1. Dr. Shais S. Jallu Dr M.J. Mador

2. Obstructive sleep apnea: Cardinal features include: Perturbations of a regular respiratory pattern during sleep including obstructive apneas, hypopneas or respiratory effort related arousals. Daytime symptoms attributable to disrupted sleep including: fatigue, sleepiness or poor concentration. Signs of disturbed sleep including snoring or restlessness.

3. Obstructive sleep apnea: Risk factors include obesity, craniofacial or upper airway soft tissue abnormalities, nasal congestion and current smokers. Prevalence Elevetated AHI -27-35%in men and 9-12% in women OSA - 3-7% in men and 2-5% in women Age African-Americans

4. Obstructive sleep apnea: Polysomnogram is the gold-standard diagnostic test: Apneas — Apnea is airflow less than 20 percent of baseline for at least ten seconds in adults Hypopneas —decrease (>50 percent) in the amplitude of breathing during sleep which lasts at least ten seconds, Apnea-Hypopnea Index RERAs RDI OSA categories: Mild- AHI 5-15 Moderate-15.1-30 Severe->30

5. Obstructive sleep apnea: Treatment: Conservative measures-weight reduction, avoidance of alcohol, BZDs or opioids CPAP Oral appliances Surgery-UPPP, genioglossus advancement Drug therapy-Modafinil Use of CPAP can reduce the rate of complications in OSA patients: Improves upper airway patency and ventilation Reduces myocardial ischemia and cardiac arrhythmias, stabilizes fluctuations in BP

6. Sedation & OSA: Patients with OSA suffer from anatomical abnormalities including short, thick neck, excessive tissue on pharyngeal wall, craniofacial abnormalities. Sedatives and opioids: Decrease pharyngeal tone & increase resistance  pharyngeal collapse CNS depressants  depression of RAS Respiratory depression Patients with OSA appear to be more sensitive to sedation than others

7. Introduction: No established guidelines for sleep apnea patients receiving conscious sedation in the endoscopy suite. Several studies have suggested increased risk for perioperative cardiorespiratory complications in OSA patients. Can these results be extrapolated to the endoscopy suite where moderate sedation and no postoperative analgesia is used?

8. Study Design: Retrospective; chart review type. Performed at VAMC, buffalo. VAMC records and any scanned non-VA records. VAMC patients who had any type of endoscopic procedure were linked with patients who had sleep study. Data collected about: Baseline Characteristics Sleep study results Endoscopy procedure Minor and major complications during the procedure

9. Inclusion Criteria: Patients who had any type of endoscopic procedure including:  Colonoscopy  EGD  Combined procedure (including EUS) performed in the GI suite. under conscious sedation. from 2002 to 2008. Linked with patients who had sleep studies: from 2001 to 2008. In the VAMC sleep lab or outside VAMC if report was scanned.

10. Exclusion Criteria: PEG tube placement procedures Bronchoscopy procedures Sigmoidoscopy procedures Patient who had procedure-related complications. Patients who had the procedure done in the ICU Patient with missing data regarding the procedure report, sleep study report or both Complicated endoscopic procedures where more intense anesthesia was used

11. Baseline Characteristics: Age Sex Race BMI (body mass index) Smoking history PFTs LVEF% Charlson co-morbidity index

12. Charlson co-morbidity index:

13. Sleep study results: patients were divided into two main groups: negative sleep study (apnea hypopnea index AHI < 5/hr) positive sleep study (apnea hypopnea index AHI > 5/hr) positive group was also divided into 3 subgroups:  mild OSA (AHI 5-15/hr)  moderate OSA (AHI 15.1-30/hr)  severe OSA (AHI > 30/hr)

14. Endoscopy procedure: Type Indication Amount of sedation Inpatient vs Outpatient Baseline vital signs right before the procedure Presence or absence of home oxygen CPAP usage before or during the procedure Minor and major complications were identified

15. Minor complications: Defined based on two definitions: 1) Patients who had vital signs within normal range before the procedure :  hypertension (SBP >160)  hypotension (SBP<90)  bradycardia (HR<55)  tachycardia (>100)  desaturation (< 90%)  hypoventilation (RR < 8) with no associated pain. 2) Patients who had abnormal vital signs:  25% change or above from the baseline vital signs.

16. Major complications: Chest pain/MI. Arrhythmias (like 3 rd degree heart block) Hypotension requiring fluid resuscitation Respiratory distress Cardio- respiratory arrest Any minor complication that required intervention including: IV fluids atropine epinephrine reversal agent up-titration of oxygen use of CPAP machine intubation transfer to ICU prolonged observation after the procedure unplanned admission

17. Results: 818 patients had both endoscopic procedures and sleep studies. 179 were excluded. 130 patients had documented negative sleep study in the last 5 years, while 509 had positive ones. 135 had mild OSA, 125 had moderate OSA and 249 had severe sleep apnea.

