Dennis Spence, PhD, CRNA - NDANA · 3/1/2014 6 OSA Airway Decreased pharyngeal area 2nd excess adipose tissue Uvula, tonsillar pillars, tongue, lateral pharyngeal walls MRI study-

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Dennis Spence, PhD, CRNA

http://www.bing.com/images/search?q=images+of+obstructive+sleep+apnea&qpvt=images+of+obstructive+sleep+apnea&FORM=IGRE

Disclaimer The views expressed in this article are those of the

author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.

The author does not endorse, promote or advertise any products presented in this presentation.

Disclosure Nothing to disclose

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Objectives Review the stages of sleep

Describe types of sleep disordered breathing with focus on OSA

Compare and contrast the normal and OSA airway

Describe the pathophysiology and clinical consequences of OSA

Review evidence on OSA related to:

Opioid effects

Screening

Difficult airway

PACU & Postoperative Complications

List perioperative precautions that may reduce risks in OSA patients

Clinical Vignette 56 y/o male scheduled for ex lap for sigmoid resection

PMH-HTN, obesity (BMI 48), DM II, colon cancer

PSH- none

Meds- HCTZ, metoprolol, glyburide

EKG- NSR w/ LAD, LVH Labs- wnl BP- 160/85, HR- 58

Airway- MP III, 3FB MO, TM 2.5 FB, limited ROM, neck

50 cm

+snoring, +daytime somnolence, witnessed apnea by wife

Clinical Vignette What is the likelihood that this patient has

undiagnosed OSA?

If he has OSA, how severe is it?

What other comorbidities might he have secondary to his OSA?

Is he a potentially difficult airway?

Does having OSA increase his risks for perioperative complications?

What perioperative OSA precautions can I use to minimize his risks?

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Stages of Sleep Non-REM (non-rapid eye mvt)

3 stages

Stage 3 physically restorative sleep

Stage 3reduced muscle tone

REM

Most muscles paralyzed/relaxed

Potential collapse of upper airway

Lack of REM may impair ability to learn complex tasks

Sleep impairment

interferes w/ growth patterns, memory, healing, & immune response

http://www.bing.com/images/search?q=images+of+stages+of+sleep&go=&qs=bs&form=QBIR

Types of Sleep Disordered Breathing

Apnea

Cessation of airflow > 10 seconds

Hypopnea

Decreased airflow >30% for > 10 seconds associated with:

Oxyhemoglobin desaturation ≥4%

Arousals

Apnea Patterns Obstructive Mixed Central

Airflow

Respiratory

effort

American Academy of Sleep Medicine. Sleep Apnea: Diagnosis and Treatment Sleep Medicine Professional Education slides. 2006.

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OSA Definition

Characterized chronic, frequent events of airway obstruction during sleep Sxs: snoring, witnessed apnea, & daytime sleepiness

Secondary HTN

During sleep OSA patients experience: Frequent episodes of apnea and/or hypopnea

Frequent oxygen desaturation

Chronic hypercarbia and hypoxemia

Frequent Arousals

Reduced Non-REM Stage 3 & REM sleep

OSA Risk Factors

Male gender

Obesity (BMI>29) present in 60-90% of OSA pts

Non-obese craniofacial & orofacial abnormalities (i.e, enlarged

tonsils)

Family hx

Large neck circumference (>17 in male, >16 in female)

Smoking and alcohol use

Medications-sedatives, opioids

Measures of Sleep Apnea Frequency Polysomnography

Gold standard for diagnosis of OSA

Apnea Index

# apneas per hour of sleep

Apnea / Hypopnea Index (AHI)

# apneas + hypopneas per hour of sleep

Oxygen desaturation index (ODI)

Number of desaturations of ≥4% per hour of sleep

ODI of >5 high likelihood of OSA

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Severity of OSA AHI

None 0-5

Mild 6-15

Moderate 16-30

Severe >30

Obstructive Apnea EEG

10 sec

Arousal

Airflow

Effort (Pes)

SaO2

Effort (Abdomen)

Effort (Rib Cage)


Normal Airway

Retropalatal (RP)

from the level of the hard palate to the caudal margin of the soft palate

Retroglossal (RG)

from the caudal margin of the soft palate to the base of the epiglottis

Schwab et al. Am J Respir Crit Care Med. 2003 168; 522–530.

