obstructive sleep apnea · sleep apnea september 17, 2011 tapan noah bunker, m.d austin...
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OBSTRUCTIVE
SLEEP APNEASeptember 17, 2011
TAPAN
Noah Bunker, M.D
Austin Anesthesiology Group, LLP
I do not have any relevant financial relationships to disclose.
OBJECTIVES
1) Define obstructive sleep apnea.
2) Discuss pathophysiology related to OSA.
3) Identify risk factors, signs & symptoms of OSA.
4) Discuss screening tools and diagnosis of patients with
OSA.
5) Discuss perioperative anesthetic & nursing
interventions appropriate for patients with OSA.
CLINICAL CASE
• 58 year old man
• BMI 45, HTN, Smoking
• Outpatient shoulder
arthroscopy
• History of snoring
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PREVALENCE• GENERAL POPULATION 1 in 10 men,
1 in 20 women with OSA
• SURGICAL POPULATION
• BARIATRIC SURGERY POPULATION 60-70%
• >65 yo: 24%
• Nursing home patients: 50%
• Undiagnosed in 80% of patients that have it
Definition of OSA
• Characterized by complete or partial
collapse of the pharyngeal airway during sleep
• Cessation of airflow > 10 sec or shallow breathing
Pathophysiology
• OSA can occur when any part of upper
airway does not function normally
• Muscle activity
• Soft tissue structure
• Sleep state
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Text
ANATOMY &
PATHOPHYSIOLOGY
Factors that predispose to upper
airway collapse• Obesity
• Male gender, > 50 years old
• Menopausal status
• Hard tissue craniofacial abnormalities
• Soft tissue abnormalities
• Neurologic disorders
• Endocrine
• Alcohol, smoking or sedative use
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ACUTE
Consequences
• 68 year old female, HTN, BMI 37, OSA for TKA
• Fentanyl, Dilaudid for pain
• Droperidol for nausea
• Valium for muscle spasm
• Dr. Leo
SEDATIVES AND
OPIOIDS WITH OSA
• SEDATIVES AND OPIOIDS
DECREASE MOTOR TONE IN PHARYNGEAL MUSCLES
The Role of the Pharyngeal
Muscles
• The pharyngeal muscles are capable of
dynamic changes in size and shape
• Adequate respiration requires a rigid and patent pharyngeal airway
• Sleep and anesthesia decrease the
regulation of the pharyngeal muscles
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Signs and symptoms of OSA• snoring
• sleepiness
• physically restless sleep
• night sweats
• morning dry mouth or sore throat
• personality change
• morning confusion
• intellectual impairment
• morning headache
Comorbidities
Adverse cardiovascular
outcomes:
HTN
Pulmonary HTN
Stroke
Atrial Fibrillation
CAD
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Other Comorbidities
Asthma 18%
Type 2 Diabetes 36%
Hypothyroidism 45%
Morbid Obesity 50-90%
GERD 60%
From Seet E & Chung F. Anesthesiology Clin, 2010, 28:199-215.
