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Page 1: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep ApneaMaki Morimoto, MDMaki Morimoto, MD

Page 2: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea

Sleep apnea is a potentially serious sleep Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly disorder in which breathing repeatedly stops during sleep.stops during sleep.

There are There are threethree types of sleep apnea types of sleep apnea

1.) 1.) Obstructive sleep apneaObstructive sleep apnea, which occurs , which occurs when your throat muscles intermittently when your throat muscles intermittently relax and block the airway during sleep.relax and block the airway during sleep.2.) 2.) CentralCentral, which is a neurological disorder, which is a neurological disorder3.) 3.) MixedMixed

Page 3: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep ApneaObstructive Sleep Apnea

most common form of sleep apnea

12 million people are affected

1 in 25 middle aged male

1 in 50 middle aged female

Only 50% are obese

Males > Females

Older > Younger

African American, Hispanics and Pacific Islanders

Only 20% is diagnosed(Helder et al - BMJ. 2004 Oct 23; 329(7472): 955–959)

Page 4: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea

(New York Times – May 14, 2009)

Which patient has OSA?

1.Harley – 53 yo male2.Ursula – 54 yo female3.Burton – 66 yo male4.Helju – 37 yo female5.Eric – 53 yo male6.Lionel – 39 yo male

Answer:

Page 5: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea

How do we diagnose OSA?How do we diagnose OSA?

Why do we need to know if the patients Why do we need to know if the patients have/do not have OSA?have/do not have OSA?

What can happen to the patients with What can happen to the patients with OSA?OSA?

How do we care for these patients?How do we care for these patients?

What should be monitored?What should be monitored?

Can we send these patients home?Can we send these patients home?

Page 6: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea - Sleep Apnea - DiagnosisDiagnosis

STOP-BANGSTOP-BANG Score Score

- Do you - Do you SSnore?nore?- Do you feel - Do you feel TTired?ired?- Has anyone - Has anyone OObserved you with apnea?bserved you with apnea?- Do you have high blood - Do you have high blood PPressure?ressure?

- - BBMI more than 35kg/m2?MI more than 35kg/m2?- - AAge over 50 years old?ge over 50 years old?- - NNeck circumference > 16 inches (40cm)?eck circumference > 16 inches (40cm)?- - GGender: Male?ender: Male?

Score: 5-8 (High), 3-4 (Mid), 0-2 (Low)Score: 5-8 (High), 3-4 (Mid), 0-2 (Low)

88% sensitivity of identifying severe OSA88% sensitivity of identifying severe OSA(F. Chung et al.)(F. Chung et al.)

Obes Surg. 2013 Dec;23(12):2050-7.

Page 7: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea - Sleep Apnea - DiagnosisDiagnosis

For the definitive diagnosis, the patients must For the definitive diagnosis, the patients must do a sleep study (Polysomnogram)do a sleep study (Polysomnogram)

The followings are recorded during the study:The followings are recorded during the study:

brain activitybrain activityeye movementseye movementsheart rateheart rateblood pressureblood pressurethe amount of oxygen in your bloodthe amount of oxygen in your bloodair movement through your noseair movement through your nosesnoringsnoringchest movementschest movements

Page 8: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and surgerysurgery

Why is important to know if the patient has Why is important to know if the patient has OSA?OSA?

- Patients are at a increased risk from - Patients are at a increased risk from anesthesia and sedationanesthesia and sedation

- Higher rate of cardiopulmonary and - Higher rate of cardiopulmonary and respiratory complicationsrespiratory complications

- Higher likelihood of “difficult” intubation- Higher likelihood of “difficult” intubation

- Higher rate of death (e.g. twofold for - Higher rate of death (e.g. twofold for hip/knee surgeries)!hip/knee surgeries)!

Page 9: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep apnea and Sleep apnea and SurgerySurgery

““A woman dies after a routine knee A woman dies after a routine knee surgery” – Boston, 2013surgery” – Boston, 2013

“ “A patient dies after a shoulder surgery” – A patient dies after a shoulder surgery” – unknown location, 2007unknown location, 2007

““48 years old female patient dies after an 48 years old female patient dies after an eye surgery” – Texas, 2008eye surgery” – Texas, 2008

Page 10: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Common factors:Common factors:

- Patients had obstructive sleep apnea- Patients had obstructive sleep apnea

- Had received general anesthesia- Had received general anesthesia

- Received opioid medications for pain- Received opioid medications for pain

- Were not monitored- Were not monitored

Page 11: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

In 2014, Center for Medicare and Medicaid Services In 2014, Center for Medicare and Medicaid Services (CMS) issued a statement:(CMS) issued a statement:

“Each year, serious adverse events, including “Each year, serious adverse events, including fatalities, associated with the use of IV opioid fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient respiratory depression has resulted in patient deaths that might have been prevented with deaths that might have been prevented with appropriate risk assessment for adverse events as appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in Hospital patients on IV opioids may be placed in units where vital signs and other monitoring units where vital signs and other monitoring typically is not performed as frequently as in post-typically is not performed as frequently as in post-anesthesia recovery or intensive care units, anesthesia recovery or intensive care units, increasing the risk that patients may develop increasing the risk that patients may develop respiratory compromise that is not immediately respiratory compromise that is not immediately recognized and treated.”recognized and treated.”