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OSA Airway Decreased pharyngeal area 2nd excess adipose tissue

Uvula, tonsillar pillars, tongue, lateral pharyngeal walls

MRI study- Large tongue and increased volume of lateral pharyngeal walls risk factors for OSA

Increased extramural pressure compresses airway (i.e., large neck)


OSA Airway OSA Normal


Normal vs. OSA Airway

Larger

smaller

airway


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OSA = airway smaller & lateral pharyngeal walls larger

OSA Airway



OSA Airway During Sleep

Spence DL. Anesthesia for Uvulipharyngopalatoplasty. In Clinical Cases in Nurse Anesthesia, Ed.: Elisha, S. Jones and Bartlett; Sudbury, MA. 2010: pp. 53-61.

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Vicious Cycle of OSA

Loss of neuromuscular

compensation

+ Decreased pharyngeal

muscle activity

Sleep Onset

Hyperventilate: correct

hypoxia & hypercapnia

Airway opens

Airway collapses

Pharyngeal muscle

activity restored

Apnea Arousal from sleep

Hypoxia &

Hypercapnia

Increased ventilatory

effort


Clinical Consequences

Moos DD, Prasch M, Cantral DE, Huls B, Cuddeford JD. Are patients with obstructive sleep apnea syndrome appropriate candidates for the ambulatory surgical center? AANA J. 2005;73(3):197-205.

Co-existing diseases/symptoms associated with OSA

Cardiovascular Neuropsychological Endocrine/Other

Hypertension

Arrhythmias:

o Atrial

Fibrillation

o Bradycardia

o A-V Block

CAD

Nocturnal angina

MI

CHF

CVD

Pulmonary HTN

Daytime

somnolence

Cognitive

Impairment

Accident proneness

Anxiety

Depression

Glucose Intolerance and

Diabetes

Obesity

Gastroesphogeal Reflux

Disease

Difficult airway

Adapted from Spence DL. Anesthesia for Uvulipharyngopalatoplasty. In Clinical Cases in Nurse Anesthesia, Ed.: Elisha, S. Jones and Bartlett; Sudbury, MA. 2010: pp. 53-61.

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OSA Prevalence

Prevale

nce

AHI >

5

Mod-S

ev Undx O

SA

0

20

40

60

80

100Men

Women

pe

rce

nta

ge

of

pa

tie

nts

(%

)

Adapted from Young T et al. N Engl J Med 1993;328.

Wisconsin Sleep Cohort Study

4% 2%

24%

9%

82%

93%

How Well Do We Do?

Screening Surgical Patients for OSA

Polysomnography considered gold standard Problem- difficult to obtain; expensive

Allows for initiation of CPAP therapy

Questionnaire screening tools ASA OSA checklist

Berlin Questionnaire

STOP-BANG

Combination of questionnaire + home sleep study

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ASA Checklist Screens & estimates risk (12 items)

High-risk = (+) ≥2 more categories

Invasiveness of surgery

Postop opioid requirements

AHI ≥ 5

Sensitivity = 72%

Specificity = 38%

AHI ≥ 15

Sensitivity = 79%

Specificity = 37%

Abrishami et al. A systematic review of screening questionnaires for obstructive sleep apnea Can J Anesth (2010) 57:423–438

Berlin Questionnaire Most widely used in primary care

11 questions in 3 categories Obstructive sxs

Daytime sleepiness

HTN hx

AHI ≥ 5 Sensitivity = 69%

Specificity = 56%

AHI ≥ 15 Sensitivity = 79%

Specificity = 51%

Abrishami et al. A systematic review of screening questionnaires for obstructive sleep apnea Can J Anesth (2010) 57:423–438

STOP-BANG Questionnaire

8 item screening tool for surgical patients

≥3 high risk OSA

AHI ≥ 5

Sensitivity = 84%

Specificity = 56%

AHI ≥ 15

Sensitivity = 93%

Specificity = 43%

Chung et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108:812-821

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STOP-BANG Does a higher score predict more severe OSA?

