OBSTRUCTIVE SLEEP APNEA

OBSTRUCTIVE

SLEEP APNEA

PERIOPERATIVE PREVENTIVE MEDICINE

Outline for OSA

OSA definition, diagnosis, risk factorsOSA definition, diagnosis, risk factors

Increased perioperative risks & adverse outcomesIncreased perioperative risks & adverse outcomes

Pre-operative management: OSA screening, Pre-operative management: OSA screening, estimating risk, inpatient vs. outpatient estimating risk, inpatient vs. outpatient (ambulatory suitability)(ambulatory suitability)

Intra-op & post-op managementIntra-op & post-op management

Sleep Apnea Defined

““Obstructive Sleep Apnea(OSA) is a syndrome Obstructive Sleep Apnea(OSA) is a syndrome characterized by periodic, partial, or complete characterized by periodic, partial, or complete obstruction of the upper airway during sleep.obstruction of the upper airway during sleep.”” ASA practice guidelines ASA practice guidelines for patients with OSA: Anesthesiology 2006; 1081for patients with OSA: Anesthesiology 2006; 1081

……a cessation of breathing for greater than or equal to a cessation of breathing for greater than or equal to 10 seconds despite continuing ventilatory efforts10 seconds despite continuing ventilatory efforts. . Joshi.2007Joshi.2007

Central Sleep Apnea constitutes less than 5% of sleep Central Sleep Apnea constitutes less than 5% of sleep apnea cases. Breathing repeatedly stops and starts apnea cases. Breathing repeatedly stops and starts again because your brain does not send proper signals again because your brain does not send proper signals to the muscles that control breathing…usually the to the muscles that control breathing…usually the result of heart failure and less commonly stroke result of heart failure and less commonly stroke

Pathophysiology:Occurs during REM sleep

Loss of upper airway muscle toneLoss of upper airway muscle tone

Increase pharyngeal resistanceIncrease pharyngeal resistance

Negative pharyngeal pressures during inspirationNegative pharyngeal pressures during inspiration

Upper airway collapseUpper airway collapse

Pathophysiology Cycle:After upper airway collapse

hypoxemia & hypercapnia arousal from sleephypoxemia & hypercapnia arousal from sleep

restoration of musclerestoration of muscle

tone and airflowtone and airflow

apnea/obstruction hypocapnia & loss of apnea/obstruction hypocapnia & loss of hyperventilationhyperventilation

respiratory driverespiratory drive

Symptoms of OSA

Hypersomnolence(excessive daytime sleepiness)Hypersomnolence(excessive daytime sleepiness)

Morning headachesMorning headaches

Decreased libidoDecreased libido

Irritability and inattentivenessIrritability and inattentiveness

Poor memory and depressionPoor memory and depression

Spector and Ryan.2012Spector and Ryan.2012

Diagnosis of OSASleep Study

Polysomnography(sleep study) is the gold Polysomnography(sleep study) is the gold standardstandard

Monitors to stage sleep: Monitors to stage sleep:

EEG(electoencephalogram)EEG(electoencephalogram)

EOG(electrooculogram)EOG(electrooculogram)

EMG(electromyogram)EMG(electromyogram)

Sleep Study additional monitors:

Oral and nasal airflowOral and nasal airflow

Respiratory effort (monitors thoracoabdominal motion & Respiratory effort (monitors thoracoabdominal motion & diaphragmatic EMG with pneumography) diaphragmatic EMG with pneumography)

Oximetry and capnographyOximetry and capnography

Blood pressure and ECGBlood pressure and ECG

Body PositionBody Position

SoundSoundJoshi.2007Joshi.2007

Sleep Study Other sleep disorders

NarcolepsyNarcolepsy

HypersomniaHypersomnia

Periodic limb movement disorderPeriodic limb movement disorder

REM behavior disorderREM behavior disorder

ParasomniasParasomnias

Portable home-based polysomnography versus standard PSG

Standard PSG can be costly and may have long Standard PSG can be costly and may have long waiting periodswaiting periods

Home-based sleep study--unattended portable Home-based sleep study--unattended portable monitoring, less costly and less disruptivemonitoring, less costly and less disruptive

