Perioperative Screening for Obstructive Sleep Apnea Patient Safety

Marietta Bellamy Bibbs, BA, RPSGTMorton Plant Mease HealthcareClearwater, FLThe Need for Perioperative Screening in Sleep Apnea Patients9/7/2013 12:03 AM 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

1Discuss the importance of recognizing undiagnosed obstructive sleep apnea (OSA)Review the patients at risk for OSADescribe the consequences of untreated OSA in the surgery patientReview screening tools to identify at risk patientsDiscuss preventative measures to decrease perioperative risk in OSA patients

Presentation Content Consequences of Untreated OSAIdentifying the At-Risk PatientUndiagnosed OSA StatisticsScreening Tools and Preventive MeasuresPost-operative catastrophesThe Surgical Patient9/7/2013 12:03 AM 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

3Untreated Obstructive Sleep Apnea82% of men and 92% of women with moderate-severe sleep apnea have not been diagnosed. 40% of obese men and 50% of obese women have OSA. 4The Risk FactorsPatients with severe OSA have a 46% chance of dying. OSA affects 4% of the population with 18-20 million adults suffering from symptomatic OSA and severe asymptomatic OSA; 90% remain undiagnosed and untreated.5Predisposing Characteristics Clinical Signs and SymptomsHistory of Airway Obstruction During SleepExcessive SleepinessSigns and symptoms in 2 or more of the above categories indicates a significant probability of having OSA.6 Why Perioperative ScreeningIn the undiagnosed Obstructive Sleep Apnea (OSA) patient population..

Minimize the number of undiagnosed patients presenting for surgery.Provide appropriate monitoring and access to post-operative evaluation.Provide longitudinal care if indicated.Continue post-operative PAP therapy since treatment requirements may increase.9/7/2013 12:03 AM 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

7OSA and The Surgical RiskIt is estimated that 82% of men and 92% of women with moderate-severe OSA have not been diagnosed40% of obese men and 50% of obese women have been identified as having OSAEstimated life span of untreated OSA is 58 years (normal men 78 yrs., women 83 years)John Hopkins study found severe OSA increased risk of dying by 46%

Prevalence of OSA18 -20 million adults suffer from symptomatic OSA or severe asymptomatic OSAIt is estimated that 90% of those suffering from OSA are still undiagnosed and untreated4% of the US population affectedFrequently goes unrecognized and undiagnosed in the medical communityAffects all aspects of life OSA patients have a higher risk of post-operative complications

Healthcare Utilization and OSAAssociated with increased sick days and loss of productivity at workPrescription costs: OSA patients with hypertension receive more anti-hypertensive prescriptions and other drug therapies that are higher in costHighest diagnosis-specific expenditures related to hypertension and cardiovascular diseaseHealthcare UtilizationA Canadian study on a targeted group of OSA patients revealed that they:used 25-50% more medical resources in the 5 years prior to diagnosis had more physician office visits spent more nights in the hospital Had higher physician costs than matched controls

Risk FactorsObesityEnlarged adenoids, tonsils, and soft palate tissues including large uvula, low lying soft palate and excessive pharyngeal tissueJaw malformationsLarge tongue

Common SymptomsSnoringWaking up from snoringWitnessed apneaFrequent nocturnal awakeningsSleep maintenance insomniaWaking unrefreshed in the mornings or following naps

Commonly Recognized SymptomsWaking up choking, short of breath or gasping for breathExcessive daytime sleepinessChronic fatigue/tirednessFalling asleep or nodding off at inappropriate times

Unrecognized SymptomsNighttime sweatingNighttime GE refluxAutomatic behaviorsSleep drunkenness

Other Indications of OSAThese symptoms are often not thought of or recognized as being associated with OSA in the medical community:Change in personality or moodWeight gainNocturiaMorning headachesMorning dry mouthLoss of libido or impotencyPoor concentrationDecreased memory, especially short term

What this means..Studies have documented that 80% of men and 90% of women have obstructive sleep apnea and have never been diagnosed.Undiagnosed OSA presents special challenges for patients and healthcare workers, particularly in surgical patientsOSA patients are at high risk for surgical complicationsOSA ComplicationsHypertensionUntreated OSA is associated with hypertension in 40 % of patients30 % of patients with idiopathic hypertension have OSAS

Cardiac arrhythmias during sleepSinus arrhythmia, sinus bradycardia, atrial fibrillation, asystole, second-degree AV block, PVCs, and VT

OSA ComplicationsHeart attacksStrokeType 2 Diabetes Mellitus

OSA Surgical PatientsHigh RiskRelated to comorbitiesCongestive Heart FailureMyocardial InfarctionArrhythmiasSudden Cardiac Event-related sleep disturbanceDecreased arousal threshold related to sleep fragmentationDecreased arousal delay due to narcotics

The Importance of Screening for Obstructive Sleep Apnea Prior to Surgery

Patient SafetyOSA patients have a higher rate of Difficult IntubationDifficult ExtubationHypercapniaOxygen desaturationsCardiac insults

Anesthesiologists know the DangersAmerican Society of Anesthesiology published guidelines recommending that patients should be screened for OSA before surgery.

