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Outline for OSA
OSA definition, diagnosis, risk factors
Increased perioperative risks & adverse outcomes
Pre-operative management: OSA screening,
estimating risk, inpatient vs. outpatient (ambulatory
suitability)
Intra-op & post-op management
Sleep Apnea Defined
“Obstructive Sleep Apnea(OSA) is a syndrome
characterized by periodic, partial, or complete
obstruction of the upper airway during sleep.” ASA practice guidelines for
patients with OSA: Anesthesiology 2006; 1081
…a cessation of breathing for greater than or equal to 10
seconds despite continuing ventilatory efforts. Joshi.2007
Central Sleep Apnea constitutes less than 5% of sleep
apnea cases. Breathing repeatedly stops and starts again
because your brain does not send proper signals to the
muscles that control breathing…usually the result of heart
failure and less commonly stroke
Pathophysiology:
Occurs during REM sleep
Loss of upper airway muscle tone
Increase pharyngeal resistance
Negative pharyngeal pressures during inspiration
Upper airway collapse
Pathophysiology Cycle:
After upper airway collapse
hypoxemia & hypercapnia
arousal from sleep
restoration of muscle
tone and airflow
apnea/obstruction
hypocapnia & loss of
respiratory drive
hyperventilation
Symptoms of OSA
Hypersomnolence(excessive daytime sleepiness)
Morning headaches
Decreased libido
Irritability and inattentiveness
Poor memory and depression
Spector and Ryan.2012
Diagnosis of OSA
Sleep Study
Polysomnography(sleep study) is the gold
standard
Monitors to stage sleep:
EEG(electoencephalogram)
EOG(electrooculogram)
EMG(electromyogram)
Sleep Study additional
monitors:
Oral and nasal airflow
Respiratory effort (monitors thoracoabdominal motion &
diaphragmatic EMG with pneumography)
Oximetry and capnography
Blood pressure and ECG
Body Position
Sound
Joshi.2007
Sleep Study
Other sleep disorders
Narcolepsy
Hypersomnia
Periodic limb movement disorder
REM behavior disorder
Parasomnias
Portable home-based
polysomnography versus
standard PSG
Standard PSG can be costly and may have long
waiting periods
Home-based sleep study--unattended portable
monitoring, less costly and less disruptive
May be a useful screening tool in the future
High rate of inadequate exams and underestimation
of sleep apnea severity
Adebola et al. 2010
More on Home Sleep
Testing(HST): AASM guidelines
HST devices cannot monitor hypoventilation and
cannot detect central or “complex” sleep apnea
Not useful for patients with comorbid conditions
such as moderate to severe pulmonary disease,
neuromuscular disease, or congestive heart
failure
SASM-proceedings of 2012 meeting
Defining Severity of OSA
The apnea-hypopnea index
AHI(apnea-hypopnea index) measures frequency of
the apneic and hypopneic events/hour
Obstructive sleep hypopnea is a greater than 30%
reduction in airflow for ≥ 10 seconds followed by an
arousal &/or 4% oxygen desaturation
Obstructive sleep apnea is a cessation of breathing
for ≥ 10 seconds followed by an arousal &/or 4%
oxygen desaturation
AHI
American Academy of Sleep Medicine
AHI: severity of OSA(AASM)
5-15 ≈ mild OSA
15-30 ≈ moderate OSA
>30 ≈ severe OSA
OSA coverage for treatment
Medicare and Medicaid
Medicare & Medicaid provides coverage for
treatment of adults with OSA when:
• AHI > 15
• AHI > 5 with excessive daytime sleepiness, impaired
cognition, mood disorders, insomnia, HTN, ischemic
heart disease, or history of stroke
Adebola et al. 2010
More on AHI
“…the sleep laboratory’s assessment (none,
mild, moderate, or severe) should take
precedence over the actual AHI.”
ASA Practice Guidelines for patients with
OSA: Anesthesiology 2006; 1083
Patients with AHI>40 have a significantly higher
prevalence of difficult intubation
Joshi. 2007.
