Number 66
- Slide Number 67
- Slide Number 68
- Slide Number 69
- Slide Number 70
-
![Page 69: Parcka Parleys - University of Utah](https://reader031.vdocuments.mx/reader031/viewer/2022011903/61d674ff5d98765242698c97/html5/thumbnails/69.jpg)
21143
35771
143
71
0
10
20
30
40
50
60
70
OAAS 0 OAAS 1 OAAS 2 OAAS 3 OAAS 4 OAAS 5
Respiratory Rate gt 10min
0 1 2 3 4ATAXIA SCORE
(N = 14)
CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
- Slide Number 1
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
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CONCLUSIONS
1 Threshold values (ie RR SpO2 ETCO2) may be useful in defining the state of respiratory depression but evidence is lacking that any reliably predict cardiorespiratory arrest
2 Erratic breathing is an important physiologic consequence of opioid induced respiratory depression and can be quantified for clinical applications and further research
3 Patterns of erratic breathing could provide early evidence for impending life threatening critical respiratory events
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