Table 1. Odds of OSA based on STOP-Bang Score

STOP-Bang score All OSA (AHI>5) Mod/Sev OSA (AHI>15) Severe OSA (AHI >30)

5 3.98 (2.38-6.66) 4.75 (2.81-8.03) 10.39 (4.45-24.26)

6 4.52 (2.34-8.74) 6.29 (3.39-11.66) 11.55 (4.64-28.71)

7 or 8 7.04 (2.82-17.55) 6.88 (3.32-14.25) 14.86 (5.58-39.56)

N = 746

STOP-BANG = 5 were 10x more likely to have Sev OSA vs. score <3

Score of 5 = Specificity 74% for Sev OSA

Chung et al. High STOP-BANG score indicates a high probability of obstructive sleep apnea Br J Anaesth 2012;108:768-75

Does STOP-BANG Predict Postop Complications? Vasu et al 2010 N = 135 surgical patients

STOP-BANG score ≥ 3 vs. ≤ 3

Outcomes = composite postop complications

Afib, hypotension, MI, hypoxemia, PE, pneumonia

Results for STOP-BANG ≥ 3

Odds: 11.4x more postoperative complications (P = 0.03)

Vasu TS et al Arch Otolarynglol Head Neck Surg; 2010;136(10):1020-4

How Common is OSA in Surgical Patients? Finkel et al (2008)

N = 2778 surgical pts

OSA screening questionnaire

High-risk pts sleep study

Compared high vs. low risk

Results

OSA prevalence = 22%

82% never diagnosed

High-risk = >BMI, >Neck circ., >HTN, >DM

Finkel et al. Sleep Medicine. 2009;10:753-58 Spence DL. Anesthesia Abstracts 2011;(5)9: 19-22.

Home Sleep Study Results (n = 207)

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How Common is OSA is Surgical Patients?

STOP-BANG study

N = 2721 surgical patients

STOP-BANG + sleep study

Results

High-risk (≥3)= 28%

OSA In

cidence

(AH

I >5)

Mild

OSA (A

HI >

5)

Modera

te O

SA (AH

I >15

)

Severe O

SA (AH

I >30

)

0

20

40

60

80

100

Sleep Study Results

N = 122

pe

rce

nta

ge

of

pa

tie

nts

(%

)

Chung et al. Anesthesiology 2008;108:812-821 Spence DL. Anesthesia Abstracts 2011;(5)9: 12-15.

How Common is OSA is GI Patients?

ERCP OSA Study

N = 231 ERCP patients

Used STOP-BANG

Results

High-risk (≥3)= 43%

>MP score, >ASA class, >age, >BMI, >male gender

Coté GA et al. Clin Gastroenterol Hepatol 2010;8:660-665

EBP STOP-BANG Projects Does incorporation of the STOP-BANG increase our ability to

identify patients at high risk for OSA?

Method

Baseline: measure incidence of high risk OSA

Educated nurses & implemented STOP-BANG

Post: measured incidence of high risk OSA (score ≥3)

Before

After

Before

After

0

10

20

30

Williams et al (2012)

Lakdawala (2011)

High-risk for OSA

pe

rce

nta

ge

of

pa

tie

nts

(%

)

Lakdawala L. J Perianesthesia Nurs. 2011. 26(1): 15-24 Williams et al. 2012. Presented at AANA State of Science Aug 2012.

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Challenges with Screening Incorporated into EMR &

preop workflow

Auto-calculated score

Score 5 to flag as high risk

8 months = 12,500 necks measured

Implementing auto-sleep study referral not possible

“Altering medical assistant and nurse practitioner workflows in the clinic was straightforward…. …but changing our anesthesia providers’ workflow has not yet been successful. While some of the variables can be derived from demographics and patient history, ... …obtaining neck circumference measurements and asking the additional screening questions adds extra time …..”

Robert Stoelting, MD, President, Anesthesia Patient Safety Foundation: “Clinically significant drug-induced respiratory depression (oxygenation and/or ventilation) in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.”

•JC Screen patients for respiratory depression risk factors (see sidebar).

Preoperative Implications OSA prevalence 22-43%

>80% of patients have OSA and don’t know it

Have high index of suspicion for coexisting diseases HTN, CAD, DM, atrial fibrillation

Difficult airway

Should develop screening process for undiagnosed OSA Polysomnography & initiation of CPAP when possible

Use the STOP-BANG

Requires multidisciplinary team, buy-in & support at all levels

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“Anesthesia Providers could potentially impact a significant public health burden and reduce the percentage of undiagnosed OSA patients in major ways: proper implementation of screening guidelines, optimization of interventional therapy (e.g., CPAP) perioperatively and ensuring follow up by sleep physician postoperatively” “Our Role does not stop within the confines of the operating room or the PACU. “ “Specialist sleep physician referral and appropriate therapy are crucial in long term cardiac and cerebrovascular outcomes”….

