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) Intra-op & post-op management

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

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

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

Symptoms of OSA Hypersomnolence(excessive daytime sleepiness)
Morning headaches Decreased libido Irritability and inattentiveness Poor memory and depression Spector and Ryan.2012

Diagnosis of OSA Sleep Study
Polysomnography(sleep study) is the gold standard Monitors to stage sleep: EEG(electoencephalogram) EOG(electrooculogram) EMG(electromyogram)

Sleep Study additional monitors:
Oral and nasal airflow Respiratory effort (monitors thoracoabdominal motion & diaphragmatic EMG with pneumography) Oximetry and capnography Blood pressure and ECG Body Position Sound Joshi.2007

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

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

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

Defining Severity of OSA The 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

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

OSA coverage for treatment Medicare 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

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

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)

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

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

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

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

What’s the prevalence of OSA among elective surgical candidates?
3% 5% 25% 60% 75%

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:Anesthesiology 2006 Increased perioperative risk for OSA patients leading to adverse outcomes

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

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

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.

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

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

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al 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

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al 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

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al 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

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al 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

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

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

Preoperative Assessment STOP-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

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

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.

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

Practice Guidelines for the perioperative management of patients with OSA
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

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

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.

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 ----- Meeting Notes (1/18/13 17:58) ----- 2nd point--a collaborative effort. developing protocols, algorithms, pathways

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 postoperative complications between the screening-only (using the ASA checklist) and polysomnography-confirmed OSA groups Chong et al. 2013

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

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 ----- Meeting Notes (1/18/13 17:58) ----- ASA task force created this table to help to identify patients with OSA…another screening tool.

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

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

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

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

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 ----- Meeting Notes (1/18/13 17:58) ----- AASM AHI numbers 5-15,15-30,>30

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

B. Invasiveness of surgery and anesthesia Peripheral surgery with general anesthesia (2 points) Airway surgery with moderate sedation(2 points) Major surgery, general anesthesia(3 points) Airway surgery, general anesthesia(3 points) ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083

C. Requirement for postoperative opioids None 0 Low-dose oral opioids 1 High-dose oral opioids, 3 parenteral or neuraxial opioids ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083

OSA Scoring System: D. Estimation of perioperative risk (modified from ASA Guidelines Table 2)
Overall score = score for A(severity) plus the greater of the score for either B(invasiveness) or C(opioid requirement). Point score is 0 to 6. One point may be subtracted if a patient has been on CPAP or NIPPV before surgery and will be using the appliance consistently in the perioperative period One point should be added if a patient with mild or moderate OSA has a resting PaCO2 > 50 mmHg ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083

OSA Scoring System: D. Estimation of perioperative risk (modified from ASA Guidelines Table 2)
Patients with a score of 4 may be at increased perioperative risk and patients with scores of 5 or 6 may be at a significantly increased perioperative risk from OSA ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083

OSA check in So now we have identified OSA(STOP BANG & ASA Table 1), assessed severity of OSA(sleep study with AASM AHI or ASA Table 1) and estimated perioperative risk (ASA’s OSA Scoring-Table 2) Before we go on to preoperative preparation a decision must be made on whether or not the patient is a candidate(if type of surgery allows)for ambulatory surgery

Inpatient vs. Outpatient Surgery for OSA patients-- ASA Task Force recommends considering:
Sleep apnea status Anatomical and physiological abnormalities Status of coexisting diseases Nature of surgery Type of anesthesia Need for postoperative opioids Patient age Adequacy of post-discharge observation Capabilities of the outpatient facility ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087

Inpatient vs. Outpatient Surgery for OSA patients
“The availability of emergency airway equipment, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer agreement with an inpatient facility should be considered…” ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087 ----- Meeting Notes (1/18/13 17:58) ----- talking more about capabilities

Inpatient vs. Outpatient Surgery for OSA patients
Consultant opinions regarding procedures that may be performed safely on an outpatient basis for patients at increased risk from OSA Table 3 in the ASA Practice guidelines for the OSA patient modified on the following slides

Consultants agree… Superficial surgery/local or regional anesthesia
Minor orthopedic surgery/local or regional anesthesia Lithotripsy ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

Consultants disagree…
Airway surgery(e.g.,UPPP) Tonsillectomy in children less than 3 years old Laparoscopic surgery, upper abdomen ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

Consultants are equivocal…
Superficial surgery/general anesthesia Tonsillectomy in children greater than 3 years old Minor orthopedic surgery/general anesthesia Gynecologic Laparoscopy ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

Inpatient vs. Outpatient Update: Society for Ambulatory Anesthesia Task Force on Practice Guidelines
Developed a consensus statement addressing this controversial issue as new evidence is available Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a CPAP device in the postoperative period. Patients with a presumed diagnosis of OSA with optimized comorbidities can be considered for ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid techniques Joshi et al.2012 ----- Meeting Notes (1/20/13 22:39) ----- a simpler way to determine suitability for oupatient surgery

