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Volatile agents depress spontaneous ventilation dose-dependently and they do it mainly by shrinking the breath rather than slowing it - as desflurane rose from 0.5 to 1.5 MAC in children, tidal volume and minute ventilation fell significantly and end-tidal carbon dioxide rose - so a normal-looking respiratory rate is not evidence of adequate ventilation.
Opioid-induced respiratory depression complicates 0.5 per cent or fewer of opioid treatments and still produces regular fatalities, and naloxone is the only reversal available, which is why it is titrated to effect and then continued rather than given once and walked away from, since most opioids outlast a single dose of it.
Residual neuromuscular block has been reported in as many as 70 per cent of patients and it does more than weaken the diaphragm - it degrades respiratory control itself and the pharyngeal coordination that keeps the upper airway open - so the fast shallow breathing of a partially reversed patient is an airway problem as much as a ventilation problem.
A train-of-four ratio of at least 0.9 became the accepted threshold for protecting the airway against aspiration before tracheal extubation, and reaching it is established by quantitative monitoring rather than by a head lift or a hand squeeze.
A rising respiratory rate in a spontaneously breathing patient is the body attempting to clear carbon dioxide, and the finding that turns that from housekeeping into an emergency is end-tidal carbon dioxide that keeps climbing despite the increased minute ventilation - the early diagnostic clue to malignant hyperthermia.
About 1.3 per cent of patients given a general anaesthetic had an unanticipated critical respiratory event in recovery - hypoxaemia, a respiratory rate below 8 or a carbon dioxide above 50 mmHg, or upper airway obstruction - and the anaesthetic risk factors were choices the anaesthetist had made, including opioid premedication, higher fentanyl doses and higher relaxant doses.
Her rate is 7 but the saturation is 99 per cent. Why does that not reassure me?
Give me four reasons a patient breathes fast in recovery, and tell me which one you can rule out from the end of the bed.
You suspect residual paralysis. What measurement, not what manoeuvre, would settle it?
When would you give naloxone here, how much, and what happens forty minutes later if you give it and walk away?