Obstructive sleep apnea(OSA) syndrome

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Obstructive sleep apnea(OSA) syndrome

• V.S.???/CR???
• Ri ???/???/???

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Basic Data of the Patient

• Name ?O?
• Chart No. 5055863
• Age 5 y/o
• Gender Male
• Body height 110 cm
• Body Weight 22 kg

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Chief Complaint

• Restlessness during sleeping for several months

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Brief Hx-1

• This 5-year-old boy who was situs inversus with
  dextrocardia and valve insufficiency diagnosed at
  VGH had been suffering from snoring for several
  months.
• There was no daytime somnolence and sleep awake.
• He visited our podiatrist OPD and polysomnography
  was arranged. He was admitted for operation this
  time.

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Brief Hx-2

• The AHI was 6.9 per hour.
• He was referred to our OPD for further
  evaluation. Local examination revealed bilateral
  hypertrophy tonsils and skull lateral view showed
  adenoid hypertrophy. Surgical intervention was
  suggested and his family accepted. He was
  admitted for operation this time.

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Past History

• 1. Situs inversus with dextrocardia and valve
  insufficiency, DM(-), HTN(-)
• 2. Drug allergy NKDA
• 3. Smoking denied
• Drinking denied
• Betel nut denied
• 4. frequent UTI/URI

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PE

• Vital sign stable
• Grade IIIII enlargement tonsils

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Hemogram/BCS/PT/PTT

• WBC 5.88 K/µL
• RBC 4.06 M/µL
• HB 11.8 g/dL
• HCT 34.7
• MCV 85.5 fL
• MCH 29.1 pg
• MCHC 34.0 g/dL
• PLT 398.0 K/µL
• RDW-CV 11.9

• D-BIL 0.15 mg/dL
• Alb 4.6 g/dL
• T-BIL 0.67 mg/dL
• AST 27 U/L
• ALT 17 U/L
• ALP 253 U/L
• LDH 478 U/L
• UN 10.0 mg/dL
• CRE 0.5 mg/dL
• Na 137 mmol/L
• K 4.0 mmol/L
• Cl 106 mmol/L
• PT/PTT 11.0/34.1

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Heart Echo 97/2/29

• 2-D/Dopplar Findings1.Detro-position of the
  heart2.No chamber enlargement.3.LVEF 624.No
  intracardia anomaly.5.Mild TR, PG 16mmHg6.R't
  aortic arch. No CoA. No PDA.

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Polysomnography (This April)

• Lowest oxygen saturation 90
• AHI 6.9 /hr.
• Obstructive apnea 3.0 /hr.
• Hypopnea 3.9 /hr.

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Diagnosis

• 1. Obstructive sleep apnea syndrome
• 2. Adenoid vegetation
• 3. Situs inversus with dextrocardia

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Anesthesia (GA)

• OP method UPPP
• Pre-anesthesia evaluation ASA class II
• Induction Atropine(0.2mg) Ketamine(455mg)
  Nimbex(3mg)
• Maintenance Sevoflurane
• IVF Lactic Ringer 200 c.c.
• Recovery Atropine(0.4mg) Vagostin(1.9mg)

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Post-OP (in recovery room)

• Nausea/Vomiting Nil
• Headache Nil
• Sore throat Nil
• Wound pain (Bain 1/3 amp)
• Other complication Nil

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Obstructive sleep apnea(OSAS) syndrome
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Sleep apnea

• Cessation or reduction in respiratory airflow ?
  abnormal gas exchange?hypoxemia and hypercapnia
• Repetitive arousals caused by apneas and
  hypopneas ?sleep fragmentation and the loss of
  restorative sleep
• Apnea cessation of air flow ? 10 seconds
• Hypopnea airflow?of 25 or 50 and an oxygen
  saturation ?34
• Apnea-hypopnea Index (AHI) Number of apneas and
  hypopneas per hour of total sleep time
• Disease-defining therashold no consensus, AHI?5

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Sleep apnea

• Obstructive An event with absence of airflow
  but with continued respiratory effort
• Central An event with absence of airflow and no
  respiratory effort
• Mixed An event with characteristics of an
  obstructive and mixed event. These events
  typically start with a period that meets the
  criteria for a central event but will end with
  respiratory effort without airflow

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OSAS in children
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Obesity and obstructive sleep apnea in children

• Redline et al obesity ( BMI? 28) was the
  strongest predictor of sleep-disordered
  breathing, 1/3 obese children abnormal PSG.
• Deposition of adipose tissue (muscle and soft
  tissue)gt external compression
• Increased chest wall and abdominal massgt reduced
  lung volumes

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Neuromotor factors

• Factors suggest neuromotor dactors
• 1. obstruction while sleeping
• 2. persisted OSAS after adenotonsillectomy
• 3. recurrence during adolescence after
  adenotonsillectomy
• 4. smaller pharynx, but stiffer, less
  collapsible
• Reduced centrally mediated activation of their
  upper-airway musclesgt collapsibility ?

