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Preoperative anesthesia recommendation for elective surgical patients who inhale cannabis
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Preoperative anesthesia recommendation for elective surgical patients who inhale cannabis
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Content
Running Head: PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
PREOPERATIVE ANESTHESIA RECOMMENDATION FOR ELECTIVE
SURGICAL PATIENTS WHO INHALE CANNABIS
By
Elizabeth Doty
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2020
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
ii
The following manuscript was contributed to in equal parts by Elizabeth Doty, Brianna Koty,
and Summer Laquerre.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
iii
Dedication
We dedicate this work to Michele Gold, PhD, CRNA. We would like to thank her for the
numerous years of dedication and determination that nurtured and supported USC CRNA
education, and laid the foundation for the Doctorate of Nurse Anesthesia Practice Program.
As members of the inaugural USC DNAP class we hope that our work will inspire future
cohorts to expand upon our findings and compile useful information pertaining to cannabis and
its impact upon anesthesia practice.
To the anesthesia community at large, we hope that this work might be a stepping stone
that draws attention to how little is known regarding the effects of cannabis use and its resultant
anesthesia implications. As the legal status evolves we hope that our findings might highlight
knowledge gaps and opportunities for further focused research.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
iv
Acknowledgments
We sincerely thank our capstone advisor Dr. Jeffrey R. Darna. His wise council,
professional expertise, and words of encouragement were ever present and carried us through.
We would like to acknowledge Dr. Michele Gold and Dr. Terrie Norris for acting as the
foundation of the USC CRNA program since 1996, and for bringing the DNAP program to
California and USC.
Dr. Bamgbose and Dr. Darna, we thank you for your leadership and expansion of the
USC CRNA DNAP program. We are privileged to learn from your passion and expertise, and we
are excited to see how you will shape the program in the future!
To Hannah Schilperoort, USC Health Sciences Campus Librarian, thank you for your
sage advice and research support! Your patience and guidance made this work possible!
We would also like to acknowledge the pioneers of cannabis research who put forth the
effort to navigate legal issues and social stigmas to objectively study and report on this
commonly encountered substance before it was considered “safe” to do so. DP Tashkin, R.
Hancox, S. Aldington, JM Tetrault, your works have laid the foundation for this report and
existing cannabis knowledge as it relates to the pulmonary system. We thank you.
Lastly, to our friends and families: your patience, love, and support have truly made it
possible for us to fulfill our dreams of pursuing higher education. For that we are forever
grateful!
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
v
Table of Contents
Distribution of Work ....................................................................................................................... ii
Dedication ...................................................................................................................................... iii
Acknowledgments.......................................................................................................................... iv
Table of Contents ............................................................................................................................ v
Abstract ......................................................................................................................................... vii
Introduction ..................................................................................................................................... 1
Chapter 1: Anesthesia Recommendations for Surgical Patients Who Inhale Cannabis ................ 1
Clinical Question and Specific Aims .................................................................................. 1
Background and Significance ............................................................................................. 2
Lack of Preoperative Guidelines ............................................................................. 3
Chapter 2: Methods ......................................................................................................................... 5
Chapter 3: Literature Review .......................................................................................................... 6
Quantifying Cannabis Use .................................................................................................. 6
Immune Response ............................................................................................................... 7
Asthma ................................................................................................................................ 8
Non-Specific Respiratory Symptoms, Including Chronic Bronchitis................................. 9
Lung Cancer ...................................................................................................................... 10
Pulmonary Function Tests ................................................................................................ 11
Chapter 4: Results and Deliverables ............................................................................................. 12
Results ............................................................................................................................... 12
Impact ............................................................................................................................... 12
Deliverables ...................................................................................................................... 13
Practice Recommendations ............................................................................................... 13
Preoperative Evaluation ........................................................................................ 13
Preoperative Assessment and Plan of Care Recommendations ............................ 13
Chapter 5: Discussion and Conclusion ......................................................................................... 16
Discussion ......................................................................................................................... 16
Limitations ........................................................................................................................ 18
Recommendations for Future Research ............................................................................ 18
Conclusion ........................................................................................................................ 19
References ..................................................................................................................................... 20
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
vi
Appendix ....................................................................................................................................... 27
Smoked Cannabis Literature Review Matrix .................................................................... 27
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS
vii
Abstract
Cannabis inhalation is increasing in prevalence and social popularity in the United States:
smoking is the most common intake method. To our knowledge, there are no anesthesia practice
guidelines or recommendations for perioperative care regarding cannabis smoking. Because
cannabis is an illegal substance under federal law, there is a paucity of data on the effects of
cannabis inhalation on the respiratory system specifically with regard to how chronic cannabis
smoking affects anesthesia care. Despite these limitations, existing research offers some insight
into potential respiratory risks. We conducted an extensive literature review on the effects of
chronic cannabis smoking on the respiratory system and produced an executive summary to
better risk-stratify patients who smoke cannabis and undergo elective surgery. There was
substantial evidence associating cannabis smoking with an increased incidence of cough,
wheeze, excessive respiratory secretions, and chronic bronchitis exacerbations. Anesthesia
practice recommendations include quantifying the cannabis exposure, assessing for commonly-
associated symptoms, optimizing the respiratory system immediately before surgery, and
formulating an anesthesia plan of care to reduce known triggers for bronchospasm and
laryngospasm.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 1
Chapter 1: Introduction
Cannabis culture evolution in the United States (US) has garnered increasing attention
from the general public including legislators, researchers, and healthcare professionals. As
cannabis continues to become socially and legally acceptable, an evaluation of current evidence
and clinical knowledge gaps is required to better inform anesthesia professionals on the
perioperative risks associated with patients who smoke cannabis and undergo elective surgery.
Smoking cannabis has greater pulmonary implications than alternatives such as consuming oral
cannabis or vaping (Biehl & Burnham, 2015). Because smoking cannabis remains the most
common method of intake the authors of this paper synthesized the current literature to provide
an executive summary of the evidence on respiratory changes associated with smoking cannabis
as a means for clinicians to optimize preoperative care in this patient population (Azofeifa et al.,
2016).
Clinical Question and Specific Aims
An extensive literature review with practice recommendations addressed the following
clinical question: What are the preoperative respiratory assessment recommendations for patients
who chronically smoke cannabis and will undergo an elective surgical procedure? The two
specific aims for this paper were: 1. Identify a preferred method to quantify smoked cannabis and
chronic use; and 2. Provide a synthesis of current literature detailing the pathophysiologic
changes in the respiratory system associated with chronic cannabis smoking for optimal risk
stratification.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 2
Background and Significance
Cannabis research in the US has been limited by its federally illegal status and resultant
lack of funding. Cannabis products and cannabis-based tinctures were commonly used in the late
1800s and early 1900s for medicinal and recreational purposes (National Institute of Drug Abuse
for Teens, 2015). However, the Marihuana Tax Act of 1937 controlled cannabis sales,
possession, and distribution (Burnett & Reiman, 2014). In 1970 cannabis was categorized as a
schedule I controlled substance by the Controlled Substances Act. State level legalization of
cannabis for medicinal use began in the 1990s followed by the legalization of cannabis for
recreational purposes in 2012. As of 2018, cannabis use and possession has been decriminalized
in 22 states (National Conference of State Legislatures, 2019), medicinal use is legal in 30 states,
and recreational use is permitted in 10 states (as well as the District of Columbia).
Public opinion has evolved alongside state level legalization. In 1995, just before
California’s 1996 approval of the use of cannabis for medical purposes, a Gallup poll reported
25% of Americans approved total legalization (2018). Since that time national approval of
cannabis legalization has steadily increased. In 2017, a Gallup poll reported an overall 64%
approval rating for complete cannabis legalization garnering a majority nod from Democrats,
Republicans, and Independents.
Cannabis’ history as an illicit substance has made it difficult to accurately assess usage
prevalence and demographics. Despite this issue, the Center for Behavioral Health Statistics
(CBHS) reports cannabis use has steadily increased since 2002 (United States Department of
Health and Human Services [USDHHS], n.d.a). In 2016 the Substance Abuse and Mental Health
Services Administration (SAMHSA) survey showed approximately 8.9% of the US population
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 3
(age 12 or older) “used cannabis within the past month”. From 2002 to 2016 incidence of
cannabis smoking was greatest in the 26 and older age range while the highest prevalence was
between the ages of 18 and 25 (USDHHS, n.d.b). The SAMHSA survey also reported males
used cannabis more than females, and prevalence of use by ethnicity was African Americans
(10.7%), Caucasians (8.4%), and Hispanics (7.2%). Lower socioeconomic status and lack of
college education also correlated with an increase in reported use.
Governmental classification of cannabis as a schedule I controlled substance has limited
the availability of federal funding for clinical trials involving cannabis despite growing curiosity
amongst medical providers of the physiologic effects of smoking cannabis. An understanding on
the part of the anesthesia professional regarding the physiologic impact of smoking cannabis is
needed to provide better patient care. Given the lack of high-level published evidence,
preliminary research may provide a useful insight into potential anesthesia-related respiratory
implications for the cannabis smoker undergoing elective surgery.
Lack of Preoperative Guidelines
National organizations representing anesthesia professionals have not established a set of
recommended clinical practice guidelines on the preoperative evaluation of patients who smoke
cannabis. The American Association of Nurse Anesthetists recently published practice
considerations for the substance use disorder patient (“Analgesia and Anesthesia,” 2019). The
guidelines specific for cannabis users is based on limited data and does not appropriately address
our clinical question or specific aims.
Cannabis use has the potential to impact several systems within the body (Hernandez,
Birnbach, & Van Zundert, 2005; Huson, Granados, & Rasko, 2018). A complete discussion of
the systemic effects associated with cannabis use is beyond the scope of this report. Therefore, a
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 4
focused investigation on the effects of smoking cannabis on the respiratory system was chosen
because the status and function of the upper and lower airways are often a primary concern when
administering general anesthesia.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 5
Chapter 2: Methodology
An extensive search of databases, including PubMed, Embase, CINAHL Complete,
Scopus, ProQuest, Joanna Briggs Institute, PscyINFO, and Web of Science was conducted.
Databases were searched using combinations of MESH terms: Cannabis smoking/use,
respiratory effects/complications/implications, respiratory disease, respiratory symptoms,
pulmonary function, COPD, asthma, chronic bronchitis, immune response, lung cancer, elective
surgery, anesthesia implications/recommendations, US prevalence/epidemiology, quantification,
lifetime/cumulative exposure, and methods/devices used to smoke cannabis. Titles and abstracts
were screened for relevance to the clinical question and aims. A snowballing technique was used
to identify additional studies. Inclusion criteria consisted of articles published between 1975-
2019, written in the English language. Case reports and studies published before 2000 were
included since higher levels of evidence and/or more recently published studies addressing
cannabis smoking were limited. Exclusion criteria consisted of animal studies.
Articles obtained from initial search results were reviewed using established assessment
tools such as STROBE guidelines for observational studies and PRISMA guidelines for
systematic reviews and meta-analyses. The three authors assessed all articles to ensure adherence
to the inclusion and exclusion criteria. All studies were included in a literature matrix describing:
summary of main concept, database, study design, level of evidence, sample size, main findings
of the study, and capstone application (i.e. quantification, epidemiology, pulmonary function,
respiratory symptoms, asthma, and immune response)
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 6
Chapter 3: Literature Review
Quantifying Cannabis Use
Limitations in quantifying cannabis use include variable individual appraisal of the
amount smoked, varying concentration of compounds and toxins, and numerous methods of
cannabis inhalation. Unlike the tobacco industry, the cannabis trade is in the early stages of
regulatory development creating a wide variety of potential delivery mechanisms, components,
and concentrations of inhaled cannabis smoke. The literature comparing cannabis and tobacco
smoke is incongruent. Some authors state cannabis and tobacco smoke contain similar amounts
of volatile and tar components (Pletcher et al., 2012). Other authors report cannabis cigarettes
may contain toxins at concentrations 20 times that of tobacco smoke (Moir et al., 2008). A
standard assessment of tobacco pack-years, defined as the number of cigarette packs smoked per
day multiplied by number of years smoked, can be calculated to estimate individual use. The
classification of pack-years provides a quantifiable assessment of tobacco use and the risks
commonly associated with different exposure levels. There is a disagreement in current medical
literature regarding a recommended system or equation for quantifying cannabis use to assess
exposure level risks.
It is difficult to quantify cannabis intake due to numerous methods of inhalation.
Smoking cannabis remains the primary method of intake (Azofeifa et al., 2016); however,
cannabis can be smoked in several ways including by an unfiltered blunt, joint, pipe, or bong.
