case presentation obstructive sleep apnea (osa)
TRANSCRIPT
Dr Bikash Subedi
Moderator: Prof. Dr Baburaja Shrestha
19th Aug,2014
O Mr Ghimire,32/m
Presenting complaints
O Snoring x 3 years
O Recurrent Throat pain/foreign body sensation x 2 yrs
O ?Disturbed sleep x 2 yrs
HOPI
O Off and on throat pain and tonsillar enlargement
O Unaware of sleeping difficulty (snoring, obstructed breathing)
O Somnolence,fatigue, headache in the
morning
O No significant past medical except for
taking painkillers & antibiotics off and on for throat pain
O No h/o surgical oR anesthetic exposure
Personal history
O Smoker- 5-6 cigarettes/day for the last 6 yrs
?left since last 1.5 mnths
O Occasional drinker
O Normal bowel/bladder habits
Physical examination
General examination
O General condition – fair
O Wt.-108 kgs, Ht.- 165 cms
O BMI – 39.66 kg/M2
O PILLCCOD – NIL
BMI- < 18.5= underweight. 18.5-25= normal wt. 25-30= overweight. 30-35= class 1 obesity. 35-40= class II. > 40= class III obesity
AirwayO Normal Dentition/ Patent nares
O Mouth opening – 3 fingers breadth
O TMD – >6 cm
O TMJ – free/mobile
O Neck mobility –
slightly restricted due to surascapular hump
O MP – II grade, tonsillar enlargement +Ve (?Grade IV)
O Thick neck
O Suprascapular hump
Systemic examinationOCVS Examination :
O Pulse: 80,regular
O BP: 130/80 mm Hg (left sitting)
O S1 + S2 + M0
ORespiratory Examination:
O RR: 16/min
O Air entry B/L on bases, otherwise NVB
OAbdomen
distended, fatty
no organomegaly,
InvestigationsO Hb:13.2 gm%
O TC: 10,300/mm3
O P72, L22, E06O PT: 15 secs
O INR: 1.1
O Platelets: 2,25,000/mm3
O Blood group: 0 +ve
O Na: 146 meq/l
O K: 4.7 meq/l
O Urea: 26 mg/dl
O Creatinine: 0.9 mg/dl
O RBS: 134 mg/dl
O ABG: N/A
O Trop I – Neg
O CK MB- 17 U/L
O Normal echocardiographic findings
LVEF-65%
O Normal Thyroid function tests
T3= 2.63 pg/L
T4= 11.49 pg/L
TSH= 1.10 mIU/L
RAD
Preoperative preparation
O NPO/Premedication PPI,Prokinetic
O IV access/ 16 G cannula
O Equipments for Difficult airway made ready
O Ramping done
O Preoxygenation & RSI
OPIOID-LESS SURGERY!!
O INDUCTION
inj Propofol 250 mg
inj Sux 150 mg
1.5 gms of PCM
150 mg of Diclofenac sodium
O 6.5 mm ID RAE tube. uneventful
O MAINTENANCE
Vecuronium,Ketamine (intermittent/analgesia)
O2 (100%), Isoflurane
O REVERSAL
DOS = 1 hr 45 mins
Neostigmine, Glycopyrrolate
Intraoperative
NOT so smooth emergence!!
O Bucking on the tube
O Oral bleeding noticed >> re-induced with Propofol
O Another 40 mins of cautery!
O Awake intubation planned >> violent pt.
>> nasopharyngeal airway sutured! >>
suctioned/extubated >> another 25 mins
of airway support maneuvers
O Shifted to ICU for monitoring/ CPAP
PCM/ NSAIDS for pain
O O2 Sats dropped to 65% during sleep
O CPAP not tolerated well >> O2 face mask >> sats above 90 %
DISCUSSION
Obstructive Sleep Apnea
O Sleep apnea-hypopnea syndrome
O Cessation or significant decrease in airflow in the presence of breathing effort
O Recurrent episodes of upper airway collapse during sleep
O Recurrent desaturations and arousals
O OSA a/w excessive daytime sleepiness
OSA syndrome
Signs & Symptoms
Night symptoms
O Snoring, usu loud & bothersome
O Witnessed apneas (interrupt snoring & end with snort)
O May have Gasping/choking that arouse
O Restless sleep (toss & turn)
O nocturia
Daytime symptoms
O Sleepiness,fatigue
O Headache, dry/sore throat
O ↓vigilance, confusion
O Personality/mood changes (depression,anxiety)
O ↓libido, GERD
O Paradoxical “good sleepers”
STOP!
O S: "Do you snore loudly, loud enough to be heard through a closed door?"
O T: "Do you feel tired or fatigued during the daytime almost every day?"
