OSA : Isn’t it about obese? Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital...

OSA : Isn’t it about obese?

Saowapark ChumpathongDepartment of Anesthesiology

Siriraj Hospital

Saowapark ChumpathongDepartment of Anesthesiology

Siriraj Hospital

OSA : Isn’t it about obese? OSA : Isn’t it about obese?

Obstructive Sleep Apnea (OSA)

• Recurrent episodes of complete or partial obstruction of the upper airway during sleep, resulting in oxygen desaturation and arousal


Obstructive Sleep ApneaClinical criteria

• Apnea: complete cessation of breathing ≥ 10 seconds

• Hypopnea: marked reduction in airflow, decreased SaO2 ≥ 4%

OSA: AHI score > 5OSAS: AHI > 5 + excessive daytime sleepiness


OSA at a glance OSA at a glancePrevalence

• OSA 11.4% (men 15.4%, women 6.3%)

• OSAS 4.4% (men 4.8%, women 1.9%)

OSA Obesity⇆

Arch Intern Med.2002;162:893-900. Obes Res.2000;8:262-9.

BMI ≥ 30 kg/m2 : 40% prevalence BMI ≥ 40 kg/m2 : 98% prevalence

Sleep Breath 2011;15:641-8.


Risk factors for OSA Variables OR (95% CI)

Male gender 8.7 (7.8-14.9)

Age > 45 years 2.7 (1.4-8.2)

Habitual smoking 2.1 (1.6-2.3)

Habitual drinking 3.2 (2.8-3.6)

Obesity 4.8 (1.9-11.4)

Hypertension 3.4 (3.1-4.9)

Sleep Breath 2011;15:641-8.


Why OSA mattersWhy OSA matters

Health consequences of OSA Problems with daytime functioning

sleepiness, accident, quality of life Cardiovascular, Cerebrovascular disease

HT, CAD, MI, AF, CHF, Stroke, Death Diabetes, Metabolic syndrome

Cleveland Clinic Journal of Medicine. 2009;76:S98-103.


Why OSA matter to us?Why OSA matter to us?• Higher prevalence in the surgical population

24% by Berlin questionnaire > 70% in obese bariatric surgery

• > 80% unrecognized OSA undergoing surgery

• Increases perioperative morbidity, mortality

Sleep.1997;20:705-6. Am Surg.2008;74:834-8.


Postoperative complications in patients with OSA

Complications AHI ≥ 5 AHI < 5 Adjusted OR Adjusted p value

(n=282) (n=189)

Hypoxemia 35 (12.4) 4 (2.1) 7.9 0.009

ICU transfer 19 (6.7) 3 (1.6) 4.43 0.069

Any complication 40 (14.2) 5 (2.6) 6.9 0.003

LOS > 2 days 135 (48.2) 53 (28.0) 1.65 0.049

Chest.2011 Aug 25. [Epub ahead of print]


Perioperative pulmonary outcomes in patients with OSA

Perioperative pulmonary outcomes in patients with OSA

Pulmonary outcomes OR (95% CI)

Aspiration pneumonia 1.37 (1.33,1.41)

ARDS 1.58 (1.54, 1.62)

Pulmonary embolism 0.90 (0.84, 0.97)

Intubation/mechanical 1.95 (1.91, 1.98)

ventilationAnesth Analg.2011;112:113-21.


Identify OSA patientIdentify OSA patient• Risk factors for OSA

• History : Sleep habits

: Symptoms and complaints Snoring Personality change

Sleepiness Morning confusion

Night sweats Physically restless sleep

Impotence Intellectual impairment

Morning headaches Morning dry mouth or sore throat


Identify OSA patientIdentify OSA patient• Physical examination Obesity HT Large neck circumference

Airway Nasal obstruction Tonsil enlargement Elongated uvula Macroglossia Retrognathia Micrognathia


Identify OSA patientIdentify OSA patientScreening tools Berlin questionnaire ASA checklist STOP questionnaire STOP-BANG questionnaire Nocturnal oximetry

Ann Intern Med.1999;131:485-91. Anesthesiology.2006;104:1081-93.

Anesthesiology.2008;108:812-21. Curr Opin Anaesthesiol.2009;22:405-11.

STOP-Bang scoring model Questions Questions Answer Snoring Do you snore loudly

(louder than talking or loud enough to be heard through closed doors)?

Yes / No

Tired Do you often feel tired, fatigued, or Yes / Nosleepy during daytime?

Observed Has anyone observed you stop Yes / Nobreathing during your sleep?

P blood pressure Do you have or are you being Yes / Notreated for high blood pressure?

BMI BMI more than 35 Yes / No Age Age over 50 years Yes / No Neck circumference Neck circumference greater than 40 cm Yes / No Gender Male Yes / No High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items

Curr Opin Anaesthesiol. 2009;22:405-11.

STOP-Bang scoring model Questions Questions Answer Snoring คุ�ณนอนกรนดังหร อไม่� ?

(ดังกว่�าเสี�ยงพู�ดั หร อ ดังพูอที่��จะไดั�ย�นออกไปนอกห�อง)

ใช่� / ไม่�ใช่�

Tired คุ�ณม่กจะร� �สี"กอ�อนเพูลี�ย ลี�า หร อ ง�ว่งนอนในระหว่�าง กลีางว่นบ่�อย ๆ หร อไม่� ?


