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Operative risk in patients with Operative risk in patients with Obstructive Sleep Apnea Syndrome Obstructive Sleep Apnea Syndrome
(OSAS).(OSAS).
Why give preference to Why give preference to RA?RA?
Luc SermeusLuc Sermeus
Antwerp University HospitalAntwerp University Hospital
BelgiumBelgium
ESRA winterweek 2012ESRA winterweek 2012
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OSA: OSA: characteristicscharacteristics
• SnoringSnoring
• Apnea caused by airway obstructionApnea caused by airway obstruction
• ArousalArousal
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AnesthesiaAnesthesia
== a state of a state of unrousableunrousable
unconsciousnessunconsciousness
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OSA: Preop OSA: Preop assessmentassessment
• OSA already diagnosedOSA already diagnosed
• OSA not (yet) diagnosed (80-95%)OSA not (yet) diagnosed (80-95%)
• 82% men, 93% women 82% men, 93% women
• Polysomnography / nocturnal oxymetry / Polysomnography / nocturnal oxymetry / HolterHolter
• Cancel surgery? Cancel surgery?
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C.L. Wang et al. Sleep Breath 2011, 16 (ahead of C.L. Wang et al. Sleep Breath 2011, 16 (ahead of print)print)
““Half of Chinese anesthesiologists lacked sufficient Half of Chinese anesthesiologists lacked sufficient knowledge and had low confidence levels in dealing knowledge and had low confidence levels in dealing
with OSA patients”with OSA patients”
OSAKA- questionaryOSAKA- questionary
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Preop OSA: Preop OSA: symptomssymptoms• SnoringSnoring
• Men 44% > women 28%Men 44% > women 28%
• 30-60y, peak 50-60y30-60y, peak 50-60y
• Obesity (60-90%) BMI > 30kg/m²Obesity (60-90%) BMI > 30kg/m²
• BMI: Western > Asian , prevalence OSA BMI: Western > Asian , prevalence OSA similar similar
5% in men, 2% in women 5% in men, 2% in women (Young, J Resp Crit Care Med 2002)(Young, J Resp Crit Care Med 2002)
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Preop OSA: Preop OSA: symptomssymptoms
• SnoringSnoring
• PredispositionPredisposition
• Alcohol, Upper airway infectionAlcohol, Upper airway infection
• Hypertrophic tonsils, nasal obstructionHypertrophic tonsils, nasal obstruction
• Craniofacial anatomy (Kushida Craniofacial anatomy (Kushida Laryngoscopy 2000)Laryngoscopy 2000)
• Lower facial height, more backward Lower facial height, more backward position jaw in Asian populationposition jaw in Asian population
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Airway obstruction with apneaAirway obstruction with apnea
• Obesity Obesity
Correlation: fatty tissue lateral of pharynx & OSACorrelation: fatty tissue lateral of pharynx & OSA
Neck Ø > 42-44 cm Neck Ø > 42-44 cm fast collapse of airwayfast collapse of airway
• Micro- / retrognathiaMicro- / retrognathia
• Hypertrophic tonsils, big tongue, position of hyod Hypertrophic tonsils, big tongue, position of hyod bonebone
• Maxillar hypoplasia, narrow oropharynx, shape of Maxillar hypoplasia, narrow oropharynx, shape of airway airway
(Ishiguro, Oral Surg Med Path Radiol Endosc 2009) (Ishiguro, Oral Surg Med Path Radiol Endosc 2009)
Preop OSA: Preop OSA: symptomssymptoms
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CHEST August 2005 vol. 128 no. 2 896-901Igor Fajdiga, MD, PhD
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CHEST August 2005 vol. 128 no. 2 896-901Igor Fajdiga, MD, PhD
Normal Apneic
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American Journal of Respiratory and Critical Care Medicine Vol 168. pp. 522-530, (2003)Richard J. Schwab et al.
