OBSTRUCTIVE SLEEP APNEA IN THE PERIOPERATIVE PATIENT John R. Burk, M. D. Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OBSTRUCTIVE SLEEP APNEA IN THE PERIOPERATIVE PATIENT - Outline 21 st Century Health Care Quality Health Care Pulmonary Post Operative Complications OSA prevalence and diagnosis ASA Practice Guidelines OSA risk What to do now? Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA IN PERIOPERATIVE PT. YEARS OF EXPERIENCE? 10 YEARS 20 YEARS 30 YEARS DEATHS IN THE RECOVERY ROOM? Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
21 ST Century Health Care Aims 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. Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
21 ST Century Health Care Aims 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
QUALITY LIKE THE BLIND MEN AND THE ELEPHANT – IN THE EYE OF THE BEHOLDER MUST BE MEASURABLE Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
VALUE = Medical outcomes + Service outcomes Cost outcomes The goal is the best possible medical and service outcomes at the lowest necessary cost Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
The Reality: 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Why is quality important? Dr. W. Edwards Deming Improve 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Why is quality important? Dr. 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. Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Pulmonary Complications after Nonthoracic 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, FEV 1/FVC), O 2 sat%, cough test 1, 055 consecutive patients enrolled 20012003 Am J Respir Crit Care Med 2004; 171: 514 -517 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Pulmonary Complications after Nonthoracic Surgery WRITE NUMBER: PULMONARY MORBIDITY none 0. 1% 1% 3% 5% 8% WRITE ANOTHER NUMBER: MORTALITY Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Pulmonary Complications after Nonthoracic 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Pulmonary Complications after Nonthoracic Surgery - Risks Age - >65 years * Pack-years smoked Positive cough test * FEV 1/FVC ratio Duration of anesthesia * Upper abdominal incision Perioperative nasogastric tube * *independently associated with increased risk Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Perioperative risk in OSA UNKNOWN If unknown OSA , likely high risk If known OSA with successful therapy, likely low risk Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA – High risk factors Male, postmenopausal female BMI >25 kg/m 2 Neck circumference – male >17 inches female >16 inches Habitual snoring/ gasping reported Daytime sleepiness, fatigue, tiredness Hypertension, gastroesophogeal reflux, nocturia High Mallampati score Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA – Low risk factors No snoring Female Premenopausal Thin Normal upper airway anatomy Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA - 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 - Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA - 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 - Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA Prevalence Barnes 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Difficult to Intubate – OSA Univ. 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA - 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA 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 (CO 2 narcosis) History of hypertension, stroke, and/or nocturia Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Factors 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Factors Worsening OSA Partial 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 hours Eikermann, et. al. , Am. JRespir. Crit. Care. Med 2007; 175: 9 -15 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea 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 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, <1 yr, obesity without sleep apnea Both inpatient and outpatient setting Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Preop 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Preop Scoring Guide – A Sleep Study None Mild Moderate Severe AHI <5 AHI 6 -20 AHI 21 -40 AHI >40 =0 =1 =2 =3 Defined by local sleep center… some use severe for AHI > 30 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Preop Scoring Guide – B Invasiveness 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Preop Scoring Guide – Postop opioid requirement -C None Low dose oral opioids High dose oral, parental, neuraxial Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 =0 =1 =3 Sleep Consultants, Inc.
Preop Scoring Guide – Score Overall score = A + greater of B or C Add 1 point if Paco 2 >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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
ASA 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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Preanethesia Holding Preoperative 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 usable Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
ASA Recommendation “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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Intraoperative Management of OSA 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 CO 2 Full reversal of neuromuscular block verified before extubation in OR or recovery, consider non-supine extubation. Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
ASA Recommendation “…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…” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
ASA Recommendation “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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Post Anesthesia Recovery (PAR) - Recommendations Epidural opoids preferable to parenteral Avoid patient controlled analgia (PCA) Avoid supine position Supplemental oxygen should be used End-tidal CO 2 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Post 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Inpatient vs Outpatient Recommendation “…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, …” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Inpatient vs Outpatient Recommendation “… 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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Criteria for Discharge to Unmonitored Settings - 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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Criteria for Discharge to Unmonitored Settings - 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. ” Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Why OSA Risk: 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Why OSA Risk: Myocardial 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
Why OSA Risk: Arrhythmias 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
WHAT TO DO NOW? Mayo Clinic: Clinical 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
WHAT TO DO NOW? Mayo Clinic: Clinical 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 Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
OSA IN THE PERIOPERATIVE PT. 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? Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
THANK YOU Copy of material available at our web site www. Sleep. Consultants. com Texas Pulmonary & Critical Care Consultants, P. A. , Copyright © 2008 Sleep Consultants, Inc.
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