osa : isn’t it about obese? saowapark chumpathong department of anesthesiology siriraj hospital...
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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
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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 : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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]
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
Identify OSA patientIdentify OSA patient• Physical examination Obesity HT Large neck circumference
Airway Nasal obstruction Tonsil enlargement Elongated uvula Macroglossia Retrognathia Micrognathia
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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� ?
ใช่� / ไม่�ใช่�
Observed ม่�คุนเคุยสีงเกตเห'นว่�าคุ�ณหย�ดัหายใจขณะที่��คุ�ณหลีบ่ อย��หร อไม่� ?
ใช่� / ไม่�ใช่�
P blood pressure คุ�ณม่�คุว่าม่ดันโลีห�ตสี�ง หร อก*าลีงรกษาโรคุคุว่าม่ดัน โลีห�ตสี�งอย�� หร อไม่� ?
ใช่� / ไม่�ใช่�
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
Intraoperative Management
• Avoid sedating premedication
• Consider gastroesophageal reflux
• Regional, multimodal analgesia
• Use of intraoperative capnography
• Resume use of PAP device
Anesthesiology Clin.2010;28:199-215.Can J Anesth.2010;57:849-64.
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
Anesthesiology Clin.2010;28:199-215.Can J Anesth.2010;57:849-64.
Sao2 <90% (x3)Bradypnea < 8/min (x3)Apnea ≥10 sec (x1)Pain sedation mismatch
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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 : Isn’t it about obese? OSA : Isn’t it about obese?
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.
OSA : Isn’t it about obese? OSA : Isn’t it about obese?
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.