Dr. Shais S. Jallu

Dr M.J. Mador

Obstructive sleep apnea:

Cardinal features include:

Perturbations of a regular respiratory pattern during sleep including obstructive apneas, hypopneas or respiratory effort related arousals.

Daytime symptoms attributable to disrupted sleep including: fatigue, sleepiness or poor concentration.

Signs of disturbed sleep including snoring or restlessness.

Obstructive sleep apnea:

Risk factors include obesity, craniofacial or upper airway soft tissue abnormalities, nasal congestion and current smokers.

Prevalence Elevetated AHI -27-35%in men and 9-12% in

womenOSA - 3-7% in men and 2-5% in women AgeAfrican-Americans

Obstructive sleep apnea:Polysomnogram is the gold-standard

diagnostic test: Apneas — Apnea is airflow less than 20 percent of

baseline for at least ten seconds in adults Hypopneas —decrease (>50 percent) in the amplitude of

breathing during sleep which lasts at least ten seconds, Apnea-Hypopnea Index RERAs RDI

OSA categories: Mild- AHI 5-15 Moderate-15.1-30 Severe->30

Obstructive sleep apnea:Treatment:

Conservative measures-weight reduction, avoidance of alcohol, BZDs or opioids

CPAPOral appliancesSurgery-UPPP, genioglossus advancementDrug therapy-Modafinil

Use of CPAP can reduce the rate of complications in OSA patients:Improves upper airway patency and

ventilationReduces myocardial ischemia and cardiac

arrhythmias, stabilizes fluctuations in BP

Sedation & OSA:Patients with OSA suffer from anatomical

abnormalities including short, thick neck, excessive tissue on pharyngeal wall, craniofacial abnormalities.

Sedatives and opioids: Decrease pharyngeal tone & increase

resistancepharyngeal collapseCNS depressantsdepression of RASRespiratory depression

Patients with OSA appear to be more sensitive to sedation than others

Introduction:

No established guidelines for sleep apnea patients receiving conscious sedation in the endoscopy suite.

Several studies have suggested increased risk for perioperative cardiorespiratory complications in OSA patients.

Can these results be extrapolated to the endoscopy suite where moderate sedation and no postoperative analgesia is used?

Study Design:

Retrospective; chart review type.Performed at VAMC, buffalo. VAMC records and any scanned non-VA records.VAMC patients who had any type of endoscopic

procedure were linked with patients who had sleep study.

Data collected about:Baseline CharacteristicsSleep study resultsEndoscopy procedureMinor and major complications during the procedure

Inclusion Criteria:Patients who had any type of endoscopic

procedure including: Colonoscopy EGD Combined procedure (including EUS)

performed in the GI suite.under conscious sedation.from 2002 to 2008.

Linked with patients who had sleep studies:from 2001 to 2008. In the VAMC sleep lab or outside VAMC if

report was scanned.

Exclusion Criteria:

PEG tube placement proceduresBronchoscopy proceduresSigmoidoscopy proceduresPatient who had procedure-related

complications.Patients who had the procedure done in the ICUPatient with missing data regarding the

procedure report, sleep study report or bothComplicated endoscopic procedures where

more intense anesthesia was used

Baseline Characteristics:Age SexRaceBMI (body mass index)Smoking historyPFTsLVEF% Charlson co-morbidity index

Charlson co-morbidity index:

Sleep study results:patients were divided into two main

groups:negative sleep study (apnea hypopnea

index AHI < 5/hr) positive sleep study (apnea hypopnea

index AHI > 5/hr)

positive group was also divided into 3 subgroups:

mild OSA (AHI 5-15/hr) moderate OSA (AHI 15.1-30/hr) severe OSA (AHI > 30/hr)

Endoscopy procedure:Type IndicationAmount of sedationInpatient vs OutpatientBaseline vital signs right before the

procedure Presence or absence of home oxygenCPAP usage before or during the procedureMinor and major complications were

identified

Minor complications: Defined based on two definitions: 1)Patients who had vital signs within normal

range before the procedure : hypertension (SBP >160) hypotension (SBP<90) bradycardia (HR<55) tachycardia (>100) desaturation (< 90%) hypoventilation (RR < 8)

with no associated pain.2)Patients who had abnormal vital signs:

25% change or above from the baseline vital signs.

Major complications:Chest pain/MI.Arrhythmias (like 3rd degree heart block)Hypotension requiring fluid resuscitationRespiratory distressCardio- respiratory arrestAny minor complication that required intervention

including: IV fluids atropine epinephrine reversal agent up-titration of oxygen use of CPAP machine intubation transfer to ICU prolonged observation after the procedure unplanned admission

Results:

818 patients had both endoscopic procedures and sleep studies.

179 were excluded.130 patients had documented negative sleep

study in the last 5 years, while 509 had positive ones.

135 had mild OSA, 125 had moderate OSA and 249 had severe sleep apnea.

Results… Majority of procedures were done in the outpatient setting (96%).