Page 12: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

In 2014, American Society of Anesthesiologists In 2014, American Society of Anesthesiologists (ASA) issued a practice guideline for OSA (ASA) issued a practice guideline for OSA patientspatients

Anesthesiology. 2014 Feb;120(2):268-86.Anesthesiology. 2014 Feb;120(2):268-86.

Page 13: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Pre-operative evaluation:Pre-operative evaluation:

- Protocol should be developed- Protocol should be developed- Patient should be seen before the day of - Patient should be seen before the day of the surgerythe surgery- Evaluation should be comprehensive- Evaluation should be comprehensive- Sleep Study is encouraged, if suspected - Sleep Study is encouraged, if suspected of OSAof OSA- Clinical criteria should be inclusive- Clinical criteria should be inclusive- Establish scoring system for peri-- Establish scoring system for peri-operatative risk from OSAoperatative risk from OSA- Inform the patient of the risks- Inform the patient of the risks

Page 14: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea

Page 15: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Pre-operative preparation (surgical day)Pre-operative preparation (surgical day)

- Initiation of CPAP should be considered- Initiation of CPAP should be considered- Use of mandibular advancement should - Use of mandibular advancement should be consideredbe considered- Weight loss should be encouraged- Weight loss should be encouraged- A Patient who has had corrective surgery - A Patient who has had corrective surgery should still be assumed to remain at risk should still be assumed to remain at risk unless a normal sleep study has been unless a normal sleep study has been documented documented - Difficult airway may be suspected- Difficult airway may be suspected

Page 16: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Intraoperative managementIntraoperative management

- Because of their propensity for airway - Because of their propensity for airway collapse, they are especially susceptible to the collapse, they are especially susceptible to the respiratory effects of sedatives, opioids, and respiratory effects of sedatives, opioids, and inhalational anestheticsinhalational anesthetics- Consider local, regional, or neuraxial - Consider local, regional, or neuraxial anesthesia techniques, if possibleanesthesia techniques, if possible- Should be monitored by capnography- Should be monitored by capnography- Consider using CPAP or other devices- Consider using CPAP or other devices- General anesthesia with endotracheal tube is - General anesthesia with endotracheal tube is preferred over deep sedationpreferred over deep sedation- Extubate while awake- Extubate while awake- Full reversal should be documented- Full reversal should be documented- If possible, extubate in non-supine position- If possible, extubate in non-supine position

Page 17: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Post-operative ManagementPost-operative Management

- Try to avoid systemic opioid use- Try to avoid systemic opioid use- If PCA is to be used, avoid basal rate- If PCA is to be used, avoid basal rate- Multi-modal pain management is - Multi-modal pain management is encouragedencouraged- Be careful with sedative medications- Be careful with sedative medications- Supplemental oxygen should be - Supplemental oxygen should be administeredadministered- Encourage CPAP use- Encourage CPAP use- Continuous pulse oximeter use- Continuous pulse oximeter use

Page 18: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep Apnea and Sleep Apnea and SurgerySurgery

Criteria for discharge to unmonitored Criteria for discharge to unmonitored settings:settings:

- Once they are no longer at risk of - Once they are no longer at risk of postoperative respiratory depressionpostoperative respiratory depression- May take twice as long for discharge- May take twice as long for discharge- Observe patients in an unstimulating - Observe patients in an unstimulating environment, preferably while a sleep, to environment, preferably while a sleep, to assess adequate oxygen saturation levels assess adequate oxygen saturation levels with room airwith room air

Page 19: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea-Lifestyle modifications (e.g. weight loss and regular sleep)

-Avoid alcohol and certain medications

-Special pillows/beds

-Mandibular advancement devices (e.g. dental gum and mouth guard)

-Mechanical therapy (e.g. CPAP and BiPAP)

-Surgery (e.g. Stimulator implants, UPPP and tonsillectomy)

Page 20: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

Sleep ApneaSleep Apnea

How do we diagnose OSA?How do we diagnose OSA?

Why do we need to know if the patients Why do we need to know if the patients have/do not have OSA?have/do not have OSA?

What can happen to the patients with What can happen to the patients with OSA?OSA?

How do we care for these patients?How do we care for these patients?

What should be monitored?What should be monitored?

Can we send these patients home?Can we send these patients home?

Page 21: Sleep Apnea Maki Morimoto, MD. Sleep Apnea  Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep.  There

The EndThe End