OBSTRUCTIVE SLEEP APNEA

1
OBSTRUCTIVESLEEP APNEA

• PERIOPERATIVE PREVENTIVE MEDICINE

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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

3
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
  breathingusually the result of heart failure and
  less commonly stroke

4
PathophysiologyOccurs during REM sleep

• Loss of upper airway muscle tone
• Increase pharyngeal resistance
• Negative pharyngeal pressures during inspiration
• Upper airway collapse

5
Pathophysiology CycleAfter upper airway collapse

• hypoxemia hypercapnia arousal
  from sleep
• restoration of muscle
• tone and airflow
• apnea/obstruction hypocapnia loss of
  hyperventilation
• respiratory drive
• 
  

6
Symptoms of OSA

• Hypersomnolence(excessive daytime sleepiness)
• Morning headaches
• Decreased libido
• Irritability and inattentiveness
• Poor memory and depression
• Spector and Ryan.2012

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Diagnosis of OSASleep Study

• Polysomnography(sleep study) is the gold standard
• Monitors to stage sleep
• 
  EEG(electoencephalogram)
• EOG(electrooculogram)
• EMG(electromyogram)

8
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

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Sleep Study Other sleep disorders

• Narcolepsy
• Hypersomnia
• Periodic limb movement disorder
• REM behavior disorder
• Parasomnias

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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

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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

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Defining Severity of OSAThe 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

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AHIAmerican Academy of Sleep Medicine

• AHI severity of OSA(AASM)
• 5-15 mild OSA
• 15-30 moderate OSA
• gt30 severe OSA

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OSA coverage for treatmentMedicare and Medicaid

• Medicare Medicaid provides coverage for
  treatment of adults with OSA when
• AHI gt 15
• AHI gt 5 with excessive daytime sleepiness,
  impaired cognition, mood disorders, insomnia,
  HTN, ischemic heart disease, or history of stroke
• Adebola et al. 2010

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More on AHI

• the sleep laboratorys 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 AHIgt40 have a significantly higher
  prevalence of difficult intubation Joshi. 2007.

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Treatment of OSA

• Dental appliances
• SurgeryUvulopalatopharyngoplasty(UPPP)
• CPAP others BiPAPNIPPV, APAP(auto adjusts)
• Weight loss
• Tracheostomy(in life-threatening cases
  unresponsive to other treatments)

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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

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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(gt17 in. males gt16 in.
  females
• Adebola et al. 2010

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OSA Predisposing Characteristics

• Predisposing Characteristics of OSA (modified
  from table 3.Adebola et al.2010)
• Patient characteristics Male gt?50 y old
• Obesity BMI gt?30 kg/m2
• Neck circumference ?gt?40 cm(15.7in.)
• ENT conditions Septal deviation, tonsillar and
  adenoidal hypertrophy, laryngomalacia,
  tracheomalacia
• Craniofacial abnormalities Down syndrome,
  micrognathia, achondroplasia, acromegaly,
  macroglossia

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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

21
Whats the prevalence of OSA among
electivesurgical candidates?

1. 3
2. 5
3. 25
4. 60
5. 75

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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 OSAAnesthesiology
  2006
• Increased perioperative risk for OSA patients
  leading to adverse outcomes

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Increased OSA perioperative risks effects of
anesthesia and surgery

• Administration of sedative-hypnotics, opioids,
  and muscle relaxants may result in the following
• Induced and worsened upper airway obstruction and
  apnea
• Decreased ventilatory response to hypoxemia and
  hypercarbia
• Lost ability to arouse and respond adequately to
  asphyxia which may be life-threatening
• Joshi.2007

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Increased OSA perioperative riskseffects 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

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Increased OSA perioperative riskseffects 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.

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More on why we carePostoperative Death

• Dr. Benumof(an anesthesiologist) was an expert
  witness in gt 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 Benum
  of.2010

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More on why we careDead 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
• B

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Adverse Outcomes in Patients With Obstructive
Sleep Apnea Undergoing Surgery (modified from
Adebola et al. 2010. Table 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

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Adverse Outcomes in Patients With Obstructive
Sleep Apnea Undergoing Surgery (modified from
Adebola et al. 2010.Table 1)

• Hwang et al (2008prospective 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

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Adverse Outcomes in Patients With Obstructive
Sleep Apnea Undergoing Surgery (modified from
Adebola et al. 2010.Table 1)

• Kaw et al (2006retrospective case control)
• Postoperative cardiac surgery patients
• Higher rates of encephalopathy, postoperative
  infections (mediastinitis)
• Longer ICU length of stay in the OSA group

31
Adverse Outcomes in Patients With Obstructive
Sleep Apnea Undergoing Surgery (modified from
Adebola et al. 2010.Table 1)

• Gupta et al (2001retrospective case control)
• Postoperative orthopedic(TKR THR) patients
• Higher rates of unplanned ICU transfers, cardiac
  events, longer hospital length of stay in the OSA
  group

32
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.

33
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

34
Preoperative AssessmentSTOP-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

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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

36
Preoperative Assessment of OSA STOP BANG
questionnaire

• B(MI) Is your BMI gt 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.

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Where does Louisiana rank in obesity among
states? (BMI 30)

• 2nd
• 1st
• 5th
• 8th

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Practice Guidelines for the perioperative
management of patients withOSA

• 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

39
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

40
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.