Society of Anesthesia & Sleep Medicine , Volume 3, Issue 1 w 2014

Opioids & OSA OSA sleep study (N = 19 moderate OSA, AHI>15-30)

Continuous remifentanil infusion in sleep lab

Results

Only 20% experienced REM sleep (P < 0.05)

Increased # arousals vs. baseline study

AHI increased (44 ± 29 vs. 24 ± 5, P = NS)

#obstructive apneas lower(4 ± 6 vs. 8 ± 5, P = NS)

#hypopneas increased (22 ± 16 vs. 15 ± 6, P = NS)

#Central apneas increased (17 ± 29 vs., 0.4 ± 1 P < 0.05)

Bernards CM et al. Anesthesiology 2009;110: 41-49

Opioids & OSA

Lowest SaO2= Baseline = 87 ± 4% Remifentanil = 80 ± 5% P< 0.05

Bernards CM et al. Anesthesiology 2009;110: 41-49 Spence DL. Anesthesia Abstracts 2011;(5)9: 7-12.

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Opioids & OSA Opioids reduce REM sleep

decreases # of obstructive apneas REM sleep is when airway most relaxed # central apneas may increase (no stimulus to breathe) REM rebounds in 48-72hrsworsening of OSA sxs*

Hypoxemia & hypercarbia may have triggered increased # arousals & reduced obstructions

Hypoxemia incidence and severity worse on remifentanil

Implication Be cautious when administering opioids to OSA patients

*Lao P, Sun F, Amirshahi B, Islam S, Vairavanathan S, Shapiro C, Chung F. A significant exacerbation of sleep breathing is OSA patients

undergoing surgery with general anesthesia. Sleep 2009;32: A223.

OSA & Difficult Airway


Are Patients with OSA more Difficult to Ventilate?

Kheterpal S et al Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics. Anesthesiology. 110(4):891-897, April 2009

Predictors of Impossible Mask Ventilation

Odds ratio

Neck radiation changes 7.1

Male sex 3.3

Sleep apnea 2.4

MP III or IV 2

Beard 2

Patients with ≥ 3 of these risk factors were 8.9x more likely to be impossible to mask ventilate

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Are Patients with OSA more Difficult to Intubate?

Palatal muscle resection for OSA (N = 115) (Lee et al 2011)

20% difficult intubation (DI) rate

Predictors Large neck ≥ 40 cm

AHI≥50

UPPP (N = 180) (Kim et al 2006)

OSA vs. no OSA

DI rate: 16.6% vs. 3.3%

Spence DL. Anesthesia Abstracts 2011;(5)9: 30-33.

OSA & Difficult Intubations Bariatric Surgery observational study (N = 180)

78% female, BMI = 49.4 ± 7.6, median OSA severity = mild

Median MP score = MP 2, neck circumference = 43.8 ± 5.4 cm

Results

DI rate = 3.3%

No relationship between OSA dx and difficult intubation in bariatric pts(P = NS)

Predictors of DI = >MP 2 & male gender

Larger neck = poorer glottic view

Meligan et al Anesth Analg 2009;109: 1182-1186

Implications Men with severe OSA & large necks at greatest risk

Airway surgery for OSA may be risk

Be prepared for difficult mask and intubation!

Ramp obese pts & optimize sniffing position

Backup device (indirect video laryngoscopy, LMA)

Call for help early!

Consider AFOB

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Sedation & OSA Cohort study N = 231

ERCP/EUS

High vs. Low risk OSA (STOP-BANG)

CRNA = propofol +/- opioid/midazolam

Outcomes = Airway maneuvers

sedation related complications

High-risk OSA 1.6x more likely to experience SAO2<90%

Coté GA et al Clin Gastroenterol Hepatol 2010;8:660-665 Spence DL. Anesthesia Abstracts 2011;(5)9: 22-26.

PACU & Suspected OSA Cohort study N = 693 surgical Non-OSA dx patients

High vs. Low-Risk OSA

Outcome = recurrent PACU respiratory complications <90% with nasal cannula; 3 episodes needed for yes

Results 32% high-risk for OSA

>1 event of SaO2 <90% = 28% vs. 11%, P < 0.001

High-risk OSA = 3.5x more likely postop resp. event

21x more likely experience recurrent PACU events

2.7x more likely experience postop complication

Unplanned ICU admission = 27% vs. 8%

Gali et al. Anesthesiology 2009;110:869-876

PACU & Suspected OSA

High-risk OSA = more likely to experience recurrent desaturation Gali et al. Anesthesiology 2009;110:869-876 Spence DL. Anesthesia Abstracts 2011;(5)9: 39-44.