BMI = 32BMI = 32
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Preop OSA: Preop OSA: symptomssymptomsArousalArousal
• OO22↓↓, CO, CO22↑↑, ventilatory effort, ventilatory effort↑↑, stretch-, stretch-receptorsreceptors↑↑
“ “awake”awake”
• Not totally conscious - muscle toneNot totally conscious - muscle tone↑↑- - obstructionobstruction↓↓
• Massive sympathetic activationMassive sympathetic activation
bradycardia bradycardia tachycardiatachycardia
AHT AHT
Cardiac ischemia - CVACardiac ischemia - CVA
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OSA: pathophysiologyOSA: pathophysiology
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Pharyngeal collapsein OSA
Sympathetic Drive
Intrathoracic Pressure
Myocardial OxygenSupply
VasoconstrictionPeriph. ResistanceHeart rateOxygen demand
Venous returnAfterloadPreload
* LVH
* RV dilatation
*Stroke Volume*LVEF*TD velocities of LV and RV
BP
Stru
ctural
alterations
Fu
nction
alalteration
sCardiovascular changesCardiovascular changes
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OSA: consequencesOSA: consequences
•AHT: related to severity OSA (risk 10XAHT: related to severity OSA (risk 10X↑↑))
•Arrhythmia's: nocturnal in 50%, risk2-4XArrhythmia's: nocturnal in 50%, risk2-4X↑↑ if if hypoxemiahypoxemia↑↑
• Mostly NSVT Mostly NSVT
• Sinus arrest, second degree AV-block, VES, AFSinus arrest, second degree AV-block, VES, AF
•Cardiac ischemia:Cardiac ischemia: 14-28%14-28% = 5x normal= 5x normal
•Heart-failure: 11-37%Heart-failure: 11-37%
•Pulmonary HT 20-42% Pulmonary HT 20-42% Right heart-failure Right heart-failure
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OSA: OSA: consequencesconsequences• Hypoxemia Hypoxemia polycythemia polycythemia
• Stroke: 62-77% of stroke has OSAStroke: 62-77% of stroke has OSA
• SeveritySeverity↑↑ of OSA = Riskof OSA = Risk↑↑ of stroke of stroke
• Terminal renal insuff: 40-60% = f(duration) of Terminal renal insuff: 40-60% = f(duration) of OSAOSA
• DiabetesDiabetes
• Edema UAEdema UA
• Impaired chemosensitivityImpaired chemosensitivity
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OSA: OSA: consequencesconsequences
Cardio vascular risk Cardio vascular risk ↑↑ with severity and duration with severity and duration OSAOSA
Overall risk of CVD = x11Overall risk of CVD = x11
= 15-20% fatal complication if severe OSA = 15-20% fatal complication if severe OSA >10j>10j
Risk post therapy = mild OSA = 4-5% Risk post therapy = mild OSA = 4-5%
Control = Control = ±±2%2%
Marin et al. Lancet Marin et al. Lancet 20052005
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Preop OSA: Preop OSA: premedicationpremedication• Benzodiazepines: CAVEBenzodiazepines: CAVE
Muscle toneMuscle tone↓↓ collapse collapse apnea apnea SatSat↓↓
Pulsoxymetry / CPAP Pulsoxymetry / CPAP
• Anti-sialorrhea: GlycopyrrolateAnti-sialorrhea: Glycopyrrolate
• CPAP : to be started, if possible, 2w before CPAP : to be started, if possible, 2w before surgerysurgery
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OSA + Consequences + Co-OSA + Consequences + Co-pathologypathology
= perop / postop risk= perop / postop risk
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Perop OSA: anestheticsPerop OSA: anesthetics
ALL ANESTHETICS :ALL ANESTHETICS :
•Negative effect on cardiac functionNegative effect on cardiac function
•CollapsibilityCollapsibility↑↑
•Arousal responseArousal response↓↓↓↓ if O if O22↓↓, CO, CO22↑↑, obstruction, obstruction
•Ventilatory responseVentilatory response↓↓ if O if O22↓↓, CO, CO22↑↑
•UA reflexesUA reflexes↓↓
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Physiology: FRCPhysiology: FRC
FRC = OFRC = O22-reserve if apnea-reserve if apnea
• BMIBMI↑↑ = FRC = FRC↓↓ + O + O22-consumption-consumption↑↑
• Supine position = FRCSupine position = FRC↓↓
• Anesthesia/sedation = FRCAnesthesia/sedation = FRC↓↓
preoxygenation before induction of preoxygenation before induction of anesthesiaanesthesia
= filling FRC with ±100% O= filling FRC with ±100% O22
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Perop OSA: UAPerop OSA: UA
21,9% difficult UA if OSA 21,9% difficult UA if OSA ↔↔ normal normal 2,6%2,6%
➡5% failed intubation (=100x 5% failed intubation (=100x normal) normal)
66% with a difficult intubation had OSA66% with a difficult intubation had OSA