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Preoperative evaluation recommendationsASA
Guidelinesa collaborative effort

• pre-procedure identification of a patients 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 20061084

42
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

43
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 20061084

44
Identification and Assessment of OSA Signs
Symptoms suggesting OSA

• Predisposing physical characteristics
• Obesity(BMIgt35)
• Increased neck circumference(gt17 in. in males
  gt16in. 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
  OSAAnesthesiology 20061083

45
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
  OSAAnesthesiology1083

46
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
  OSAAnesthesiology 20061083

47
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 20061083

48
Preoperative Recommendations Estimating risk for
the OSA patient

• A patients 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 20061084

49
OSA Scoring System(modified from ASA Guidelines
Table 2)

• 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
  patientAnesthesiology20061083

50
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
  patientAnesthesiology20061083

51
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
  patientAnesthesiology20061083

52
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, 3
• parenteral or neuraxial
• opioids
• ASA Practice Guidelines for the OSA
  patientAnesthesiology20061083

53
OSA Scoring SystemD. 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 gt 50 mmHg
• ASA Practice Guidelines for the OSA
  patientAnesthesiology20061083

54
OSA Scoring SystemD. 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
  patientAnesthesiology20061083

55
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 (ASAs 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

56
Inpatient vs. Outpatient Surgery for OSA
patients-- ASA Task Force recommends considering

• Sleep apnea status
• Anatomical and physiological abnormalities
• Status of coexisting diseases
• Nature of surgery
• Type of anesthesia
• Need for postoperative opioids
• Patient age
• Adequacy of post-discharge observation
• Capabilities of the outpatient facility
• ASA Practice Guidelines for the OSA patient
  Anesthesiology 20061087

57
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 20061087

58
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

59
Consultants agree

• Superficial surgery/local or regional anesthesia
• Minor orthopedic surgery/local or regional
  anesthesia
• Lithotripsy
• ASA Practice Guidelines for the OSA
  patientAnesthesiology 20061087

60
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
  patientAnesthesiology 20061087

61
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
  patientAnesthesiology 20061087

62
Inpatient vs. OutpatientUpdate 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

63
Inpatient vs. OutpatientUpdate 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

64
What country has the most obese population?

1. Nauru
2. Mexico
3. USA
4. Australia

65
OSA check inagain

• 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 (ASAs OSA Scoring-Table 2)
• And we have made an educated decision(Table
  3-Consultant 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

66
Preoperative Preparation recommendations ASA
Guidelines

• Consider pre-op initiation of CPAP/NIPPV(Non-invas
  ive 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
  patientAnesthesiology 20061085

67
Preoperative PreparationBenefits 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 .

68
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
  patientAnesthesiology 20061085

69
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
  patientAnesthesiology 20061085

70
Intraoperative ManagementRegional anesthesia
benefits

• Regional anesthesia obviates the need for airway
  manipulation and reduces the need for
  intraoperative sedatives and opioidsthese
  techniques provide postoperative analgesia, and
  reduce postoperative opioid requirements.
  Joshi.2007

71
Intraoperative ManagementPreoxygenation 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

72
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.

73
Postoperative managementRespiratory 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
  patientAnesthesiology 20061085

74
Postoperative managementRespiratory depression

• REM rebound occurs on the third or fourth
  post-operative day as sleep patterns are
  re-established exacerbating respiratory
  depression ASA Practice Guidelines for the OSA
  patientAnesthesiology 20061085
• 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

75
Postoperative ManagementASA Guideline
recommendationsPostoperative 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
  patientAnesthesiology 20061086

76
Postoperative ManagementASA Guideline
recommendationsPostoperative 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
  patientAnesthesiology 20061086

77
Postoperative ManagementOpioid requirementgood
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

78
Postoperative ManagementASA 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
  patientAnesthesiology 20061086

79
Postoperative ManagementCPAP -- 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
  patientAnesthesiology 20061086-1087.

80
Postoperative ManagementCPAP

• 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

81
Postoperative ManagementASA 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
  patientAnesthesiology 20061087

82
Postoperative ManagementDischarge from PACU with
or without continuous pulse oximetry and
monitoring

• Patients that exhibit respiratory events such as
  apnea, bradypnea, desaturations, and
  pain-sedation mismatch in PACU(recovery room)
  should be admitted to a monitored bed with
  continuous oxygen saturation monitoring
• Adebola et al. 2010

83
Postoperative ManagementASA 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 patientAnesthesiology
  20061087
• 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 patientAnesthesiology
  20061087
• These recommendations may play a part in deciding
  suitability for ambulatory surgery, especially in
  a free standing ASC

84
Postoperative managementDischarge 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!

85
What perioperative protocol system do we use here
for OSA patients?

1. Stop-Bang
2. ASA Guidelines
3. Gambits best of N.O.
4. None

86
Summary OSA

• OSA definition, diagnosis, risk factors
• Increased perioperative risks adverse outcomes
• Pre-operative management OSA screening,
  estimating risk, inpatient vs. outpatient(ambulato
  ry suitability)
• Intra-op post-op management

87
Bibliography

1. Practice Guidelines for the Perioperative
   Management of Patients with Obstructive Sleep
   Apnea. Anesthesiology. 2006 1041081-1093
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.
   2010138(6)1489-1498.

88
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• Joshi G.,MD, Ankichetty S.,MD, Gan T.,MD, Chung
  F. Society for Ambulatory Anesthesia Consensus
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  2012
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   Postoperative complications in patients with
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• 11. Kaw  R, Golish  J, Ghamande  S, Burgess  R,
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• 12. Liao  P, Yegneswaran  B, Vairavanathan  S,
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• 14. Society of anesthesia and sleep medicine
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