May be a useful screening tool in the futureMay be a useful screening tool in the future

High rate of inadequate exams and High rate of inadequate exams and underestimation of sleep apnea severityunderestimation of sleep apnea severity

Adebola et al. 2010 Adebola et al. 2010

More on Home Sleep Testing(HST): AASM guidelines

HST devices cannot monitor hypoventilation HST devices cannot monitor hypoventilation and cannot detect central or “complex” sleep and cannot detect central or “complex” sleep apnea apnea

Not useful for patients with comorbid Not useful for patients with comorbid conditions such as moderate to severe conditions such as moderate to severe pulmonary disease, neuromuscular disease, or pulmonary disease, neuromuscular disease, or congestive heart failure congestive heart failure

SASM-proceedings of 2012 meetingSASM-proceedings of 2012 meeting

Defining Severity of OSA

The apnea-hypopnea index

AHI(apnea-hypopnea index) measures frequency AHI(apnea-hypopnea index) measures frequency of the apneic and hypopneic events/hour of the apneic and hypopneic events/hour

Obstructive sleep hypopnea is a greater than 30% Obstructive sleep hypopnea is a greater than 30% reduction in airflow for ≥ 10 seconds followed by reduction in airflow for ≥ 10 seconds followed by an arousal &/or 4% oxygen desaturationan arousal &/or 4% oxygen desaturation

Obstructive sleep apnea is a cessation of breathing Obstructive sleep apnea is a cessation of breathing for ≥ 10 seconds followed by an arousal &/or 4% for ≥ 10 seconds followed by an arousal &/or 4% oxygen desaturationoxygen desaturation

AHIAmerican Academy of Sleep Medicine

AHI: severity of OSA(AASM)AHI: severity of OSA(AASM)

5-15 ≈ mild OSA5-15 ≈ mild OSA

15-30 ≈ moderate OSA15-30 ≈ moderate OSA

>30 ≈ severe OSA>30 ≈ severe OSA

OSA coverage for treatment

Medicare and Medicaid

Medicare & Medicaid provides coverage for Medicare & Medicaid provides coverage for treatment of adults with OSA when:treatment of adults with OSA when:

• AHI > 15AHI > 15

• AHI > 5 with excessive daytime sleepiness, AHI > 5 with excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, impaired cognition, mood disorders, insomnia, HTN, ischemic heart disease, or history of strokeHTN, ischemic heart disease, or history of stroke

Adebola et al. 2010Adebola et al. 2010

More on AHI

“…“…the sleep laboratory’s assessment (none, the sleep laboratory’s assessment (none, mild, moderate, or severe) should take mild, moderate, or severe) should take precedence over the actual AHI.” precedence over the actual AHI.” ASA Practice Guidelines for patients ASA Practice Guidelines for patients

with OSA: Anesthesiology 2006; 1083with OSA: Anesthesiology 2006; 1083

Patients with AHI>40 have a significantly Patients with AHI>40 have a significantly higher prevalence of difficult intubation higher prevalence of difficult intubation Joshi. 2007.Joshi. 2007.

Treatment of OSA

Dental appliancesDental appliances

Surgery—Uvulopalatopharyngoplasty(UPPP)Surgery—Uvulopalatopharyngoplasty(UPPP)

CPAP & others: BiPAP≈NIPPV, APAP(auto adjusts)CPAP & others: BiPAP≈NIPPV, APAP(auto adjusts)

Weight lossWeight loss

Tracheostomy(in life-threatening cases Tracheostomy(in life-threatening cases unresponsive to other treatments)unresponsive to other treatments)

OSA Risk Factors

Old age and obesity are the strongest risk factorsOld age and obesity are the strongest risk factors

Other risk factors:Other risk factors:

• Male sexMale sex

• Excessive alcohol intakeExcessive alcohol intake

• Female menopauseFemale menopause

• Craniofacial abnormalitiesCraniofacial abnormalities


OSA Risk Factors continued

• Retrognathia (either maxilla or mandible or both Retrognathia (either maxilla or mandible or both recede with respect to the frontal plane of the recede with respect to the frontal plane of the forehead)forehead)

• MacroglossiaMacroglossia

• Wide neck circumference(>17 in. males & >16 in. Wide neck circumference(>17 in. males & >16 in. femalesfemales


OSA Predisposing Characteristics

Predisposing Characteristics of OSA Predisposing Characteristics of OSA (modified from table 3.Adebola et al.2010)(modified from table 3.Adebola et al.2010)

Patient characteristicsPatient characteristics Male; > 50 y oldMale; > 50 y old

ObesityObesity BMI > 30 kg/m2BMI > 30 kg/m2

Neck circumferenceNeck circumference > 40 cm(15.7in.) > 40 cm(15.7in.)

