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OSA : Isn’t it about obese? Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital Saowapark Chumpathong Department of Anesthesiology Siriraj.

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Presentation on theme: "OSA : Isn’t it about obese? Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital Saowapark Chumpathong Department of Anesthesiology Siriraj."— Presentation transcript:

1 OSA : Isn’t it about obese? Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital

2 OSA : Isn’t it about obese? Obstructive Sleep Apnea (OSA) Recurrent episodes of complete or partial obstruction of the upper airway during sleep, resulting in oxygen desaturation and arousal

3 OSA : Isn’t it about obese? Obstructive Sleep Apnea Clinical criteria Apnea: complete cessation of breathing ≥ 10 seconds Hypopnea: marked reduction in airflow, decreased SaO 2 ≥ 4% OSA: AHI score > 5 OSAS: AHI > 5 + excessive daytime sleepiness

4 OSA : Isn’t it about obese? OSA at a glance Prevalence OSA 11.4% (men 15.4%, women 6.3%) OSAS 4.4% (men 4.8%, women 1.9%) OSA ⇆ Obesity Arch Intern Med.2002;162:893-900. Obes Res.2000;8:262-9.  BMI ≥ 30 kg/m 2 : 40% prevalence  BMI ≥ 40 kg/m 2 : 98% prevalence Sleep Breath 2011;15:641-8.

5 OSA : Isn’t it about obese? Risk factors for OSA Variables OR (95% CI) Male gender 8.7 (7.8-14.9) Age > 45 years 2.7 (1.4-8.2) Habitual smoking 2.1 (1.6-2.3) Habitual drinking 3.2 (2.8-3.6) Obesity 4.8 (1.9-11.4) Hypertension 3.4 (3.1-4.9) Sleep Breath 2011;15:641-8.

6 OSA : Isn’t it about obese? Why OSA matters Health consequences of OSA  Problems with daytime functioning sleepiness, accident, quality of life  Cardiovascular, Cerebrovascular disease HT, CAD, MI, AF, CHF, Stroke, Death  Diabetes, Metabolic syndrome Cleveland Clinic Journal of Medicine. 2009;76:S98-103.

7 OSA : Isn’t it about obese? Why OSA matter to us? Higher prevalence in the surgical population  24% by Berlin questionnaire  > 70% in obese bariatric surgery > 80% unrecognized OSA undergoing surgery Increases perioperative morbidity, mortality Sleep.1997;20:705-6. Am Surg.2008;74:834-8.

8 OSA : Isn’t it about obese? Postoperative complications in patients with OSA Complications AHI ≥ 5 AHI < 5 Adjusted OR Adjusted p value (n=282) (n=189) Hypoxemia 35 (12.4) 4 (2.1) 7.9 0.009 ICU transfer 19 (6.7) 3 (1.6) 4.43 0.069 Any complication 40 (14.2) 5 (2.6) 6.9 0.003 LOS > 2 days 135 (48.2) 53 (28.0) 1.65 0.049 Chest.2011 Aug 25. [Epub ahead of print]

9 OSA : Isn’t it about obese? Perioperative pulmonary outcomes in patients with OSA Pulmonary outcomes OR (95% CI) Aspiration pneumonia 1.37 (1.33,1.41) ARDS 1.58 (1.54, 1.62) Pulmonary embolism 0.90 (0.84, 0.97) Intubation/mechanical 1.95 (1.91, 1.98) ventilation Anesth Analg.2011;112:113-21.