Joint and bowl preparation varies: one joint or pipe bowl may not contain the same amount of
cannabis as another (Pletcher et al., 2012). Blunts often contain one and a half times the amount
of cannabis of joints (Russell, Rueda, Room, Tyndall, & Fischer, 2018). Joint
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 7
equivalents are defined as one blunt equaling three joints (Newmeyer, Swortwood, Abulseoud, &
Huestes, 2017). As of yet, research and current clinical practice do not consider these variables
when assessing and quantifying cannabis exposure.
The literature most commonly defines cannabis use in terms of joint-year equivalents.
Joint-years are determined by lifetime cannabis exposure: One joint or filled pipe bowl a day for
365 days is equal to one joint-year (Hancox et al., 2009). Alternatively, Tan et al. (2009) define
cannabis users in terms of lifetime cannabis dose, calculated as the total number of cannabis
cigarettes ever smoked. This method has several limitations including how a cannabis cigarette is
defined, whether or not other forms of cannabis smoking are made equivalent and reported as
cannabis cigarettes, and the duration of cannabis use.
Another gap in standardized quantification lies in categorizing occasional versus chronic
use. Newmeyer et al. (2017) described occasional use as greater than, or equal to twice a month,
but less than three times per week, and frequent use as greater than five times per week for the
previous three months and a positive cannabinoid urine screening. Other literature describes
chronic use as having a 10 to 20 joint-year history (Pletcher et al., 2012). Tan et al. (2009)
classify substantial cannabis smoking as greater than 50 cannabis cigarettes smoked in a lifetime.
Immune Response
The pulmonary histological changes from cannabis smoke may present similar to those of
chronic tobacco smoke. Tashkin, Baldwin, Sarafian, Dubinett, and Roth (2002) conducted a
systematic review revealing cannabis-only smokers had a greater incidence and severity of
histopathological changes. The changes observed in cannabis-only smokers were similar to
tobacco-only smokers. The histological changes were reportedly more frequent in persons who
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 8
smoked both cannabis and tobacco. Despite the increased histological changes, there was not an
increase in respiratory symptoms or alterations in pulmonary function tests (PFTs) for concurrent
cannabis and tobacco smokers.
Tetrahydrocannabinol (THC) is a known immune modulator with various
immunosuppressive effects (Klein, Friedmen, & Specter, 1998). Mechanical immune changes
occur with chronic cannabis smoking. In a study conducted by Roth et al. (1998) alveolar
macrophages were recovered upwards of twofold in cannabis smokers and fourfold in cannabis
and tobacco smokers when compared to nonsmokers during bronchoalveolar lavage. This is
likely due to chemotaxis or abnormal replication stimulated by smoke inhalation itself.
Functional studies of recovered alveolar macrophages from cannabis smokers
demonstrated impaired phagocytic ability to manage infectious material; tobacco smokers and
nonsmokers showed no impairment, or significantly less impairment, respectively (Tashkin et
al., 2002). These results suggest cannabis-related inhibition of key proinflammatory cytokines
and compromised lung immune defenses. Airway injury from cannabis smoke may contribute to
dysregulated bronchial epithelial cell growth, compromised mucociliary function, decreased
phagocytosis, and decreased respiratory clearance, which increases the risk of lower respiratory
infection (Baldwin et al., 1997).
Asthma
According to Kempker, Honig, and Martin (2015) an estimated 19% of cannabis
smokers have been diagnosed with asthma. According to the National Institute of Health (2012)
symptoms of asthma include “Cough, recurrent wheezing, recurrent difficulty breathing,
recurrent chest tightness.” Several case studies and journal editorials describe inhaled cannabis
smoke as having the potential to induce an allergic or asthmatic response in smokers who
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 9
concurrently have asthma (Gaeta, Hammock, Spevack, Brown, & Rhoden, 1996; Hernandez,
Martinez, Blair, & Miller, 1981). In contrast, other studies have described the short-term
bronchodilator effect of cannabis inhalation as potentially beneficial to those with asthma
(Tashkin, Shapiro, Lee, & Harper, 1975; Wu, Wright, Sassoon, & Tashkin, 1992). The official
2017 position statement from the National Academies of Sciences, Engineering, and Medicine
(NASEM) reads, “There is no or insufficient evidence to support or refute a statistical
association between cannabis smoking and asthma development or asthma exacerbations”
(2017).
Non-Specific Respiratory Symptoms, Including Chronic Bronchitis
Non-specific respiratory symptoms include cough, sputum production, wheeze, dyspnea,
and chest tightness (Morice et al., 2004). Both tobacco and cannabis smoking are associated with
increased respiratory symptoms compared to non-smoking (Tashkin, Simmons, & Tseng, 2012).
In numerous observational studies cannabis smoking has been correlated with a higher
prevalence of wheeze, cough, and chronic bronchitis symptoms than for nonsmokers (Aldington,
et al., 2007; Hancox, Shin, Gray, Poulton, & Malcolm, 2015; Macleod et al., 2015; Tashkin, et
al., 2012). A systematic review and meta-analysis by Ghasemiesfe and colleagues (2018)
confirmed previous assertions that cannabis smoking is associated with non-specific respiratory
symptoms of cough, sputum production, and wheezing.
The NASEM 2017 consensus report states, “Regular cannabis use is associated with
airway injury, worsening respiratory symptoms, and more frequent chronic bronchitis episodes.”
A systematic review by Tetrault et al. (2007) also reports a positive association between smoking
cannabis and bronchitis as well as dyspnea. Aldington et al. (2007) found the following group-
specific associations: wheezing was observed with concomitant cannabis and tobacco use, chest
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 10
tightness only with cannabis use, and cough with smoking either tobacco or cannabis, but not
when combined. Aldington et al. (2007) also reported concurrent cannabis and tobacco smoking
had no obvious additional impact on respiratory symptoms. Hancox et al. (2015) found cannabis
smokers were more likely to experience wheezing but did not find an association with frequent
cannabis use and dyspnea.
Respiratory symptomology appears to worsen in a dose-dependent manner but the exact
timeline and implications of quantity, frequency, and duration remain unclear. In 1999 the
Institute of Medicine reported that chronic cannabis smoking may lead to both acute and chronic
bronchitis. A systematic review conducted by Tetrault, et al. (2007) also summarily reports that
long-term cannabis smoking worsens respiratory symptoms including cough, sputum, and
wheezing. Walden and Earleywine (2008) directed an observational study of 5989 participants
who smoked cannabis once a month or more. Their study reported a positive correlation between
increasing respiratory symptoms and increasing frequency and amount of cannabis smoked. In a
longitudinal cohort study of 1037 participants, Hancox et al. (2015) found that both cough and
sputum production increased over time with cumulative cannabis smoking while those who
stopped smoking experienced a decline in both symptoms.
Lung Cancer
There is mixed evidence regarding chronic inhaled cannabis and incidence of lung
cancer. Aldington et al. (2008) found a statistically significant increase in lung cancer for people
who had more than 10.5 joint years of cannabis inhalation. Another study by Callaghan,
Allebeck, and Sidorchuk (2013) observed a twofold increase in lung cancer risk for those having
cumulative lifetime exposure exceeding 50 joints. This study was limited due to the data being
collected by self-reporting and poorly controlled confounders such as tobacco smoke. On behalf
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 11
of the International Lung Cancer Consortium, Zhang et al. (2015) examined evidence from six
international case-control studies. After adjusting for tobacco smoking they found no increased
risk of lung cancer even with chronic cannabis use. According to NASEM, “There is moderate
evidence of no statistical association between cannabis smoking and the incidence of lung
cancer” (2017).
Pulmonary Function Tests
Ghasemiesfe et al. (2018) performed a systematic review examining 13 studies that
measured PFT changes among inhaled cannabis users with a minimum of 30 days of lifetime
cannabis use. The majority of studies showed no change in forced expiratory volume within the
first second (FEV
1
) of the forced vital capacity (FVC) maneuver whether cannabis use was
continuous or intermittent. Of the 13 studies evaluating for FVC, six assessed the effect of
cannabis on FVC and demonstrated either no change or an increase in FVC. The FEV
1
to FVC
ratio data had more limitations for interpretation since data were frequently reported as cannabis
and tobacco smokers combined. However, data which reported on cannabis users separately,
frequently showed a decrease in FEV
1
to FVC ratio, sometimes less than 70%.
Tetrault et al. (2007) performed a systematic review on long-term cannabis smoking and
changes in PFTs. Five studies assessed FEV
1
in response to cannabis. After smoking cannabis,
three studies showed an increase of 15-25% in FEV
1
, one demonstrated a decrease, and one
study showed no difference. Of the fourteen studies that assessed for smoked cannabis’ effect on
FEV
1
-FVC ratio, a majority of the results revealed a decreased FEV
1
-FVC ratio; however, after
adjusting for tobacco smoking there was no difference between nonsmokers and cannabis
smokers. There were few studies addressing cannabis use only, which limited generalizability of
how to effectively use PFTs to measure the physiologic effects of smoked cannabis.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 12
Chapter 4: Results and Practice Recommendations
Results
The findings of this extensive literature review highlight:
1. Substantial evidence exists detailing how cannabis smoking causes an increased
incidence of cough, wheeze, excessive pulmonary secretions, and chronic bronchitis
exacerbations (Aldington et al., 2007; Ghasemiesfe et al., 2018; Hancox et al., 2015;
Macleod et al., 2015; NASEM, 2017; Tashkin et al., 2012; Tetrault et al., 2007).
2. The incidence of cough, wheeze, and sputum production increases with cumulative
exposure (Hancox et al., 2015; IOM, 1999; Macleod et al., 2015; Tetrault et al., 2007;
Walden and Earleywine, 2008).
3. Moderate evidence supports that cannabis smoking causes PFT changes including an
increased FVC with a consequential decrease in the FEV
1
/FVC ratio (Pletcher et al.,
2012).
4. Insufficient evidence exists to confirm or refute immunological consequences associated
with cannabis inhalation (NASEM, 2017).
5. No conclusive data support or refute a relationship between cannabis smoking and the
development of asthma or lung cancer (NASEM, 2017).
Impact
In an era of evolving cannabis perception, legality, and consumption, anesthesia
clinicians are likely to encounter patients who smoke cannabis in their daily practice. Adequate
understanding of the impact and potential effects of cannabis inhalation is necessary to create a
basis for the ongoing development of evidence-based practices. This report serves to inform
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 13
providers regarding areas where more research is needed and facilitate a more open discussion of
the state of cannabis evidence and ensuing practice implications.
Deliverables
To facilitate a clear understanding of existing evidence for the respiratory implications of
smoked cannabis, the authors prepared an executive summary describing existing evidence and
subsequent gaps in knowledge. In addition, an academic poster presentation was completed,
serving as the basis for the discussion of findings and resultant implications for clinicians.
Practice Recommendations
Preoperative Evaluation
The patient assessment and interview should focus on the presence of respiratory
symptoms including but not limited to cough, wheeze, sputum production, and estimation of
cumulative/lifetime cannabis exposure including frequency, duration and method of inhalation
(American Association of Nurse Anesthetists, 2019).
Preoperative Assessment and Plan of Care Recommendations
1. Quantify cannabis exposure
● Method
○ Assess mechanism of cannabis inhalation.
● Amount
○ One joint-equivalent: one blunt equals 1.5 times the amount of cannabis of
a joint (Mariani, Brooks, Haney, & Levin, 2011).
o One joint-equivalent: one pipe filled bowl approximately equals one joint
(Pletcher et al., 2012).
● Frequency and duration
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 14
○ Joint-years: number of joint-equivalents smoked per day times the number
of years smoking (Aldington et al., 2007; Hancox et al., 2009; Macleod et
al., 2015; Pletcher et al., 2012; Zhang et al., 2015).
2. Consider reactive airway risk reduction strategies (Ghasemiesfe et al., 2018; NASEM, 2017;
Tetrault et al., 2007).
● Avoid laryngoscopy and endotracheal intubation when appropriate
o Avoid airway manipulation by using regional and local anesthesia techniques
o Use a supraglottic airway when appropriate
o Attenuate the sympathetic response from airway manipulation/instrumentation
o Avoid inhalation agents known for causing airway irritation (e.g. desflurane)
● Reduce excessive oral and airway secretions
o Administer an anti-sialagogue (such as an anticholinergic medication)
o Avoid medications that increase secretions (e.g. ketamine) or ensure co-
administration of an anti-sialagogue
● Use medications and interventions that promote bronchodilation (Dobyns, 2019)
o Administer a bronchodilator preoperatively
o Consider intravenous induction and maintenance agents with bronchodilation
properties
3. Pulmonary function testing should not be ordered on the sole basis of reported cannabis
smoking (Pletcher et al., 2012).