ENT conditionsENT conditions Septal deviation, tonsillar and Septal deviation, tonsillar and adenoidal hypertrophy, adenoidal hypertrophy, laryngomalacia, tracheomalacialaryngomalacia, tracheomalacia

Craniofacial abnormalities Craniofacial abnormalities Down syndrome, micrognathia, Down syndrome, micrognathia, achondroplasia, acromegaly, achondroplasia, acromegaly,

macroglossiamacroglossia

Pediatric OSA

Between 2 & 6 years old, behavioral disturbancesBetween 2 & 6 years old, behavioral disturbances

PSG reserved for children with obesity, trisomy 21, PSG reserved for children with obesity, trisomy 21, craniofacial abnormalities, neuromuscular craniofacial abnormalities, neuromuscular disorders, sickle cell disease & disorders, sickle cell disease & mucopolysaccharidosismucopolysaccharidosis

Adenotonsillectomy alleviates symptoms in mostAdenotonsillectomy alleviates symptoms in most

Children with significant OSA and ≥ 4yrs. old Children with significant OSA and ≥ 4yrs. old should stay overnight following adenotonsillectomyshould stay overnight following adenotonsillectomy

SASM: proceedings of 2012 meetingSASM: proceedings of 2012 meeting

What’s the prevalence of OSA among electivesurgical candidates?

A.A. 3%3%

B.B. 5%5%

C.C. 25%25%

D.D. 60%60%

E.E. 75%75%

Why do we care?

Comorbidities of OSA include heart disease (arrhythmias and Comorbidities of OSA include heart disease (arrhythmias and myocardial ischemia), hypertension, asthma, pulmonary HTN, stroke, myocardial ischemia), hypertension, asthma, pulmonary HTN, stroke, diabetesdiabetes

Prevalence of OSA is estimated to be 25% among candidates for Prevalence of OSA is estimated to be 25% among candidates for elective surgery and as high as 80% for patients undergoing bariatiric elective surgery and as high as 80% for patients undergoing bariatiric surgery. 80% OSA pts. are undiagnosed at time of surgery surgery. 80% OSA pts. are undiagnosed at time of surgery Memstoudis et al.2013Memstoudis et al.2013

OSAOSA “…likely to increase as the population becomes older and more “…likely to increase as the population becomes older and more obese.” obese.” ASA Practice Guidelines for Patients with OSA:Anesthesiology 2006ASA Practice Guidelines for Patients with OSA:Anesthesiology 2006

Increased perioperative risk for OSA patients leading to adverse Increased perioperative risk for OSA patients leading to adverse outcomesoutcomes

Increased OSA perioperative risks:

effects of anesthesia and surgeryAdministration of sedative-hypnotics, opioids, and muscle Administration of sedative-hypnotics, opioids, and muscle relaxants may result in the following:relaxants may result in the following:

1.1. Induced and worsened upper airway obstruction and apneaInduced and worsened upper airway obstruction and apnea

2.2. Decreased ventilatory response to hypoxemia and Decreased ventilatory response to hypoxemia and hypercarbia hypercarbia

3.3. Lost ability to arouse and respond adequately to asphyxia Lost ability to arouse and respond adequately to asphyxia which may be life-threateningwhich may be life-threatening

Joshi.2007Joshi.2007


effects of anesthesia and surgery

Postoperative anxiety, pain, and opioids cause Postoperative anxiety, pain, and opioids cause sleep deprivation and fragmentation reducing REM sleep deprivation and fragmentation reducing REM sleep in the immediate postoperative periodsleep in the immediate postoperative period

