Respiratory Toolkit

Avoiding respiratory complications addresses measures PUL 01, and all NMB measures (NMB 01-05)


The Avoiding Respiratory Complications Toolkit is designed to meet the following objectives:

  • Define post pulmonary complications (PPCs)
  • Review the incidence of pulmonary complications
  • Describe the impact of PPCs relative to anesthesia care
  • Neuromuscular blocade (NMB) administration considerations
  • Recommend lung protective ventilation strategies to reduce the incidence of pulmonary complication
  • Identify ASPIRE measures that support protective mechanical ventilation
  • Propose practical solutions to prevent pulmonary complications


  • ARC Presentation: PowerPoint presentation for site champions to introduce the interventions associated with preventing respiratory complications.
  • ARC Checklist: List of potential practice and documentation system changes that can be implemented at your site to assist anesthesia providers in successfully avoiding respiratory complications.
  • Ideal Body Weight / Tidal Volume Chart: For placement in Operating Rooms as a reference tool for anesthesia providers calculating tidal volumes
  • Neuromuscular Blockade: Summary of Recommendations 


Neuromuscular Blockade

  1. Thilen, Stephan R., Wade A. Weigel, Michael M. Todd, Richard P. Dutton, Cynthia A. Lien, Stuart A. Grant, Joseph W. Szokol, et al. 2023. “2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade.” Anesthesiology 138 (1): 13–41. doi:
    • Practice guidelines provide evidence-based recommendations for the management of neuromuscular monitoring and reversal medications during and after general anesthesia. Provides information for type of monitoring and recommended site of monitoring. Recommendation to use quantitative monitoring at the adductor pollicus and confirm TOF recovery >/= 0.9 prior to extubation.
  2. Renew JR, Hex K, Johnson P, Lovett P, Pence R. Ease of Application of Various Neuromuscular Devices for Routine Monitoring. Anesth Analg. 2021;132(5):1421-1428. doi:10.1213/ANE.0000000000005213
    • Comparative study to analyze the time to place three different devices: SunStim Plus PNS, acceleromyography-based IntelliVue NMT device, and electromyography-based TetraGraph device. Participants were timed and a Friedman test and pairwise Wilcoxon signed-rank tests were used to evaluate the difference in time to connect different devices. Study concluded that it takes 19 seconds longer to apply quantitative neuromuscular monitor than a PNS. The minimal additional time should not be seen as a barrier to the application of quantitative monitors.
  3. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to
    reduce the risk of residual weakness. Anesthesia and Analgesia. 2010;111(1):129-140.
    • Review article that examines optimal neuromuscular management strategies used by clinicians to
      reduce the risk of residual paralysis in the early postoperative period. Current evidence demonstrates
      that frequently utilized clinical tests of neuromuscular junction (head lift or hand grip) cannot reliably
      exclude presence of residual paralysis. Clinicians are often unable to detect fade when TOF ratios are
      between .6 and 1.0. Strong evidence that acceleromyography detects small degrees of residual
      blockade (TOF ratios > .6). Complete recovery of neuromuscular function is more likely when
      anticholinesterases are administered early (>15-20 mins before extubation) and at shallower depth of
      block (TOF count of 4). Selective neuromuscular reversal agents may provide clinicians with better tools
      for prevention of postoperative residual weakness.
  4. Fortier LP, McKeen D, Turner K, et al. The RECITE Study: A Canadian Prospective, Multicenter
    Study of the Incidence and Severity of Residual Neuromuscular Blockade. Anesthesia and analgesia.
    • A prospective observational study within 8 Canadian hospitals investigating the incidence of residual
      NMB (neuromuscular blockade). Primary objective of the RECITE (Residual Curarization and its
      Incidence of Tracheal Extubation) study was to investigate the incidence of postoperative residual NMB,
      defined as TOF ratio <0.9, at tracheal extubation. Secondary objective was to determine incidence of
      residual NMB upon arrival in PACU. 302 adult patients undergoing open or laparoscopic abdominal
      surgery lasting <4 hours, with ASA 1-3, scheduled for general anesthesia with at least one dose of NMB
      agents for tracheal intubation or maintenance of NMB were enrolled. Data were available for 241
      patients at tracheal extubation, and 207 patients at PACU arrival. Rocuronium was the NMB used in
      99% percent of cases, with remaining participants receiving cisatracurium. Patients intubated with
