Opioid induced ventilatory impairment
Aug 21, 2025
Poking the bear - OIVI in the recovery room
Opioid-Induced Ventilatory Impairment (OIVI) is a significant clinical risk, particularly in the recovery room where patients are extremely vulnerable to opioid side effects in the immediate postoperative period.
OIVI is an umbrella term encompassing:
- Opioid induced respiratory depression
- Opioid induced sedation
- Opioid induced upper airway obstruction
Recognition and timely intervention are essential, as OIVI can be insidious and may be life-threatening if not managed quickly.
Detection 🔹
OIVI often presents subtly and slowly. Tell tale signs include:
- sedation that is disproportionate to the analgesic dose they have received
- irregular or shallow breathing
- bradypnea
- desaturation
- rising CO₂ levels if monitored
- snoring or airway obstruction
- reduced responsiveness to verbal or tactile stimuli
Bear in mind, if your patient is receiving supplemental oxygen, this will mask hypoventilation by maintaining normal oxygen saturations despite underlying CO₂ retention.
Risk Factors 🔸
As always, certain patients are at higher risk:
- elderly
- opioid-naïve individuals
- obstructive sleep apnoea,
- obesity
- co-administration of sedatives
- patients receiving neuraxial (intrathecal or epidural) or high doses of intravenous opioids
- Long-acting opioids (e.g. methadone) or concurrent PCA infusions can also increase risk.
Management 💉
Immediate priorities include airway support and stimulation of the patient. Encourage deep breathing, apply oxygen, and ensure airway patency with basic manoeuvres if needed. It may be that you spend the next hour of your recovery shift poking your patient and telling them to take a deep breath - so settle in!
If respiratory depression persists, naloxone may be required, however attempts should be made to avoid this if possible, as this will likely cause an escalation in acute pain and create another issue. Continuous monitoring should be maintained until the patient has stabilised, with consideration for extended observation in higher-risk individuals.
Recovery nurses play a critical role in the early detection of OIVI through vigilant assessment of sedation, respiratory pattern, and responsiveness. Structured sedation scoring, combined with regular respiratory assessment, are key. Timely recognition and escalation ensure patient safety and prevent serious complications.
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References:
Adams, T. J et al (2023) Perioperative opioids: a narrative review contextualising new avenues to improve prescribing. BJA, V130 (6) pp 709-718. DOI: 10.1016/j.bja.2023.02.037
Simpson, A.K. et al (2023) Opioid stewardship. BJA education, V 23(10) pp 389-397. DOI: 10.1016/j.bjae.2023.05.007
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