20. Results… Majority of procedures were done in the outpatient setting (96%). Type of Procedure: 438 colonoscopy procedures (68.5%), 12 9 EGD procedures (20.1 %) 72 combined procedures (including EUS, combined EGD and Colonoscopy) (11.4%). 38% of the procedures were done for screening purposes while the rest were diagnostic. Sedation: Both Versed and Fentanyl were used in almost all the procedures. the median amount of versed and fentanyl was 4 mg, 87.5 mg respectively. The amount of sedation was distributed equally with no significant difference among the groups. 20 % of patients had minor complications, while 7.3 % had major complications. Only one case that had severe sleep apnea, had respiratory arrest that required transfer to ICU.

27. Discussion: Studies have shown that benzodiazepines and opioids have detrimental effect on sleep apnea Various studies have documented increased perioperative risk of cardiopulmonary complications in sleep apnea patients receiving general anesthesia Mechanisms include: Effect on ventilatory control and upper airway tone Depression of RAS Sleep deprivation and fragmentation postoperatively causing rebound increase in REM sleep Postoperative analgesia

28. Discussion: Gupta et al (2001) assessed risk of post-op complications in patients with OSA undergoing hip or knee replacement and found that sleep apnea patients had higher rate of adverse postoperative outcome. Hwang et al (2008) recorded home nocturnal oximetry on patients with clinical features of OSA and found that ODI 4% > 5 was associated with increased rate of postoperative complications.

29. Discussion: conscious sedation is different from general anesthesia in terms of: Short acting agents No postoperative analgesia Short procedures No mechanical ventilation Literature concerning sleep apnea patients receiving conscious sedation in the endoscopy suite is inadequate.

30. Discussion: Sharma et al (2003) conducted a prospective study which concluded that OSA was detected in a majority of previously undiagnosed patients undergoing outpatient procedures (bronchoscopy and colonoscopy) under conscious sedation. Khiani et al (2008) conducted a prospective study on 233 patients stratifying them into low & high risk for OSA (using Berlin Questionnaire): Patients underwent either EGD or colonoscopy under conscious sedation Sedation related transient hypoxia was compared between the 2 groups with no resultant difference.

31. Discussion: Our data was analyzed in two different ways : comparing patients with positive and negative sleep study. merging normal and mild sleep apnea into a single category Both showed same conclusions Chung et al (2008) compared postoperative complications in sleep apnea patients and concluded  patients with positive sleep studies had increased risk as compared to negative ones  however no increased risk with mild OSA group

32. Discussion: In our retrospective analysis, sleep apnea patients undergoing endoscopy procedures (colonoscopy, EGD,EUS or combination of those) under conscious sedation are at no increased risk of cardiopulmonary complications as compared to those without sleep apnea. Patients with sleep apnea can undergo procedures under conscious sedation using standard monitoring practices. Use of CPAP during the procedure may not be required.

33. Limitations: Problems with documentation: Retrospective design Baseline co-morbidities Minor complications Missing data Sample bias: Elderly patients Majority are males, Caucasians Multiple co-morbidities preselected for sleep study

34. Conclusion Sleep apnea does not appear to predispose to a significantly increased rate of cardiopulmonary complications during endoscopy procedures under conscious sedation. In terms of clinical implication, it appears that sleep apnea patients can undergo such procedures safely using present monitoring practices.

35. References: Frances Chung, F.R.C.P.C.,* Balaji Yegneswaran, M.B.B.S 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 Blacke, Chia et al, Preoperative assessment for OSA and the prediction of postoperative respiratory obstruction and hypoxemia anesthesia intensive care 2008 Shireen, Alexander et al, Postoperative Hypoxemia in Morbidly Obese Patients with and Without Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery anesthesia analog 2008 Daniel D. Moos, CRNA, MS Obstructive Sleep Apnea and Sedation in the Endoscopy Suite Gastroenterology Nursing 2006 Vijay S. Khiani, Santo Maimone et al, Safety of Conscious Sedation During Routine Endoscopy for Patients At Risk for Obstructive Sleep Apnea Gastrointestinal endoscopy 2008 Roop Kaw, ; Franklin Michota et al, Unrecognized Sleep Apnea in the Surgical Patient* Implications for the Perioperative Setting Chest 2006 Hwang, Shakir et al, association of sleep-disordered breathing with postoperative complications. Chest 2008 Gupta, Parvizi et al. Postoperative complications in patients with OSA undergoing hip or knee replacement: a case control study. Mayo Clin Proc 2001 Sharma, Haber et al. unexpected risk during administration of conscious sedation: previously undiagnosed OSA. Ann Intern Med 2003 Moote, Skinner. Morphine disrupts nocturnal sleep in a dose-dependent fashion.Anesth Analog 1989

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