● Pulmonary function test interpretation for the cannabis smoker:
o If the FEV
1
-FVC ratio is decreased, assess FEV
1
and FVC independently.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 15
▪ Increased FVC can result in a decreased ratio but is unlikely indicative of
pulmonary disease (Ghasemiesfe et al., 2018; Tetrault et al., 2007).
▪ Decreased FEV
1
may require further investigation as greater than 20-30
joint-years may be associated with a dose dependent decline in FEV
1
(Pletcher et al., 2012).
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 16
Chapter 5: Discussion and Conclusion
Discussion
The investigation into the preoperative respiratory assessment recommendations for
patients who chronically smoke cannabis and will undergo an elective surgical procedure has
offered relatively inconclusive evidence towards definitive guidelines for anesthesia
professionals. In summary, the authors identified the need to continue the current practice of
offering patient-specific care based on physical assessment and reported medical history.
A standard cannabis unit does not exist, which limits the clinician’s ability to quantify
cannabis use and create a standardized joint-year assessment. Many studies demonstrate self-
reported quantity and frequency of cannabis use are reliable (Rygaard Hjorthoj, Rygaard
Hjorthoj, & Nordentoft, 2012). Until potency is standardized, clinicians must rely on self-
reporting to calculate joint-years and determine chronic use. Current cannabis smokers with at
least one joint-year smoking history may be considered chronic cannabis users. However, patient
treatment should depend on physical assessment and reported respiratory symptoms.
Smoking cannabis more than once a week for at least one year is associated with
worsening respiratory symptoms and bronchitis exacerbations (Ghasemiesfe et al., 2018;
NASEM, 2017; Tetrault et al., 2007). Nonspecific respiratory symptoms of cough, sputum
production, and wheeze are the most commonly reported with cannabis smoking. It is unclear
whether the cough from cannabis smoking is induced by smoke-related airway injury or a
compensatory cough to aid in the clearance of pulmonary secretions, or both. Inhaled THC
contributes to decreased respiratory clearance by compromising mucociliary function (Baldwin
et al., 1997). Additionally, there is an increased risk of respiratory infection in the setting of
increased secretions, decreased mucociliary clearance, and THC-mediated immune suppression
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 17
of lung parenchyma (Baldwin et al., 1997). Respiratory symptoms associated with smoking
cannabis appear to exacerbate and diminish in a dose-dependent fashion (Hancox et al., 2015;
Tashkin et al., 2012). However, due to the limited evidence available, specific recommendations
on preoperative cessation cannot be made.
There is insufficient evidence to support that smoking cannabis leads to asthma or asthma
exacerbations (NASEM, 2017). However, acute cannabis smoking has been linked to
hyperreactive airway responses including wheezing (Aldington et al., 2007; Tetrault et al., 2007).
Preoperative wheezing, with or without a pre-existing diagnosis of asthma, should prompt further
investigation and consideration of interventions such as administration of an inhaled beta-
adrenergic agonist, anticholinergic, or nebulized bronchodilator. In the cannabis smoker with
wheezing, there is an increased risk for perioperative bronchospasm. Techniques aimed at
preventing bronchospasm should be considered including avoiding airway manipulation when
possible, minimizing airway secretions using anti-sialagogues, blunting sympathetic response to
airway stimulation using opioids (sparingly) or IV lidocaine, utilizing bronchodilator anesthetic
agents such as propofol, ketamine, dexmedetomidine, sevoflurane, and isoflurane, and avoidance
of histamine-releasing drugs (Dobyns, 2019).
The evidence is inconclusive regarding cannabis smoking as a causative agent for lung
cancer despite several studies reporting carcinogenic effects associated with long term inhalation
because these reports poorly controlled for confounders such as concomitant tobacco
smoking (Aldington et al., 2008; Callaghan, Allebeck, and Sidorchuk, 2013). For patients who
present with long-term smoking of any kind a thorough physical assessment is essential, and if
the findings are suggestive of impaired oxygenation or respiratory compromise additional testing
should be considered.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 18
Chronic cannabis use increases FVC, or total lung capacity, with little to no decrease in
FEV
1.
Increased FVC is often attributed to deep inspiratory maneuvers practiced with cannabis
smoking (Pletcher et al., 2012). Increased FVC causes a decreased FEV
1
-FVC ratio, but is not
indicative of pulmonary disease. Tobacco smoking demonstrates a decreased FEV
1
and therefore
if used concomitantly with cannabis may contribute to a decreased ratio, which might signify
pulmonary disease. Current evidence investigating the effects of inhaled cannabis smoke on PFT
changes typically have small sample populations, confounding factors, and fail to report the
effects on PFTs over time.
Limitations
The numerous limitations of existing cannabis research are likely a result of its federally
illegal status in the US, which has limited funding and availability of study participants. Potential
for bias based on ethical and moral beliefs about cannabis has also proven problematic. In
existing studies of cannabis, currently accepted standards for rigorous research have not been
met. Most studies lack adequate controls for confounders such as environmental factors, variable
methods of cannabis inhalation, variable quantities and composition of cannabis, and
concomitant tobacco smoking. Some existing systematic reviews and medical professional
organization conclusions and recommendations have been drawn from case studies, letters to
editors, expert opinion, and isolated reports. Additionally, existing cannabis research includes
studies with inadequate sample sizes, many of which were published more than ten years ago.
Recommendations for Future Research
As cannabis culture continues to evolve, controlled clinical trials are needed to determine
the pulmonary effects of smoking cannabis. Future research should explore when clinically
significant symptoms begin in both acute and chronic cannabis smokers and decrease after
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 19
cessation of cannabis smoking. Future research should focus on longitudinal studies with larger
cohorts of chronic cannabis smokers (greater than 20 joint-years) without concomitant tobacco
use, after their fourth decade of life, in order to better approximate cannabis’ long-term impact
on the respiratory system. Limitations of current cannabis research can be improved by the
development of a standardized approach to quantifying cannabis inhalation. Federal legalization
and funding for cannabis research would allow researchers to expand participation and develop
more focused cannabis investigations with a greater potential to produce more generalizable
results.
Conclusion
Despite numerous limiting factors, existing cannabis research may offer valuable insight
into potential pulmonary symptomatology of the cannabis smoker. Increasing public interest in
cannabis use warrants thorough evaluation and consideration of existing evidence. This will
improve the healthcare practitioner’s understanding of what they might encounter when caring
for a cannabis smoker. The authors of this paper have synthesized current literature and
provided an executive summary of the evidence on respiratory changes associated with smoking
cannabis as a means for anesthesia professionals to optimize preoperative care for this patient
population.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 20
References
Agrawal, A., Budney, A. J., & Lynskey, M. T. (2012). The co-occurring use and misuse of
cannabis and tobacco: A review. Addiction,107(7), 1221-1233.
https://doi:10.1111/j.1360-0443.2012.03837.x
Aldington, S., Harwood, M., Cox, B., Weatherall, M., Beckert, L., Hansell, A., … Beasley, R.
(2008). Cannabis use and risk of lung cancer: A case-control study. European
Respiratory Journal,31(2), 280-286. https://doi:10.1183/09031936.0006570
Aldington, S., Williams, M., Nowitz, M., Weatherall, M., Pritchard, A., Mcnaughton, A., . . .
Beasley, R. (2007). Effects of cannabis on pulmonary structure, function and symptoms.
Thorax, 62(12), 1058-1063. https://doi:10.1136/thx.2006.077081
American Association of Nurse Anesthetists. (2019). Analgesia and anesthesia for the substance
use disorder patient. https://www.aana.com/docs/default-source/practice-aana-com-web-
documents-(all)/analgesia-and-anesthesia-for-the-substance-use-disorder-
patient.pdf?sfvrsn=3e6b7548_2
Azofeifa, A., Mattson, M. E., Schauer, G., McAfee, T., Grant, A., Lyerla, R. (2016). National
estimates of marijuana use and related indicators—National survey on drug use and
health, United States, 2002-2014. Morbidity and Mortality Weekly Report Surveillance
Summary, 65, 1-28. https://doi:10.15585/mmwr .ss6511a1
Baldwin, G., Tashkin, D., Buckley, D., Park, A., Dubinett, S., & Roth, M. (1997). Marijuana and
cocaine impair alveolar macrophage function and cytokine production. American Journal
of Respiratory and Critical Care Medicine,156(5), 1606-1613.
https://doi:10.1164/ajrccm.156.5.9704146
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 21
Biehl, J. R., & Burnham, E. L. (2015). Cannabis smoking in 2015: A concern for lung health?
Chest,148(3), 596-606. https://doi:10.1378/chest.15-0447
Burnett, M., & Reiman, A. (2014). How did marijuana become illegal in the first
place?
http://www.drugpolicy.org/blog/how-did-marijuana-become-illegal-first-place
Callaghan, R., Allebeck, P., & Sidorchuk, A. (2013). Marijuana use and risk of lung cancer: A
40-year cohort study. Cancer Causes & Control,24(10), 1811-1820.
https://doi:10.1007/s10552-013-0259-0
Dobyns, J. (2019). Anesthesia for adult patients with asthma.
https://www.uptodate.com/contents/anesthesia-for-adult-patients-with-asthma
Douglas, I., Albertson, T., Folan, P., Hanania, N., Tashkin, D., Upson, D., & Leone, F. (2015).
Implications of marijuana decriminalization on the practice of pulmonary, critical care,
and sleep medicine. A report of the American Thoracic Society Marijuana Workgroup.
Annals of the American Thoracic Society,12(11), 1700-1710.
https://doi:10.1513/annalsats.201504-195ar
Gaeta, T., Hammock, R., Spevack, T., Brown, H., & Rhoden, K. (1996). Association between
substance abuse and acute exacerbation of bronchial asthma. Academic Emergency
Medicine,3(12), 1170-1172. https://doi:10.1111/j.1553-2712.1996.tb03386.x
Gallup. (n.d.). [Graphic data describing United States’ opinion on illegal drugs from 1970 to
2018]. Illegal drugs.
https://news.gallup.com/poll/1657/illegal-drugs.aspxhttps://news.gallup.com/poll/1657/ill
Egal-drugs.aspx
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 22
Ghasemiesfe, M., Ravi, D., Vali, M., Korenstein, D., Arjomandi, M., Frank, J., Austin, P.,
Keyhani, S. (2018). Marijuana use, respiratory symptoms, and pulmonary function.
Annals of Internal Medicine, 169(2), 106. https://doi:10.7326/m18-0522
Hancox, R. J., Poulton, R., Ely, M., Welch, D., Taylor, D. R., Mclachlan, C. R., . . . Sears, M. R.
(2009). Effects of cannabis on lung function: A population-based cohort study. European
Respiratory Journal,35(1), 42-47. https://doi:10.1183/09031936.00065009
Hancox, R. J., Shin, H. H., Gray, A. R., Poulton, R., & Sears, M. R. (2015). Effects of quitting
cannabis on respiratory symptoms. European Respiratory Journal, 46, 80-87.
https://doi:10.1183/09031936.00228914
Hernandez, M., Birnbach, D. J., & Van Zundert, A. A. J. (2005). Anesthetic management of the
illicit-substance-using patient. Current Opinion in Anaesthesiology, 18, 315-324.
https://doi:10.1097/01.aco.0000169241.21680.0b
Hernandez, M., Martinez, F., Blair, H., & Miller, W. (1981). Airway response to inhaled
histamine in asymptomatic long-term marijuana smokers. Journal of Allergy and Clinical
Immunology,67(2), 153-155. https://doi:10.1016/0091-6749(81)90011-7
Huson, H. B., Granados, T. M., & Rasko, Y. (2018). Surgical considerations of marijuana use in
elective procedures. Heliyon,4(9). https://doi:10.1016/j.heliyon.2018.e00779
Institute of Medicine, Division of Neuroscience and Behavioral Health. (1999). Marijuana and
medicine: Assessing the science base. Washington, DC: National Academy Press.
https://doi.org/10.17226/6376
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 23
Kempker, J., Honig, E., & Martin, G. (2015). The effects of marijuana exposure on expiratory
airflow. A study of adults who participated in the U.S. National Health and Nutrition
Examination Study. Annals of the American Thoracic Society,12(2), 135-141.
https://doi:10.1513/annalsats.201407-333oc
Klein, T.W., Friedman, H., Specter, S. (1998). Marijuana, immunity and infection. Journal of
Neuroimmunology, 83(1-2), 102-115. https://doi:10.1016/s0165-5728(97)00226-9.
