texas pulmonary & critical care consultants, p.a., copyright © 2008 sleep consultants, inc....

Texas Pulmonary & Critical Care Consultants, P.A., Copyright © 2008 Sleep Consultants, Inc.

OBSTRUCTIVE SLEEP APNEA OBSTRUCTIVE SLEEP APNEA IN THE PERIOPERATIVE IN THE PERIOPERATIVE PATIENTPATIENT

John R. Burk, M.D.


OBSTRUCTIVE SLEEP APNEA IN THE OBSTRUCTIVE SLEEP APNEA IN THE PERIOPERATIVE PATIENT - OutlinePERIOPERATIVE PATIENT - Outline

21st Century Health Care

Quality Health Care

Pulmonary Post Operative Complications

OSA prevalence and diagnosis

ASA Practice Guidelines

OSA risk

What to do now?


OSA IN PERIOPERATIVE PT.OSA IN PERIOPERATIVE PT.YEARS OF EXPERIENCE?YEARS OF EXPERIENCE?

10 YEARS 20 YEARS 30 YEARS

DEATHS IN THE RECOVERY ROOM?


2121STST Century Health Care Aims Century Health Care AimsHealth Care Should Be:Health Care Should Be:

Safe – avoiding injuries to patients from the care that is intended to help them

Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit

Patient-centered – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.


2121STST Century Health Care Aims Century Health Care AimsHealth Care Should Be:Health Care Should Be:

Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.

Efficient – avoiding waste, including waste of equipment, supplies, ideas, and energy

Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status


QUALITYQUALITY

LIKE THE BLIND MEN AND THE ELEPHANT –

IN THE EYE OF THE BEHOLDER MUST BE MEASURABLE


VALUE =VALUE =

Medical outcomes + Service outcomes

Cost outcomes

The goal is the best possible medical and service outcomes at the lowest

necessary cost


The Reality:The Reality:To Err is Human *To Err is Human *

…it is becoming clear that progress (in improving patient safety, ed.) requires substantial, long-term effort directed at supporting human performance rather than trying to prevent its failure 1

1. Woods et.al. Perspectives on human error: Hindsight biases and local rationality. In Durso FT et. Al. Handbook of applied cognition, New York, Eiley&Sons 1999:141-171

* Hamilton Medical


99% performance means?99% performance means?

20,000 lost articles of mail per hour in the United States Postal Service

5,000 incorrect surgical operations per week in the United States

200,000 wrong drug prescriptions each year in the United States

No electricity for almost 7 hours each month


99.9% performance means?99.9% performance means?

Two short or long landings daily at most airports in the United States

32,000 checks deducted from the wrong banking account per hour

1.7 errors per day in Intensive Care Units (ICUs), one in five is fatal


Why is quality important?Why is quality important?Dr. W. Edwards DemingDr. W. Edwards Deming

Improve Quality Quality is the focus; all that follows in the Chain Reaction results from improvement in quality and will not be sustainable over the long term without it.

Reduce Costs As quality improves, costs are reduced because waste is minimized.

Improve Productivity As costs are reduced, fewer of the organization's resources are spent producing defective goods and services, leaving them free to be devoted to work that adds value


Why is quality important?Why is quality important?Dr. W. Edwards DemingDr. W. Edwards Deming

Capture the Market Improved productivity enables the organization to pass savings along to customers, thus attracting more customers to the market through lower prices as well as improved quality. New markets are created by producing products and services that meet changing customer needs.

Stay in Business Capturing the increasing market helps ensure the long-term viability of the organization.

Provide Jobs and More Jobs An organization that focuses on quality realizes the benefits that come from continuous improvement.


Pulmonary Complications after Pulmonary Complications after Nonthoracic SurgeryNonthoracic Surgery

University of Alberta Hospital, tertiary center, prospective cohort study

Pre-Admission Clinic sees all patients preop, excluded OSA, cognitive impairment, neuromuscular disease, ICU admissions

History (pack-years), examination (BMI), spirometry (FVC, FEV1, FEV1/FVC), O2 sat%, cough test

1,055 consecutive patients enrolled 2001- 2003Am J Respir Crit Care Med 2004;171:514-517


Pulmonary Complications after Pulmonary Complications after Nonthoracic SurgeryNonthoracic Surgery

WRITE NUMBER:PULMONARY MORBIDITY none 0.1% 1% 3% 5% 8% WRITE ANOTHER NUMBER: MORTALITY


Pulmonary Complications after Pulmonary Complications after Nonthoracic Surgery - ResultsNonthoracic Surgery - Results

Post op chart review done at day 7 Post op complications include 1)

respiratory failure 2) pneumonia 3) major atelectasis 4) pneumothorax or pleural effusion requiring intervention

28 patients, 2.8%, suffered a pulmonary complication, 1 died.