10 OSA : Isn’t it about obese? Identify OSA patient Risk factors for OSA History : Sleep habits : Symptoms and complaints  Snoring  Personality change  Sleepiness  Morning confusion  Night sweats  Physically restless sleep  Impotence  Intellectual impairment  Morning headaches  Morning dry mouth or sore throat

11 OSA : Isn’t it about obese? Identify OSA patient Physical examination  Obesity  HT  Large neck circumference  Airway  Nasal obstruction  Tonsil enlargement  Elongated uvula  Macroglossia  Retrognathia  Micrognathia

12 OSA : Isn’t it about obese? Identify OSA patient Screening tools  Berlin questionnaire  ASA checklist  STOP questionnaire  STOP-BANG questionnaire  Nocturnal oximetry Ann Intern Med.1999;131:485-91. Anesthesiology.2006;104:1081-93. Anesthesiology.2008;108:812-21. Curr Opin Anaesthesiol.2009;22:405-11.

13 OSA : Isn’t it about obese? CATEGORY 1 1. Do you snore? a. Yes b. No c. Don’t know If you snore: 2. Your snoring is: a. Slightly louder than breathing b. As loud as talking c. Louder than talking d. Very loud – can be heard in adjacent rooms 3. How often do you snore a. Nearly every day b. 3-4 times a week c. 1-2 times a week d. 1-2 times a month e. Never or nearly never 4. Has your snoring ever bothered other people? a. Yes b. No c. Don’t Know 5. Has anyone noticed that you quit breathing during your sleep? a. Nearly every day b. 3-4 times a week c. 1-2 times a week d. 1-2 times a month e. Never or nearly never Berlin questionnaire Item 1: if ‘Yes’, assign 1 point Item 2: if ‘c’ or ‘d’ is the response, assign 1 point Item 3: if ‘a’ or ‘b’ is the response, assign 1 point Item 4: if ‘a’ is the response, assign 1 point Item 5: if ‘a’ or ‘b’ is the response, assign 2 points Add points. Category 1 is positive if the total score is 2 or more points

14 OSA : Isn’t it about obese? Berlin questionnaire CATEGORY 2 6. How often do you feel tired or fatigued after your sleep? a. Nearly every day b. 3-4 times a week c. 1-2 times a week d. 1-2 times a month e. Never or nearly never 7. During your waking time, do you feel tired, fatigued or not up to par? a. Nearly every day b. 3-4 times a week c. 1-2 times a week d. 1-2 times a month e. Never or nearly never 8. Have you ever nodded off or fallen asleep while driving a vehicle? a. Yes b. No If yes: 9. How often does this occur? a. Nearly every day b. 3-4 times a week c. 1-2 times a week d. 1-2 times a month e. Never or nearly never item 9 should be noted separately Item 6: if ‘a’ or ‘b’ is the response, assign 1 point Item 7: if ‘a’ or ‘b’ is the response, assign 1 point Item 8: if ‘a’ is the response, assign 1 point Add points. Category 2 is positive if the total score is 2 or more points

15 OSA : Isn’t it about obese? Berlin questionnaire CATEGORY 3 10. Do you have high blood pressure? a) Yes b) No c) Don’t know Category 3 is positive if the answer to item 10 is ‘Yes’ OR if the BMI of the patient is greater than 30kg/m2. (BMI must be calculated. BMI is defined as weight (kg) divided by height (m) squared, i.e., kg/m2). High Risk: if there are 2 or more Categories where the score is positive Low Risk: if there is only 1 or no Categories where the score is positive

16 ASA checklist Category 1: predisposing physical characteristics Category 2: history of apparent airway obstruction during sleep Category 3: somnolence BMI >35Two or more of the following are present (if patient lives alone or sleep is not observed by another person, then only one of the following need be present) One or more of the following are present Neck circumference >43 cm /17 inches (men) or 40 cm /16 inches (women) Craniofacial abnormalities affecting the airway Snoring (loud enough to be heard through closed door) Frequent snoring Frequent somnolence or fatigue despite adequate ‘sleep’ Falls asleep easily in a nonstimulating environment(e.g. watching television, reading, riding in or driving a car) despite adequate ‘sleep’ Anesthesiology.2006;104:1081-93.

