Running head: POST ANESTHESIA RESPIRATORY COMPLICATIONS
Post Anesthesia Respiratory Complications in Children Exposed to Second Hand Smoke
Aaron Duebner
Texas A&M University Corpus Christi
Research Design in Nursing
NURS 5314
Dr. Sara Baldwin
November 26, 2013
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POST ANESTHESIA RESPIRATORY COMPLICATIONS
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Post Anesthesia Respiratory Complications in Children Exposed to Second Hand Smoke
Each year approximately 450,000 children in the United States are admitted to inpatient
settings for surgery, of these children approximately 115,000 are under three years old (Tzong
KY ; Han S ; Roh A ; Ing C, 2012). Many of these cases are elective in nature with the majority
being urological, orthopedic or gastrointestinal (Tzong et al., 2012).
While anesthesia in otherwise healthy pediatric patients is often considered low risk,”
respiratory adverse events are the most common perioperative critical event” (So Yeon et al.,
2013, p. 137 ) associated with anesthesia. Some aspects related to respiratory complications in
the surgical setting such as procedural techniques and sedation methods can vary widely among
surgeons and anesthesiologists, and can be difficult to quantify. Other respiratory risks such as
pre-procedural exposure to second hand smoke can more easily be measured.
The purpose of this problem investigation is to evaluate the evidence in relation to
pediatric exposure to second hand or passive smoke and post anesthesia respiratory
complications. The author’s aim is to identify perianesthesia risk associated with exposing
children to passive smoke so that a knowledge base can be developed to provide an evidenced
based intervention strategy to pediatric patients and their families prior to anesthesia services.
Identification of Problem and Importance to Nursing Practice
Passive or second hand smoke is defined as” the caseous by- product of burning tobacco
products...it has been further defined as 15% mainstream smoke and 85% sidestream smoke from
a smoldering cigarette. It is estimated that there are upwards of 4000 chemical compounds in
environmental tobacco smoke (ETS)” (Thikkurissy, S., Crawford, B., Groner, J., Stewart, R., &
Smiley, M, 2012, p. 143). Lyons (2012) states the World Health Organization in 2005 estimated
that approximately 57.2% of children worldwide were exposed to passive smoke at home. What
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is known about passive smoking and its effects on children undergoing anesthesia is that
evidence shows there to be an” increased incidence of perioperative coughing, laryngospasm,
hypoxemia, bronchospasm, and overall respiratory complications by up to 60% “(O’Rourke,
J.M., Kalish, L.A., McDaniel, S., & Lyons, B., 2006, p. 566).
One reason this is of importance in nursing is because it is a modifiable risk factor. This
means that nurses have the opportunity during their assessments to identify at risk individuals
and their families and provide interventions such as patient education regarding increased
anesthesia risk and referral to smoking cessations programs. Another area of importance includes
the need for respiratory interventions involving the nurse such as breathing treatments, rescue
measures (suctioning/bagging), and oxygen support.
Finally, the need for bedside interventions mean increased cost related to elongated
perianesthesia time; this includes turnover time, anesthesia billing, and facility costs. According
to O’Rourke et al. (2006), one way to mitigate these complications is to arrange for Pulmonary
Function Testing. PFT can help determine the severity of lung dysfunction in children prior to
anesthesia procedures. Furthermore, the authors conclude that the use of this simple, noninvasive
and inexpensive test can help to identify at risk patients and provide the opportunity for
additional testing or interventions (O’Rourke et al., 2006).
Conceptual Model/Theory
Children are primarily exposed to passive smoke in the home which makes smoking
cessation of a child’s caregiver a priority. According to (Winickoff et al., 2008), “ the 2006
Surgeon General's Report on the health consequences of involuntary exposure to tobacco smoke
emphasizes that SHS is a major cause of disease, with no safe level of exposure”. Caregiver
smoking cessation prior to anesthesia can be initialized in the clinical setting during pre-
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procedure consultations or during routine physical exams. ” Parental smokers often see
their child's healthcare clinician more frequently than their own, with an average of over four
visits per year, and 11 pediatric well-child visits in the first two years of a child's life. Therefore,
child healthcare offices are in a key position to influence, in a repeated and consistent manner,
parents who are willing to address their smoking” (Winickoff et al., 2008, p. 365).
One middle-range nursing theory that can be used to accommodate this intervention is
Pender’s Health Promotion Model. This theory has two individual assessment components. The
first part directs the nurse to assess the client for health promoting behaviors including: self –
efficacy, perceived barriers, perceived benefits, and interpersonal and situational influences. The
second portion has the nurse assess client characteristics that may provide insight into health
behaviors such as: prior behavior, demographic characteristics, and perceived health status.
Through the use of information based on this assessment the nurse can tailor a plan to help the
client achieve improved health (Peterson & Bredlow, 2013, Chapter 14). In this case the
improved health would benefit both the parent and the child, and significantly reduce the risk for
respiratory complications for the child undergoing anesthesia.