O O: "Has anyone observed that you stop breathing during sleep?"
O P: "Do you have a history of high blood pressure with or without treatment?“
O >>2 OUT OF 4 >>
low likelihood of OSA. A SBQ of
questionnaires include the Berlin
PATHOPHYSIOLOGY
STATIC FACTORS
• Anatomic factors
• ↓pharyngeal diameter
• Gravity/posture
DYNAMIC FACTORS
• Airway resistance
• Bernoulli’s effect
• Dynamic adherence
OSA is smaller than that of
including the tongue, lateral
parapharyngeal
Nonstructural risk factors
O Obesity
O Central fat distribution
O Male sex (M:F=2:3.1O Age (inc with inc age)
O Postmenopausal state
O Alcohol use
O Sedative use
O Smoking
O Supine sleep position
O Hypothyroidism, Acromegaly
O Rapid eye movement (REM) sleep
PATHOPHYSIOLOGYpressure and the surrounding tissue
sectional area
inward. The airway is obstructed.
pressure to a net tissue force that is
, the airway remains
obstructed. OSA duration is equal to
Examination may reveal
O Obesity (BMI usu > 30)
O Enlarged neck circumference
men > 43 cm. Women >37 cm
O High MP scores, enlarged tonsils (grade 3/4)
O Retro/micrognathia, overjet
O High arched palate
BANG! – BMI, AGE > 50 ,Neck circum Gender M
O Systemic arterial HTN (upto 50% OSA cases)
O Pulm. HTN, CHF
O Type II DM, Metabolic syndrome
DIAGNOSIS
The Apnea Hypopnea Index(AHI)
O defined as the average number of abnormal breathing events per hour of sleep
O APNEA refers to cessation of airflow for 10s,
O Hypopnea -reduced airflow with desaturation ≥4%.
O The American Academy of Sleep Medicine (AASM) diagnostic criteria either an AHI ≥15, or AHI ≥5 with symptoms, such as daytime sleepiness, loud snoring, or observed obstruction during sleep.
O OSA severity is
O mild for AHI ≥5 to15, moderate for AHI 15 to 30, and severe for AHI >30.
Overnight sleep study Polysomnography
SLEEP STAGES
EEG,electro-oculogram,chin electromyogram
BREATHING
Flow
Apnea,hypoapnea
HEART RHYTHM
via ECG
LEG MOVEMENT
Tibialis anterior electromyogram
(using both a thermal sensor and a
Apnea,Hypoapnea & RERA
Derivation and validation of a simple perioperative sleep apnea prediction
score. Ramachandran et al Anesth Analg. al.2010 Apr 1lO Abstract/BACKGROUND:….
O METHODS:
O A retrospective, observational study was designed to identify patients with a known diagnosis of OSA. Independent predictors of a diagnosis of OSA were derived by logistic regression, based on which prediction tool (P-SAP score) was developed. The P-SAP score was then validated in patients undergoing overnight polysomnography.
O RESULTS:
O The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. 3 demographic variables: age > 43 years, male gender, and obesity; 3 history variables: history of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures: thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score > or = 2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score > or = 6, sensitivity was poor (0.239) with excellent specificity (0.911). Validation of this P-SAP score was performed in 512 patients with similar accuracy.
O CONCLUSION: The P-SAP score predicts diagnosis of OSA with dependable accuracy across mild to severe disease. The elements of the P-SAP score are derived from a typical university hospital surgical population
Conservative therapy & prevention
O Sleep position (NOT supine)
O Upright position for markedly obese
O Smoking cessation
O Alcohol/ sedatives avoidance
O Avoidance of sleep deprivation
Baseline Risk Reduction Strategies
O Preoperative CPAP
O Opioid sparing techniques
O Regional anesthesia/analgesia
O Non-opioid adjuncts
O Minimal access surgery
O Continuous pulse oximetry monitoring
O Postoperative CPAP
Mechanical means
O CPAP
O Bilevel positive airway pressure
O Oral appliance therapy ??
Surgical options
O Underlying cause= tonsillectomy, adenoidectomy
O Uvulopalatopharyngoplasty
O Craniofacial reconstruction
O Tracheostomy
O Implantable neurostimulator for OSA
O http://emedicine.medscape.com/article/295807-clinical#aw2aab6b3b2
O http://journal.frontiersin.org/Journal/10.3389/fneur.2012.00095/full
O http://www.stopbang.ca/pdf/pub10.pdf
O http://www.michiganrc.org/sites/michiganrc.org/files/u1258/SKR%20Boston%20IARS%20-%20Ramachandran.pdf
O http://www.sasmhq.org/wp-content/uploads/2014/05/SASM14_Educational_v3.pdf
O http://www.sign.ac.uk/pdf/qrg73.pdf