Obstructive Sleep Apnea Cory M. Furse, MD, MPH. Disclosure Multiple photographs used in this...
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Transcript of Obstructive Sleep Apnea Cory M. Furse, MD, MPH. Disclosure Multiple photographs used in this...
Obstructive Sleep Apnea
Cory M. Furse, MD, MPH
Disclosure Multiple photographs used
in this presentation have been obtained from GOOGLE.
I have no financial relationships to disclose.
I will be referring to most researchers by first name and/or nickname as if I actually know them.
Objectives
• Review the pathophysiology of obstructive sleep apnea
• Review current recommendations concerning the patient with obstructive sleep apnea for outpatient surgery
Alae nasi
Tensor palatini
Genioglossis
Geniohyoid
Thyrohyoid
Sternohyoid
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Normal State
Polysomnography• Electroencephalogram• Electrooculogram• Electromyogram of respiratory muscles• Airflow at the nose or mouth via thermistor• End-tidal CO2
• Impedance plethysmography for chest/abdomen movement
• EKG, NIBP, and SpO2
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Polysomnography
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Sleep Apnea Event
Symptoms of OSA Loud snoring
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Sleep Apnea Event Altered body position
Decreased pharyngeal muscle tone
Respiratory drive depression- MV 16%- SPO2 2%- PaCO2 4-6mmHg
Depression of protective respiratory reflexes during normal Non-REM sleep
DefinitionsOSA: 15 or more apneas/hypopneas per hour during
sleep, caused by collapse of the upper airwayApnea: 10s or more without airflowHypopnea: 50% reduction in thoracoabdominal movement
lasting for 10s
Levitsky – LSU Adv Physiol Educ 32: 196–202, 2008
Curr Opin Anaesthesiol 22:405–411
Epidemiology ~24% of middle-aged men ~9% of middle-aged women ~5% of 3-5yr old children Prevalence of OSA increases with age and
body weight An estimated 85% of people with OSA are
undiagnosed!
Chung – Toronto Western Hospital
Lanphier EH – SUNY at Buffalo J Appl Physiol 18: 471-477, 1963
Lanphier EH – SUNY at Buffalo J Appl Physiol 18: 471-477, 1963
Lanphier EH – SUNY at Buffalo J Appl Physiol 18: 471-477, 1963
Lanphier EH – SUNY at Buffalo J Appl Physiol 18: 471-477, 1963
Symptoms of OSA Loud snoring Hypersomnolence Depressed mentation
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Levitsky – LSU Adv Physiol Educ 32: 196–202, 2008
Levitsky – LSU Adv Physiol Educ 32: 196–202, 2008
Symptoms of OSA Loud snoring Hypersomnolence and Depressed mentation
– Interference with normal sleep architecture, esp. REM sleep
– Increases risk of motor vehicle accidents Morning Headaches
– Repeated dialation of cerebral blood vessels
Adv Physiol Educ 32: 196–202, 2008Levitsky – LSU
Somers – Iowa J. Clin. Invest. 1995. 96:1897-1904.
Signs of OSA Systemic hypertension
- Chronic recurrent sympathetic stimulation- Increase in endothelin, a potent, long lasting
vasoconstrictor Heart failure
- Right heart 2° to pulmonary HTN- Left heart 2° to systemic HTN
Arrhythmias- Atrial fibrillation
Ann Intern Med. 2005;142:187-197.Caples – Mayo Clinic
Signs of OSA Polycythemia
- Chronic hypoxic episodes stimulate renal release of renin
- Increase in blood viscosity further exacerbating heart failure if present
Metabolic alkalosis- Respiratory acidosis while asleep with renal
retention of bicarbonate ions and excretion of H+
Ann Intern Med. 2005;142:187-197.Caples – Mayo Clinic
Obstructive Sleep Apnea
Signs Systemic HTN Heart Failure Arrhythmias Polycythemia Metabolic Alkalosis
Symptoms Loud Snoring Hypersomnolence Depressed Mentation Morning Headaches Nocturia
Why do we care?• Difficult Intubation
– If GA is employed
• Difficult Sedation– If MAC/Regional is employed
• Postoperative Pain Control– May increase the severity of
their OSA
• Liability?– If a patient with OSA has an
adverse event at home
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Endorsed- American Academy of Sleep Medicine- American Academy of Otorhinolaryngology – Head and Neck Surgery
“Affirmation of Value” - American Academy of Pediatrics
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Chung – Toronto Western Hospital Curr Opin Anaesthesiol 22:405–411
Identification of Patients with OSA
Identification of Perioperative Risk
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Preoperative Preparation
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Recommendations- Initiation of CPAP- Use of mandibular advancement devices- Preoperative weight loss
Prior corrective surgery for OSA- Assume these patients are still at risk, unless they
have a normal sleep study Beware of the difficult airway
Liang – MGH Anesthesiology 2008; 108:998–1003
Liang – MGH Anesthesiology 2008; 108:998–1003
Intraoperative Management
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Recommendations- Intraoperative medications should be selected
with consideration of the potential for postoperative respiratory compromise
- If moderate sedation is used, consider using the patients CPAP or oral appliance
- Awake extubation- Extubation and recovery in the lateral,
semiupright, or other nonsupine position
Postoperative Management
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Recommendations- Regional > Neuraxial > Oral Opioids > Parental
Opioids - Supplemental O2 until at baseline SPO2 on RA- CPAP when feasible- Nonsupine positions- Continuous monitoring of SPO2 when hospitalized
Outpatient Surgery?
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Discharge Criteria
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
Recommendations- SPO2 should return to baseline on RA- Patients should be monitored a median of 3hr
longer then their non-OSA counterparts- Monitoring should continue for a median of 7hr
after last episode of obstruction or hypoxemia while breathing RA in an unstimulating environment
Appendix:
Gross – Farmington, CT Anesthesiology 2006; 104:1081–93
A median of 10% of outpatients would need to be inpatients if these guidelines were followed
73% indicate that sensitivity of the criteria for detecting patients previously undiagnosed with OSA is “about right”
82% indicate that the scoring system for assessing perioperative risk is “about right”
Chung – University of Toronto Anesthesiology 2008; 108:812–21
STOP BANG
S – Snoring, loudly, heard through a closed doorT – Tiredness, during daytimeO – Observed, witnessed apneic episodesP – Pressure, hypertension
B – BMI, > 35A – Age, > 50 yrN – Neck Circumference, > 40 cmG – Gender, Male
Chung – University of Toronto Anesthesiology 2008; 108:812–21
STOP BANG vs. ASA guidelines
Sensitivity AHI >5 AHI >15 AHI >30
STOP-BANG 83.6 92.9 100
ASA Guidelines 72.1 78.6 87.2
Advantage of STOP-BANG is the markedly decreased amount of time required to administer the questionnaire as compared to ASA guideline checklist
Chung – University of Toronto Anesthesiology 2008; 108:822–830
QUESTIONS?