17 Category 1: predisposing physical characteristics Category 2: history of apparent airway obstruction during sleep Category 3: somnolence Anatomical nasal obstruction Observed pauses in breathing during sleep [Parent or teacher comments that child appears sleepy during the day, is easily distracted, is overly aggressive or has difficulty concentrating] a Tonsils nearly touching or touching the midline Awakens from sleep with choking sensation Frequent arousals from sleep [Child often difficult to arouse at usual awakening time] a Scoring: If two or more items in category 1 are positive, category 1 is positive. If two or more items in category 2 are positive, category 2 is positive. If one or more items in category 3 are positive, category 3 is positive. High risk of OSA, two or more categories scored as positive. Low risk of OSA, only one or no category scored as positive. a Items in brackets refer to pediatric patients.

18 Anesthesiology.2008;108:812-21.

19 STOP-Bang scoring model Questions Answer Snoring Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes / No Tired Do you often feel tired, fatigued, or Yes / No sleepy during daytime? Observed Has anyone observed you stop Yes / No breathing during your sleep? P blood pressure Do you have or are you being Yes / No treated for high blood pressure? BMI BMI more than 35 Yes / No Age Age over 50 years Yes / No Neck circumferenceNeck circumference greater than 40 cm Yes / No Gender Male Yes / No High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items Curr Opin Anaesthesiol. 2009;22:405-11.

20 STOP-Bang scoring model Questions Answer Snoring คุณนอนกรนดังหรือไม่ ? ( ดังกว่าเสียงพูด หรือ ดังพอที่จะได้ยินออกไป นอกห้อง ) ใช่ / ไม่ใช่ Tired คุณมักจะรู้สึกอ่อนเพลีย ล้า หรือ ง่วงนอนใน ระหว่าง กลางวันบ่อย ๆ หรือไม่ ? ใช่ / ไม่ใช่ Observed มีคนเคยสังเกตเห็นว่าคุณหยุดหายใจขณะที่คุณ หลับ อยู่หรือไม่ ? ใช่ / ไม่ใช่ P blood pressure คุณมีความดันโลหิตสูง หรือกำลังรักษาโรคความ ดัน โลหิตสูงอยู่ หรือไม่ ? ใช่ / ไม่ใช่ BMI ดัชนีมวลกายมากกว่า 35 หรือไม่ ? ใช่ / ไม่ใช่ Age อายุมากกว่า 50 ปี หรือไม่ ? ใช่ / ไม่ใช่ Neck circumference เส้นรอบวงคอมากกว่า 40 ซม. หรือไม่ ? ใช่ / ไม่ใช่ Gender เป็นเพศชายหรือไม่ ? ใช่ / ไม่ใช่ High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items Curr Opin Anaesthesiol. 2009;22:405-11.

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22 OSA : Isn’t it about obese? Identify level of OSA Polysomnography (PSG) : gold standard Severity of OSA AHI Mild 5-15 Moderate 15-30 Severe > 30 If no study available  positive in two categories of signs/symptoms  moderate OSA  any severe abnormality on the list  presume severe OSA Anesthesiology.2006;104:1081-93. American Academy of Sleep Medicine 2007

23 Obstructive sleep Apnea : Preoperative Assessment Suspected OSA patient Severity Assessment from history or Polysomnography High risk of OSA Comorbidities and Major Elective Surgery Preoperative PAP therapy. Perioperative OSA precautions. Preoperative PAP therapy. Perioperative OSA precautions. Known OSA patient Screening using STOP or STOP –Bang questionnaire Screening using STOP or STOP –Bang questionnaire Mild OSA Low risk of OSA Moderate or Severe OSA Moderate or Severe OSA Yes No Routine perioperative management. No preoperative PAP therapy required Routine perioperative management. No preoperative PAP therapy required Consider preoperative Sleep Medicine referral Consider preoperative Sleep Medicine referral Assume possibility of moderate OSA. Perioperative OSA precautions Anesthesiology Clin.2010;28:199-215. Can J Anesth.2010;57:849-64.

