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OBSTRUCTIVE SLEEP APNEA

OBSTRUCTIVE SLEEP APNEA. PERIOPERATIVE PREVENTIVE MEDICINE. 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)

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OBSTRUCTIVE SLEEP APNEA

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  1. OBSTRUCTIVESLEEP APNEA PERIOPERATIVE PREVENTIVE MEDICINE

  2. 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 breathing…usually the result of heart failure and less commonly stroke

  4. Pathophysiology:Occurs during REM sleep Loss of upper airway muscle tone Increase pharyngeal resistance Negative pharyngeal pressures during inspiration Upper airway collapse

  5. Pathophysiology Cycle:After 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

  7. 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 thoracoabdominalmotion & diaphragmatic EMG with pneumography) • Oximetryand capnography • Blood pressure and ECG • Body Position • Sound Joshi.2007

  9. Sleep Study Other sleep disorders • Narcolepsy • Hypersomnia • Periodic limb movement disorder • REM behavior disorder • Parasomnias

  10. 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

  11. 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

  12. 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

  13. AHIAmerican Academy of Sleep Medicine AHI: severity of OSA(AASM) 5-15 ≈ mild OSA 15-30 ≈ moderate OSA >30 ≈ severe OSA

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

  15. More on AHI • “…the sleep laboratory’s 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 AHI>40 have a significantly higher prevalence of difficult intubation Joshi. 2007.

  16. Treatment of OSA • Dental appliances • Surgery—Uvulopalatopharyngoplasty(UPPP) • CPAP & others: BiPAP≈NIPPV, APAP(auto adjusts) • Weight loss • Tracheostomy(in life-threatening cases unresponsive to other treatments)

  17. 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

  18. 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(>17 in. males & >16 in. females Adebola et al. 2010

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

  20. 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. What’s the prevalence of OSA among electivesurgical candidates? • 3% • 5% • 25% • 60% • 75%

  22. 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 OSA:Anesthesiology2006 • Increased perioperative risk for OSA patients leading to adverse outcomes

  23. 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

  24. Increased OSA perioperative risks:effects 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

  25. Increased OSA perioperative risks:effects 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.

  26. More on why we care…Postoperative Death • Dr. Benumof(an anesthesiologist) was an expert witness in > 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 Benumof.2010

  27. More on why we care…“Dead 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

  28. 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

  29. Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery(modified from Adebola et al. 2010.Table 1) • Hwang et al (2008—prospective 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

  30. Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al. 2010.Table 1) • Kaw et al (2006—retrospective 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 (2001—retrospective 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

  35. 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 > 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.

  37. 2nd • 1st • 5th • 8th Where does Louisiana rank in obesity among states? (BMI ≥ 30)

  38. 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.

  41. Preoperative evaluation recommendations:ASA Guidelines—a collaborative effort • “…pre-procedure identification of a patient’s 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 2006;1084

  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 postoperativecomplications 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 2006;1084

  44. Identification and Assessment of OSA: Signs & Symptoms suggesting OSA Predisposing physical characteristics • Obesity(BMI>35) • Increased neck circumference(>17 in. in males & >16in. 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 OSA:Anesthesiology 2006;1083

  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 OSA:Anesthesiology;1083

  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 OSA:Anesthesiology 2006;1083

  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 2006;1083

  48. Preoperative Recommendations: Estimating risk for the OSA patient • A patient’s 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 2006;1084

  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 patient:Anesthesiology2006;1083

  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 patient:Anesthesiology2006;1083

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