Inpatient vs. Outpatient Update: Society for Ambulatory Anesthesia Task Force on Practice Guidelines
OSA patients with nonoptimized comorbid conditions may not be good candidates Recommend use of STOP-BANG for OSA screen Current literature does not support the ASA recs. that upper abdominal procedures (on OSA patients) are not appropriate for ambulatory surgery Joshi et al.2012

What country has the most obese population?
Nauru Mexico USA Australia

OSA check in again So now we have identified OSA(STOP BANG & ASA Table 1), assessed severity of OSA(sleep study with AASM AHI or ASA Table 1) and estimated perioperative risk (ASA’s OSA Scoring-Table 2) And we have made an educated decision(Table 3- Consultant opinion. ASA Guidelines &/or SAMBA task force consensus statement) as to whether or not the OSA patient is a candidate for ambulatory surgery Now we can move on to preoperative preparation

Preoperative Preparation recommendations: ASA Guidelines
Consider pre-op initiation of CPAP/NIPPV(Non-invasive positive pressure ventilation) Consider having the patient use mandibular advancement devices or oral appliances Preoperative weight loss if feasible A patient who has had corrective airway surgery remains at risk for OSA complications until a normalized sleep study is obtained and symptoms resolve Consider difficult airway probability ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Preoperative Preparation Benefits of CPAP use
“Gupta et al found that patients who were using CPAP preoperatively had a lower incidence of postoperative complications and shorter hospital length of stay when compared with those who were not on CPAP.” This “carryover protection” may be explained by decreased inflammation and/or edema of the upper airway, decrease tongue size, and increased upper airway volume and stability Adebola et al

Intraoperative Management: ASA Guideline Recommendations
Consider the potential for postoperative respiratory compromise when selecting intraoperative medications Consider use of local anesthesia or peripheral nerve blocks(with or without moderate sedation) Continuously monitor ventilation with capnography if moderate sedation is used Consider CPAP or dental appliance use on patients treated with these devices preoperatively ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Intraoperative Management: ASA Guideline Recommendations
General anesthesia with a secure airway is safer than deep sedation Consider spinal or epidural anesthesia Proceed with extubation after patient is awake and has full reversal of neuromuscular blockade Lateral and semi-upright positions(not supine) for extubation and recovery ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Intraoperative Management Regional anesthesia benefits
“Regional anesthesia obviates the need for airway manipulation and reduces the need for intraoperative sedatives and opioids…these techniques provide postoperative analgesia, and reduce postoperative opioid requirements.” Joshi.2007

Intraoperative Management Preoxygenation with CPAP
CPAP acts as a pneumatic splint to keep the airway open Preoxygenation with 100% oxygen and CPAP at 10cm H2O is a good recommendation Adebola et al. 2010

Postoperative management
Patients with OSA have post-op complications more frequently Common post-op complications: Airway obstruction Oxygen desaturation Reintubation Systemic hypertension Cardiac dysrhythmias Admission to ICU Joshi.2007.

Postoperative management Respiratory depression
Postoperative respiratory depression risk factors: Systemic and neuraxial administration of opioids Administration of sedatives Site and invasiveness of surgical procedure Underlying severity of sleep apnea ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Postoperative management Respiratory depression
“REM rebound” occurs on the third or fourth post-operative day as sleep patterns are re- established exacerbating respiratory depression ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085 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

Postoperative Management ASA Guideline recommendations Postoperative Pain
Consider regional analgesic techniques to reduce or eliminate requirement for systemic opioids Neuraxial analgesia benefits are improved analgesia and decreased need for systemic opioids Neuraxial analgesia risk is rostral spread causing respiratory depression Consider these in choosing an opioid, opioid-local mixture or local anesthetic alone ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086

Postoperative Management ASA Guideline recommendations Postoperative pain
Continuous background infusions with patient controlled systemic opioids(PCA) should be used with extreme caution or avoided To reduce opioid requirement consider NSAIDS and other modalities(e.g., ice, transcutaneous electrical nerve stimulation) Be aware of the increased risk of respiratory depression and airway obstruction with concurrent use of sedatives(e.g.,benzodiazepines, barbiturates) ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086

Postoperative Management Opioid requirement…good news!
“Brown et al found that total analgesic opiate dose in patients with OSA and recurrent hypoxemia was half that required in patients without such a history and attributed this finding to upregulation of central opioid receptors due to recurrent hypoxemia.” Adebola et al. 2010 ----- Meeting Notes (1/18/13 17:58) ----- so that may be one of the only benefits of recurrent hypoxemia... ----- Meeting Notes (1/20/13 22:46) ----- and this is especially important when combined with a patient who has pain-sedation mismatch

Postoperative Management ASA Guideline recommendations
“Supplemental oxygen should be administered continuously to all patients who are at increased perioperative risk from OSA until they are able to maintain their baseline oxygen saturation while breathing room air.” Supplemental O2 should be used with caution as it may reduce hypoxic respiratory drive. Treat recurrent hypoxemia with CPAP & oxygen. Joshi 2006. “The task force cautions that supplemental oxygen may increase the duration of apneic episodes and may hinder detections of atelectasis, transient apnea, and hypoventilation by pulse oximetry.” ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086 ----- Meeting Notes (1/20/13 22:50) ----- so a transient one time episode of hypoxemia in the immediate postop period should be treated with oxygen but any more episodes of hypoxemia with CPAP and a minimum amount of oxygen if any at all