Type of Procedure: 438 colonoscopy procedures (68.5%), 12 9 EGD procedures (20.1 %) 72 combined procedures (including EUS, combined EGD and

Colonoscopy) (11.4%).

38% of the procedures were done for screening purposes while the rest were diagnostic.

Sedation:  Both Versed and Fentanyl were used in almost all the procedures. the median amount of versed and fentanyl was 4 mg, 87.5 mg

respectively.  The amount of sedation was distributed equally with no

significant difference among the groups.

20 % of patients had minor complications, while 7.3 % had major complications.

Only one case that had severe sleep apnea, had respiratory arrest that required transfer to ICU.

Discussion:

Studies have shown that benzodiazepines and opioids have detrimental effect on sleep apnea

Various studies have documented increased perioperative risk of cardiopulmonary complications in sleep apnea patients receiving general anesthesia

Mechanisms include:Effect on ventilatory control and upper airway toneDepression of RASSleep deprivation and fragmentation

postoperatively causing rebound increase in REM sleep

Postoperative analgesia

Discussion:

Gupta et al (2001) assessed risk of post-op complications in patients with OSA undergoing hip or knee replacement and found that sleep apnea patients had higher rate of adverse postoperative outcome.

Hwang et al (2008) recorded home nocturnal oximetry on patients with clinical features of OSA and found that ODI 4% > 5 was associated with increased rate of postoperative complications.

Discussion:conscious sedation is different from general

anesthesia in terms of:Short acting agentsNo postoperative analgesiaShort proceduresNo mechanical ventilation

Literature concerning sleep apnea patients receiving conscious sedation in the endoscopy suite is inadequate.

Discussion:Sharma et al (2003) conducted a prospective

study which concluded that OSA was detected in a majority of previously undiagnosed patients undergoing outpatient procedures (bronchoscopy and colonoscopy) under conscious sedation.

Khiani et al (2008) conducted a prospective study on 233 patients stratifying them into low & high risk for OSA (using Berlin Questionnaire):Patients underwent either EGD or colonoscopy

under conscious sedationSedation related transient hypoxia was compared

between the 2 groups with no resultant difference.

Discussion:

Our data was analyzed in two different ways :comparing patients with positive and negative

sleep study.merging normal and mild sleep apnea into a single

category

Both showed same conclusions

Chung et al (2008) compared postoperative complications in sleep apnea patients and concluded patients with positive sleep studies had increased

risk as compared to negative ones however no increased risk with mild OSA group

Discussion:In our retrospective analysis, sleep apnea patients

undergoing endoscopy procedures (colonoscopy, EGD,EUS or combination of those) under conscious sedation are at no increased risk of cardiopulmonary complications as compared to those without sleep apnea.

Patients with sleep apnea can undergo procedures under conscious sedation using standard monitoring practices.

Use of CPAP during the procedure may not be required.

Limitations:

Problems with documentation:Retrospective designBaseline co-morbiditiesMinor complications

Missing data

Sample bias:Elderly patientsMajority are males, CaucasiansMultiple co-morbiditiespreselected for sleep study

ConclusionSleep apnea does not appear to predispose to

a significantly increased rate of cardiopulmonary complications during endoscopy procedures under conscious sedation.

In terms of clinical implication, it appears that sleep apnea patients can undergo such procedures safely using present monitoring practices.

References:Frances Chung, F.R.C.P.C.,* Balaji Yegneswaran, M.B.B.S et al ,Validation of the Berlin

Questionnaire and American Society of Anesthesiologists Checklist as Screening Tools for Obstructive Sleep Apnea in Surgical Patients anesthesiology 2008

Blacke, Chia et al, Preoperative assessment for OSA and the prediction of postoperative respiratory obstruction and hypoxemia anesthesia intensive care 2008

Shireen, Alexander et al, Postoperative Hypoxemia in Morbidly Obese Patients with and Without Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery anesthesia analog 2008

Daniel D. Moos, CRNA, MS Obstructive Sleep Apnea and Sedation in the Endoscopy Suite Gastroenterology Nursing 2006

Vijay S. Khiani, Santo Maimone et al, Safety of Conscious Sedation During Routine Endoscopy for Patients At Risk for Obstructive Sleep Apnea Gastrointestinal endoscopy 2008

Roop Kaw, ; Franklin Michota et al, Unrecognized Sleep Apnea in the Surgical Patient* Implications for the Perioperative Setting Chest 2006

Hwang, Shakir et al, association of sleep-disordered breathing with postoperative complications. Chest 2008

Gupta, Parvizi et al. Postoperative complications in patients with OSA undergoing hip or knee replacement: a case control study. Mayo Clin Proc 2001

Sharma, Haber et al. unexpected risk during administration of conscious sedation: previously undiagnosed OSA. Ann Intern Med 2003

Moote, Skinner. Morphine disrupts nocturnal sleep in a dose-dependent fashion.Anesth Analog 1989

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