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Clinical features

• Snoring, labored breathing, paradoxical
  respiratory effort, observed apnea, restlessness,
  sweating, unusual sleep positions and enuresis
• Normal height and weight or obesity, failure to
  thrive and developmental delay
• Tonsillar hypertrophy (adenoids correlate with
  the severity of OSAS on PSG)

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Complications

• Chronic nocturnal hypoxemia and sleep
  fregmentation
• Growth impairment, decreased growth hormone
  (growth spurt after adenotonsillectomy)
• Cardiovascular pulmonary hypertension, cor
  pulmonale, and heart failure
• Neurocognitive deficits, learning problems,
  behavioral problems, attention deficit
  hyperactivity

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Evaluation

• Gold standard polysomnography(PSG)
• PSG differentiate between primary snoring and
  OSAS has lower functional residual capacity and
  higher respiratory rate?desaturate with
  relatively short apnea ?apneas lt 10-second may be
  significant
• Degree of PSG abnormalities that produce sequelae
  is yet unclear

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Surgical treatment

• Adenotonsillectomy is the mainstay of treatment
  for OSAS .
• Down syndrome or obesity tend to improve after
  adenotonsillectomy, although additional treatment
  may sometimes be needed.
• Uvulopalatopharyngoplasty, a tongue reduction,or
  a craniofacial reconstruction has also been used
  in selected cases.
• Tracheostomy

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Medical treatment

• When Surgery is contraindication or failure.
• CPAP
• BiPAP
• Supplemental oxygen has been shown to improve
  oxygenation in patients with OSAS, it does not
  alter the increased work of breathing
• Few individuals develop a marked rise in their
  Pco2 in response to supplemental oxygen

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Preanesthesia evaluation

• History
• CXR ,EKG , Cardiac echo if needed
• VBG
• In most cases, OSAS is considered a chronic
  health condition and warrants a classification of
  ASA II.
• Children who experience respiratory failure that
  requires mechanical ventilatory support and those
  who have severe anatomical malformationsof the
  airway or morbid neurologic disease may be
  classified as ASA III
• or IV.

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Intraoperative anesthetic plan

• Those children will present with exacerbation of
  obstructed breathing and apnea when under the
  affects of anesthesia.
• Children with OSAS show an exaggeration of the
  blunted respiratory drive in response to opioid
  and BZD administration
• and are at risk for airway obstruction
• Presedation with opioids or benzodiazepines or
  both before surgery should be used with
  appropriate preoperative monitoring

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Intraoperative anesthetic plan

• A neuromuscular blockade for children with OSAS
  is often used to facilitate endotracheal
  intubation with an oral RAE endotracheal tube.
• Skilled clinicians and the equipment for managing
  a difficult airway, such as a fiber-optic
  laryngoscope as well as a laryngeal mask airway,
  also should be readily available.

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Intraoperative anesthetic plan

• the two person ventilation method and laryngeal
  mask airway are reported to be helpful in adult
  with OSAS .
• The jaw thrust to treat airway obstruction in
  these patients is the most useful and is superior
  to the chin lift.
• Antireflux medications and antisialagogue drugs
  are important adjuncts to consider for the
  prevention of aspiration and laryngospasm in the
• OSAS population

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Intraoperative monitoring

• Continuous EKG , end-tidal gas, and carbon
  dioxide concentrations, pulse oximetry and
  temperature.
• A-line is rarely needed.

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extubation

• Deep extubation is not suitable because the
  child with OSAS will be less likely to breath
  spontaneously and maintain airway patency
• while under the residual effects of
  anesthesia.
• Children with OSAS are extubated when they are
  fully awake and demonstrating markers of airway
  muscle control such as age-appropriate
  respiratory rate without assisted ventilation in
  OR or ICU.

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Postoperative care

• Children with severe OSAS or cardiovascular
  disease or those who are recovering from
• airway or craniofacial surgery should be
  monitored after surgery in the pediatric
• intensive care unit.
• Patients who do not experience respiratory
  compromise during the initial recovery phase
  still may require continued monitoring because
  obstructive apnea may recur along with the return
  of REM sleep on postanesthesia day 2 or 3.

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Respiratory support

• The use of supplemental oxygen during recovery
  from anesthesia in the child with OSAS is
  controversial.
• Hyperoxygenation can mask hypoventilation, making
  it difficult to determine the severity of
  postoperative apnea.
• Children who experience postanesthetic hypoxemia
  should be evaluated first for pulmonary edema,
  atelectasis, and pneumonia.

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Pain management

• Opioid analgesics will further depress
  respiratory drive and relax the pharyngeal
  dilator muscles, must be used judiciously during
  the postoperative period.
• Acetaminophen seems to be the safest choice as
  either a narcotic-sparing or a primary analgesic,
  with limited risk of bleeding or airway compromise

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Conclusion

• Preanesthesia evaluation is important.
• Opioid is relative contraindication.
• Jaw thurst position with RAE endo tube is better
  choice.
• Postanesthesia monitoring with adequate
  respiratory support helps patients a lot.

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References

• Obstructive Sleep Apnea Syndrome in Children,
  Preetam Bandla, MD, Anesthesiology Clin N Am 23
  (2005) 535 549
• Demographics and Diagnosis of Obstructive Sleep
  Apnea, Tracey Stierer, MDa,, Naresh M. Punjabi,
  MD, PhD, Anesthesiology Clin N Am 23 (2005) 405
  420
• Anaesthesia and sleep apnoea, J.A. Loadsman nad
  D.R.Hillman, British Journal of Anaesthesia
  86(2) 254-66(2001)
• Millers anesthesia, 6th ed.