Postoperative Management CPAP -- ASA Guideline recommendations
Unless contraindicated by the surgical procedure continuous use of CPAP or NIPPV should be used by patients who were using these devices preoperatively Patients should bring their own equipment(CPAP/NIPPV) to the hospital to improve compliance Consider postoperative initiation of CPAP or NIPPV for frequent or severe airway obstruction and hypoxemia ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;

Postoperative Management CPAP
“Prophylactic CPAP for h after extubation have been reported to reduce major complications despite unrestricted opioid use.”Joshi.2007 “Another study showed that the rate of postoperative CPAP use was relatively low (58%-63%) even in patients on established home CPAP, reflecting a lack of hospital policy guiding the consistent use of CPAP…” Adebola et al. 2010 ----- Meeting Notes (1/20/13 22:54) ----- If patient obtunded from hypercapnia then mask/mechanical ventilation may be indicated. ----- Meeting Notes (1/20/13 23:15) ----- disregard the note!!!!

Postoperative Management ASA Guideline recommendations
OSA patients should be placed in nonsupine positions throughout the entire recovery period Continuous pulse oximetry and monitoring should follow the OSA patient from the recovery room(PACU) to the next level of care in the hospital. An appropriately trained professional observer in the patients room should be used to monitor if patient is not in a telemetry or critical care area “Intermittent pulse oximetry or continuous bedside oximetry without continuous observation does not provide the same level of safety.” ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

Postoperative Management Discharge from PACU with or without continuous pulse oximetry and monitoring Patients that exhibit respiratory events such as apnea, bradypnea, desaturations, and pain- sedation mismatch in PACU(recovery room) should be admitted to a monitored bed with continuous oxygen saturation monitoring Adebola et al. 2010

Postoperative Management ASA Guideline recommendations Criteria for discharge to unmonitored settings The most significant postoperative complications in OSA patients usually occur within 2 hours after surgery Joshi.2007. OSA patients should be monitored for a median of 3 hours longer than their non-OSA counterparts before discharge from the facility ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087 OSA patients should continue to be monitored for a median of 7 hours after the last episode of obstruction or hypoxemia while breathing room air in an unstimulating environment ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087 These recommendations may play a part in deciding suitability for ambulatory surgery, especially in a free standing ASC

Postoperative management Discharge Instructions
Continued use of CPAP at home should be included in post-discharge instructions for patients who use CPAP preoperatively Joshi Remember the rebound!

What perioperative protocol system do we use here for OSA patients?
Stop-Bang ASA Guidelines Gambit’s best of N.O. None

Summary 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

Bibliography: Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology. 2006; 104: Joshi G., MD. The Patient with Sleep Apnea for Ambulatory Surgery. ASA Refresher Courses in Anesthesiology. 2007; 35(1):97-106 Spector R.,MD and Ryan R. Obstructive Sleep Apnea for All Specialties: Reducing Perioperative Risk. A CME Monograph Adebola A., MD, FCCP; Lee W, MD; Greilich N., MD; Joshi G., MD. Perioperative Management of Obstructive Sleep Apnea. CHEST ;138(6):

Bibliography: Joshi G.,MD, Ankichetty S.,MD, Gan T.,MD, Chung F. Society for Ambulatory Anesthesia Consensus Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery. Anesthesia & Analgesia. 2012 Memstoudis S, Liu SS, Ma Y, Chiu YL., Walz JM,Gaber-Baylis LK, Mazumdar M, Perioperative Outcomes in Patients with Sleep Apnea after Noncardiac Surgery. Anesth. Analg. 2011;112: Benumof JL. Summary of the prototypical OSA malpractice law case. Paper presented at: Challenges in the perioperative management of OSA patients symposium;October 15,2010;San Diego, CA. Gupta RM, Parvizi J, Hanssen AD, Gay PC; Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study, Mayo Clin Proc Brown KA, Laferrière A, Lakheeram I, Moss IR; Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates, Anesthesiology

Bibliography: 10. Hwang D, Shakir N, Limann B; et al. Association of sleep- disordered breathing with postoperative complications, Chest Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N, Walker E; Incremental risk of obstructive sleep apnea on cardiac surgical outcomes, J Cardiovasc Surg (Torino) Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F; Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study, Can J Anaesth Chong C, Tey J, Leow S; et al. Management Plan to Reduce Risks in Periopeerative Care of Patients with Obstructive Sleep Apnoea Averts the Need for Presurgical Polysomnography, Ann Acad of Med Singapore 2013;42:110-9

Bibliography: 14. Society of anesthesia and sleep medicine: proceedings of 2012 meeting. 15. Memstoudis S., Besculides M., Mazumdar M. et. al. A Rude Awakening—The Perioperative Sleep Apnea Epidemic, NEJM 2013; 368;25:

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