Macleod, J., Robertson, R., Copeland, L., Mckenzie, J., Elton, R., & Reid, P. (2015). Cannabis,
tobacco smoking, and lung function: A cross-sectional observational study in a general
practice population. British Journal of General Practice,65(631).
https://doi:10.3399/bjgp15x683521
Mariani, J. J., Brooks, D., Haney, M., & Levin, F. R. (2011). Quantification and comparison of
marijuana smoking practices: Blunts, joints, and pipes. Drug and Alcohol
Dependence,113(2-3), 249-251. https://doi:10.1016/j.drugalcdep.2010.08.008
Moir, J., Rickert, W. S., Levasseur, G., Larose, Y., Maertens, R., White, P., Desjardins, S.
(2008). A comparison of mainstream and sidestream marijuana and tobacco cigarette
smoke produced under two machine smoking conditions. Chemical Research in
Toxicology, 21, 494-502. https://doi:10.1021/tx700275p
Morice, A.H., Fontana, G.A., Sovijarvi, M., Pistolesi, K.F., Chung, J., Widdicombe, F., …
Kastelik, J. (2004). The diagnosis and management of chronic cough. European
Respiratory Journal, 24(3), 481-492. https://doi:10.1183/09031936.04.00027804
National Academies of Sciences, Engineering, and Medicine. (2017). The health effects of
cannabis and cannabinoids: The current state of evidence and recommendations for
research. https://doi:10.17226/24625
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 24
National Conference of State Legislatures. (2019). Deep dive: Marijuana.
http://www.ncsl.org/bookstore/state-legislatures-magazine/marijuana-deep-dive.aspx
National Conference of State Legislatures. (2018). Marijuana overview.
http://www.ncsl.org/research/civil-and-criminal-justice/marijuana-overview.aspx
The National Institute on Drug Abuse Blog Team. (2015). History of cannabis, part 2.
https://teens.drugabuse.gov/blog/post/history-of-cannabis-part-2
National Institute of Health, United States Department of Health and Human Services, National
Heart, Lung, and Blood Institute. (2012). Asthma care quick reference: Diagnosing and
managing asthma. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-
management-of-asthma
Newmeyer, M. N., Swortwood, M. J., Abulseoud, O. A., & Huestis, M. A. (2017). Subjective
and physiological effects, and expired carbon monoxide concentrations in frequent and
occasional cannabis smokers following smoked, vaporized, and oral cannabis
administration. Drug and Alcohol Dependence,175, 67-76.
https://doi:10.1016/j.drugalcdep.2017.02.003
Pletcher, M. J., Vittinghoff, E., Kalhan, R., Richman, J., Safford, M., Sidney, S., . . . Kertesz, S.
(2012). Association between marijuana exposure and pulmonary function over 20 years.
Journal of the American Medical Association,307(2), 173.
https://doi:10.1001/jama.2011.1961
Roth, M. D., Arora, A., Barsky, S. H., Kleerup, E. C., Simmons, M., Tashkin, D. P. (1998).
Visual and pathologic evidence of injury to the airways of young marijuana smokers.
American Journal of Respiratory and Critical Care Medicine, 157, 928-937.
https://doi.org/10.1164/ajrccm.157.3.9701026
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 25
Russell, C., Rueda, S., Room, R., Tyndall, M., & Fischer, B. (2018). Routes of administration for
cannabis use – Basic prevalence and related health outcomes: A scoping review and
synthesis. International Journal of Drug Policy,52, 87-96.
https://doi:10.1016/j.drugpo.2017.11.008
Rygaard Hjorthoj, C., Rygaard Hjorthoj, A., Nordentoft, M. (2012). Validity of Timeline
Follow-Back for self-reported use of cannabis and other illicit substances - Systematic
review and meta-analysis. Addictive Behaviors, 37, 225-233.
https://doi:10.1016/j.addbeh.2011.11.025
Tan, W. C., Lo, C., Jong, A., Xing, L., Fitzgerald, M. J., Vollmer, W. M., . . . Sin, D. D. (2009).
Marijuana and chronic obstructive lung disease: A population-based study. Canadian
Medical Association Journal,180(8), 814-820. https://doi:10.1503/cmaj.081040
Tashkin, D. P., Baldwin, G. C., Sarafian, T., Dubinett, S., & Roth, M. D. (2002). Respiratory and
immunologic consequences of marijuana smoking. The Journal of Clinical
Pharmacology,42(S1). https://doi:10.1002/j.1552-4604.2002.tb06006.x
Tashkin, D., Shapiro, B., Lee, Y., & Harper, C. (1975). Effects of smoked marijuana in
experimentally induced asthma. American Review of Respiratory Disease,112, 377-386.
Tashkin, D. P., Simmons, M. S., & Tseng, C. (2012). Impact of changes in regular use of
marijuana and/or tobacco on chronic bronchitis. COPD: Journal of Chronic Obstructive
Pulmonary Disease, 9, 367-374. https://doi:10.3109/15412555.2012.671868
Tetrault, J. M., Crothers, K., Moore, B. A., Mehra, R., Concato, J., & Fiellin, D. A. (2007).
Effects of marijuana smoking on pulmonary function and respiratory complications.
Archives of Internal Medicine,167, 221-228. https://doi:10.1001/archinte.167.3.221
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 26
United States Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Center for Behavioral Health Statistics and Quality.(n.d.).
[Graphic data showing national statistics on drug use and health markers]. 2015 National
survey on drug use and health: Detailed tables.
https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2015-NSDUH
United States Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration. (n.d.). [Graphic data showing survey results regarding substance
use and mental health markers in the United States]. Key substance use and mental health
indicators in the United States: Results from the 2017 national survey on drug use and
health. https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report
Walden, N., & Earleywine, M. (2008). How high: Quantity as a predictor of cannabis-related
problems. Harm Reduction Journal, 5(1), 20. https://doi:10.1186/1477-7517-5-20
Wu, H., Wright, R., Sassoon, C., & Tashkin, D. (1992). Effects of smoked marijuana of varying
potency on ventilatory drive and metabolic rate. American Review of Respiratory
Disease,146(3), 716-721. https://doi:10.1164/ajrccm/146.3.716
Zhang, L., Morgenstern, H., Greenland, S., Chang, S., Lazarus, P., Teare, M., . . . Hung, R.
(2014). Cannabis smoking and lung cancer risk: Pooled analysis in the International Lung
Cancer Consortium. International Journal of Cancer,136(4), 894-903.
https://doi:10.1002/ijc.29036
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 27
Appendix
Smoked Cannabis Literature Review Matrix
AMA References Summary of Main Concept Database Study
Design and
Level of
evidence
(LOE)
Main Findings of the
Study
Capstone Application
Abdallah SJ, Smith BM,
Ware MA, Moore M, Li
PZ, Bourbeau J, Jensen D.
Effect of Vaporized
Cannabis on Exertional
Breathlessness and
Exercise Endurance in
Advanced Chronic
Obstructive Pulmonary
Disease. A Randomized
Controlled Trial. Annals
of the American Thoracic
Society.
2018;15(10):1146-1158.
doi:10.1513/annalsats.201
803-198oc.
Prior studies have described
bronchodilator properties of
cannabis. This study tested
whether single-dose inhaled
cannabis had any effect on
breathlessness (fev1) in pts
with COPD while they were
exercising.
12/18/18
Embase
RCT
n=16
LOE 2
There was no difference in
single-dose inhaled
cannabis vs placebo in
breathlessness (fev1) or
any tested parameter for
COPD pts during exercise
Single-dose admin is a
weakness of study but
could correlate to
dose-dependent effect
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 28
AHC MEDIA. Ethics and
Science, Cannabinoids
and Healthcare. Primary
Care Reports.
2018;24(1):1-N.PAG.
http://search.ebscohost.co
m.libproxy1.usc.edu/login
.aspx?direct=true&db=cc
m&AN=126986254&auth
type=sso&custid=s898398
4. Accessed December 18,
2018.
Potential for contamination
of products with pathogens
and/or pesticides. Whole-
plant cannabis and
concentrations have the
potential to be contaminated
with bacteria, molds, and
spores. Pesticides can be
pyrolysis, resulting in
toxicities. Many pesticides
are carcinogenic. Cannabis
can increase risk of infection
by direct physical damage of
respiratory cilia when
smoked as well as through
immunosuppressive
properties. Clinicians should
be concerned for respiratory
exacerbations in asthmatic
pts with COPD.
12/18/18
CINAHL
LOE 4 -Lack of healthcare
consensus on efficacy and
hazards of cannabis may
lead to uncertainty and
mistrust for many patients
who are cannabis users.
-Bias against cannabis
may affect physician-pt
relationship leading to
mistrust or mistreatment.
-Stigmatization of
cannabis may have
negative effects on care
provided.
Legal and ethical
concerns
Aldington, S., Harwood,
M., Cox, B., Weatherall,
M., Beckert, L., Hansell,
A., … Beasley, R.
Cannabis use and risk of
lung cancer: a case-control
study. European
Respiratory Journal.
2008; 31(2), 280–286.
https://doi.org/10.1183/09
031936.00065707
NZ study. Looks at males
<55, who had lung CA
diagnosis, then matched and
controlled for length and
frequency of use, also
tobacco use
12/20/18
Joanna
Briggs
via
PubMed
Case-
control
study
n=~400
LOE 3
The longer that Joint year
history the higher the
incidence of lung CA
Lung CA section
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 29
Aldington S, Williams M,
Nowitz M, et al. Effects of
cannabis on pulmonary
structure, function and
symptoms. Thorax.
2007;62(12):1058-1063.
doi:10.1136/thx.2006.077
081
NZ study. Compares
cannabis smokers, combined
tobacco & cannabis smokers,
and non-smokers PFTs, lung
density
1/5/19
Ref in
several
SRs
Convenienc
e sample
n=339
LOE=4-5
Cannabis smoking assoc c
hyperinflation and large
airway impairment; not
necessarily emphysema
PFT section
Baldwin GC, Tashkin DP,
Buckley DM, Park AN,
Dubinett SM, Roth MD.
Marijuana and Cocaine
Impair Alveolar
Macrophage Function and
Cytokine Production.
American Journal of
Respiratory and Critical
Care Medicine.
1997;156(5):1606-1613.
doi:10.1164/ajrccm.156.5.
9704146.
Little is known about
cannabis’ effects on the lung
microenvironment. Evaluated
the function of alveolar
macrophages (AMs)
recovered from the lungs of
nonsmokers and habitual
smokers of either tobacco,
marijuana, or crack cocaine.
AMs recovered from
marijuana smokers were
deficient in their ability to
phagocytose Staphylococcus
aureus (p < 0.01). AMs from
marijuana smokers and from
cocaine users were also
severely limited in their
ability to kill both bacteria
and tumor cells (p < 0.01).
4/3/19
Reference
from
Tashkin
article
Convenienc
e sample,
single non
experiment
al study
LOE 4
n=56
AMs from marijuana
smokers, but not from
smokers of tobacco or
cocaine, produced less
than normal amounts of
tumor necrosis factor-
granulocyte-macrophage
colony-stimulating factor,
and interleukin-6 when
stimulated in culture with
lipopolysacch. These
findings indicate that
habitual exposure of the
lung to either marijuana or
cocaine impairs the
function and/or cytokine
production of AMs.
Pulmonary immune
response to smoking
cannabis
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 30
Beaulieu, P. Anesthetic
implications of
recreational drug use. Can
J Anesth. 2017; 64: 1236-
1264.
Epidemiology & clinical
presentation of recreational
drug use & anesthetic
implications
Critical to obtain info about
pt drug use & other
associated tx in order to
construct an appropriate
anesthetic plan, including
specific considerations
during surgery, emergence,
& in PACU.
Scopus
7/1/2018
Review
S/sx: (acute vs cx)
Periop approach
(interview/labs)
3 areas intraop
management: managing
intoxication,
preventing/treating
withdrawal, achieving
adequate recovery &/or
analgesia
Perioperative approach
to patients with
cannabis addiction
Biehl JR, Burnham EL.
Cannabis smoking in
2015. Chest.
2015;148(3):596-606.
doi:10.1378/chest.15-0447
Epidemiological study
reporting effects of inhaled
MJ in review
format. Includes synopsis of
MJ plant and contents,
studies showing pulmonary
effects of inhaled MJ,
weakness in research and
areas for improvement
12/27/18
Embase
LOE 1-2?
Review?
Lists pulmonary health
implications and potential
areas to be studied for a
more complete picture
Great brief summary
of pulm implication,
discusses methods in
inhalation
Bryson EO, Frost EAM.