24 OSA : Isn’t it about obese? Perioperative OSA precautions Anticipating possible difficult airway Use of short-acting anesthetic agent Opioid- minimization Full reversal of neuromuscular blockade Extubation in a non-supine position Anesthesiology Clin.2010;28:199-215. Can J Anesth.2010;57:849-64.

25 OSA : Isn’t it about obese? Intraoperative Management Avoid sedating premedication Consider gastroesophageal reflux Regional, multimodal analgesia Use of intraoperative capnography Resume use of PAP device Anesthesiology Clin.2010;28:199-215. Can J Anesth.2010;57:849-64.

26 Prolonged stay in the PACU Known OSA Recurrent PACU Respiratory Event Recurrent PACU Respiratory Event Discharge to home if minor surgery or postoperative care on the surgical ward. Suspected OSA Non-compliant with PAP therapy Severe OSA Recurrent PACU Respiratory Event Non-compliant with PAP therapy Severe OSA Recurrent PACU Respiratory Event No Yes Postoperative PAP therapy and care in a monitored bed with continuous oximetry. Discharge to home if minor surgery. Yes Postoperative care on the surgical ward. No Yes Moderate OSA Postoperative opioids Moderate OSA Postoperative opioids No Anesthesiology Clin.2010;28:199-215. Can J Anesth.2010;57:849-64. Sao 2 <90% (x3) Bradypnea < 8/min (x3) Apnea ≥10 sec (x1) Pain sedation mismatch

27 OSA : Isn’t it about obese? OSA & Ambulatory surgery Estimation of perioperative risk Severity of OSA Invasive of surgery and anesthesia Requirement for postoperative opioids OSA scoring system > 4: increased risk Anesthesiology.2006;104:1081-93.

28 OSA Scoring System Points A.Severity of sleep apnea based on sleep study (or clinical indicators if sleep study not available). Point score_____ (0-3)*+ Severity of OSA None0 Mild1 Moderate2 Severe3 * One point may be subtracted if patient has been on continuous positive airway pressure (CPAP) or noninvasive positive-pressure ventilation (NIPPV) before surgery and will be using his or her appliance consistently during the postoperative period.+ One point should be added if a patient with mild or moderate OSA also has a resting arterial carbon dioxide tension (Paco 2 ) greater than 50 mmHg.

29 Points B.Invasiveness of surgery and anesthesia. Point score ___ (0-3) Type of surgery and anesthesia Superficial surgery under local or peripheral nerve block0 anesthesia without sedation Superficial surgery with moderate sedation or general1 anesthesia Peripheral surgery with spinal or epidural anesthesia (with1 no more than moderate sedation) Peripheral surgery with general anesthesia2 Airway surgery with moderate sedation2 Major surgery, general anesthesia3 Airway surgery, general anesthesia3

30 Points C.Requirement for postoperative opioids. Point score ___(0-3) Opioid requirement None0 Low-dose oral opioids1 High-dose oral opioids, parenteral or neuraxial opioids3 D.Estimation of perioperative risk. Overall score = the score for A plus the greater of the score for either B or C. Point score ___ (0- 6)* *Patient with score of 4 may be at increased perioperative risk from OSA; patients with a score of 5 or 6 may be at significantly increased perioperative risk from OSA. Anesthesiology.2006;104:1081-93.

31 OSA : Isn’t it about obese? OSA & Ambulatory surgery Mild-moderate OSA patients optimized comorbid conditions not requiring postoperative opioids  safely undergo surgery Severe OSA patients requiring postoperative opioids  not safe to undergo surgery Current Opinion in Anesthesiology. 2011;24:605-11.

32 OSA : Isn’t it about obese? Take Home Message OSA is strongly associated with obesity. Higher prevalence & unrecognized OSA are undergoing surgery. Patients with OSA are at an increased risk of perioperative complications. Identification,risk stratification of patients with OSA is essential in preventing postoperative complications.


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