Diagnosis
• GOLD STANDARD:
• OVERNIGHT POLYSOMNOGRAPHY
DETAILING THE APNEA HYPOPNEA INDEX: (AHI)
• MILD: AHI 5-15
• MOD: AHI 16-30
• SEVERE > 30
PRACTICAL
SCREENING TOOLS
• Berlin Questionnaire
• ASA checklist
• STOP BANG QUESTIONAIRRE
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STOP-BANG QUESTIONNAIRE
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Intraoperative
Anesthetic Concerns
and Management
CLINICAL CASE
• 58 year old man
• BMI 45, HTN, Smoking
• Outpatient shoulder
arthroscopy
• History of snoring
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OSA PATIENT AT
ASC??• Severity of OSA
• Coexisting Disease
• Invasiveness of Surgery
• Type of anesthesia
• Anticipated Opioid requirements
• Adequacy of post op observation
ASA Practice
Guidelines for
discharge of OSA
from facility• OSA patient to be monitored 3 hours
longer than Non OSA pts prior to D/C
• Monitoring should continue 7 hours after last episode
• SATS TO BASELINE
• NO OBSTRUCTION
INTERVENTIONS• CONSIDER NERVE BLOCK FOR PAIN
MANAGEMENT
• BETTER MONITORING: REMOTE
• REMOTE TELEMETRIC PULSE OXIMETRY
• LONG TERM: SURGICAL
• HIGHER ACUITY OBSERVATION
• SURGICAL
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INTERVENTIONS• MINIMIZE NARCOTICS AND SEDATIVES
• CONSIDER NERVE BLOCK FOR PAIN MANAGEMENT
• SLEEP ON SIDE OR ABDOMEN
• STIMULATION
• BETTER MONITORING: REMOTE
• LONG TERM: SURGICAL & WEIGHT LOSS
• NON INVASIVE VENTILATION:
CPAP/BIPAP
Perioperative PAP
Therapy
• Mild OSA patients may not require
• Moderate and Severe OSA patients
should continue PAP therapy in the perioperative period
• Noncompliant with CPAP and in need
of CPAP post-surgery pose the highest risk of complications
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WHEN DO MOST
SIGNIFICANT POST OP COMPLICATIONS OCCUR
in OSA Patients?
WITHIN 2 HOURS OF
SURGERY
CLINICAL CASE58 year old man, BMI 45, HTN, Smoking
Outpatient shoulder arthroscopyHistory of snoring
Poor pain tolerance with significant opioid requirements in PACU
Periods of apnea, obstruction and desaturation in PACU
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HOW LONG DO WE
MONITOR?Continuous in PACU
Continuous through POD #1Longer if ongoing hypoxiaLonger if ongoing narcotic
requirements
DISCHARGE?
• SATS TO BASELINE
• NO OBSTRUCTION
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FUTURE
• HOME SLEEP TEST MACHINES
• PLACED ON POSITIVE PRESSURE
DEVICES PREOP AND FOR FIRST WEEK POST OP
SUMMARY
• Defined obstructive sleep apnea.
• Discussed pathophysiology related to OSA.
• Identified risk factors, signs, symptoms, and comorbidities of OSA.
• Discussed perioperative screening tools and diagnosis of patients with OSA.
• Discussed perioperative anesthetic & nursing interventions appropriate for patients with OSA.
Preoperative assessment for OSA, particularly its severe form, is important because of
its implications for possible preoperative treatment and perioperative management and
outcomes. Co-morbidities beyond arterial hypertension associated with OSA include
coronary artery disease, cerebrovascular disease and stroke, congestive heart failure
(CHF), cardiac dysrythmias and diabetes mellitus. OSA is an independent risk factor
for the development of the metabolic syndrome, which includes impaired glucose
tolerance, insulin resistance and dyslipidemia, and for all-cause mortality.
Pathophysiological consequences of OSA can be reversed or mitigated by continuous
positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) treatment
periods of variable duration, depending on the condition targeted. Two weeks of
effective CPAP administration in obese hypercapneic patients can correct their
abnormal ventilatory drive. Three weeks of nightly CPAP improves left-ventricular
ejection fraction (EF) in patients with heart failure (CHF), and 4 weeks reduces blood
pressure and heart rate and results in a 35% relative increase in EF in patients with
OSA and CHF. Four to 6 weeks of CPAP reduces tongue volume and increases
pharyngeal space, and cardiovascular risk and morning hypertension was improved
following 8 weeks of CPAP therapy (mask use > 4 h per night) in patients with severe
OSA and metabolic syndrome. In several small studies, CPAP for 3–6 months reduced
pulmonary hypertension in OSA patients. Finally, CPAP normalises the genioglossus
muscle (major pharyngeal dilator) functionally and structurally. Some evidence
suggests that patients with OSA, who have been treated with CPAP preoperatively,
have fewer peri- operative complications than those untreated.