Treatment of OSA
Dental appliances
Surgery—Uvulopalatopharyngoplasty(UPPP)
CPAP & others: BiPAP≈NIPPV, APAP(auto adjusts)
Weight loss
Tracheostomy(in life-threatening cases unresponsive
to other treatments)
OSA Risk Factors
Old age and obesity are the strongest risk factors
Other risk factors:
•
Male sex
•
Excessive alcohol intake
•
Female menopause
•
Craniofacial abnormalities
Adebola et al. 2010
OSA Risk Factors
continued
• Retrognathia (either maxilla or mandible or both
recede with respect to the frontal plane of the
forehead)
• Macroglossia
• Wide neck circumference(>17 in. males & >16 in.
females
Adebola et al. 2010
OSA Predisposing
Characteristics
Predisposing Characteristics of OSA (modified from table 3.Adebola et al.2010)
Patient characteristics
Male; > 50 y old
Obesity
BMI > 30 kg/m2
Neck circumference
> 40 cm(15.7in.)
ENT conditions
Septal deviation, tonsillar and
adenoidal hypertrophy,
laryngomalacia, tracheomalacia
Craniofacial abnormalities
Down syndrome, micrognathia,
achondroplasia, acromegaly,
macroglossia
Pediatric OSA
Between 2 & 6 years old, behavioral disturbances
PSG reserved for children with obesity, trisomy 21,
craniofacial abnormalities, neuromuscular disorders,
sickle cell disease & mucopolysaccharidosis
Adenotonsillectomy alleviates symptoms in most
Children with significant OSA and ≥ 4yrs. old should
stay overnight following adenotonsillectomy
SASM: proceedings of 2012 meeting
What’s the prevalence of OSA among elective
surgical candidates?
A. 3%
B. 5%
C. 25%
D. 60%
E. 75%
Why do we care?
Comorbidities of OSA include heart disease (arrhythmias and
myocardial ischemia), hypertension, asthma, pulmonary HTN, stroke,
diabetes
Prevalence of OSA is estimated to be 25% among candidates for elective
surgery and as high as 80% for patients undergoing bariatiric surgery.
80% OSA pts. are undiagnosed at time of surgery
Memstoudis et al.2013
OSA “…likely to increase as the population becomes older and more
obese.” ASA Practice Guidelines for Patients with OSA:Anesthesiology 2006
Increased perioperative risk for OSA patients leading to adverse
outcomes
Increased OSA perioperative risks:
effects of anesthesia and surgery
Administration of sedative-hypnotics, opioids, and muscle
relaxants may result in the following:
1. Induced and worsened upper airway obstruction and apnea
2. Decreased ventilatory response to hypoxemia and
hypercarbia
3. Lost ability to arouse and respond adequately to asphyxia
which may be life-threatening
Joshi.2007
Increased OSA perioperative risks:
effects of anesthesia and surgery
Postoperative anxiety, pain, and opioids cause sleep
deprivation and fragmentation reducing REM sleep in
the immediate postoperative period
REM rebound (the lengthening & increasing
frequency & depth of REM sleep which occurs after
periods of sleep deprivation) further increasing the
risk of obstruction and apnea
Joshi.2007
Increased OSA perioperative risks:
effects of anesthesia and surgery
These aforementioned postoperative sleep
disturbances, hypoxemia and apnea may
contribute to myocardial ischemia and
infarction, cardiac dysrhythmias, and stroke in at
risk patients
Joshi.2007.
More on why we care…
Postoperative Death
Dr. Benumof(an anesthesiologist) was an expert witness in
> 50 OSA malpractice claims. * 70% of these claims
involved a postoperative OSA patient found dead in bed
He identified some common characteristics of these
cases stating that most/all of these cases had most/all of
these characteristics
*the other 30% had adverse outcomes due to intubation and/or extubation difficulties
Benumof.2010
More on why we care…
“Dead in bed” characteristics:
Severe OSA
Morbidly obese
Abdominal incision
On narcotics
Extubated
Not on CPAP
Not on oxygen
Unmonitored
Patient in a relatively isolated ward/room
Benumof.2010
Adverse Outcomes in Patients With
Obstructive Sleep Apnea Undergoing
Surgery (modified from Adebola et al. 2010. Table 1)
1. Liao et al (2009--retrospective matched cohort)
• Postoperative patients from many types of
surgeries
• Higher incidence of respiratory complications,
including oxygen desaturation & prolonged O2
therapy
• Need for additional monitoring & more ICU
admissions in the OSA group
Adverse Outcomes in Patients With
Obstructive Sleep Apnea Undergoing
Surgery (modified from Adebola et al. 2010.Table 1)
2. Hwang et al (2008—prospective case control)
• Postoperative patients from many types of surgeries
• Higher rates of respiratory, cardiovascular,
gastrointestinal, & bleeding complications
• Longer post-anesthesia recovery stay in the OSA group
Adverse Outcomes in Patients With
Obstructive Sleep Apnea Undergoing
Surgery (modified from Adebola et al. 2010.Table 1)
3. Kaw et al (2006—retrospective case control)
• Postoperative cardiac surgery patients
• Higher rates of encephalopathy, postoperative
infections (mediastinitis)
• Longer ICU length of stay in the OSA group
Adverse Outcomes in Patients With
Obstructive Sleep Apnea Undergoing
Surgery (modified from Adebola et al. 2010.Table 1)
4. Gupta et al (2001—retrospective case control)
• Postoperative orthopedic(TKR &THR) patients
• Higher rates of unplanned ICU transfers, cardiac
events, longer hospital length of stay in the OSA
group
More adverse outcomes
“Reviewing over six million general surgery and
orthopedic procedures, Memstoudis et al(2011)
reported increased risks in OSA patients of
repeat intubation/mechanical ventilation,
pneumonia, ARDS, and pulmonary emboli in
orthopedic cases.” Spector and Ryan. 2012.