Goal:Identify patients undiagnosed OSA patients prior to surgery.

Diagnose and treat prior to surgery when possible.

If unable to diagnose prior to surgery, treat patients as if they have documented OSA in order to avoid complications.

Starting a Perioperative ProgramQuestions for AnesthesiologistsPerioperative Program GoalGoal in Identifying OSA Surgical PatientsThere is a limitation in screening patients with questionnaires because it will not discriminate between mild, moderate or severe OSA and will not identify true at risk patients.26The Presenting OSA Surgical PatientOSA patients will present for surgery in one of three categories:

Known OSA and compliant with therapyKnown OSA :Mild OSA and therapy not recommendedRefused therapy or non-compliantOther therapy, e.g., weight loss, surgical intervention, dental appliancesStatus unknown9/7/2013 12:03 AM 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

27The Presenting OSA Surgical PatientPatients with known OSA and on no active therapy:May be asymptomatic or minimally symptomaticMay become symptomatic post-opPatients who are non-compliant and unrecognized:These patients should be the primary focus of a perioperative sleep apnea safety program

Surgical Risk FactorsScreening tools assist with identifying patients at highest risk for OSA using established risk factors. Obesity and increasing age are strong risk factors for OSA. Common signs and symptoms include loud snoring, observed apnea, daytime hypersomnolence, urinary frequency at night and morning headaches.

Additional Surgical Risk FactorsMale sex, excessive alcohol intake, and female menopause.Craniofacial abnormalities, such as retrognathia and macroglossia.Wide neck circumference (17 inches for men and 16 inches for women), are also considered as risk factors for OSA.

Why Surgical Screening for OSASurgeons/anesthesiologists may not be informed of sleep study results (clinical diagnosis of OSA noted by record review).

One study indicated: 86% of patients were not identified by surgeons.47% of OSA patients were not identified by Anesthesiologists.

Why Perioperative OSA Safety?OSA is a major risk factor for perioperative adverse events; however, no screening tool for OSA has been validated specifically in surgical patients.If you think someone might have sleep apnea, you might not be correct. You cannot always pick out OSA patients by looking at them. The American Society of Anesthesiologists screening guidelines recommend that OSA screening should be done on every patient.

32Perioperative ComplicationsFactors in OSA that could increase perioperative complications:Anatomical imbalanceLung volume reduction (decreased FRC and ERV)Sympathetic nervous system activationVentilatory instability

9/7/2013 12:03 AM 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

33Sedatives and the OSA PatientImpact of sedatives, anesthetics and analgesics on respiratory function:Dose dependent depression of upper airway muscles.Depression of central respiratory output and upper airway reflexes (increased collapsibility of the upper airway).Increased collapsibility of the upper airway.Direct action (peripheral) on hypoglossal and phrenic nerves (phrenic nerve depression leads to decrease in lung volume).

Present a Sample Case

Needs AssessmentCase #1:A 40-year old male with history of mobid obesity and prior laparoscopic cholecystectomy and nephrolithiasis presented to the hospital for an incisional hernia repair. He was noted to have a difficult airway preoperatively, but was intubated with a glide scope without difficulty and was ventilated fairly easily through surgery.

Postoperatively the patient was extubated and it was noted that he would drop his oxygen saturation down into the 40% or less range, even with nasal and high-flow mask O2. His baseline oxygen range was 80% or less when awake. The patient was reportedly aware of a diagnosis of obstructive sleep apnea, but never pursued treatment. Case 1 (Continued)The Anesthesiologist became concerned about releasing the patient home with witnessed severe O2 desats. This resulted in the patient being admitted to the ICU with plans to titrate him on the Vision BiPAP. Pulmonary consult was ordered with resulting impression that the patient had severe obstructive sleep apneaCase 1 (continued)Patient was immediately placed on empirical BiPAP settings in the ICU at pressures of 12/4 cmH2O (IPAP/EPAP). The consulting Pulmonologist scheduled an emergency sleep study on the patient which was performed the next day as a split-night procedure.

The diagnostic portion of the sleep study confirmed sleep apnea with AHI of 115 events per hour, SpO2 nadir of 51% and average SpO2 of 69% in absence of REM or slow wave sleep. Severe snoring and oxygen desaturations with a pathological short sleep latency and abnormal sleep architecture also noted.

ResultsThe patient failed CPAP and was changed to BPAP with significant improvement but not significant resolution of his sleep apnea. Best response at pressures of 24/18 cmH2O.Patient was sent home on Auto BPAP with 6 l/minute of O2 bleed-in with overnight oximetry and a follow-up download of his BPAP machine to follow response to treatment.