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Implications- PACU Desaturation most common complication

What about hypercarbia?

Points to need to have plan for high-risk OSA pts ICU vs. Step-down unit

Question: Should OSA pts have continuous ETCO2 & SaO2

monitoring?

Severity?

Gali et al. Anesthesiology 2009;110:869-876

OSA & Postop Complications Case-control study of TKA surgery pts

clinically suspected or diagnosed OSA pts vs. control (N = 202)

Respiratory complications = 28% vs. 10%, P = 0.019

Note. Serious complications were defined as complications necessitating transfer to the

ICU for cardiac events or urgent respiratory support with need for intubation or CPAP. undx OSA vs. dx OSA =

Total complications = 32% vs. 3%, P <0.05 Gupta et al. Mayo Clin Proc 2001;76:897-905 Spence DL. Anesthesia Abstracts 2011;(5)9:.

OSA & Postop Complications

Liao P et al. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anesth 2009;56:819-828

Spence DL. Anesthesia Abstracts 2011;(5)9.

N = 240

N = 240

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Liao P et al. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anesth 2009;56:819-828

OSA group (N = 240) • 2x increased risk of postop complication • 27% require CPAP 2nd hypoxemia • Complications occurred more often after

transfer to ward • CV & neuro complications same • 2 vs. 1 cardiac arrests in OSA pts

• 2 for difficult intubation/reintubation


• National Inpatient Sample OSA Study N = 3,441,262

21. Memtsoudis S et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011;112: 113-121.

OSA & Postop Complications • National Inpatient Sample OSA Study N = 3,441,262

Table 1. Odds of Postoperative pulmonary complications in OSA patients

General surgery

Aspiration pneumonia

ARDS

PE

Intubation/mechanical ventilation

1.37 (1.33-1.41)

1.58 (1.54-1.62)

0.90 (0.84-0.97)

1.95 (1.91-1.98)

Orthopedic

Aspiration pneumonia

ARDS

PE

Intubation/mechanical ventilation

1.41 (1.35-1.47)

2.39 (2.28-2.51)

1.22 (1.15-1.29)

5.20 (5.05-5.37)

Note. Results are odds ratio (95% confidence interval). All are significant (P < 0.05).

21. Memtsoudis S et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011;112: 113-121.

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Non-SDB group • Higher Hospital charges,

• $39,977 vs. $37,934, P < 0.001 • Slightly higher mortality

• 0.3% vs. 0.1%, P 0.001 • Longer LOS

• 7.1 days vs. 5.8 days, P < 0.01

Why???? • Higher vigilance in those dx w/ OSA?

• Some Non-SDB group could have had

undiagnosed OSA?

Does Technique Matter?

• Neuraxial anesthesia +/- GA associated with improved outcomes

• Reduced odds of major complications, requirement for critical care admission (especially for neuraxial anesthesia alone), or mechanical ventilation

• Associated with reduced hospital length of stay and costs.

• Randomized N = 177 OSA patients (AHI>15) to auto-titrated CPAP • started 3 days prior to surgery or routine care

• CPAP significantly reduced postoperative AHI • Low compliance

• <48% of patients used the CPAP >4h per night

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CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. Methods: Pre-surgical patients who screened positive for OSA on the STOP-Bang questionnaire and underwent PSG before surgery. CPAP was offered to patients with moderate or severe OSA. Results: Median Adherence only 2.5 h/n Conclusion: Adherence to prescribed CPAP therapy during the perioperative period was extremely low.

J Clin Sleep Med. 2012 Oct 15;8(5):501-6

Postoperative Implications Known or suspected OSA patients increased risk for

postoperative pulmonary/respiratory complications

Hypoxemia

Need for higher level of care

CPAP improves postop AHI, but compliance poor

Neuraxial improved outcomes reduced costs

Mod-Sev OSA may need continuous ETCO2 +/- SPO2

Smart Pump Technology

Patient Surveillance systems

OSA During Pregnancy Home sleep study

N = 161 obese parturients @21 w

BMI > 30 kg/m2

AHI >5 vs. AHI <5

Outcomes

Perinatal outcomes

Predictors of preeclampsia

controlled for BMI, age, diabetes

Results

OSA incidence = 15%

Age

30±6 vs. 27±6 (P = 0.04)

Prepregnancy BMI

48±11 vs. 39±6 (P <0.001)

CHTN

58% vs. 33% (P = 0.02)

Asthma

50% vs. 31% (P = 0.005)