Preoperative assessment of
OSA: Why?
“Failure to recognize (or diagnose) OSA
preoperatively is one of the major causes of
perioperative complications.”
Joshi.2007
Primary care doctors, sleep doctors, surgeons, and
anesthesiologists must have ready access to all
OSA-related information in OSA patients. The best
way to ensure this continuity of care is to issue
medical alert bracelets to patients who have severe
OSA.
Benumof. 2010
Preoperative Assessment
STOP-BANG
Screening tool for patients that are to have
elective surgery
Self-administered and uses only yes/no
questions
Brief, simple and requires only a 5th-grade
reading level
Adebola et al. 2010
Preoperative Assessment
of OSA: STOP BANG questionnaire
S(nore)
Have you been told you snore loud enough to be heard through a
closed door?
T(ired)
Are you often tired or sleepy during the day?
O(bstruction)
Do you know if you stop breathing, or has anyone witnessed you
stop breathing while asleep?
P(ressure)
Do you have high blood pressure or are you on medication for high
blood pressure?
High risk of OSA if yes to ≥ 2 STOP questions
Preoperative Assessment
of OSA: STOP BANG questionnaire
B(MI)
Is your BMI > 35?
A(ge)
Are you 50 years or older?
N(eck)
Is your neck circumference greater than 17 inches?(43cm)
G(ender)
Are you male?
High risk of OSA if yes to ≥ 3 for combined STOP BANG
STOP BANG is an excellent preoperative tool to screen for OSA.
Where does Louisiana rank in
obesity among states? (BMI ≥ 30)
A. 2nd
B. 1st
C. 5th
D. 8th
Practice Guidelines for the
perioperative management of patients with
OSA
ASA task force provided guidelines to help to reduce
perioperative morbidity and mortality in OSA patients
In doing so made recommendations for preoperative
evaluation and preparation, intraoperative
management, postoperative management, inpatient
vs. outpatient surgery and finally criteria for
discharge to unmonitored settings
ASA Task Force
Included anesthesiologist in both private &
academic practices from various geographic
areas of the United States, a bariatric surgeon,
an otolaryngologist, and two methodologists
from the American Society of Anesthesiologists
Committee on Practice Parameters
Practice Guidelines
Practice guidelines are recommendations that
assist doctor and patient in decision making.
Guidelines are NOT standards or absolute
requirements and use of guidelines do not
guarantee specific outcomes.
Preoperative evaluation
recommendations:
ASA Guidelines—a collaborative effort
“…pre-procedure identification of a patient’s OSA status
improves perioperative outcomes…”
Anesthesiologists and surgeons should work together to
ensure that a system is in place for evaluation of
suspected OSA patients well before the day of surgery.
If a targeted history and physical suggest that a patient
has OSA then surgeon and anesthesiologist again should
decide together whether or not to obtain sleep studies
prior to surgery
ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1084
Is Preoperative PSG
necessary?
Not with a proper management plan including an
OSA screen to reduce risks
Recent study showed no statistically significant
difference in postoperative complications
between the screening-only (using the ASA
checklist) and polysomnography-confirmed OSA
groups
Chong et al. 2013
Preoperative evaluation
recommendations: ASA Guidelines
If sleep studies are not available or obtained
then “…some patients may be treated more
aggressively than would be necessary if a sleep
study were available.”
ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1084
Identification and Assessment
of OSA: Signs & Symptoms suggesting OSA
Predisposing physical characteristics
•
Obesity(BMI>35)
•
Increased neck circumference(>17 in. in males & >16in. in females)
•
Craniofacial abnormalities affecting the airway
•
Anatomical nasal obstruction
•
Large tonsils nearly touching or touching in the midline
ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083
Identification and Assessment
of OSA: Signs & Symptoms suggesting OSA
History of apparent airway obstruction during sleep (≥ 2 of the following*)
•
Loud snoring(heard through closed doors)
•
Frequent snoring
•
Witnessed apnea
•
Awakens from sleep choking
•
Frequent arousals from sleep
•
Intermittent vocalization during sleep**
•
Parental report of restless sleep, difficulty breathing, or struggling respiratory efforts during sleep**
*if patient lives alone only one or more of the following needs to be present
**pediatric patients
ASA Practice Guidelines for patients with OSA:Anesthesiology;1083
Identification and Assessment
of OSA: Signs & Symptoms suggesting OSA
Somnolence(1 or more of the following)
•
Frequent somnolence or fatigue despite adequate “sleep”
•
Falls asleep easily in a non-stimulating environment despite
adequate “sleep”
•
Parent or teacher comments that child appears sleepy during the
day, is easily distracted, is overly aggressive, or has difficulty
concentrating*
•
Child often difficult to arouse at usual awakening time*
*pediatric population
ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083
Identification and Assessment
of severity of OSA
There is a significant probability of OSA if the patient has
signs or symptoms in 2 or more of the above categories
Severity of OSA is ideally determined by a sleep study
If sleep study not available then treat as if patient has
moderate OSA
If 1 or more of the signs or symptoms above is severely
abnormal then treat patient as a severe OSA patient
ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1083
Preoperative Recommendations:
Estimating risk for the OSA patient
A patient’s perioperative risk depends on the severity of
the OSA, the invasiveness of the procedure and the
requirement for postoperative analgesics
The OSA Scoring System incorporates these measures
and can be used as a guide to estimate risk for the patient
who presumably has OSA or has a diagnosis of OSA
ASA Practice Guidelines for the OSA Patient: Anesthesiology 2006;1084
OSA Scoring System
(modified from ASA Guidelines Table 2)
A. Severity of Sleep Apnea(based on sleep study or clinical indicators)
None
0
Mild
1
Moderate
2
Severe
3
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA Scoring System
(modified from ASA Guidelines Table 2)
B. Invasiveness of surgery and anesthesia
Superficial surgery under local or peripheral nerve block
anesthesia without sedation(0 points)
Superficial surgery with moderate sedation or general
anesthesia(1 point)
Peripheral Surgery with spinal or epidural anesthesia(with no
more than moderate sedation) (1point)
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA Scoring System
(modified from ASA Guidelines Table 2)
B. Invasiveness of surgery and anesthesia
Peripheral surgery with general anesthesia
(2 points)
Airway surgery with moderate sedation(2 points)
Major surgery, general anesthesia(3 points)
Airway surgery, general anesthesia(3 points)
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA Scoring System
(modified from ASA Guidelines Table 2)
C. Requirement for postoperative opioids
None
0
Low-dose oral opioids
1
High-dose oral opioids,
parenteral or neuraxial
opioids
3
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA Scoring System:
D. Estimation of perioperative risk
(modified from ASA Guidelines Table 2)
Overall score = score for A(severity) plus the greater of
the score for either B(invasiveness) or C(opioid requirement).
Point score is 0 to 6.
One point may be subtracted if a patient has been on
CPAP or NIPPV before surgery and will be using the
appliance consistently in the perioperative period
One point should be added if a patient with mild or
moderate OSA has a resting PaCO2 > 50 mmHg
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA Scoring System:
D. Estimation of perioperative risk
(modified from ASA Guidelines Table 2)
Patients with a score of 4 may be at increased
perioperative risk and patients with scores of 5
or 6 may be at a significantly increased
perioperative risk from OSA
ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083
OSA check in
So now we have identified OSA(STOP BANG &
ASA Table 1), assessed severity of OSA(sleep
study with AASM AHI or ASA Table 1) and
estimated perioperative risk (ASA’s OSA
Scoring-Table 2)
Before we go on to preoperative preparation a
decision must be made on whether or not the
patient is a candidate(if type of surgery
allows)for ambulatory surgery
Inpatient vs. Outpatient Surgery for OSA
patients-- ASA Task Force recommends considering:
1.