REM rebound (the lengthening & increasing REM rebound (the lengthening & increasing frequency & depth of REM sleep which occurs after frequency & depth of REM sleep which occurs after periods of sleep deprivation) further increasing the periods of sleep deprivation) further increasing the risk of obstruction and apnearisk of obstruction and apnea

Joshi.2007Joshi.2007


effects of anesthesia and surgery

These aforementioned postoperative sleep These aforementioned postoperative sleep disturbances, hypoxemia and apnea may disturbances, hypoxemia and apnea may contribute to myocardial ischemia and contribute to myocardial ischemia and infarction, cardiac dysrhythmias, and stroke in infarction, cardiac dysrhythmias, and stroke in at risk patientsat risk patients

Joshi.2007.Joshi.2007.

More on why we care…

Postoperative DeathDr. Benumof(an anesthesiologist) was an expert witness Dr. Benumof(an anesthesiologist) was an expert witness in > 50 OSA malpractice claims. * 70% of these claims in > 50 OSA malpractice claims. * 70% of these claims involved a postoperative OSA patient found dead in bedinvolved a postoperative OSA patient found dead in bed

He identified some common characteristics of these He identified some common characteristics of these cases stating that most/all of these cases had most/all cases stating that most/all of these cases had most/all of these characteristicsof these characteristics

*the other 30% had adverse outcomes due to intubation and/or extubation difficulties*the other 30% had adverse outcomes due to intubation and/or extubation difficulties Benumof.2010Benumof.2010

More on why we care…“Dead in bed” characteristics:

Severe OSASevere OSA

Morbidly obese Morbidly obese

Abdominal incisionAbdominal incision

On narcoticsOn narcotics

Extubated Extubated

Not on CPAPNot on CPAP

Not on oxygenNot on oxygen

UnmonitoredUnmonitored

Patient in a relatively isolated ward/roomPatient in a relatively isolated ward/room

Benumof.2010Benumof.2010

BB

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al. 2010. Table 1)

1.1. Liao et al (2009--retrospective matched Liao et al (2009--retrospective matched cohort)cohort)

• Postoperative patients from many types of Postoperative patients from many types of surgeriessurgeries

• Higher incidence of respiratory complications, Higher incidence of respiratory complications, including oxygen desaturation & prolonged Oincluding oxygen desaturation & prolonged O22 therapytherapy

• Need for additional monitoring & more ICU Need for additional monitoring & more ICU admissions in the OSA groupadmissions in the OSA group

Adverse Outcomes in Patients With Obstructive Sleep Apnea Undergoing Surgery (modified from Adebola et al. 2010.Table 1)

2.2. Hwang et al (2008—prospective case control)Hwang et al (2008—prospective case control)

• Postoperative patients from many types of surgeriesPostoperative patients from many types of surgeries

• Higher rates of respiratory, cardiovascular, Higher rates of respiratory, cardiovascular, gastrointestinal, & bleeding complicationsgastrointestinal, & bleeding complications

• Longer post-anesthesia recovery stay in the OSA Longer post-anesthesia recovery stay in the OSA groupgroup


3.3. Kaw et al (2006—retrospective case control)Kaw et al (2006—retrospective case control)

• Postoperative cardiac surgery patientsPostoperative cardiac surgery patients

• Higher rates of encephalopathy, postoperative Higher rates of encephalopathy, postoperative infections (mediastinitis)infections (mediastinitis)

• Longer ICU length of stay in the OSA groupLonger ICU length of stay in the OSA group


4.4. Gupta et al (2001—retrospective case Gupta et al (2001—retrospective case control)control)

• Postoperative orthopedic(TKR &THR) patientsPostoperative orthopedic(TKR &THR) patients

• Higher rates of unplanned ICU transfers, Higher rates of unplanned ICU transfers, cardiac events, longer hospital length of stay cardiac events, longer hospital length of stay in the OSA groupin the OSA group

More adverse outcomes

““Reviewing over six million general surgery Reviewing over six million general surgery and orthopedic procedures, Memstoudis et and orthopedic procedures, Memstoudis et al(2011) reported increased risks in OSA al(2011) reported increased risks in OSA patients of repeat intubation/mechanical patients of repeat intubation/mechanical ventilation, pneumonia, ARDS, and pulmonary ventilation, pneumonia, ARDS, and pulmonary emboli in orthopedic cases.” emboli in orthopedic cases.” Spector and Ryan. 2012.Spector and Ryan. 2012.