LOS 27.9 days vs. 4.5 days


Pulmonary Complications after Pulmonary Complications after Nonthoracic Surgery - RisksNonthoracic Surgery - Risks

Age - >65 years * Pack-years smoked Positive cough test * FEV1 FEV1/FVC ratio Duration of anesthesia * Upper abdominal incision Perioperative nasogastric tube *

*independently associated with increased risk


Perioperative risk in OSAPerioperative risk in OSA

UNKNOWN

If unknown OSA , likely high risk If known OSA with successful therapy,

likely low risk


OSA – High risk factorsOSA – High risk factors

Male, postmenopausal female BMI >25 kg/m2 Neck circumference – male >17 inches

female >16 inches Habitual snoring/ gasping reported Daytime sleepiness, fatigue, tiredness Hypertension, gastroesophogeal reflux,

nocturia High Mallampati score


OSA – Low risk factorsOSA – Low risk factors

No snoring Female Premenopausal Thin Normal upper airway anatomy


OSA - PrevalenceOSA - Prevalence

Random sample of 602 men and women between 30 and 60 years received sleep studies (NPSG)

Male and obesity strongly associated OSA Male and female snorers associated OSA Male 24% AHI >5, 15% > 10, 9.1% > 15 Female 9% AHI >5, 5%> 10, 4% > 15

NEJM 1993; 328:1230-


OSA - PrevalenceOSA - Prevalence

Honolulu – Asia Aging Study 718 males under observation for dementia,age 70-97

<5 AHI = normal, >30 = severe osa >70% had sleep disordered breathing 19% had severe SDB, associated with

obesity, habitual snoring, and sleepiness

Sleep 2003; 26:596-


OSA PrevalenceOSA PrevalenceBarnes Hospital, 2007Barnes Hospital, 2007

2867 patients undergoing surgery studied App. 6% had diagnosed OSA App. 14% had undiagnosed OSA, found by

questionnaire screening then sleep study Worse in supine position

Dr. Kevin J Finkel, ASA 2007, Washington University, St. Louis


Difficult to Intubate – OSADifficult to Intubate – OSAUniv. of Toronto, 2007Univ. of Toronto, 2007

If 2 or more attempts to intubate then “difficult to intubate”

83 patients identified OSA by polysomnography in approx.

65%

Dr. Frances Chung, ASA 2007, Univ. Toronto


OSA - DiagnosisOSA - Diagnosis

Clinical examination (history and physical examination) carries a diagnostic sensitivity and specificity of only 50 to 60% even when performed by experienced sleep physicians

Clinics of Chest Med 1998; 19:1-19


OSA Exploring questionnaireOSA Exploring questionnaire

People tell me that I snore I wake up at night with a feeling of shortness

of breath or choking People tell me that I gasp, choke or snort

while I am asleep People tell me that I stop breathing while I am

sleeping I often awake with headache (CO2 narcosis) History of hypertension, stroke, and/or

nocturia


OSA Exploring questionnaireOSA Exploring questionnaire

I awake feeling almost as tired or more tired than when I went to bed

I often have difficulty breathing through my nose

I fight sleepiness during the day I fall asleep when I relax before or after

dinner Friends, colleagues or family comment on my

sleepiness


Factors worsening OSAFactors worsening OSA

Cardiopulmonary effects of SDB Reduced functional residual capacity and

oxygen reserve resulting from obesity and supine position

Reduced ventilatory drive resulting from anesthetic agents or analgesics

Increased upper airway instability related to anesthetic agents and narcotic analgesics


Factors Worsening OSAFactors Worsening OSAPartial Neuromuscular BlockadePartial Neuromuscular Blockade

Ten healthy volunteers’ upper airway volume studied by MRI and PFT, given low dose rocuronium (Zemuron) without clinical symptoms or change

Upper airway dilator muscles impaired with resultant decrease in upper airway volume, esp. retropalatal space, and inspiratory flow

Effect may persist for hoursEikermann, et.al., AmJRespirCritCareMed 2007; 175:9-15