Louis J et al. Perinatal Outcomes Associated With Obstructive Sleep Apnea in Obese Pregnant Women. Obstet Gynecol 2012;120:1085–92

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OSA during Pregnancy Predictors of preeclampsia

3.5x more likely w/ OSA

2.8x more likely w/ previous preeclampsia

4.3x more likely w/CHTN

OSA No OSA0

20

40

60

80

100Cesarean Delivery

Preeclampsia

Wound Complications

NICU Admission

Hyperbilirubinemia

All P < 0.05

per

cen

tag

e o

f p

ati

ents

(%

)

Perioperative OSA Precautions • Need to ID those with known or suspected OSA (especially moderate-severe)

• Minimize preoperative sedation

• Prepare for possible difficult airway

• Minimize use of long acting opioids. Consider utilizing multimodal analgesic techniques

and regional anesthesia when possible

• Utilize short acting inhaled or intravenous anesthetics intraoperatively

• Utilize capnography during monitored anesthetic care

• Ensure patient is full reversal of neuromuscular blockade. Ensure patient is fully

conscious and cooperative prior to extubation

• Utilize non-supine posture for extubation and recovery

• Resume or consider use of CPAP therapy in patients with OSA

• Have plan for postop monitoring. Consider continuous ETCO2 +/- SPO2

Seet E, Chung F. Management of sleep apnea in adults- functional algorithms for the perioperative period: continuing professional development. Can J Anesth. 2010;57: 849-65.

Society of Ambulatory Anesthesia Consensus Guidelines 2012

• Recommend screening with STOP-BANG & presume patient has OSA based on sxs

• Literature unclear of benefit of sleep study or CPAP on postop outcomes

• Non-optimzed patients may not be suitable for ambulatory surgery

• Optimal duration of CPAP therapy prior to surgery unknown

• Recommend nonopioid analgesic/multimodal techniques especially for painful ambulatory surgery

• Encourage patients w/ OSA to use CPAP postop whenever sleep

• Educate surgeons, patient and family on minimizing opioids, use of CPAP, and sleeping in lateral position

• Patients should f/u with primary care MD for sleep study postop if identified as high risk

for OSA based on STOP-BANG

Joshi et al. Anesthesia & Analgesia. 115(5):1060-1068, November 2012.

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Joshi et al. Anesthesia & Analgesia. 115(5):1060-1068, November 2012.

References 1. American Academy of Sleep Medicine. Sleep Apnea: Diagnosis and Treatment Sleep Medicine Professional Education slides. 2006. 2. Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107(5):1543-1563. 3. Spence DL. Anesthesia for Uvulipharyngopalatoplasty. In Clinical Cases in Nurse Anesthesia, Ed.: Elisha, S. Jones and Bartlett; Sudbury, MA. 2010: pp. 53-61. 4. Schwab et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med. 2003 168; 522–530. 5. Horner RL. Respiratory motor activity: influence of neuromodulators and implications for sleep disordered breathing. Can J Physiol Pharmacol 2007;85: 155-165. 6. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anesthesiol 2009;22: 502-508. 7. Chung F, Yegnesaran B, Liao P et al. Validation of the Berlin Questionnaire and American Society of Anesthesiologists Checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008;108:822-830. 8. Chung F et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108: 812-821. 9. Lakdawala L. Creating a safer perioperative environment with an obstructive sleep apnea screening tool. J Perianesthesia Nurs. 2011. 26(1): 15-24.

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References 10. Bernards CM, Knowlton SL, Schmidt DF, DePaso WJ, Lee MK, McDonald SB, Bains OS. Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology 2009;110: 41-49.

11. Chung et al. High STOP-BANG score indicates a high probability of obstructive sleep apnea Br J Anaesth 2012;108:768-75.

12. Finkel et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Medicine. 2009;10:753-58.

13. Gross et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006;104: 1081-93.

14. Coté GA, Hovis CE, Waldbaum L et al. A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010;8:660-665.

15. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: review of 50,000 anesthetics. Anesthesiology 2009;110:891-897.

16. Lee SJ, Lee JM, Kim TS, Park YC. The relationship between the predictors of obstructive sleep apnea and difficult intubation. Korean J Anesthesiol 2011;60: 173-178.

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Dennis Spence, PhD, CRNA - NDANA · 3/1/2014 6 OSA Airway Decreased pharyngeal area 2nd excess adipose tissue Uvula, tonsillar pillars, tongue, lateral pharyngeal walls MRI study-

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