Sleep apnea status
2.
Anatomical and physiological abnormalities
3.
Status of coexisting diseases
4.
Nature of surgery
5.
Type of anesthesia
6.
Need for postoperative opioids
7.
Patient age
8.
Adequacy of post-discharge observation
9.
Capabilities of the outpatient facility
ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087
Inpatient vs. Outpatient
Surgery for OSA patients
“The availability of emergency airway equipment,
respiratory care equipment, radiology facilities,
clinical laboratory facilities, and a transfer
agreement with an inpatient facility should be
considered…”
ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087
Inpatient vs. Outpatient
Surgery for OSA patients
Consultant opinions regarding procedures that
may be performed safely on an outpatient basis
for patients at increased risk from OSA
Table 3 in the ASA Practice guidelines for the
OSA patient modified on the following slides
Consultants agree…
Superficial surgery/local or regional anesthesia
Minor orthopedic surgery/local or regional
anesthesia
Lithotripsy
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087
Consultants disagree…
Airway surgery(e.g.,UPPP)
Tonsillectomy in children less than 3 years old
Laparoscopic surgery, upper abdomen
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087
Consultants are equivocal…
Superficial surgery/general anesthesia
Tonsillectomy in children greater than 3 years
old
Minor orthopedic surgery/general anesthesia
Gynecologic Laparoscopy
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087
Inpatient vs. Outpatient
Update: Society for Ambulatory Anesthesia
Task Force on Practice Guidelines
Developed a consensus statement addressing this
controversial issue as new evidence is available
Patients with a known diagnosis of OSA and optimized
comorbid medical conditions can be considered for
ambulatory surgery, if they are able to use a CPAP device
in the postoperative period.
Patients with a presumed diagnosis of OSA with optimized
comorbidities can be considered for ambulatory surgery,
if postoperative pain can be managed predominantly with
nonopioid techniques
Joshi et al.2012
Inpatient vs. Outpatient
Update: Society for Ambulatory Anesthesia
Task Force on Practice Guidelines
OSA patients with nonoptimized comorbid conditions
may not be good candidates
Recommend use of STOP-BANG for OSA screen
Current literature does not support the ASA recs.
that upper abdominal procedures (on OSA patients)
are not appropriate for ambulatory surgery
Joshi et al.2012
What country has the most
obese population?
A. Nauru
B. Mexico
C. USA
D. Australia
OSA check in
again
So now we have identified OSA(STOP BANG & ASA
Table 1), assessed severity of OSA(sleep study with
AASM AHI or ASA Table 1) and estimated
perioperative risk (ASA’s OSA Scoring-Table 2)
And we have made an educated decision(Table 3Consultant opinion. ASA Guidelines &/or SAMBA task
force consensus statement) as to whether or not the
OSA patient is a candidate for ambulatory surgery
Now we can move on to preoperative preparation
Preoperative Preparation
recommendations: ASA Guidelines
Consider pre-op initiation of CPAP/NIPPV(Non-invasive positive pressure
ventilation)
Consider having the patient use mandibular advancement devices or oral
appliances
Preoperative weight loss if feasible
A patient who has had corrective airway surgery remains at risk for OSA
complications until a normalized sleep study is obtained and symptoms
resolve
Consider difficult airway probability
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085
Preoperative Preparation
Benefits of CPAP use
“Gupta et al found that patients who were using CPAP
preoperatively had a lower incidence of postoperative
complications and shorter hospital length of stay when
compared with those who were not on CPAP.”
This “carryover protection” may be explained by
decreased inflammation and/or edema of the upper
airway, decrease tongue size, and increased upper airway
volume and stability
Adebola et al. 2010 .
Intraoperative Management:
ASA Guideline Recommendations
Consider the potential for postoperative respiratory
compromise when selecting intraoperative medications
Consider use of local anesthesia or peripheral nerve
blocks(with or without moderate sedation)
Continuously monitor ventilation with capnography if
moderate sedation is used
Consider CPAP or dental appliance use on patients treated
with these devices preoperatively
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085
Intraoperative Management:
ASA Guideline Recommendations
General anesthesia with a secure airway is safer
than deep sedation
Consider spinal or epidural anesthesia
Proceed with extubation after patient is awake and
has full reversal of neuromuscular blockade
Lateral and semi-upright positions(not supine) for
extubation and recovery
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085
Intraoperative Management
Regional anesthesia benefits
“Regional anesthesia obviates the need for
airway manipulation and reduces the need for
intraoperative sedatives and opioids…these
techniques provide postoperative analgesia, and
reduce postoperative opioid requirements.”