A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea

Anesthesiology 2006; 104:1081-93©2006 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Texas Pulmonary & Critical Care Consultants, P.A., Copyright © 2006

Practice Guidelines for the Practice Guidelines for the Perioperative Management of Perioperative Management of Patients with Obstructive Sleep Patients with Obstructive Sleep ApneaApnea


Practice GuidelinesPractice Guidelines

Includes sleep apnea from obesity, pregnancy, upper airway obstruction

Excludes patients with pure central sleep apnea, airway abnormalities without apnea, daytime hypersomnolence from other causes, <1yr, obesity without sleep apnea

Both inpatient and outpatient setting


Preop Scoring Guide – ScorePreop Scoring Guide – Score

Overall score = A + greater of B or C

4 may be at increased perioperative risk from OSA

5 or greater may be at significantly increased perioperative risk from OSA


Preop Scoring Guide – A - Preop Scoring Guide – A - Sleep Study Sleep Study

None AHI <5 = 0

Mild AHI 6-20 = 1

Moderate AHI 21-40 = 2

Severe AHI >40 = 3

Defined by local sleep center… some use severe for AHI > 30


Preop Scoring Guide – B -Preop Scoring Guide – B -Invasiveness of surgery/anesthInvasiveness of surgery/anesth

Superficial surgery under local or peripheral nerve block w/o sedation = 0

Superficial surgery with moderate sedation or general anesthesia or peripheral surgery with spinal or epidural anesthesia =1

Peripheral surgery with general or airway surgery with moderate sedation = 2

Major or airway surgery with general =3


Preop Scoring Guide – Postop Preop Scoring Guide – Postop opioid requirement -Copioid requirement -C

None = 0

Low dose oral opioids = 1

High dose oral, parental, neuraxial = 3


Preop Scoring Guide – ScorePreop Scoring Guide – Score

Overall score = A + greater of B or C Add 1 point if Paco2 >50 Subtract 1 point if pt compliant on PAP 4 may be at increased perioperative risk from

OSA 5 or greater may be at significantly

increased perioperative risk from OSA thus consider postponing elective surgery and not at outpatient facility


ASA RecommendationASA Recommendation

“Anesthesiologist should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan.”


ASA Recommendation, cont.ASA Recommendation, cont.

“If this evaluation does not occur until the day of surgery, the surgeon and anesthesiologist together may elect for presumptive management based on clinical criteria or a last-minute delay of surgery. … The patient and his or her family as well as the surgeon should be informed of the potential implications of OSA on the perioperative course.”


Preanethesia HoldingPreanethesia HoldingPreoperative AssessmentPreoperative Assessment

Get history for OSA from patient, family, or medical record

If negative then proceed If positive then consider risk If known OSA patient, is therapy at

hand and usable



“preoperative initiation of CPAP, Bipap, NIPPV, oral appliance, weight loss should be considered….

A patient who has had corrective airway surgery should be assumed to remain at risk for OSA complications unless a normal sleep study has been obtained.

May have potentially difficult upper airways thus be prepared for difficult intubation / airway management


Intraoperative Management of Intraoperative Management of OSA PatientOSA Patient

May have potentially difficult upper airways thus be prepared for difficult intubation / airway management

Choice of anesthetic technique Patient monitoring – oximetry and end-tidal

CO2 Full reversal of neuromuscular block verified

before extubation in OR or recovery, consider non-supine extubation.



“…in selecting intraoperative medications, the potential for postoperative respiratory compromise should be considered.

…ventilation should be monitored by capnography or other automated method…

…consider administering CPAP or using orthodonic appliance during sedation to patients previously using these…

General anesthesia with a secure airway is preferable to deep sedation without a secure airway, esp. for airway procedures…”



“Major conduction anesthesia (spinal/ epidural) should be considered for peripheral procedures.

…should be extubated while awake. Full reversal of neuromuscular block should

be verified before extubation. …extubation and recovery should be carried

out in the lateral, semiupright , or other nonsupine position.”