Savva D.1994 Br J Anaesthesia 73(2):149-53Savva D.1994 Br J Anaesthesia 73(2):149-53
Chung F et al. 2008 Anesth Analg 107(3):915-20Chung F et al. 2008 Anesth Analg 107(3):915-20
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Perop OSA: UAPerop OSA: UA
• Difficult Upper AirwayDifficult Upper Airway
• Experienced anesthetistExperienced anesthetist
Inadequate face mask ventilationInadequate face mask ventilation
Difficult ( > 2 attempts) intubationDifficult ( > 2 attempts) intubation
• Predictive factorsPredictive factors
• ComplicationsComplications
• Dental injury / UA traumaDental injury / UA trauma
• Severe hypoxia Severe hypoxia cerebral ischemiacerebral ischemia
+ laryngoscopy + laryngoscopy asystoleasystole
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OSA: prediction OSA: prediction difficult UAdifficult UA
• Anatomical factorsAnatomical factors
• Craniofacial morphology / trauma / surgeryCraniofacial morphology / trauma / surgery
• Cervical mobility / mouth openingCervical mobility / mouth opening
• Micro- / retrognathia / macroglossiaMicro- / retrognathia / macroglossia
• Long soft palateLong soft palate
• MallampatiMallampati
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MallampatiMallampati
Mallampati 3-4 + OSA = difficult intubation Mallampati 3-4 + OSA = difficult intubation until proven otherwiseuntil proven otherwise
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Cormack - LehaneCormack - Lehane
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Difficult intubationDifficult intubation
==
Difficult Difficult extubation!!!extubation!!!
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OSA: Difficult OSA: Difficult extubationextubation CausesCauses
• AnatomyAnatomy
• Residual sedationResidual sedation
• Instrumentation UAW during intubation / surgery Instrumentation UAW during intubation / surgery of UAof UA
• EdemaEdema
• BloodBlood
• SecretionsSecretions
• Nasal packsNasal packs
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OSA: difficult OSA: difficult extubationextubation
•5% life threatening postextubation 5% life threatening postextubation obstruction following surgical treatment of obstruction following surgical treatment of OSAOSA
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OSA: difficult OSA: difficult extubationextubation
Pre requisitesPre requisites
• Complete recovery of muscle relaxationComplete recovery of muscle relaxation
• Wide awake / communicatingWide awake / communicating
• Spontaneous breathing Spontaneous breathing adequate TV adequate TV
oxygenationoxygenation
• Semi sitting position Semi sitting position FRCFRC↑↑
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OSA: difficult OSA: difficult extubationextubation
Pre requisitesPre requisites
•Stable haemodynamicsStable haemodynamics
•CPAPCPAP +/- O2
•Re-intubation equipment readyRe-intubation equipment ready
•Perop corticosteroids if necessaryPerop corticosteroids if necessary
•Intensive care / Medium care if necessaryIntensive care / Medium care if necessary
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OSA: postop OSA: postop complicationscomplications
• Rebound REM ±3Rebound REM ±3thth day postop. day postop.
• PainPain↓↓, surgical stress, surgical stress↓↓ ±normal sleep pattern ±normal sleep pattern
• Obstruction, apnea, sympathetic activationObstruction, apnea, sympathetic activation
• Hemodynamic instability (pt not yet Hemodynamic instability (pt not yet recovered)recovered)
• Confused / CVAConfused / CVA
• Disturbed wound healingDisturbed wound healing
• Myocardial ischemia / infarction / sudden Myocardial ischemia / infarction / sudden deathdeath
• NB: respiratory depression lasts for a week NB: respiratory depression lasts for a week (morphine??)(morphine??)
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OSA: conclusionsOSA: conclusions
• OSA = cause of cardio-vascular complicationsOSA = cause of cardio-vascular complications
• OSA = cause of difficult UA OSA = cause of difficult UA
• Enough reasons to prefer RA and to convince Enough reasons to prefer RA and to convince your patientyour patient
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Obstructive Sleep Apnea, Stroke, and Cardiovascular DiseasesBagai, Kanika MD, MSThe Neurologist
Issue: Volume 16(6), November 2010, p 329–339
LiteratureLiterature