Joshi.2007
Intraoperative Management
Preoxygenation with CPAP
CPAP acts as a pneumatic splint to keep the
airway open
Preoxygenation with 100% oxygen and CPAP at
10cm H2O is a good recommendation
Adebola et al. 2010
Postoperative management
Patients with OSA have post-op complications more frequently
Common post-op complications:
•
Airway obstruction
•
Oxygen desaturation
•
Reintubation
•
Systemic hypertension
•
Cardiac dysrhythmias
•
Admission to ICU
Joshi.2007.
Postoperative management
Respiratory depression
Postoperative respiratory depression risk factors:
• Systemic and neuraxial administration of opioids
• Administration of sedatives
• Site and invasiveness of surgical procedure
• Underlying severity of sleep apnea
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085
Postoperative management
Respiratory depression
“REM rebound” occurs on the third or fourth
post-operative day as sleep patterns are reestablished exacerbating respiratory depression
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085
REM rebound(the lengthening & increasing
frequency & depth of REM sleep which occurs
after periods of sleep deprivation) further
increasing the risk of obstruction and apnea
Postoperative Management
ASA Guideline recommendations
Postoperative Pain
Consider regional analgesic techniques to reduce or
eliminate requirement for systemic opioids
Neuraxial analgesia benefits are improved analgesia and
decreased need for systemic opioids
Neuraxial analgesia risk is rostral spread causing
respiratory depression
Consider these in choosing an opioid, opioid-local mixture
or local anesthetic alone
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086
Postoperative Management
ASA Guideline recommendations
Postoperative pain
Continuous background infusions with patient controlled
systemic opioids(PCA) should be used with extreme
caution or avoided
To reduce opioid requirement consider NSAIDS and other
modalities(e.g., ice, transcutaneous electrical nerve
stimulation)
Be aware of the increased risk of respiratory depression
and airway obstruction with concurrent use of
sedatives(e.g.,benzodiazepines, barbiturates)
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086
Postoperative Management
Opioid requirement…good news!
“Brown et al found that total analgesic opiate
dose in patients with OSA and recurrent
hypoxemia was half that required in patients
without such a history and attributed this finding
to upregulation of central opioid receptors due
to recurrent hypoxemia.”
Adebola et al. 2010
Postoperative Management
ASA Guideline recommendations
“Supplemental oxygen should be administered continuously to all
patients who are at increased perioperative risk from OSA until they are
able to maintain their baseline oxygen saturation while breathing room
air.”
Supplemental O2 should be used with caution as it may reduce hypoxic
respiratory drive. Treat recurrent hypoxemia with CPAP & oxygen. Joshi 2006.
“The task force cautions that supplemental oxygen may increase the
duration of apneic episodes and may hinder detections of atelectasis,
transient apnea, and hypoventilation by pulse oximetry.”
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086
Postoperative Management
CPAP -- ASA Guideline recommendations
Unless contraindicated by the surgical procedure
continuous use of CPAP or NIPPV should be used by
patients who were using these devices preoperatively
Patients should bring their own equipment(CPAP/NIPPV)
to the hospital to improve compliance
Consider postoperative initiation of CPAP or NIPPV for
frequent or severe airway obstruction and hypoxemia
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086-1087.
Postoperative Management
CPAP
“Prophylactic CPAP for 24-48 h after extubation have
been reported to reduce major complications
despite unrestricted opioid use.”
Joshi.2007
“Another study showed that the rate of postoperative
CPAP use was relatively low (58%-63%) even in
patients on established home CPAP, reflecting a lack
of hospital policy guiding the consistent use of
CPAP…”
Adebola et al. 2010
Postoperative Management
ASA Guideline recommendations
OSA patients should be placed in nonsupine positions
throughout the entire recovery period
Continuous pulse oximetry and monitoring should follow the
OSA patient from the recovery room(PACU) to the next level
of care in the hospital. An appropriately trained professional
observer in the patients room should be used to monitor if
patient is not in a telemetry or critical care area
“Intermittent pulse oximetry or continuous bedside oximetry
without continuous observation does not provide the same
level of safety.”