Post Anesthesia Recovery Post Anesthesia Recovery (PAR) - Recommendations(PAR) - Recommendations

Epidural opoids preferable to parenteral Avoid patient controlled analgia (PCA) Avoid supine position Supplemental oxygen should be used End-tidal CO2 monitoring if available Pulse oximetry monitoring if patient on room

air (does not monitor ventilation if patient on oxygen, just oxygenation)

Resume CPAP/BIPAP therapy from home and assist patient in care and use


Post PARPost PAR

May require monitoring first night or until off opoids

May require assistance with CPAP/BIPAP use, care, and cleaning of home equipment

Do not discharge until observed asleep on room air with normal oximetry or with use of their home PAP equipment


Inpatient vs OutpatientInpatient vs OutpatientRecommendationRecommendation

“…Factors to be considered in determining whether outpatient care is appropriate include 1) sleep apnea status, 2) anatomical and physiologic abnormalities, 3) status of coexisting diseases, 4) nature of surgery, 5) type of anesthesia, 6) need for postoperative opioids, 7) patient’s age,…”


Inpatient vs OutpatientInpatient vs OutpatientRecommendationRecommendation

“…8) adequacy of postdischarge observation, 9) capabilities of the outpatient facility. The availability of emergency difficult airway equipment, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer agreement with an inpatient facility should be considered in making this determination.”


Criteria for Discharge to Unmonitored Criteria for Discharge to Unmonitored Settings - RecommendationsSettings - Recommendations

“These patients should not be discharged from the recovery area to an unmonitored setting (ie., home or unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression. … this may require a longer stay as compared with non-OSA patients undergoing similar procedures.”


Criteria for Discharge to Unmonitored Criteria for Discharge to Unmonitored Settings - RecommendationsSettings - Recommendations

“Adequacy of postoperative respiratory function may be documented by observing patients in an unstimulated environment, preferably while they seem to be asleep, to establish that they are able to maintain their baseline oxygen saturation while breathing room air.”


Why OSA Risk:Why OSA Risk:REM REM

REM sleep frequently absent on 1-3 postoperative days, then REM rebound occurs with increased instability of heart rate, respiration, and blood pressure, ie. REM related hypoxic episodes 2 to 3 times increased; pharyngeal motor tone is further diminished; with hypoxia sympathetic tone increased

Chest 2006;129:198-205


Why OSA Risk: Why OSA Risk: Myocardial infarctionMyocardial infarction

Majority of unexpected and unexplained postoperative deaths occur at night within 7 days of surgery

In MI survivors, OSA found in 36%, and 3.8% of matched controls

After correcting for known risk factors, OSA with AHI>5.3 was independently predictive of MI with an odds ratio of 23.3 (p<0.001)

Chest 2006;129:198-205


Why OSA Risk: Why OSA Risk: ArrhythmiasArrhythmias

Sinus pauses of 2-13 sec in 9-11% of OSA patients

Second-degree AV block in 4-8% of OSA Atrial Fibrillation has odds ratio of 4.5 of

occurring in OSA, and twice as likely to recur if untreated OSA

In OSA - CAB patients relative risk of 2.8 for developing atrial fibrillation postoperatively

PVC and VT associated with hypoxia <83%Chest 2006;129:198-205


WHAT TO DO NOW? Mayo Clinic:WHAT TO DO NOW? Mayo Clinic:Clinical Practice ImprovementClinical Practice Improvement

Preoperative screening of 2206 pts. with assessment tool = questionnaire + neck circumference + hypertension. (High score associated with ICU admission)

PACU assessment including respiratory impairments, desaturations, A-a gradient, pain-sedation mismatch,

J Clin Sleep Med 2007;3(6):582-588


WHAT TO DO NOW? Mayo Clinic:WHAT TO DO NOW? Mayo Clinic:Clinical Practice ImprovementClinical Practice Improvement

Nocturnal oximetry used to measure oximetry desaturation index (ODI)

Those with high preop and PACU assessments had ODI >10 in 57%

Those with low preop and PACU assessments had ODI >10 in 12%

Thus able to identify those at increase risk to monitor more closely

Perhaps a model to follow

J Clin Sleep Med 2007;3(6):582-588


OSA IN THE PERIOPERATIVE PT.OSA IN THE PERIOPERATIVE PT.A SIGNIFICANT PROBLEM???A SIGNIFICANT PROBLEM???

How many have seen nonoperative deaths in the PACU?

How many know of nonoperative deaths within 24 hours of surgery?

Within 1 week of surgery?

HOW MANY OF THESE COULD HAVE BEEN AVOIDED WITH RECOGNITION AND TREATMENT OF OBSTRUCTIVE SLEEP APNEA?


THANK YOUTHANK YOU

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