Observed ม่�คุนเคุยสีงเกตเห'นว่�าคุ�ณหย�ดัหายใจขณะที่��คุ�ณหลีบ่ อย��หร อไม่� ?


P blood pressure คุ�ณม่�คุว่าม่ดันโลีห�ตสี�ง หร อก*าลีงรกษาโรคุคุว่าม่ดัน โลีห�ตสี�งอย�� หร อไม่� ?


BMI ดัช่น�ม่ว่ลีกายม่ากกว่�า 35 หร อไม่� ? ใช่� / ไม่�ใช่� Age อาย�ม่ากกว่�า 50 ป, หร อไม่� ? ใช่� / ไม่�ใช่� Neck circumference เสี�นรอบ่ว่งคุอม่ากกว่�า 40 ซม่. หร อไม่� ? ใช่� / ไม่�ใช่� Gender เป.นเพูศช่ายหร อไม่� ? ใช่� / ไม่�ใช่� High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items

Curr Opin Anaesthesiol. 2009;22:405-11.


Identify level of OSAIdentify level of OSA• Polysomnography (PSG) : gold standard

Severity of OSA AHI

Mild 5-15

Moderate 15-30

Severe > 30

• If no study available positive in two categories of signs/symptoms moderate OSA any severe abnormality on the list presume severe OSA

Anesthesiology.2006;104:1081-93.

American Academy of Sleep Medicine 2007

Obstructive sleep Apnea : Preoperative AssessmentObstructive sleep Apnea : Preoperative Assessment

Suspected OSA patientSuspected OSA patient

Severity Assessment from history or Polysomnography

Severity Assessment from history or Polysomnography

High risk of OSAHigh risk of OSA

Comorbidities and Major Elective

Surgery

Comorbidities and Major Elective

Surgery

Preoperative PAP therapy.Perioperative OSA precautions.

Preoperative PAP therapy.Perioperative OSA precautions.

Known OSA patientKnown OSA patient

Screening using STOP or STOP –Bang questionnaire Screening using STOP or

STOP –Bang questionnaire

Mild OSAMild OSALow risk of OSALow risk of OSA

Moderate or Severe OSAModerate or Severe OSA

YesYes NoNo Routine perioperative management.No preoperative PAP therapy required

Routine perioperative management.No preoperative PAP therapy required Consider

preoperative Sleep Medicine referral

Consider preoperative Sleep Medicine referral

Assume possibility of moderate OSA. Perioperative OSA precautions

Assume possibility of moderate OSA. Perioperative OSA precautions Anesthesiology Clin.2010;28:199-215.

Can J Anesth.2010;57:849-64.


Perioperative OSA precautions

• Anticipating possible difficult airway

• Use of short-acting anesthetic agent

• Opioid- minimization

• Full reversal of neuromuscular blockade

• Extubation in a non-supine position

Anesthesiology Clin.2010;28:199-215.Can J Anesth.2010;57:849-64.


Intraoperative Management

• Avoid sedating premedication

• Consider gastroesophageal reflux

• Regional, multimodal analgesia

• Use of intraoperative capnography

• Resume use of PAP device


Prolonged stay in the PACU Prolonged stay in the PACU

Known OSAKnown OSA

Recurrent PACU Respiratory EventRecurrent PACU Respiratory Event

Discharge to home if minor surgery or postoperative care on the surgical ward.

Discharge to home if minor surgery or postoperative care on the surgical ward.

Suspected OSASuspected OSA

• Non-compliant with PAP therapy• Severe OSA • Recurrent PACU Respiratory Event

• Non-compliant with PAP therapy• Severe OSA • Recurrent PACU Respiratory Event

NoNo YesYes

Postoperative PAP therapy and care in a monitored bed with continuous oximetry.

Postoperative PAP therapy and care in a monitored bed with continuous oximetry.

Discharge to home if minor surgery.

Discharge to home if minor surgery.

YesYes

Postoperative care on the surgical ward.

Postoperative care on the surgical ward.

NoNoYesYes

• Moderate OSA• Postoperative opioids

• Moderate OSA• Postoperative opioids

NoNo


Sao2 <90% (x3)Bradypnea < 8/min (x3)Apnea ≥10 sec (x1)Pain sedation mismatch


OSA & Ambulatory surgeryOSA & Ambulatory surgery

Estimation of perioperative risk

• Severity of OSA

• Invasive of surgery and anesthesia

• Requirement for postoperative opioids• OSA scoring system > 4: increased risk

Anesthesiology.2006;104:1081-93.


OSA & Ambulatory surgeryOSA & Ambulatory surgery

• Mild-moderate OSA patients

optimized comorbid conditions

not requiring postoperative opioids safely undergo surgery

• Severe OSA patients requiring postoperative opioids not safe to undergo surgery

Current Opinion in Anesthesiology. 2011;24:605-11.


Take Home Message• OSA is strongly associated with obesity.

• Higher prevalence & unrecognized OSA are undergoing surgery.

• Patients with OSA are at an increased risk of perioperative complications.

• Identification,risk stratification of patients with OSA is essential in preventing postoperative complications.

OSA : Isn’t it about obese? Saowapark Chumpathong Department of Anesthesiology Siriraj Hospital...

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