The perioperative
implications of tobacco,
marijuana, and other
inhaled toxins.
International
Anesthesiology Clinics.
2011;49(1):103-118.
doi:10.1097/AIA.0b013e3
181dd4f53.
-Increased coughing, sputum,
occasional wheezing.
Increased risk for lung
cancer, possibly from deep
inhalation and breath
holding, 5x exposure to
carboxyhemoglobine.
CINAHL
12/18/18
Review
Article
LOE 5
-Increased induction dose
of propofol for LMA
placement. One case
report of airway
hyperreactivity 4h post
cannabis use.
Not applicable.
Lacking scientific
support and frequent
bias.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 31
Callaghan RC, Allebeck
P, Sidorchuk A. Marijuana
use and risk of lung
cancer: a 40-year cohort
study. Cancer Causes &
Control.
2013;24(10):1811-1820.
doi:10.1007/s10552-013-
0259-0
Nearly 50k Young Swedish
men tracked for 40 yrs, 10%
reg used MJ, 1.7%
categorized as heavy users
12/20/18
Embase
Population-
based
Cohort
study
n= ~50,000
LOE 3
Heavy use resulted in
twofold increase in rate of
lung CA
Lung CA section
Caponnetto P, Auditore R,
Russo C, et al.
“Dangerous
Relationships”: Asthma
and Substance Abuse.
Journal of Addictive
Diseases. 2013;32(2):158-
167.
doi:10.1080/10550887.20
13.795469.
Cannabis users require more
healthcare due to chronic
respiratory conditions from
cannabis use. They speculate
it causes more issues in the
asthmatic.
CINAHL
12/18/18
Review
Article
LOE 5
Would have to look at the
literature they cited to
verify cannabis smoking’s
effect on asthma.
Not applicable.
Minimal info on
cannabis use and
asthma. Sites a few
studies that could be
useful 16, 26, 28, 29
Chatkin JM, Zabert G,
Zabert I, Chatkin G, et al.
Lung disease associated
with marijuana use. Arch
Bronconeumol. 2017; 53
(9): 510-515.
MJ use and lung disease.
Available evidence is still
inconclusive and many
aspects need confirmation or
further studies.
PubMed
12/18/18
Review
Calculating exposure can’t
be used to estimate effects
on health
Recreational use of MJ is
not free of risks
Epidemiology
Pharmacology
Health Effects
Respiratory infections
Lung function &
COPD
Respiratory Symptoms
Lung Cancer
Bullous Disease,
pneumothorax,
pneumomediastinum,
barotrauma
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 32
Chatkin JM, Zani-Silva L,
Ferreira I, Zamel N.
Cannabis-associated
asthma and allergies.
Clinical Reviews in
Allergy & Immunology.
2017.
doi:10.1007/s12016-017-
8644-1
Review of effects of cannabis
on asthma and allergies.
Embase
LOE 1
Review
Mixed results however
sufficient evidence that
ppl with asthma should
avoid inh MJ
Asthma and
allergies. Also great
source of
demographics and
statistics. Or map to
original sources
Decuyper II, Faber MA,
Sabato V, et al. Where
there's smoke, there's fire:
Cannabis allergy through
passive exposure. Journal
of Allergy and Clinical
Immunology.In Practice.
2017;5(3):864-
865.doi.org.libproxy1.usc.
edu/10.1016/j.jaip.2016.1
0.019.
Case study of 2 non-cannabis
users with h/o cannabis
exposure conducted by skin-
prick and multi- IgE testing
with questionnaires/physical
assessments
1/5/19
Stem
from
Chatkin
Letter to
Editor/2
case studies
LOE 5
Even passive exposure to
cannabis (second hand)
can result in sensitization
and allergy; correlation of
cannabis allergy with food
allergies
Allergy conversation,
referenced work of
prolific allergy author.
Prob a good source for
other research from
same author.
Ebo DG, Swerts S, Sabato
V, et al. New food
allergies in a european
non-mediterranean region:
Is cannabis sativa to
blame? Int Arch Allergy
Immunol.
2013;161(3):220-8.
doi.org.libproxy1.usc.edu/
10.1159/000346721.
A case-control study
involving 21 patients
consulting for plant food
allergies. Twelve patients
were cannabis allergic and 9
had a pollen or latex allergy
without cannabis allergy.
Skin tests and IgE were
correlated with cannabis use
and allergy.
1/5/19
Stem
from
chatkin
Case
control
n=21
Cannabis use may
increase or induce allergic
sensitivity which may
cause cross-sensitivity and
increased reaction to
foods, alcohol, and latex
Allergy
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 33
Gates P, Jaffe A,
Copeland J. Cannabis
smoking and respiratory
health: Consideration of
the literature. Respirology.
2014;19(5):655-662.
doi:10.1111/resp.12298
Review of pulmonary
implications of inhaled
MJ. Not a SR or meta-
analysis but contains
significant supporting data.
Also addresses difficulties
with studies such as how to
control for dosing, variable
routes of inhalation, and
concurrent cigarette smoking
12/27/18
Embase
Level 1-2
Review
Covers pathophysiology,
gen lung health implic incl
bronchitis, and lung ca
Good possible guide
and source of level 1
studies
Gaeta TJ, Hammock R,
Spevack TA, Brown H,
Rhoden K. Association
between Substance Abuse
and Acute Exacerbation of
Bronchial Asthma.
Academic Emergency
Medicine.
1996;3(12):1170-1172.
doi:10.1111/j.1553-
2712.1996.tb03386.x
Letter to the editor describing
a convenience sampling of
ED pts presenting with
bronchoconstriction. Not
matched or controlled by
type of inhaled drug. This
article cited as evidence that
MJ causes asthma by
Caponetto
stem
Level 5
Letter to
editor
Authors conclude that
because they found a stat
signif percentage of
substance inhalers
presenting with
bronchospasm that these
subst incl MJ cause
bronchospasm and asthma
Cited as source for MJ
causing asthma
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 34
Ghasemiesfe M, Ravi D,
Vali M, et al. Marijuana
Use, Respiratory
Symptoms, and
Pulmonary Function: A
Systematic Review and
Meta-analysis. Annals of
Internal Medicine.
2018;169(2):106-115.
doi:10.7326/M18-0522.
-Current marijuana smoking
is associated with chronic
cough, sputum production,
and wheezing. Some data
supports increasing dyspnea
with longer duration of use.
-Marijuana users are at
increased risk for bronchitis.
-Ten studies found no change
in FEV1 with high quality
data and adjustment of
confounders adequate.
Neither intermittent or
continuing marijuana users
had a significant decrease in
FEV1. Many studies report
FEV1 for marijuana and
tobacco users together,
limiting interpretation and
generalizability.
-Most studies assessing
FEV1-FVC ratio had
significant limitations but
demonstrate no association
between marijuana use and
decreased FEV1-FVC ratio.
12/18/18
CINAHL
Systematic
review and
meta-
analysis.
LOE 1
-Marijuana smokers have
increased risk for chronic
cough, sputum, wheezing.
-Dyspnea increases with
joint-years.
-Mixed results with risk of
bronchitis.
-Most data supports no
change in FEV1. Multiple
limitations in data and
confounding tobacco use.
-Most larger, higher
quality studies report
increase in FVC.
-Mixed data on reductions
in FEV1-FVC ratio,
stronger evidence supports
decreased ratio.
-Current marijuana users
report increased incidence
of respiratory illnesses.
Pulmonary data useful
for proposal and paper
Cx bronchitis
Dyspnea
FEV1, FVC,
FEV1/FVC ratio
Airway resistance
Airway conductance
(flow)
Airway reactivity
Respiratory Symptoms
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 35
Gordon AJ, Conley JW,
Gordon JM. Medical
consequences of
marijuana use: a review of
current literature. Curr
Psychiatry Rep.
2013;15(419). https://doi-
org.libproxy1.usc.edu/10.
1007/s11920-013-0419-7.
Review of multi-system
effects of cannabis
consumption
1/6/19
Stem
from
Chatkin
SR of
research
from 200 to
2013
Possible resource if we
choose to expand to
multi systems. Also
gives general
summary in pulm
section
Hancox RJ, Poulton R,
Ely M, et al. Effects of
cannabis on lung function:
a population-based cohort
study. European
Respiratory Journal.
2010;35(1):42-47.
doi:10.1183/09031936.00
065009
NZ study comparing
cannabis smokers and
tobacco smokers. Looked at
symptomatology, PFT
changes, CO levels.
-Cannabis use was associated
with higher lung volumes,
suggesting hyperinflation and
increased large-airways
resistance, but there was little
evidence for airflow
obstruction or impairment of
gas transfer.
1/5/19
Stem
from
Chatkin
Cohort
study
n=1037
Cumulative cannabis use
was associated with higher
FVC, TLC, FRC and
FRV. Cannabis was also
associated with higher
airway resistance but not
FEV1, forced expiratory
ratio or transfer factor.
These findings were
similar among those who
did not smoke tobacco.
-Tobacco use was
associated with lower
FEV1, lower forced
expiratory ratio, lower
transfer factor and higher
static lung volumes, but
not with airway resistance.
PFTs
CO/parenchymal
effects
Increased secretions,
cough section as cited
in Chatkin not found
Airway resistance
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 36
Hancox RJ, Shin HH,
Gray AR, Poulton R,
Sears MR. Effects of
quitting cannabis on
respiratory symptoms. Eur
Respir J. 2015; 46: 80-87.
doi:
10.1183/09031936.00228
914
Frequent cannabis smoking is
associated with symptoms of
bronchitis, independent of
tobacco use.
Reduction or quitting use
reduces respiratory
symptoms.
CINAHL
4/6/2019
Observatio
nal cohort
n= 1037
LOE 3
Frequent cannabis use was
associated with morning
cough, sputum production,
and wheeze.
Reducing or quitting
cannabis use was
associated with reductions
in the prevalence of
cough, sputum, and
wheeze to levels similar to
nonusers.
Respiratory Symptoms
Smoking cessation
Dose-dependence
Hasin DS. US
epidemiology of cannabis
use and associated
problems.
Neuropsychopharmacolog
y. 2018; 43: 195-212.
Epidemiology of cannabis
use and associated problems
in US
Implications for clinicians,
policy makers, and public are
considered, and future
research directions are
suggested.
Scopus
12/28/18
Review
MJ increasingly viewed as
harmless. Potential harms
are listed. National
increases in MJ potency.
MJ is being substituted for
opiods
Epidemiology
Hernandez M, Birnbach
DJ, Van Zundert AAJ.
Anesthetic management of
the illicit-substance-using
patient. Current Opinion
in Anaesthesiology. 2005;
18: 315-324.
Anesthetic management of
illicit-substance-using patient
Reviews effects on organ
systems & some tips for
providing anesthesia for
these pts.
Scopus
8/26/18
Review
Although acute toxicity or
major anesthesia
interactions from MJ are
rare, every system is
affected by its use and its
clinical picture is
unpredictable.
Anesthetic
considerations with
marijuana use
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 37
Hernandez M, Martinez F,
Blair H, Miller W. Airway
response to inhaled
histamine in
asymptomatic long-term
marijuana smokers.
Journal of Allergy and
Clinical Immunology.
1981;67(2):153-155
Bronchial challenge with
histamine was used to assess
bronchial reactivity in
asymptomatic individuals
who were long-term social
smokers of marijuana. Their
reactivity was compared to
that of nonsmokers and
asthmatics.
PubMed
Cohort
study
n=23
Spirometry results were
normal in the marijuana
users. There was no
significant difference in
bronchial reactivity
between marijuana
smokers and nonsmoking
controls, whereas the
asthmatics demonstrated
the expected
hyperreactivity. These
observations suggest that
customary social use of
marijuana may not
produce abnormalities in
airway function detectable
by spirometry or
bronchoprovocation.
Asthma
Hunault CC, Eijkeren
JCV, Mensinga TT, Vries
ID, Leenders ME,
Meulenbelt J. Disposition
of smoked cannabis with
high Δ9-
tetrahydrocannabinol
content: A kinetic model.
Toxicology and Applied
Pharmacology.
2010;246(3):148-153.
doi:10.1016/j.taap.2010.0
4.019
Experimental design seeking
to establish a
pharmacokinetic model for
inhaled high-concentrations
of THC mixed c tobacco.
Embase
Experiment
al
Two compartment
model. Kinetics close to
linear. Discusses
metabolites and
metabolism.
May be useful if we
need to discuss serum
concentrations or PK
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 38
Huson HB, Granados TM,
Rasko Y. Surgical
considerations of
marijuana use in elective
procedures. Heliyon.