      succinylcholine received at least 1 dose of nondepolarizing agent, with neostigmine used for reversal.
      The incidence of residual NMB without reversal (TOF ratio < 0.9) was 63.5% at extubation and 56.5%
      upon arrival at PACU. Among patients receiving NMB reversal with neostigmine, residual paralysis was
      present in 64.6% at tracheal extubation and 59.7% at PACU arrival. Exploratory analysis showed use of
      qualitative peripheral neuromuscular monitoring was associated with significantly lower NMB at PACU
      arrival. The incidence of residual NMB both at tracheal extubation and PACU arrival was positively
      associated with significantly higher doses of rocuronium per minute of surgery. This article concluded
      that residual paralysis was common with use of NMB agents, even when monitoring and reversal was
      used. Better use of these agents and monitoring tools is needed.
      3. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes
  5. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM. Nondepolarizing
    Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia. Anesthesiology.
    • An observational study including 13,290 surgical cases involving patients receiving general anesthesia
      between July 2005 and September 2013 were extracted from Vanderbilt University Medical Center’s
      NSQIP database. Of the 13,100 eligible cases, 1,455 surgical cases receiving an intermediate-acting
      depolarizing NMBA were compared to 1,455 propensity score-matched cases not receiving NMBA.
      Additionally, 1,320 cases with NMBA and reversal with neostigmine were compared to 1,320 propensityscore matched cases without reversal. Cases were followed 30 days postoperatively. Two propensityscore-matched analyses was performed. Postoperative pneumonia IRRs (incidence rate ratios) and
      bootstrapped 95% CIs were calculated. Of the 1,455 surgical cases in the cohort receiving NMBA
      intraoperatively, 38 developed pneumonia. Of the surgical cases who did not receive NMBA, 22
      developed postoperative pneumonia. IRR was statistically significant. Of the 1,320 surgical cases who
      received an NMBA intraoperatively without reversal, 149 developed postoperative pneumonia. Of the
      surgical cases who received NMBA with neostigmine, 70 developed pneumonia within 30 days postop.
      Patients not reversed with acetylcholinesterase inhibitor were more than twice as likely to develop
      pneumonia postoperatively compared to those who received reversal with neostigmine. Intraoperative
      use of intermediate nondepolarizing NMBAs is associated with postoperative pneumonia. Among
      patients receiving NMBAs, non-reversal is associated with increased risk of postoperative pneumonia.
  6. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular
    blockade. Current opinion in anaesthesiology. 2014;27(6):616-622.
    • Literature review of neuromuscular monitoring and minimum specifications for the purpose of
      improving patient management. Adequate recovery of neuromuscular function has been defined as TOF
      of at least 0.9 measured at the adductor pollicis, monitoring with qualitative nerve stimulator facilitates
      actual TOF ratio. Peripheral nerve stimulators are not routinely used in clinical practice, suggesting
      dosing of NMBAs and anticholinesterases is inappropriate when recovery of neuromuscular function
      upon extubation cannot be guaranteed. Routine use of peripheral nerve stimulators allows rational
      administration of NMBAs.
  7. Abad-Gurumeta A, Ripolles-Melchor J, Casans-Frances R, et al. A systematic review of
    sugammadex vs neostigmine for reversal of neuromuscular blockade. Anaesthesia. 2015;70(12):1441-
    • Systematic review of Sugammadex versus Neostigmine for reversing neuromuscular blockade. 14 RCTs
      included 1,553 participants. Sugammadex reduced all signs of residual postoperative paralysis
      compared to neostigmine, confirming reliable relative risk reduction of at least 50%. Residual paralysis
      after administration of Neostigmine was 8.4 per 100 participants, whereas Sugammades reduced by 4.5
      per 100 to 3.9 per 100. Sugammadex reduced minor postoperative paralysis compared to neostigmine
      with a relative risk of at least 75%. Pooled rate of weakness post neostigmine was 9.4 per 100,
      compared to 4.7 out of 100 with Sugammadex. Sugammadex reduced drug-related side effects
      compared with Neostigmine, while rates of PONV were similar for Sugammadex and Neostigmine.
      Sugammadex reduced the number of patients with clinical signs of postoperative residual paralysis
      caused by Rocuronium as compared to Neostigmine.

