Fentanyl and Respiratory Depression

Myron Yaster MD

Original article

Adler AC, Chandrakantan A, Nathanson BH, von Ungern-Sternberg BS. An assessment of opioids on respiratory depression in children with and without obstructive sleep apnea. Paediatr Anaesth. 2021 Sep;31(9):977-984. PMID: 34053151

There’s a bell-shaped curve for pretty much everything.  For those of you who know me, I often find myself outside the 2 standard deviations from the mean in many aspects of clinical practice.  One of these involves fentanyl.  For many of you, fentanyl is the elixir of the gods and is used ubiquitously in almost every anesthetic.  I get it…fast onset and short duration.  Patients can get out of the PACU quickly.  In a busy practice administrators love you.  On the other hand, for surgical procedures in which post op pain is expected, like T&As, I prefer opioids that are longer lasting, like morphine, hydromorphone, and oxycodone.  One group of patients, those with documented obstructive sleep apnea with documented desaturations, the use of any opioids are really problematic.  Since Karen Brown’s landmark series of papers1-6 it has been well established that OSA patients, particularly those who experience intermittent hypoxia, are exquisitely sensitive to the respiratory depressant effects of opioids and have reduced opioid requirements to achieve equivalent pain relief.  Perhaps because of this and the desire to limit opioid use perioperatively7, fentanyl has become a go to opioid for many of you in T&A (and other) patients.  However, in OSA patients is it safe?

In today’s PAAD, Adler et al. in a small, non-randomized, prospective, single center study found that in pediatric surgical patients, obstructive sleep apnea status was not associated with significant differences in central respiratory depression following a single dose of fentanyl (1 mcg/kg).  Patients with or without OSA had similar transient decreases in respiratory rate and minute ventilation and none experienced apnea or desaturation below 90%.

So, is it safe?  Does this study answer this question?  The patients in this study were intubated and anesthetized with a half MAC of sevoflurane and 100% oxygen.  The presence of an endotracheal tube, a subanesthetic dose of sevoflurane, and oxygen almost certainly affected the results and may not be translatable to a natural airway in a spontaneously breathing patient in room air, as the authors acknowledge as a limitation of the study design, although mandated by the patients’ age and surgical procedure. The authors did not evaluate characteristics of ventilation in the OSA and non-OSA groups in the post-extubation period.

Almost 1 million pediatric patients undergo ENT surgery every year in the United States.  We really need better information on how to treat pain perioperatively in these patients.

Myron Yaster MD

References

1.           Brown KA, Laferrière A, Lakheeram I, Moss IR: Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology 2006; 105: 665-9

2.           Brown KA, Laferrière A, Moss IR: Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology 2004; 100: 806-10; discussion 5A

3.           Brown KA, Moss IR: Opiate usage in children with obstructive sleep apnea syndrome. Anesth Analg 2007; 105: 547-8

4.           Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown KA: An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg 2010; 110: 1093-101

5.           Brown KA: Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth 2011; 21: 771-80

6.           Brown KA, Brouillette RT: The elephant in the room: lethal apnea at home after adenotonsillectomy. Anesth Analg 2014; 118: 1157-9

7.           Franz AM, Martin LD, Liston DE, Latham GJ, Richards MJ, Low DK: In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg 2021; 132: 788-797