2018;4(9).
doi:10.1016/j.heliyon.201
8.e00779.
Main respiratory concept:
Inhalation peak effect in
15m, Duration: dose-
dependent 4h.
Cognitive/psychomotor
effects can last up to 24h.
Highly lipid soluble,
elimination may take 30d.
Low doses: increased
sympathetic activity; high
doses: increase
parasympathetic activity.
Cannabis causes a 5 fold
increase in
carboxyhemoglobin,
decreasing oxygen supply.
Increased risk of chronic
bronchitis 10 year younger
age, increased wheezing,
SOB, phlegm, cough. 3-4
cannabis cigarettes = 20
tobacco cigarettes in terms of
bronchial damage. Increases
lung cancer risk. Drug
synergism or cross-tolerance.
THS depletes acetylcholine
stores and exerts an
anticholinergic effect.
Cessation prior to surgery
may decrease risk of
complications.
Web of
science
11/11/18
Review
Article
LOE 4
1. How is marijuana
screened preop.
2. What are potential
complications periop for
marijuana use.
3. How should surgeons
address marijuana use and
elective surgery.
4. Are marijuana's effects
different from tobacco.
Most common to smoke
cannabis unfiltered =
increased carcinogens,
irritants and tar in upper
airways with 3 fold
increased in tar inhalation
and ⅓ more tar deposits in
the cannabis user over
filtered tobacco user. Most
cannabis users attempt to
maximize THC absorption
by increasing puff volume
by ⅔, increasing
inhalation depth by ⅓, and
4 fold longer breath
holding than tobacco
users, leading to an
increased exposure and
concentration of
benzantharcenes and
benzopyrenes
(carcinogens).
A lot of good material.
I’ve listed the
respiratory material
but if we expand, there
is a lot of good info.
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 39
Institute of Medicine,
Division of Neuroscience
and Behavioral Health.
Marijuana and
medicine: Assessing the
science base. Washington,
DC: National Academy
Press; 1999.
Executive Summary:
summarizes and analyzes
what is know about medical
use of MJ; EBP
Effects of isolated
cannabinoids; Risks of
medical MJ use; Evaluation
of smoked MJ
PubMed
3/6/19
Review The accumulated data
suggest a variety of
indications (pain relief,
antiemesis, appetite
stimulation)
Harmful substance
delivered to body in
addition to THC and
cannabinoids
Cannabinoid biology
Risks of MJ use
Medical use
Prospects of drug
development
Jett J, Stone E, Warren G,
Cummings KM. Cannabis
Use, Lung Cancer, and
Related Issues. Journal of
Thoracic Oncology.
2018;13(4):480-487.
doi:10.1016/j.jtho.2017.12
.013
Smoking cannabis is
associated with increased
chronic bronchitis, cough,
sputum production and
histologic lung changes.
CINAHL
12/18/18
Review
Article
LOE 4
Current evidence does not
suggest an association
with lung cancer and
cannabis smoking. Studies
were relatively small with
individuals who were
heavy, chronic users.
Chronic bronchitis
Histologic lung
changes
Lung cancer
Karam K, Abbasi S, Khan
FA. Anaesthetic
consideration in a
cannabis addict. Journal
of the College of
Physicians and Surgeons
Pakistan. 2015; 25
(special supplement 1):
S2-S3.
Case Study: 20 yr hx
smoking cannabis & tobacco
Scopus
8/27/18
Case
Report
LOE 5
Increased narcotic
requirement
No change in propofol
dose
Anecdotal report,
author seems biased,
not appropriate
Excluded
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 40
Kempker JA, Honig EG,
Martin GS. The effects of
marijuana exposure on
expiratory airflow. A
study of adults who
participated in the U.S.
National Health and
Nutrition Examination
Study. Annals of the
American Thoracic
Society. 2015;12(2):135-
141.
doi:10.1513/AnnalsATS.2
01407-333OC.
Current MJ Use on
Respiratory Health
-Mj cigarette smoking in the
last 30 days: 0, 1-5, 6-20, >
20.
-Trends toward increases in
reported bronchitis
symptoms and respiratory
illness for increasing mj use:
cough, cold, phlegm, or
respiratory illness in the
previous 7 days (16.9%,
22.4%, 26.1%, 24%
respectively). Those
reporting flu, pneumonia, ear
infection (3.9%, 4.7%, 4.8%,
5.1%).
-Multivariable regression
controlling for age, sex, race,
tobacco use and presence of
asthma, emphysema, and
chronic bronchitis, frequency
of mj use was associated with
changes in spirometric
parameters. No change in
percent predicted FEV1,
associated increase in percent
predicted FVC P=0.0001,
and decrease in FEV1/FVC
ratio P < 0.0001.
CINAHL
12/18/18
Cross
section
(survey
cycles from
2007-2010)
N = 2,956
LOE 3
-Current mj smokers are
more likely to report
respiratory symptoms or
report illness but have
little clinically significant
associated changes in
spirometry.
-With mj, the decreased
FEV1/FVC is driven by
increasing FVC where
tobacco it is driven by a
relatively larger decrease
in FEV1 compared with
FVC.
-Table 2 suggests that,
tobacco smokers with >
20py, increasing mj
exposure seems to have a
protective effect on FEV1
and likewise to mj
smokers with 20jy, the
deleterious effects of
increasing tobacco
exposure on FEV1 seems
to be diminished.
Yes for spirometry
findings and
respiratory symptoms
Primary spirometry
outcomes FEV1, FVC,
FEV1/FVC-
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 41
Klein TW, Friedman H,
Specter S. Marijuana,
immunity and infection.
Journal of
Neuroimmunology.
1998;83(1-2):102-115.
doi:10.1016/s0165-
5728(97)00226-9.
Cannabinoid effects on
immune cell function
modulate host resistance to
various infectious agents.
Studies suggest that
cannabinoids modulate host
resistance, especially the
secondary immune response.
A major area of host
immunity and cannabinoids
is involving drug effects on
the cytokine network.
4/1/19
From
Tankish
article
Review
article
LOE 4
In vivo and in vitro
models, it has been
determined that
cannabinoids modulate the
production and function of
acute phase and immune
cytokines as well as
modulate the activity of
network cells such as
macrophages. Under
certain conditions,
cannabinoids can be
immunomodulatory and
enhance the disease proc.
Cannabis and immune
response
Lee MH, Hancox RJ.
Effects of smoking
cannabis on lung function.
Expert Review of
Respiratory Medicine.
2011;5(4):537-547.
doi:10.1586/ers.11.40
Examines short-term effects
of smoking cannabis on lung
function, Evaluates the long-
term effects of cannabis use
on lung function, Describe
the effects of cannabis use in
promoting emphysema and
lung bullae, Analyzes the
effects of cannabis use on the
risk for cancer
Embase
LOE 1
SR
SR summary of
deleterious pulm effects of
MJ inhalation: large
airway inflammation,
emphysema, bullae
Highlights deviation from
PFT effects of tobacco
Good arguments to
differentiate btwn
cannabis and tobacco
inhalation
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 42
Lucas CJ, Galettis P,
Schneider J. The
pharmacokinetics and the
pharmacodynamics of
cannabinoids. British
Journal of Clinical
Pharmacology.
2018;84(11):2477-2482.
doi:10.1111/bcp.13710.
High Vd for inhaled:
3.4L/kg.
Metabolism predominantly
hepatic via cytochrome P450.
There is further hepatic
metabolism and subsequent
fecal and lesser extent
urinary excretion of
metabolites.
Elimination half-life: initial
fast ~6m; long: 22h. Latter
influenced by equilibration
between lipid storage and
blood compartments. A
relatively longer elimination
half-life is observed in heavy
users, attributable to slow
redistribution from deep
compartments such as fatty
tissues. Serum THC
concentrations > 1mcg/L
may be measurable in heavy
users > 24h after last use.
Web of
science
11/11/18
Review
article
LOE 4
Most data
available
was
obtained
from
studies
with
healthy
volunteers
or cannabis
users.
With chronic use,
cannabinoids may
accumulate in adipose
tissue. Subsequent release
and redistribution may
result in the persistence of
cannabinoid activity for
several weeks post admin.
Cannabis use can induce
or inhibit enzyme
pathways, disrupting
metabolism.
Cannabis produces
sedation, concomitant
administration with
sedatives or hypnotics can
potentiate central effects.
Cannabis can induce
tachycardia and
hypertension with
coadmin of meth, cocaine,
atropine or other
sympathomimetics.
Background
information on
pharmacokinetics and
pharmacodynamics of
cannabinoids
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 43
Macleod J, Robertson R,
Copeland L, McKenzie J,
Elton R, & Reid P.
Cannabis, tobacco
smoking, and lung
function: a cross-sectional
observational study in a
general practice
population. British
Journal of General
Practice. 2015; e89- e95.
Investigated association
between tobacco-only
smoking compared w/
tobacco plus MJ smoking &
adverse outcomes in
respiratory health & lung fxn
PubMed
11/3/18
Cross-
sectional
observation
al study
LOE 3
n= 500
Cannabis & tobacco use
together was associated
with increased cough,
sputum production, &
wheeze.
After adjustment for
tobacco use, age, sex, &
deprivation, each
additional joint-year of
cannabis was associated
with 0.3% increase in
prevalence of an
FEV1/FVC < 70%.
Respiratory Symptoms
Pulmonary Function
Tests
Mariani J, Brooks D,
Haney M, Levin F.
Quantification and
comparison of marijuana
smoking practice: Blunts,
joints, and pipes. Drug
and Alcohol Dependence.
2011;113(2-3), 249-251.
doi:10.1016/j.drugalcdep.
2010.08.008
Compared the quantity of
cannabis used among users
of blunts, joints, and pipes
enrolled. Surrogate substance
were used to represent
marijuana to enable
participants to estimate the
amount of cannabis used
5/24/19
CINAHL
RCT
N = 251
LOE
Blunts = 1.5 x the amount
of cannabis as joints.
Yes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 44
Marsot A, Audebert C,
Attolini L, Lacarelle B,
Micallef J, Blin O.
Population
pharmacokinetics model
of THC used by
pulmonary route in
occasional cannabis
smokers. Journal of
Pharmacological and
Toxicological Methods.
2017;85:49-54.
doi:10.1016/j.vascn.2017.
02.003
Occasional cannabis smokers
studied to examine
pharmacokinetics of THC
(inhaled)
12/20/18
Embase
Observatio
nal study
n=12
LOE 3-4
3 compartment model
First-order elimination
Description of dose-
dependent serum
concentrations
Effect on ALT
Some info for
background,
importance
Also valuable if we
need to support PK
McKernan K, Spangler J,
Zhang L et al.Cannabis
microbiome sequencing
reveals several mycotoxic
fungi native to dispensary
grade Cannabis flowers
[version 2; referees: 2
approved].
F1000Research 2016,
4:1422
(https://doi.org/10.12688/f
1000research.7507.2)
Cannabis flower is required
to be tested for potency and
bacteria pre-dispension
Embase
12/20/18
RCT? Fungal spores are detected
by microbiome
sequencing
Current standard is
culturing which does not
detect fungi
Mycotoxin and
aspergillis infections
have been traced to
cannabis inhalation
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 45
McGraw MD, Houser GH,
Galambos C, Wartchow
EP, Stillwell PC, &
Weinman JP. Marijuana
medusa: the many
pulmonary faces of
marijuana inhalation in
adolescent males.
Pediatric Pulmonology.
2018; 53: 1619-1626.
(doi: 10.1002/ppul.24171)
Highlights variety of severe
pulmonary presentations in
adolescents following recent
MJ inhalation
Absence of literature r/t
interstitial lung disease
secondary to MJ inhalation;
even fewer focus on effects
of adolescent lung function
Case series of 3 adolescents
w/ bilateral pulmonary
nodules and ground glass
opacities with recent MJ
inhalation.
PubMed
12/18/18
Case Series
n = 3
Level 5
2 of 3 pts presented with
ARDS, adt to ICU w/
significant hypoxemia
2 cases of silica-induced
pneumoconiosis
1 case of acute
hypersensitivity
pneumonitis
Improved lung function
after cessation 2 of 3 (3rd
didn’t quit)
Implications of
various inhalation
methods/delivery
devices (dabbing &
juuling)
Interstitial lung
disease
Improvements after
cessation
Moir D, Rickert WS,
Levasseur G, et al. A
Comparison of
Mainstream and
Sidestream Marijuana and
Tobacco Cigarette Smoke
Produced under Two
Machine Smoking
Conditions. Chemical
Research in Toxicology.
