Transcript Sleep Apnea

Sleep Apnea
Maki Morimoto, MD
Sleep Apnea
 Sleep apnea is a potentially serious sleep
disorder in which breathing repeatedly stops
during sleep.
 There are three types of sleep apnea
1.) Obstructive sleep apnea, which occurs
when your throat muscles intermittently relax
and block the airway during sleep.
2.) Central, which is a neurological disorder
3.) Mixed
Sleep Apnea
Obstructive Sleep Apnea
most common form of sleep apnea
12 million people are affected
1 in 25 middle aged male
1 in 50 middle aged female
Only 50% are obese
Males > Females
Older > Younger
African American, Hispanics and
Pacific Islanders
(Helder et al - BMJ. 2004 Oct 23; 329(7472): 955–959)
Only 20% is diagnosed
Sleep Apnea
Which patient has OSA?
1.Harley – 53 yo male
2.Ursula – 54 yo female
3.Burton – 66 yo male
4.Helju – 37 yo female
5.Eric – 53 yo male
6.Lionel – 39 yo male
Answer:
(New York Times – May 14, 2009)
Sleep Apnea
 How do we diagnose OSA?
 Why do we need to know if the patients
have/do not have OSA?
 What can happen to the patients with OSA?
 How do we care for these patients?
 What should be monitored?
 Can we send these patients home?
Sleep Apnea - Diagnosis
 STOP-BANG Score
- Do you Snore?
- Do you feel Tired?
- Has anyone Observed you with apnea?
- Do you have high blood Pressure?
- BMI more than 35kg/m2?
- Age over 50 years old?
- Neck circumference > 16 inches (40cm)?
- Gender: Male?
 Score: 5-8 (High), 3-4 (Mid), 0-2 (Low)
 88% sensitivity of identifying severe OSA
(F. Chung et al.)
Obes Surg. 2013 Dec;23(12):2050-7.
Sleep Apnea - Diagnosis
 For the definitive diagnosis, the patients must do
a sleep study (Polysomnogram)
 The followings are recorded during the study:
brain activity
eye movements
heart rate
blood pressure
the amount of oxygen in your blood
air movement through your nose
snoring
chest movements
Sleep Apnea and surgery
 Why is important to know if the patient has OSA?
- Patients are at a increased risk from anesthesia
and sedation
- Higher rate of cardiopulmonary and respiratory
complications
- Higher likelihood of “difficult” intubation
- Higher rate of death (e.g. twofold for hip/knee
surgeries)!
Sleep apnea and Surgery
 “A woman dies after a routine knee surgery”
– Boston, 2013

“A patient dies after a shoulder surgery” –
unknown location, 2007
 “48 years old female patient dies after an
eye surgery” – Texas, 2008
Sleep Apnea and Surgery
 Common factors:
- Patients had obstructive sleep apnea
- Had received general anesthesia
- Received opioid medications for pain
- Were not monitored
Sleep Apnea and Surgery

In 2014, Center for Medicare and Medicaid Services
(CMS) issued a statement:
“Each year, serious adverse events, including
fatalities, associated with the use of IV opioid
medications occur in hospitals. Opioid-induced
respiratory depression has resulted in patient deaths
that might have been prevented with appropriate
risk assessment for adverse events as well as frequent
monitoring of the patient’s respiration rate, oxygen
and sedation levels. Hospital patients on IV opioids
may be placed in units where vital signs and other
monitoring typically is not performed as frequently as
in post-anesthesia recovery or intensive care units,
increasing the risk that patients may develop
respiratory compromise that is not immediately
recognized and treated.”
Sleep Apnea and Surgery
 In 2014, American Society of Anesthesiologists
(ASA) issued a practice guideline for OSA
patients
Anesthesiology. 2014 Feb;120(2):268-86.
Sleep Apnea and Surgery
 Pre-operative evaluation:
- Protocol should be developed
- Patient should be seen before the day of
the surgery
- Evaluation should be comprehensive
- Sleep Study is encouraged, if suspected of
OSA
- Clinical criteria should be inclusive
- Establish scoring system for perioperatative risk from OSA
- Inform the patient of the risks
Sleep Apnea
Sleep Apnea and Surgery
 Pre-operative preparation (surgical day)
- Initiation of CPAP should be considered
- Use of mandibular advancement should
be considered
- Weight loss should be encouraged
- A Patient who has had corrective surgery
should still be assumed to remain at risk
unless a normal sleep study has been
documented
- Difficult airway may be suspected
Sleep Apnea and Surgery
 Intraoperative management
- Because of their propensity for airway collapse,
they are especially susceptible to the respiratory
effects of sedatives, opioids, and inhalational
anesthetics
- Consider local, regional, or neuraxial
anesthesia techniques, if possible
- Should be monitored by capnography
- Consider using CPAP or other devices
- General anesthesia with endotracheal tube is
preferred over deep sedation
- Extubate while awake
- Full reversal should be documented
- If possible, extubate in non-supine position
Sleep Apnea and Surgery
 Post-operative Management
- Try to avoid systemic opioid use
- If PCA is to be used, avoid basal rate
- Multi-modal pain management is
encouraged
- Be careful with sedative medications
- Supplemental oxygen should be
administered
- Encourage CPAP use
- Continuous pulse oximeter use
Sleep Apnea and Surgery
 Criteria for discharge to unmonitored
settings:
- Once they are no longer at risk of
postoperative respiratory depression
- May take twice as long for discharge
- Observe patients in an unstimulating
environment, preferably while a sleep, to
assess adequate oxygen saturation levels
with room air
Sleep Apnea
- Lifestyle modifications (e.g.
weight loss and regular sleep)
- Avoid alcohol and certain
medications
- Special pillows/beds
- Mandibular advancement
devices (e.g. dental gum and
mouth guard)
- Mechanical therapy (e.g.
CPAP and BiPAP)
- Surgery (e.g. Stimulator
implants, UPPP and
tonsillectomy)
Sleep Apnea
 How do we diagnose OSA?
 Why do we need to know if the patients
have/do not have OSA?
 What can happen to the patients with OSA?
 How do we care for these patients?
 What should be monitored?
 Can we send these patients home?
The End