Practice Problem
As mentioned earlier, nearly a half a million children in the United States will undergo
surgery each year, add to that the number of children undergoing anesthesia for day surgery and
diagnostic procedures, one then sees that the scope of pediatric anesthesia is vast. Many times a
child will present in the surgical setting with respiratory symptoms attributable to second hand
smoke exposure such as middle ear disease, low birth weight, lower respiratory illness, asthma,
increased mucous production or cough (Best, D., Committee on Environmental Health,
Committee on Native American Child Health and Committee on Adolescence, 2009).
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These children are then anesthetized utilizing varying techniques. According to the
literature most children receive inhalation gas anesthesia (sevoflurane, nitrous oxide) followed
by tracheal intubation or the use of an LMA (Lyons, 2011)(Dragonowsi et al., 2003). The
following question attempts to determine the respiratory risk in the pediatric population exposed
to SHS after anesthesia in the recovery phase.
PICO Question
The PICO question for this statement of a problem paper is: Are children undergoing surgery,
which have been exposed to second hand smoke at increased risk for respiratory complications
during the post anesthesia recovery phase? Respiratory complications can be measured both
quantitatively and qualitatively. Quantitative measures include pulse oximetry values,
carboxyhemoglobin values, PFT results, oxygen delivery, and recovery time. Qualitative
measures include evaluation of mucous production, ease of emergence, and amount of coughing
and presence/absence of wheezing (Dragonowsi et al., 2003). These signs and symptoms of
respiratory complications or lack thereof can be assessed by the nurse at the bedside, in the
operating room or in the recovery area.
Operational Variables
The dependent variable in this investigation is respiratory complications. Respiratory
complications in this situation are hypothesized to increase or decrease following the
manipulation of the independent variable which is second hand smoke. The PICO question
presented attempts to answer whether children exposed to second hand smoke (independent
variable) have an increased risk of respiratory complications (dependent variable) post
anesthesia. The causal relationship between respiratory complications following pediatric
exposure to second hand smoke is the focus of this research. By manipulating the exposure of
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second hand smoke, preferably eliminating in through caregiver education, the expected outcome
is to see a decrease in the amount of respiratory complications following anesthesia in children.
Moderator variables include in utero versus postnatal exposure, amount of exposure
(number of cigarettes smoked by caregivers for X amount of time), airway management,
induction agent, use of reversal agent, and presence or absence of secondary health issues such
as the presence of a cold, nasal congestion, presence of sputum, or snoring history, (So Yeon, et
al., 2013) (O’Rourke et al., 2006). According to O’Rourke (2006), “Children who have a had a
history of ETS present a greater risk of anesthesia, but this risk needs to be evaluated in the
context of other factors that could contribute to respiratory complications “(O’Rourke, J.M.,
Kalish, L.A., McDaniel, S., & Lyons, B., 2006, p. 565).
Summary
The literature shows a preponderance of evidence regarding the increase in respiratory
complications following anesthesia in pediatric patients exposed to second hand smoke (passive
smoking, environmental exposure to smoke). The literature documents that in healthy children,
studies show an “increase in the frequency of respiratory symptoms during the recovery room
stay in the smoke exposed population (56%) compared with the non-exposed (31%)”. However
the total RR time was similar (Dragonowsi et al., 2003, p. 309). According to O’Rourke (2006),
perioperative complications such as “laryngospasm, bronchospasm, wheeze, coughing, stridor,
increased mucous production, and oxygen desaturations occur more frequently in ETS exposed
children. There is also a dose-response correlation between the complications and the degree of
exposure” (O’Rourke et al., p. 565).
The mechanism behind the increase in respiratory symptoms is systemic inflammation
from inflammatory cytokines released by basal cells, activated by the smoke damaged epithelium
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(Lyons, 2011). Studies also suggest that smoking is known to “induce drug metabolizing
enzymes, especially in the liver” (Resli et al., 2004, p. 247). This might affect emergence as well.
Finally, the literature supports the need for nurses and physicians to initiate discussion
regarding caregiver use of tobacco and the exposure of children in their care to second hand
smoke. Early attempts to talk with caregivers about smoking cessation could provide
opportunities for education and potentially alleviate health complications both in the clinical
setting and in the surgical setting. Several office based intervention programs are documented in
the literature.
One evidence-based interventions listed is the 5A’s for child health care clinicians. This
involves asking about tobacco use at every visit, advise all tobacco users to quit, assess readiness
to quit, assist in quitting, and arrange follow up (Winickoff, 2005, p. 755). While time
management is always a concern, especially in a pediatric office, it is important to utilize
available staff such as nurses to facilitate this intervention and also provide information for
telephone quit lines that can provide more extensive counseling (Winickoff, 2005). A study by
Liles (2009), showed that” blending smoking cessation counseling with SHS reduction
counseling can increase the quite attempts made by low-income mothers with young children
Liles, Hovell, Matt, Zakarian, & Jones, 2009, p. 1402).
Through the use of pre-procedural efforts to eliminate children’s exposure to second hand
smoke, and the identification of children exposed prior to surgery, nurses and clinicians can
better care for pediatric patients in the surgical setting. While the evidence shows children
exposed to second hand smoke are at increased risk for respiratory complications in the post
anesthesia recovery phase, it also shows that an informed staff can anticipate and quickly
respond to potential complications decreasing the likelihood of an adverse event.
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