2008;21(2):494-502.
doi:10.1021/tx700275p.
chemistry of marijuana
smoke, especially in direct
comparison to tobacco
smoke. A systematic
comparison of the smoke
composition of mainstream
and sidestream smoke from
marijuana and tobacco
cigarettes prepared in the
same way and consumed
under two sets of smoking
conditions. examined
chemicals routinely analyzed
in tobacco smoke
3/29/19
From Jett
article
review
LOE 3
Control
trial
without
randomizati
on
Qualitative similarities
with some quantitative
differences. Ammonia was
found in mainstream
marijuana smoke at levels
up to 20-fold greater than
that found in tobacco.
Hydrogen cyanide, NO,
NOx, and some aromatic
amines were found in
marijuana smoke at
concentrations 3–5 times
those found in tobacco
smoke.
Differences in
cannabis and tobacco
cigarettes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 46
Morice AH, Fontanta GA,
Sovijarvi M, et al. The
diagnosis and
management of chronic
cough. Eur Respir J.
2004; 24: 481-492.
doi: 10.1183/09031936.0
4.00027804
European Respiratory
Society Guidelines
The key to successful
management is to establish a
dx & tx the cause of cough.
There are 3 common causes
of cx cough that arise from 3
different anatomical areas
CINAHL
4/2019
Review Most cx cough is
treatable, provided
characteristic features of 3
key causes (asthma,
reflux, rhinitis)are
recognized
Management strategy
Chronic cough
H&P, questions, tests,
therapies
Muniyappa, R., Sable, S.,
Ouwerkerk, R., Mari, A.,
Gharib, A., Walter, M.,
Courville, A., Hall, G.,
Chen, K., Volkow, N.,
Kunos, G., Huestis, M.
and Skarulis, M. (2013).
Metabolic Effects of
Chronic Cannabis
Smoking. Diabetes Care,
36(8), pp.2415-2422.
Cannabinoid receptors and
their endocannabinoids play
an important role in
regulating energy, appetite,
insulin sensitivity, pancreatic
beta cell function and lipid
metabolism.
Web of
science
11/14/18
LOE 4
Cross
sectional,
case
controlled
Chronic cannabis smoking
is associated with hepatic
steatosis, insulin
resistance, reduced beta
cell function and
dyslipidemia in healthy
individuals.
No respiratory content.
Metabolic effects of
cannabis smoking.
National Academies of
Sciences, Engineering,
and Medicine. 2017. The
health effects of cannabis
and cannabinoids: The
current state of evidence
and recommendations for
research. Washington,
DC: The National
Academies Press. Doi:
10.17226/24625.
Nationally conducted SR and
official position statements
broken down by subtopic re
MJs effects on body systems
Stem SR MJ does not cause asthma
Probably doesnt cause
lung CA...
Recent and relevant in
most pulmonary
subheadings
Great guide to original
sources
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 47
National Institute of
Health, United States
Department of Health and
Human Services, National
Heart, Lung, and Blood
Institute. Asthma care
quick reference. Retrieved
from
https://www.nhlbi.nih.gov
/files/docs/guidelines/asth
ma_qrg.pdf. Published
2012. Accessed April 10,
2019.
Clinician reference for
diagnosis and treatment of
asthma
NA Provides nationally
recognized definition
of asthma
Newmeyer MN,
Swortwood MJ,
Abulseoud OA, Huestis
MA. Subjective and
physiological effects, and
expired carbon monoxide
concentrations in frequent
and occasional cannabis
smokers following
smoked, vaporized, and
oral cannabis
administration. Drug and
Alcohol Dependence.
2017;175:67-76.
doi:10.1016/j.drugalcdep.
2017.02.003.
Double-blind RCT
examining subjective and
physiologic effects (CO
levels) in occasional vs
chronic cannabis consumers
in PO, smoked, and
vaporized cannabis.
12/18/18
Embase
RCT
n=20
LOE 2
Smoked cannabis yielded
signif higher CO levels
May provide good
illustration of benefit
of vaporizing vs
smoking
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 48
Nugent SM, Morasco BJ,
O’Neil ME, et al. The
Effects of Cannabis
Among Adults With
Chronic Pain and an
Overview of General
Harms: A Systematic
Review. Annals of
Internal Medicine.
2017;167(4):N.PAG.
doi:10.7326/M17-0155.
-2 moderate strength cohort
control studies suggest low
levels of cannabis smoking
do not adversely affect lung
function over 20 years.
CINAHL
12/18/18
Systematic
Review
LOE 1
Some show daily use may
have adverse pulmonary
effects over long period.
Minimal respiratory
adverse effects, other
effects for mental
health and safety listed
Ocampo TL, Rans TS.
Cannabis sativa: the
unconventional “weed”
allergen. Annals of
Allergy, Asthma &
Immunology.
2015;114(3):187-192.
doi:10.1016/j.anai.2015.0
1.004
Compilation of studies
related to cannabis allergy
1/6/19
Stem
from
Chatkin
Covers allergic
components of cannabis,
methods of exposure,
resultant potential cross-
sensitivities
Allergy section
resource
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 49
Pletcher MJ, Vittinghoff
E, Kalhan R, et al.
Association between
marijuana exposure and
pulmonary function over
20 years. JAMA: Journal
of the American Medical
Association.
2012;307(2):173-181.
doi:10.1001/jama.2011.
-Median intensity of tobacco
use was substantially higher
8-9 cigarettes/day than
median intensity of
marijuana smokers 2-3
episodes/30 days.
-only 91 participants had no
tobacco exposure and more
than 10 joint years. 40
participants had more than 20
joint years. Contributing to
153 observations of
pulmonary function.
-Fev1 and FVC varied across
participants, increased
slightly with age through the
late 20s and declined slowly
thereafter.
-Tobacco users have
significantly lower FEV1 and
FVC in use dependent
fashion.
-Marijuana users, both
current and lifetime, was
associated with higher FEV1
and FVC as lifetime
exposure is increased up to
10 joint years or up to 20
smoke episodes/30 days then
declines.
12/18/18
CINAHL
LOE 3
longitudina
l. Repeated
measures
of tobacco
and
marijuana
smoking
and
pulmonary
function.
- n=5115
-FEV1 and FVC increase
in marijuana smokers.
-With 10 lifetime joint
years, there is a
nonsignificant decline in
FEV1. At more than
20jt/30days, a significant
use dependent decline in
FEV1 is seen. However
FVC remains higher in
heavy users.
-Less than 7 jt years
lifetime exposure, see no
adverse effects on
pulmonary function,
higher FEV1 and FVC.
-Insufficient numbers of
heavy users to confirm
detrimental effects of
marijuana.
Yes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 50
Ribeiro LI, Ind PW. Effect
of cannabis smoking on
lung function and
respiratory symptoms: A
structured literature
review. npj Primary Care
Respiratory Medicine.
2016;26(1).
doi:10.1038/npjpcrm.2016
.71
Compilation of up to date
study results re inhaled
cannabis. In-depth review of
PFT related studies, airway
reactivity, effect of quitting
smoking, lung CA
Embase
LOE 1 Mixed reports inmost area,
however
strengths/weaknesses
discussed, major details
given for each study
Very thorough 2016
SR. Could def guide
our report.
Ribeiro L, Ind PW.
Marijuana and the lung:
hysteria or cause for
concern? Breathe. 2018;
14: 196-205.
Reviews current evidence,
highlighting differences
between MJ & tobacco
smoking
Detailed inhalational drug
history should be part of
standard assessment in both
primary and secondary care.
PubMed
12/18/18
Review Long-term respiratory
effects of MJ differ from
tobacco smoking
Cx MJ use is associated
with cx bronchitis but an
increase in FVC w/ no
change in FEV1 and not
w/ COPD.
Reducing or eliminating
cannabis smoking benefits
those suffering from
cough & phlegm
Pharmacology
Increased MJ use
Epidemiology
Chronic respiratory
effects
Symptoms
Lung Function
Acute airway effects
of cannabis
Bullous diseases
Lung Cancer
Pneumonia
Interstitial disease
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 51
Roth, MD, Arora, A,
Barsky, SH, Kleerup, EC,
Simmons, M, Tashkin,
DP. Visual and pathologic
evidence of injury to the
airways of young
marijuana smokers. Am. J.
Respir. Crit. 1998;157:
928-937.
Forty healthy young subjects,
ages 20 to 49 yr, underwent
videobronchoscopy, mucosal
biopsy, and bronchial lavage
to evaluate the airway
inflammation produced by
habitual smoking of
marijuana and/or tobacco.
Videotapes were graded in a
blinded manner for central
airway erythema, edema, and
airway secretions using a
modified visual bronchitis
index. The bronchitis index
scores were significantly
higher in marijuana smokers
(MS), tobacco smokers (TS),
and in combined
marijuana/tobacco smokers
(MTS), than in nonsmokers
(NS).
4/2/19
Tashkin
article
LOE 4
n=40
Biopsies were positive for
two of these criteria in
97% of all smokers and
for three criteria in 72%.
None of the biopsies from
NS exhibited greater than
one positive finding.
Regular smoking of
marijuana by young adults
is associated with
significant airway
inflammation that is
similar in frequency, type,
and magnitude to that
observed in the lungs of
tobacco smokers
Yes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 52
Ruchlemer R, Amit-Kohn
M, Raveh D, Hanuš L.
Inhaled medicinal
cannabis and the
immunocompromised
patient. Supportive Care
in Cancer.
2014;23(3):819-822.
doi:10.1007/s00520-014-
2429-3
Cannabis contains bacteria
and fungus which lead to
incidence of bacterial and
fungal infections, primarily
aspergillus. For the
immunocompromised pt
cannabis is beneficial but
how can you reduce or
remove the risk of infection
while maintaining
potency? This experimental
study sampled oil and flower
for bacterial and fungal
content. Then it tested
different methods of
sterilization including
vaporization.
Embase
Experiment
al
study/repor
t
Flower and oil contain
bacteria and fungal spores;
flower>oil. Plasma
sterilization is the best
way to kill them s losing
potency.
??? Bacterial infection
and aspergillus
Russell C, Rueda S, Room
R, Tyndall M, Fischer B.
Routes of administration
for cannabis use - basic
prevalence and related
health outcomes: A
scoping review and
synthesis. International
Journal of Drug Policy.
2018;52:87-96.
doi:10.1016/j.drugpo.2017
.11.008.
Routes of admin for cannabis
are increasingly diversified in
part by increased
legalization. Review of
health outcomes associated
with different routes of
administration of cannabis.
CINAHL
12/18/18
LOE 5
Review
article
ROA distinctly influence
health outcomes from
cannabis use. Vaporizers
and edibles may offer
potential for reduced
health risks.
Yes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 53
Rygaard Hjorthoj C,
Rygaard Hjorthoj A,
Nordentoft M. Validity of
Timeline Follow-Back for
self-reported use of
cannabis and other illicit
substances - Systematic
review and meta-analysis.
Addictive Behaviors.
2012;37:225-233.
doi:10.1016/j.addbeh.2011
.11.025
TLFB method is widely used
to measure self-reported
illicit substance use. TLFB
method is a validated tool for
recalling alcohol use during a
certain time period but is not
intended to enhance
truthfulness of self-report.
CINAHL
5/14/19
LOE 1
SR & MA
Review of current
literature demonstrated
validity when using the
TLFB method for
cannabis use recall
compared to biological
measurements in the
substance abuse
population.
Yes
Schwartz, DA. Cannabis
and the
lung. International
Journal of Mental Health
and Addiction. 2018; 16
(4): 797-800. https://doi-
org.libproxy2.usc.edu/10.
1007/s11469-018-9902-z
Short Review. Summary of
current knowledge r/t chronic
cannabis inhalation
Embase
LOE 2 Substantiates MJ causing
changes in FEV1,
bronchitis, and lung CA
Great chart showing
large studies, LOE,
and findings. Also
good source for LOE1
sources
Sullivan N, Elzinga S,
Raber JC. Determination
of pesticide residues in
cannabis smoke. Journal
of Toxicology.
2013;2013:1-6.
doi:10.1155/2013/378168
Are there significant levels of
pesticides in inhaled
cannabis? Comparison of
pre-smoking levels of
chemical with post-smoking
levels. Looked at differing
methods of smoking.
Compared/mimicked
methods for testing tobacco
and acceptable levels.
Embase
Experiment
al study
Variable amounts of
pesticides found. Cotton
filters are most effective
and lowering inhaled
chem levels, smoking
from glass pipe conveys
the highest levels of
chemicals.
Need for regulation and
standards.
???