Protective Lung Strategies

  1. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with
    lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute
    respiratory distress syndrome. The New England journal of medicine. 2000;342(18):1301-1308.
    • A multicenter randomized trial performed in the United States with 861 ICU patients with Acute Lung
      Injury or Acute Respiratory Distress Syndrome. 387 patients received lower tidal volumes 6 mL/kg for
      predicted body weight and 405 patients received traditional tidal volumes of 12mL/kg for predicted
      body weight. Patients were monitored for 28 days for pulmonary and non-pulmonary complications.
      The mortality rate in the group with lower tidal volumes was significantly lower as compared to the
      traditional tidal volume group (31 percent vs. 39.8 percent). In addition, ventilator-free days were
      significantly lower in the group with lower tidal volumes with ventilator days at 8 as compared to those
      in the traditional tidal volume group with ventilator days totaling 10.5. The incidence of barotrauma was
      the same in both groups.
  2. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume
    ventilation in abdominal surgery. The New England journal of medicine. 2013;369(5):428-437.
    • A multicenter, double-blind, parallel-group trial with 400 patients randomly assigned to receive either
      protective mechanical ventilation or non-protective mechanical ventilation intraoperatively. All patients
      were at least 40 years old and scheduled to undergo elective abdominal surgery lasting 2 or more hours.
      Participating patients were assessed preoperatively for risk of pulmonary complications. Those with a
      score greater than 2 on a 5 point index were included in the trial. Patients in the protective ventilation
      group received tidal volumes of 6-8 mL/kg of predicted body weight, PEEP of 6-8 cm of water, and
      recruitment maneuvers every 30 minutes after tracheal intubation. Patients in the non-protective
      ventilation group received tidal volumes of 10-12 mL/kg of predicted body weight, no PEEP, and no
      recruitment maneuvers. The patients who did not receive protective ventilation had a higher incidence
      of atelectasis (17%) and pneumonia (8%) within 7 days as compared to the protective ventilation group
      with rates of 6.5% of atelectasis and 1.5% experiencing pneumonia. In addition, non-protective
      ventilation strategies resulted in 3% of patients in that group having acute lung injury or ARDS within 7
      days postoperatively compared to only 0.5% in the protective ventilation group. The median length of
      stay for the protective ventilation patients was shorter than the non-protective ventilation group
      (adjusted difference of 2.45 days shorter). There was no difference in ICU admissions or mortality
      between the two groups.
  3. Guldner A, Kiss T, Serpa Neto A, et al. Intraoperative protective mechanical ventilation for
    prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal
    volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology. 2015;123(3):692-713.
    • A comprehensive review article that explains the pathophysiology associated with postoperative
      pulmonary complications and further compares the literature regarding protective ventilation
      strategies. Guldner et al categorize patients as either having either non-injured or injured lungs
      preoperatively. Both groups are recommended to receive low tidal volumes: 6-8 mL/kg for predicted
      body weight for non-injured lung patients and 6 mL/kg predicted body weight for injured lung patients.
      Low tidal volumes were determined to be the most important protective ventilation strategy. There is
      less evidence for a specific PEEP value or recruitment maneuvers.
  4. Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ. High versus low positive end-expiratory
    pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre
    randomised controlled trial. Lancet (London, England). 2014;384(9942):495-503.
    • In this randomized controlled trial involving 30 centers across Europe and North and South America,
      patients undergoing open abdominal surgery were divided into two groups. Both groups received low
      tidal volumes (7 mL/kg PBW). However, 445 patients were assigned to a group with high PEEP settings
      (12 cm of water) & recruitment maneuvers while 449 patients were assigned to a second group
      receiving low PEEP (2cm of water) and no recruitment maneuvers. Postoperative pulmonary
      compliations were identified in 174 (39%) of the 445 patients receiving high PEEP and recruitment
      maneuvers as compared to 172 (38%) of the 449 patients in the low PEEP group. The study concluded
      that in patients undergoing open abdominal surgery, the incidence of postoperative pulmonary
      complications was comparable in the first 5 days after surgery. However, patients in the high PEEP group
      experienced hypotension (46%) and required more vasoactive drugs (62%) intraoperatively as compared
      to the low PEEP group (hypotension: 36%; vasoactive drugs: 51%).
  5. Sato H, Nakamura K, Baba Y, Terada S, Goto T, Kurahashi K. Low tidal volume ventilation with
    low PEEP during surgery may induce lung inflammation. BMC anesthesiology. 2016;16(1):47.
    • Twenty-eight patients were enrolled in a prospective, randomized controlled study examining the
      effects of low tidal volume ventilation paired with low PEEP for hepatectomy surgery. Half of the
      patients (14) received traditional tidal volumes of 12 mL/kg for predicted body weight and the other half
      of patients (14) received reduced tidal volumes of 6 mL/kg for predicted body weight. Both groups
      received PEEP of 3 cm of water. After six hours of ventilation, interleukin-8 levels were found to be
      elevated in the epithelial lining of the airway for the low tidal volume group. In addition, the P/F ratio
      was higher in the PACU for the traditional tidal volume patients (12mL/kg) when compared to the lower
      tidal volume group. The study concluded that low tidal volume with low PEEP may lead to pulmonary
      inflammation in hepatectomy surgery.
  6. Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for
    Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology.
    • In this meta-analysis of fifteen randomized controlled trials, there was a decreased incidence of
      postoperative pulmonary complications (PPCs) in patients receiving low tidal volumes (≤8mL/kg for
      predicted body weight (PBW)) as compared to patients receiving conventional ventilation (>8 mL/kg
      PBW). The use of PEEP and/or recruitment maneuvers was not included in the definitions for protective
      or conventional ventilation. The reviewers did not determine a difference in PPC incidence with patients
      receiving high or low levels of PEEP when low tidal volumes were applied. However, there was a higher
      incidence of PPCs in patients who received tidal volumes >10 mL/kg PBW and PEEP ≥5 cm of water.

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