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Individuals with neuromuscular disorders face unique perioperative respiratory challenges due to reduced ventilatory capacity, impaired airway protection, and variability in disease progression. Preoperative evaluation should quantify respiratory reserve, cough effectiveness, and bulbar function, along with comorbidities such as scoliosis, restrictive lung disease, and sleep-disordered breathing. A structured risk stratification helps identify patients who may benefit from prehabilitation, optimization of respiratory muscles, and targeted physiotherapy. Shared decision-making with patients and families clarifies goals, expectations, and the potential need for postoperative intensive monitoring. Multidisciplinary coordination involving anesthesia, pulmonology, neurology, and physical therapy improves individualized care pathways and patient safety.

Preparing a patient for anesthesia begins with documenting baseline respiratory status, including peak cough flow, forced vital capacity, and nocturnal oxygen saturation if available. Medication reconciliation is essential, particularly avoiding agents that depress respiratory drive or interact adversely with neuromuscular disease–specific therapies. For individuals on chronic respiratory support, a plan for perioperative weaning, tracheostomy considerations, and noninvasive ventilation during recovery should be outlined. Intraoperative strategies focus on preserving diaphragmatic function while ensuring adequate muscle relaxation and airway control. Regional anesthesia may reduce systemic exposure to neuromuscular blocking agents when clinically appropriate. Clear handoffs between anesthesia teams and the surgical unit are critical to prevent perioperative miscommunication.

A thorough preoperative assessment should map disease subtype and progression, noting how muscle weakness affects respiratory mechanics during anesthesia. Bulbar involvement influences airway clearance and aspiration risk, guiding prophylactic measures such as careful intubation planning and rapid-sequence techniques when indicated. Nutritional status and obesity-related comorbidities influence wound healing and infection risk, which in turn affect ventilatory demand postoperatively. Sleep-disordered breathing, if present, warrants optimization of nocturnal ventilation strategies and possibly extended observation after surgery. The aim is to anticipate marginal respiratory reserve and implement proactive measures rather than react to complications after they arise. Documentation should reflect this proactive approach.

Intraoperative management prioritizes maintaining adequate ventilation while minimizing neuromuscular compromise. Neuromuscular blocking agents require careful titration with objective monitoring, as patients may exhibit exaggerated responses or sensitivity. Prefer short-acting agents when feasible and utilize reversal strategies guided by neuromuscular monitoring. Avoid routine use of agents that can complicate recovery of respiratory muscles. Temperature regulation is essential, as hypothermia can worsen neuromuscular inhibition and coexisting pulmonary problems. Hemodynamic stability supports organ perfusion, including respiratory muscles, thereby reducing postoperative respiratory failure risk. Team communication remains vital to adapt plans if airway anatomy or disease severity changes.

Prehabilitation aims to strengthen respiratory muscles and improve cough effectiveness before surgery. Interventions may include inspiratory muscle training, breath-holding exercises, and chest physiotherapy to enhance airway clearance skills. Smoking cessation, vaccination, and treatment of chronic infections reduce perioperative pulmonary risk. Patients should be instructed on incentive spirometry and diaphragmatic breathing techniques, practicing them ahead of the procedure. A coordinated plan for postoperative mobilization and early ambulation supports pulmonary function and reduces the likelihood of atelectasis. When feasible, a staged approach to anesthesia and surgery allows incremental improvements in respiratory resilience.

Postoperative care emphasizes early detection and management of respiratory compromise. Continuous monitoring should track respiratory rate, oxygenation, and signs of fatigue or insufficient ventilation. Noninvasive ventilation or supplemental oxygen may be needed, guided by objective criteria and clinical judgment. Pain control strategies should minimize respiratory depression; multimodal analgesia is preferred. Sputum clearance techniques, upright positioning, and mobilization support airway hygiene and lung expansion. Nursing teams play a pivotal role in recognizing subtle declines in respiratory status and initiating timely escalation to critical care if necessary. Clear discharge criteria ensure safe transition to home or rehabilitation settings.

Collaboration with neurology helps tailor disease-specific considerations for anesthetic planning. Pharmacologic profiles must account for existing therapies and potential interactions that could influence muscle strength or neuromuscular function. Neuromuscular disease registries or patient-specific risk registries can inform decisions about prophylactic antibiotics, electrolyte management, and medication timing to preserve respiratory capacity. Regular communication across specialties enhances consistency in care, and clinicians should revisit goals if disease status changes. Care plans should be revisited after any transfer of care or new findings, ensuring that all providers understand the patient’s unique respiratory risk profile.

The anesthesia team should maintain a dynamic airway plan, recognizing that airway anatomy may be altered by scoliosis, spinal deformities, or prior surgeries. Difficult airway strategies, equipment readiness, and backup plans must be in place before induction. Postoperative ventilation decisions require balancing the benefits of extended respiratory support against the risks of immobilization and infection. Early involvement of respiratory therapists ensures that airway clearance strategies are embedded in the recovery process. Families should receive clear explanations about the anticipated course and any potential complications, strengthening trust and adherence to postoperative instructions.

For patients with bulbar weakness, protecting airway patency during anesthesia is critical. Techniques that minimize aspiration risk include head-down or lateral positioning when appropriate, careful suctioning, and rapid assessment of airway protection needs. Postextubation monitoring should be intensified if signs of airway weakness emerge, such as poor cough, inability to clear secretions, or airway obstruction. Multimodal analgesia reduces opioid exposure, a common contributor to respiratory depression. In select cases, early use of noninvasive ventilation can support recovery while decreasing the risk of complications associated with prolonged intubation. Regular reassessment of respiratory effort informs timely transitions between support modalities.

Education for patients and caregivers reinforces safe perioperative practices. Preoperative coaching covers breathing exercises, secretions management, and recognizing warning signs after discharge. Providers should supply written action plans detailing whom to contact for respiratory concerns, criteria for readmission, and steps to adjust therapies if new symptoms appear. Documentation should capture anticipated respiratory scenarios and the corresponding response. Empowered patients participate actively in their care, which correlates with improved outcomes and reduced readmission rates. Ongoing research and quality improvement efforts should measure the impact of perioperative strategies on respiratory failure rates.

Facility readiness impacts perioperative safety for neuromuscular patients. Hospitals should maintain staffed units with equipment appropriate for noninvasive ventilation, airway clearance devices, and respiratory monitoring. Simulation-based training for airway management and neuromuscular pharmacology strengthens team preparedness. Protocols that standardize preoperative optimization, intraoperative choices, and postoperative escalation help reduce variability in care. Data collection and auditing identify gaps and opportunities for improvement, while patient-centered metrics capture the experiences and outcomes most meaningful to families. Scheduling flexibility and resource allocation ensure that high-risk patients receive appropriate attention without delaying essential procedures.

Finally, clinicians must remain vigilant for evolving evidence and disease-specific considerations. New pharmacologic agents, monitoring technologies, and rehabilitation approaches continually reshape best practices. Clinicians should update perioperative pathways to reflect emerging data, integrate patient-reported outcomes, and align with institutional safety standards. When uncertainties arise, seeking second opinions and consulting neuromuscular specialists helps maintain high-quality care. The ultimate goal is to minimize respiratory complications, optimize recovery trajectories, and preserve functional independence for patients navigating surgery within the context of neuromuscular disorders. Regular audits and multidisciplinary reviews support sustained improvements.