Inhaled cannabis can
contain pesticides and
chemicals
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 54
Symons IE. Cannabis
smoking and anaesthesia.
Anaesthesia. 2002; 57:
1142-3.
Cannabis smoking and
anesthesia.
More questions than
answers from this
article- yet cited in
literature many times
many times
Scopus
12/20/18
Case study
Level 5
Difficult to “settle”
Desaturation issues
Recommends using
dexamethasone for
cannabis smokers for GA
Biased descriptive
language
Excluded
Tan WC, Lo C, Jong A,
Xing L, Fitzgerald MJ,
Vollmer WM, et al.
Marijuana and chronic
obstructive lung disease: a
population-based study.
(CMAJ) 4/14/2009; 180
(8): 814-798 (105503349)
-Determine combined and
independent effects of
tobacco and marijuana
smoking on respiratory
symptoms and COPD for
people over 40.
-COPD FEV1:FVC 0.7 after
bronchodilator therapy
(albuterol).
-Marijuana use = self
reported of previous
smoking. “Significant”
marijuana use = self report
lifetime total of at least 50
marijuana cigarettes smoked.
Tobacco use = self-report of
lifetime total of 365
cigarettes smoked.
-Effects on lung function: 1
mj cig = 3-5 tobacco cigs.
CINAHL
12/18/18
LOE 3
n=878
-significant marijuana use
had significantly greater
baseline lung function,
FEV1:FVC.
-Participants with COPD
more likely to have
significant comorbidities
and hospital admission for
respiratory problems
younger than 10.
-Those who smoked both
tobacco and mj had a
significantly greater risk
of COPD and respiratory
symptoms.
Yes for tobacco and
mj use with COPD.
Insufficient power for
mj use and COPD
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 55
Tashkin DP, Baldwin GC,
Sarafian T, Dubinett S,
Roth MD. Respiratory and
immunologic
consequences of
marijuana smoking.
Journal of Clinical
Pharmacology.
2002;42(11):71S-81S.
http://search.ebscohost.co
m.libproxy2.usc.edu/login
.aspx?direct=true&db=cc
m&AN=105714795&auth
type=sso&custid=s898398
4.
Habitual smoking of
marijuana has a number of
health effects on the
respiratory and immune
systems.
CINAHL
12/18/18
Review
article
LOE 4
Frequent histopathological
changes in tobacco and
cannabis smokers and
none in non-smokers.
Increased acute and
chronic bronchitis.
Endoscopic airway injury
findings lead to decreased
respiratory immune
function.
Yes
Tashkin DP, Simmons
MS, Tseng CH. Impact of
changes in regular use of
marijuana and/or tobacco
on chronic bronchitis.
COPD: Journal of
Chronic Obstructive
Pulmonary Disease. 2012;
9(4), 367-374. doi:
10.3109/15412555.2012.671
868
Continuing smoking MJ,
either alone or with tobacco,
is associated with net
persistence of symptoms of
chronic bronchitis, similar to
finding in continuing
smokers of tobacco alone.
PubMed
3/6/19
Longitudin
al cohort
LOE 3
n = 299
Continuing smokers of either
cannabis or tobacco had a
significantly increased
likelihood of having chronic
bronchitis at follow-up
compared to both never
smokers and former
smokers. Former smokers of
either substance were no
more likely to have chronic
respiratory symptoms at
follow-up than never
smokers.
Respiratory Symptoms
Changes in Smoking
Status
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 56
Tashkin, D P, Shapiro, B
J, Lee, Y E, Harper, C E.
Effects of smoked
marijuana in
experimentally induced
asthma. American journal
of respiratory and critical
care medicine : an official
journal of the American
Thoracic Society, medical
section of the American
Lung Association.
112(3):377-386.
doi:10.1164/arrd.1975.112
.3.377
Asthma attacks were
experimentally induced in 8
subjects. Placebo vs inhaled
cannabis were given, airway
conductance and thoracic gas
volume were
measured. Cannabis group
demonstrated resolution of
increased airway resistance
and hyperinflation.
stem
Observatio
nal study
n=8
Highly referenced early
study reporting
bronchodilator effects
Asthma,
bronchodilation
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 57
Taylor DR & Hall W.
Respiratory health effects
of cannabis: position
statement of the thoracic
society of Australia and
New Zealand. Internal
Medicine Journal. 2003;
33: 310-313.
Position Paper on respiratory
health effects of cannabis.
Not enough studies of
sufficient duration to assess
the long-term effects of MJ
smoking compared to the
substantial evidence for
adverse effects of tobacco
smoking.
The effects of MJ smoking
are frequently confounded
(69% concurrent tobacco use
in one study).
Such evidence as does exit
strongly suggests that
smoking MJ will result in
similar range of adverse
effects in lungs to that of
tobacco smoking.
PubMed
12/18/18
Review +
Expert
Opinion
Level 7
Tobacco & MJ smoke
have similar pro-
inflammatory &
carcinogenic substances
(level 1 evidence) &
histopathological effects
of are also similar (level 1
evidence)
Not enough evidence to
confirm MJ smoking
causes malignancy in the
respiratory tract (level 3
evidence)
Acute use results in small
decrements in lung fxn +
respiratory symptoms
(level 2); with regular use,
tobacco & MJ have
additive effects on lung
fxn & respiratory
symptoms (level 2)
Smoke Contents
Immune response
Carcinogens (lung
cancer)
Lung function
Respiratory Symptoms
Taylor, D. R., Poulton, R.
, Moffitt, T. E.,
Ramankutty, P. and Sears,
M. R. (2000), The
respiratory effects of
cannabis dependence in
young adults. Addiction,
95: 1669-1677.
doi:10.1046/j.1360-
0443.2000.951116697.x
NZ study in which 1000
males were followed from
birth, classified based on
tobacco use, MJ dependence,
and non-smokers. Examined
wheezing, exercise induced
SOB, AM sputum. Also
used DSM-III criteria to
classify MJ dependence
PubMed
Longitudin
al cohort
study
n=1037
Even at just 21 yrs of age
there was signif worse
pulm outcomes for MJ
smoker compared to
nonsmokers
Asthma
Sputum
Quantification
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 58
Tetrault JM, Crothers K,
Moore BA, Mehra R,
Concato J, Fiellin DA.
Effects of marijuana
smoking on pulmonary
function and respiratory
complications: a
systematic review.
Archives of Internal
Medicine.
2007;167(3):221-228.
http://search.ebscohost.co
m.libproxy2.usc.edu/login
.aspx?direct=true&db=cc
m&AN=106017914&auth
type=sso&custid=s898398
4. Accessed December 21,
2018.
-5 studies for FEV1- 3
showed increase in FEV1
after smoking mj, one
showed no difference, one
showed increase in peak flow
immediately after mj
inhalation.
-Almost all studies showed
decrease in FEV1/FVC ratio.
One study, after controlling
confounders, FEV1/FVC was
reduced to nonsignificant.
One study failed to show
significant relationship
between mj smoking and
FEV1 decline, 65% lost to
follow up, lack adjustment of
duration of mj smoking.
-3 studies showed decrease in
DLco with long term mj
smoking, one showed no
difference.
-All 14 studies demonstrated
an increase in respiratory
symptoms: cough, sputum,
wheezing, bronchitis,
dyspnea, pharyngitis, hoarse
voice, worsening asthma
symptoms, worsening CF,
abnormal chest sounds, chest
tightness.
CINAHL
12/18/18
LOE 1
Systematic
review
-Bronchodilating effects
soon after mj inhalation,
one study suggests
reversal of this with long
term mj smoking.
-Failure to report constant
association between mj
smoking and FEV1/FVC
ratio, DLco, airway
hyperreactivity.
-Long term mj smoking is
associated with increased
respiratory complications.
Yes
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 59
Walden N, Earleywine M.
How high: Quantity as a
predictor of cannabis-
related problems. Harm
Reduction Journal.
2008;5(1):20.
doi:10.1186/1477-7517-5-
20
Convenience sample internet
survey , n=>5987
participants who smoke
cannabis more than once per
month. Investigated use,
social problems, dependence,
pulmonary health. Also
reports on several methods of
quantification of
use: number of quarter
ounces consumed per month,
average level of intoxication,
maximum level of
intoxication
Stem
from
NASEM
Observatio
nal study
Frequency of use, monthly
consumption, and levels of
intoxication predicted
respiratory symptoms,
social problems and
dependence. What is
more, each measure of
quantity accounted for
significant variance in
outcomes after controlling
for the effects of
frequency
Dose-dependent
pulmonary effects,
quantification
Weekes JC, B.S., Cotton
S, PhD., McGrady ME,
M.A. Predictors of
substance use among
black urban adolescents
with asthma: A
longitudinal assessment. J
Natl Med Assoc.
2011;103(5):392-8.
Comparison of incidence of
asthma in specific
population- black, urban
adolescents
Referenced by Natl acad of
sciences official position
statement
PubMed
Longitudin
al
observation
al
Shows correlation but not
causation
Asthma
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 60
Wu, H D, Wright, R S,
Sassoon, C S, Tashkin, D
P. Effects of smoked
marijuana of varying
potency on ventilatory
drive and metabolic rate.
American journal of
respiratory and critical
care medicine : an official
journal of the American
Thoracic Society, medical
section of the American
Lung Association.
146(3):716-721.
doi:10.1164/ajrccm/146.3.
716
Examined responses to
hypercapnia and hypoxia in
11 young, healthy men who
smoked marijuana regularly
but refrained from any
smoked substance, alcohol,
caffeine, or other drugs for ⩾
12 h before study.
Ventilatory and P0.1
responses to hypoxia and
hypercapnia were measured
on 3 separate days before and
5 and 35 min (hypoxia) and
15 and 45 min (hypercapnia)
after smoking. In a
companion 3-day study, 12
young male habitual
marijuana smokers
underwent measurements of
Ve, VO2, and CO2
production (VCO2) before
and 5 to 135 min after
smoking marijuana
containing 0, 15, or 27 mg
THC.
stem Observatio
nal study,
n=11
Historical report of
bronchodilator effect of
inhaled cannabis,
None of the active
marijuana preparations
caused significant changes
in ventilatory or P0.1
responses to either
hypercapnia or hypoxia or
in resting Ve, VO2 or
VCO2
Asthma, PFTs
PREOPERATIVE RECOMMENDATIONS FOR CANNABIS SMOKERS 61
Zhang LR, Zhang Z-F,
Morgenstern H, et al.
Cannabis smoking and
lung cancer risk: Pooled
analysis in the
International Lung Cancer
Consortium. International
Journal of Cancer.
2015;136:894-903.
doi:10.1002/ijc.29036
Groups matched by cannabis
intake, tobacco intake, CA
diagnosis and demographics
to attempt to link cannabis
smoking to lung CA
12/20/18
Joanna
Briggs
Pooled data
from 6
internationa
l case-
control
studies
n~5000
LOE 1
Weak correlation between
lung CA and inhaled
cannabis
Supports that cannabis
prob doesn’t cause
lung CA
Abstract (if available)
Abstract
Cannabis inhalation is increasing in prevalence and social popularity in the United States: smoking is the most common intake method. To our knowledge, there are no anesthesia practice guidelines or recommendations for perioperative care regarding cannabis smoking. Because cannabis is an illegal substance under federal law, there is a paucity of data on the effects of cannabis inhalation on the respiratory system specifically with regard to how chronic cannabis smoking affects anesthesia care. Despite these limitations, existing research offers some insight into potential respiratory risks. We conducted an extensive literature review on the effects of chronic cannabis smoking on the respiratory system and produced an executive summary to better risk-stratify patients who smoke cannabis and undergo elective surgery. There was substantial evidence associating cannabis smoking with an increased incidence of cough, wheeze, excessive respiratory secretions, and chronic bronchitis exacerbations. Anesthesia practice recommendations include quantifying the cannabis exposure, assessing for commonly-associated symptoms, optimizing the respiratory system immediately before surgery, and formulating an anesthesia plan of care to reduce known triggers for bronchospasm and laryngospasm.
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Asset Metadata
Creator
Doty, Elizabeth Diane
(author)
Core Title
Preoperative anesthesia recommendation for elective surgical patients who inhale cannabis
School
Keck School of Medicine
Degree
Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Publication Date
04/30/2020
Defense Date
05/16/2020
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anesthesia,cannabis,OAI-PMH Harvest,preoperative
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Darna, Jeffrey (
committee chair
), Bamgbose, Elizabeth (
committee member
), Gold, Michele (
committee member
)
Creator Email
elizabdd@usc.edu,elizabeth_doty@ymail.com
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Tags
anesthesia
cannabis
preoperative