Screening Tools33% -High Risk27% high risk28% high riskNo significant difference in the questionnaires ability to identify patients with OSA)When compared with diagnostic PSG testing for preoperative screening, both the Berlin and the ASA checklist had sensitivities >85% for an AHI >30 and >78% for an AHI >15. The specificities were 46% and 36%, respectively for the Berlin and ASA checklist, respectively for Berlin and ASA checklists when AHI >30 and 50% and 37% for AHI >15. 40The Berlin QuestionnaireThe Berlin Questionnaire was initially used and validated for outpatient screening of OSA in primary care clinics but has also been validated as a screening tool in the surgical population.The Berlin Questionnaire10 questions5 on snoring3 on EDSOne on witnessed apneaOne on hypertensionIncludes age, gender, weight, height, neck circumference

The Berlin QuestionnaireCategory 16 questions on snoring and apneaCategory positive if score 2 or more pointsCategory 23 questions on tiredness and fatigueCategory positive if score two or more pointsCategory 3 positive if HTN or BMI > 30 kg/m2Question 9 has second part on frequency of nodding off or falling asleep driving and is noted separately.

High Risk2 or more categories positiveLow Risk0-1 categories positiveSensitivity 0.89Specificity 0.71Netzer NC et al. Ann Internal Med 1999; 131:485-491

The ASA ChecklistIn 2006, the American Society of Anesthesiologists published obstructive sleep apnea guidelines for anesthesiologists. The ASA recommends that anesthesiologists screen for obstructive sleep apnea utilizing the ASA checklist of 14 questions (12 for adults and 14 for children).The ASA OSA scoring checklist combines the severity of OSA, invasiveness of surgery and anesthesia, and postoperative opioid requirements to estimate overall perioperative risk.Not always practical to use in a busy preoperative practice--too many questions.

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The ASA ChecklistSensitivity5-14/hr AHI 72.115-30/hr AHI 78.6>30/hr AHI 87.2 Chung F, et al. Anesthesiology 2008; 108: 822-830

The STOP Questionnaire The STOP questionnaire is a concise and easy-to-use more practical screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics.

Four questions combined with body mass index, age, neck size, and gender. A high sensitivity, especially for patients with moderate to severe OSA. Two positive questions on the STOP indicates that the patient may be at high risk for OSA.The STOP QuestionnaireSnoringTirednessObserved apneaHigh blood pressure

High risk is yes to 2 or moreLow risk is yes to < 2Sensitivity 5-14/hr AHI 65.615-30/hr AHI 74.3>30/hr 79.3Chung F, et al. Anesthesiology 2008; 108: 822-830The STOP BANG QuestionnaireS=Snoring. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? T=Tiredness. Do you often feel tired, fatigued, or sleepy during daytime? O=Observed apnea. Has anyone observed you stop breathing during your sleep? P=Pressure. Do you have or are you being treated for high BP?B=BMI >35 kg/m2 A=Age >50 y N=Neck circumference >40 cm G=Male gender

High risk of OSA: 3 or more questions answered yes Low risk of OSA: 35, age >50 years, neck circumference >40 cm, and male gender). The advantage of the STOP-Bang model is that it is brief, simple to administer, and requires only a fifth-grade reading level.42 Most importantly, the STOP questionnaire predicted the occurrence of postoperative complications, particularly respiratory complications.4249The STOP BANG QuestionnaireHigh risk greater or equal to 3Sensitivity5-14/hr AHI 83.615-30/hr AHI 92.9>30/hr AHI - 100

Chung F, et al. Anesthesiology 2008; 108: 822-830

Clinical Management StrategyClinical Management ProtocolPatient with diagnosed OSA

Intraoperative Management in the OSA PatientPostoperative Anesthesia Recovery Management of the OSA PatientManaging the OSA Patient on the Hospital FloorManaging the OSA Patient after DischargeDate:Re: Patient: _____________________________Dear Dr. ___________________: As a part of pre-anesthesia assessment prior to surgery, your patient was screened for obstructive sleep apnea using the Stop-Bang Questionnaire*. The results identified your patient as at-risk for obstructive sleep apnea. Patients identified as at-risk may require further evaluation and follow up for sleep apnea.Sincerely yours,____________, MD, DABSMMedical DirectorSleep Disorders Center*Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D, Santhira Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C., Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.1

Make it EasyPAT Scripting for Nurses:

The Questionnaire you completed is part of a program to screen for patients who may have undiagnosed obstructive sleep apnea. The results indicated that you have a likelihood of having obstructive sleep apnea. Because of these results, we would like to include you in the program for follow-up with your primary care physician for further evaluation. This means that your physician will be sent a letter indicating the results, and we will include your name in the pilot program for evaluation and follow-up. Would you like for us to include you in the pilot program for obstructive sleep apnea follow-up?Ensure Follow-upDate:

Re: Patient: _____________________________

Dear Dr. ___________________:

During pre-anesthesia assessment, your patient was identified as at-risk for obstructive sleep apnea. The validated assessment tool (The STOPBang1 questionnaire1) revealed a score of ____, indicating a ____fold risk of obstructive sleep apnea. Patients identified as at-risk indicate the need to be further evaluated for sleep apnea.

Sincerely yours,

1Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D, Santhira Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C., Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.1Other Useful ToolsThe Stop BangHow to Make It WorkUse Other Programs as examplesUse OSA Near Misses as a Teaching ToolPresent SAMBA Patient Selection GuidelinesIdentify the Challenges in Implementing a Perioperative ProtocolThe Joint Commission Sentinel Event AlertHandouts for patients: Preparing for an Operation When You Have Sleep apnea