Transcript OBSTRUCTIVE SLEEP APNEA IN THE PERIOPERATIVE PATIENT

OBSTRUCTIVE SLEEP APNEA
IN THE PERIOPERATIVE
PATIENT
John R. Burk, M.D.
Texas Pulmonary & Critical Care Consultants, P.A., Copyright © 2008
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OBSTRUCTIVE SLEEP APNEA IN THE
PERIOPERATIVE 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?
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OSA IN PERIOPERATIVE PT.
YEARS OF EXPERIENCE?
 10 YEARS
 20 YEARS
 30 YEARS
 DEATHS IN THE RECOVERY ROOM?
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21ST 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.
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21ST 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
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QUALITY
 LIKE THE BLIND MEN AND THE
ELEPHANT –
 IN THE EYE OF THE BEHOLDER
 MUST BE MEASURABLE
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VALUE =
Medical outcomes + Service outcomes
Cost outcomes
The goal is the best possible medical and
service outcomes at the lowest
necessary cost
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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
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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
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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
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Why is quality important?
Dr. 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
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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.
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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, FEV1, FEV1/FVC), O2
sat%, cough test
 1,055 consecutive patients enrolled 20012003
Am J Respir Crit Care Med 2004;171:514-517
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Pulmonary Complications after
Nonthoracic Surgery
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WRITE NUMBER:PULMONARY MORBIDITY
none
0.1%
1%
3%
5%
8%
WRITE ANOTHER NUMBER: MORTALITY
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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
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Pulmonary Complications after
Nonthoracic Surgery - Risks
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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
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Perioperative risk in OSA
UNKNOWN
 If unknown OSA , likely high risk
 If known OSA with successful therapy,
likely low risk
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OSA – 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
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OSA – Low risk factors
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No snoring
Female
Premenopausal
Thin
Normal upper airway anatomy
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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-
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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-
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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
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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
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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
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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 (CO2 narcosis)
 History of hypertension, stroke, and/or
nocturia
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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
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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
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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., AmJRespirCritCareMed 2007; 175:9-15
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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.
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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,
<1yr, obesity without sleep apnea
 Both inpatient and outpatient setting
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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
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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
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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
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Preop Scoring Guide – Postop
opioid requirement -C
None
Low dose oral opioids
High dose oral, parental, neuraxial
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=0
=1
=3
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Preop Scoring Guide – Score
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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
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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.”
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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.”
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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
and usable
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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
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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
CO2
 Full reversal of neuromuscular block verified
before extubation in OR or recovery, consider
non-supine extubation.
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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…”
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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.”
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Post Anesthesia Recovery
(PAR) - Recommendations
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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
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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
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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,…”
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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.”
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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.”
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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.”
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Why OSA Risk:
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
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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
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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
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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
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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
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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?
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THANK YOU
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