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087
Postoperative Management
Discharge from PACU with or without continuous
pulse oximetry and monitoring
Patients that exhibit respiratory events such as
apnea, bradypnea, desaturations, and painsedation mismatch in PACU(recovery room)
should be admitted to a monitored bed with
continuous oxygen saturation monitoring
Adebola et al. 2010
Postoperative Management
ASA Guideline recommendations
Criteria for discharge to unmonitored settings
The most significant postoperative complications in OSA patients
usually occur within 2 hours after surgery Joshi.2007.
OSA patients should be monitored for a median of 3 hours longer
than their non-OSA counterparts before discharge from the facility
ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087
OSA patients should continue to be monitored for a median of 7
hours after the last episode of obstruction or hypoxemia while
breathing room air in an unstimulating environment ASA Practice Guidelines for the OSA
patient:Anesthesiology 2006;1087
These recommendations may play a part in deciding suitability for
ambulatory surgery, especially in a free standing ASC
Postoperative management
Discharge Instructions
Continued use of CPAP at home should be
included in post-discharge instructions for
patients who use CPAP preoperatively
Joshi. 2007.
Remember the rebound!
What perioperative protocol system
do we use here for OSA patients?
A. Stop-Bang
B. ASA Guidelines
C. Gambit’s best of N.O.
D. None
Summary OSA
OSA definition, diagnosis, risk factors
Increased perioperative risks & adverse
outcomes
Pre-operative management: OSA screening,
estimating risk, inpatient vs.
outpatient(ambulatory suitability)
Intra-op & post-op management
Bibliography:
1.
Practice Guidelines for the Perioperative Management of Patients
with Obstructive Sleep Apnea. Anesthesiology. 2006; 104:10811093
2.
Joshi G., MD. The Patient with Sleep Apnea for Ambulatory Surgery.
ASA Refresher Courses in Anesthesiology. 2007; 35(1):97-106
3.
Spector R.,MD and Ryan R. Obstructive Sleep Apnea for All
Specialties: Reducing Perioperative Risk. A CME Monograph. 2011.
4.
Adebola A., MD, FCCP; Lee W, MD; Greilich N., MD; Joshi G., MD.
Perioperative Management of Obstructive Sleep Apnea. CHEST.
2010;138(6):1489-1498.
Bibliography:
5.
Joshi G.,MD, Ankichetty S.,MD, Gan T.,MD, Chung F. Society for Ambulatory Anesthesia Consensus
Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for
Ambulatory Surgery. Anesthesia & Analgesia. 2012
6.
Memstoudis S, Liu SS, Ma Y, Chiu YL., Walz JM,Gaber-Baylis LK, Mazumdar M, Perioperative Outcomes
in Patients with Sleep Apnea after Noncardiac Surgery. Anesth. Analg. 2011;112:113-121
7.
Benumof JL. Summary of the prototypical OSA malpractice law case. Paper presented at: Challenges in
the perioperative management of OSA patients symposium;October 15,2010;San Diego, CA.
8.
Gupta RM, Parvizi J, Hanssen AD, Gay PC; Postoperative complications in patients with obstructive
sleep apnea syndrome undergoing hip or knee replacement: a case-control study, Mayo Clin Proc 2001
769 897-905
9.
Brown KA, Laferrière A, Lakheeram I, Moss IR; Recurrent hypoxemia in children is associated with
increased analgesic sensitivity to opiates, Anesthesiology 2006 1054 665-669
Bibliography:
10. Hwang D, Shakir N, Limann B; et al. Association of sleep- disordered
breathing with postoperative complications, Chest 2008 1335 1128-1134
11. Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N,
Walker E; Incremental risk of obstructive sleep apnea on cardiac surgical
outcomes, J Cardiovasc Surg (Torino) 2006 476 683-689
12. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P,
Chung F; Postoperative complications in patients with obstructive sleep apnea: a
retrospective matched cohort study, Can J Anaesth 2009 5611 819-828
13. Chong C, Tey J, Leow S; et al. Management Plan to Reduce Risks in
Periopeerative Care of Patients with Obstructive Sleep Apnoea Averts the Need
for Presurgical Polysomnography, Ann Acad of Med Singapore 2013;42:110-9
Bibliography:
14. Society of anesthesia and sleep medicine:
proceedings of 2012 meeting.
15. Memstoudis S., Besculides M., Mazumdar M. et.
al. A Rude Awakening—The Perioperative Sleep
Apnea Epidemic, NEJM 2013; 368;25:2352-2353.