Preoperative

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Preoperative Postoperative Nursing
Considerations in Patients with Obstructive Sleep
Apnea

• Andrea Riekstins, MN, NP-Peds
• Hospital for Sick Children

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Overview

• Sleep
• Obstructive sleep apnea (OSA)
• Preoperative Postoperative Considerations in
  patients with OSA

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Sleep

• Definition reversible behavioural state of
  decreased responsiveness and interaction with the
  environment
• (Finn, April 2004)

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Sleep

• 2 stages of sleep
• REM dream sleep
• NREM

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Sleep

• Function
• Memory consolidation
• Energy conservation
• Brain and body growth
• Immune function regulation

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Physiology During Sleep

• Decreased minute ventilation
• Decreased heart rate, blood pressure
• Decreased muscular tone
• Relative hypoxemia (PO2 3-10 mmHg)
• Relative hypercapnia (PCO2 6-8 mmHg)

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Common Sleep Disorders

• Obstructive Sleep Apnea (OSA)
• Central Sleep Apnea (CSA)
• Behavioural
• Parasomnias

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OSA

• Definition of an obstructive apnea
• No airflow
• Complete obstruction of the airway
• Paradoxical chest movements
• May be associated with hypoxemia/ hypercapnia

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Diagnosing OSA

• Number of obstructive apneas /hour (AHI)

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OSA

• Demographics1,2
• 1-3 of all children
• Peak age, 2-8 years
• MF, 11
• 1. Ali, Arch Dies Child 1993, 2. Redline,
  AJRCCM 1999

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OSA Basic Pathophysiology

• Upper airway obstruction
• Tonsil and adenoid hypertrophy
• Altered upper airway tone
• Anatomy of face, jaw and airway, eg retrognathia
• Obesity

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OSA High Risk Patients

• Syndromes, eg Trisomy 21
• Craniofacial, eg Crouzons
• Metabolic syndromes, eg Mucopolysaccharidosis
• Endocrine eg Prader Willi
• Haemoglobinopathies eg Sickle cell disease,
  Thalassaemia
• Documented OSA on polysomnogram

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Effects Of Anesthesia

• Depresses respiration in normal patients, so
  preexisting breathing issue can be exacerbated

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Prior To Anesthesia

• What we evaluate
• Past medical history
• Birth history
• Hospitalizations
• Surgeries previous anesthesia
• Allergies/Medications
• Review of systems
• Family History

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Sleep History Daytime Symptoms

• Mouth breathing
• Inconsistent behavior
• Hyperactivity
• Poor academic performance
• Daytime sleepiness

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Sleep History Night-time Symptoms

• Snoring
• Gasping
• Pauses in breathing
• Mouth breathing
• Paradoxical breathing

• Increased work of breathing
• Restless
• Excessive diaphoresis
• Neck hyperextension
• Secondary enuresis

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Prior To Anesthesia

• Examination
• Age
• Ethnicity
• Height/Weight
• Mouth breathing, adenoidal facies
• Nasal congestion
• Hyponasal / muffled voice
• Retrognathia, micrognathia, midface hypoplasia
• Septal deviation, mucosal thickening, polyps,
  patency of nares
• Macroglossia, palate
• Tonsillar hypertrophy

Mazumdar,2008
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Prior To Anesthesia

• Physical Examination
• Respiratory
• Cardiac
• Neurological
• Diagnostic Tests
• Pulmonary function
• Capillary blood gas
• X-ray chest, lateral head/neck
• Echocardiogram

Mazumdar, 2008
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Prior To Anesthesia

• Diagnostic Test for OSA
• Polysomnogram (PSG) is Gold standard
• Overnight oximetry

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Postoperative Care

• Patients with OSA undergoing surgery is
  associated with multiple postoperative
  complications
• Respiratory morbidity following TA in general
  pediatric population is 1
• OSA increases the risk to 20 in the
  postoperative period
• Hypoxemia, arrhythmias, hypercapnia

Nixon, 2004
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Postoperative Care

• Sleep and breathing on the first night after TA
  for OSA
• 10 children classified into groups based on
  preoperative testing
• PSG
• All 10 had sleep disordered breathing marked
  sleep disturbance, airway obstruction and
  desaturation
• Those identified as severe preoperatively had
  more frequent obstructive apneas/hypopneas and
  more severe desaturation episodes

Nixon, 2005
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Postoperative Care

• Observation
• Continuous monitoring, frequent visual monitoring
  (ECG, Pulse ox)
• Positioning
• CPAP/BIPAP/Oxygen
• Analgesia
• No sedatives

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Summary

• OSA recurrent partial or complete upper airway
  obstruction during sleep resulting in disruption
  of normal ventilation
• Preoperative screening postoperative
  observation essential in patients with OSA