Preoperative assessment of OSA: Why?

““Failure to recognize (or diagnose) OSA Failure to recognize (or diagnose) OSA preoperatively is one of the major causes of preoperatively is one of the major causes of perioperative complications.” perioperative complications.” Joshi.2007Joshi.2007

Primary care doctors, sleep doctors, surgeons, and Primary care doctors, sleep doctors, surgeons, and anesthesiologists must have ready access to all anesthesiologists must have ready access to all OSA-related information in OSA patients. The best OSA-related information in OSA patients. The best way to ensure this continuity of care is to issue way to ensure this continuity of care is to issue medical alert bracelets to patients who have medical alert bracelets to patients who have severe OSA. severe OSA. Benumof. 2010Benumof. 2010

Preoperative AssessmentSTOP-BANG

Screening tool for patients that are to have Screening tool for patients that are to have elective surgeryelective surgery

Self-administered and uses only yes/no Self-administered and uses only yes/no questionsquestions

Brief, simple and requires only a 5Brief, simple and requires only a 5thth-grade -grade reading levelreading level


Preoperative Assessment of OSA: STOP BANG questionnaire

SS(nore)(nore) Have you been told you snore loud enough to be heard through Have you been told you snore loud enough to be heard through a a closed door?closed door?

TT(ired)(ired) Are you often tired or sleepy during the day?Are you often tired or sleepy during the day?

OO(bstruction)(bstruction) Do you know if you stop breathing, or has anyone witnessed Do you know if you stop breathing, or has anyone witnessed you you stop breathing while asleep?stop breathing while asleep?

PP((ressure)ressure) Do you have high blood pressure or are you on medication for Do you have high blood pressure or are you on medication for high high blood pressure?blood pressure?

High risk of OSA if yes to ≥ 2 STOP questionsHigh risk of OSA if yes to ≥ 2 STOP questions

Preoperative Assessment of OSA: STOP BANG questionnaire

BB(MI)(MI) Is your BMI > 35?Is your BMI > 35?

AA(ge)(ge) Are you 50 years or older?Are you 50 years or older?

NN(eck)(eck) Is your neck circumference greater than 17 inches?(43cm)Is your neck circumference greater than 17 inches?(43cm)

GG(ender)(ender) Are you male?Are you male?

High risk of OSA if yes to ≥ 3 for combined STOP BANGHigh risk of OSA if yes to ≥ 3 for combined STOP BANG

STOP BANG is an excellent preoperative tool to screen for OSA. STOP BANG is an excellent preoperative tool to screen for OSA.

Where does Louisiana rank in obesity among states? (BMI ≥ 30)

A.A. 22ndnd

B.B. 11st st

C.C. 55thth

D.D. 88thth

Practice Guidelines for the perioperative management of patients withOSA

ASA task force provided guidelines to help to ASA task force provided guidelines to help to reduce perioperative morbidity and mortality in reduce perioperative morbidity and mortality in OSA patientsOSA patients

In doing so made recommendations for In doing so made recommendations for preoperative evaluation and preparation, preoperative evaluation and preparation, intraoperative management, postoperative intraoperative management, postoperative management, inpatient vs. outpatient surgery and management, inpatient vs. outpatient surgery and finally criteria for discharge to unmonitored finally criteria for discharge to unmonitored settingssettings

ASA Task Force

Included anesthesiologist in both private & Included anesthesiologist in both private & academic practices from various geographic academic practices from various geographic areas of the United States, a bariatric surgeon, areas of the United States, a bariatric surgeon, an otolaryngologist, and two methodologists an otolaryngologist, and two methodologists from the American Society of from the American Society of Anesthesiologists Committee on Practice Anesthesiologists Committee on Practice ParametersParameters

Practice Guidelines

Practice guidelines are recommendations that Practice guidelines are recommendations that assist doctor and patient in decision making. assist doctor and patient in decision making.

Guidelines are NOT standards or absolute Guidelines are NOT standards or absolute requirements and use of guidelines do not requirements and use of guidelines do not guarantee specific outcomes.guarantee specific outcomes.

Preoperative evaluation recommendations:ASA Guidelines—a collaborative effort

“…“…pre-procedure identification of a patient’s OSA status pre-procedure identification of a patient’s OSA status improves perioperative outcomes…”improves perioperative outcomes…”

Anesthesiologists and surgeons should work together to Anesthesiologists and surgeons should work together to ensure that a system is in place for evaluation of ensure that a system is in place for evaluation of suspected OSA patients well before the day of surgery. suspected OSA patients well before the day of surgery.

If a targeted history and physical suggest that a patient If a targeted history and physical suggest that a patient has OSA then surgeon and anesthesiologist again has OSA then surgeon and anesthesiologist again should decide together whether or not to obtain sleep should decide together whether or not to obtain sleep studies prior to surgerystudies prior to surgery

ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1084ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1084

Is Preoperative PSG necessary?

Not with a proper management plan including Not with a proper management plan including an OSA screen to reduce risksan OSA screen to reduce risks

Recent study showed no statistically Recent study showed no statistically significant difference in postoperative significant difference in postoperative complications between the screening-only complications between the screening-only (using the ASA checklist) and (using the ASA checklist) and polysomnography-confirmed OSA groupspolysomnography-confirmed OSA groups

Chong et al. 2013Chong et al. 2013

Preoperative evaluation recommendations: ASA

GuidelinesIf sleep studies are not available or obtained If sleep studies are not available or obtained then “…some patients may be treated more then “…some patients may be treated more aggressively than would be necessary if a aggressively than would be necessary if a sleep study were available.”sleep study were available.”


Identification and Assessment of OSA: Signs &

Symptoms suggesting OSAPredisposing physical characteristics Predisposing physical characteristics

•Obesity(BMI>35)Obesity(BMI>35)

•Increased neck circumference(>17 in. in males & >16in. in females)Increased neck circumference(>17 in. in males & >16in. in females)

•Craniofacial abnormalities affecting the airwayCraniofacial abnormalities affecting the airway

•Anatomical nasal obstructionAnatomical nasal obstruction

•Large tonsils nearly touching or touching in the midlineLarge tonsils nearly touching or touching in the midline

ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083 ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083


Symptoms suggesting OSAHistory of apparent airway obstruction during sleep (≥ 2 of the following*)History of apparent airway obstruction during sleep (≥ 2 of the following*)

•Loud snoring(heard through closed doors)Loud snoring(heard through closed doors)

•Frequent snoringFrequent snoring

•Witnessed apneaWitnessed apnea

•Awakens from sleep chokingAwakens from sleep choking

•Frequent arousals from sleepFrequent arousals from sleep

•Intermittent vocalization during sleep**Intermittent vocalization during sleep**

•Parental report of restless sleep, difficulty breathing, or struggling respiratory efforts during sleep**Parental report of restless sleep, difficulty breathing, or struggling respiratory efforts during sleep**

**if patient lives alone only one or more of the following needs to be presentif patient lives alone only one or more of the following needs to be present

****pediatric patientspediatric patients

ASA Practice Guidelines for patients with OSA:Anesthesiology;1083ASA Practice Guidelines for patients with OSA:Anesthesiology;1083


Symptoms suggesting OSASomnolence(1 or more of the following)Somnolence(1 or more of the following)•Frequent somnolence or fatigue despite adequate “sleep”Frequent somnolence or fatigue despite adequate “sleep”

•Falls asleep easily in a non-stimulating environment despite Falls asleep easily in a non-stimulating environment despite adequate “sleep”adequate “sleep”

•Parent or teacher comments that child appears sleepy during the Parent or teacher comments that child appears sleepy during the day, is easily distracted, is overly aggressive, or has difficulty day, is easily distracted, is overly aggressive, or has difficulty concentrating*concentrating*

•Child often difficult to arouse at usual awakening time*Child often difficult to arouse at usual awakening time*

**pediatric populationpediatric population

ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083 ASA Practice Guidelines for the patient with OSA:Anesthesiology 2006;1083

Identification and Assessment of severity of OSAThere is a significant probability of OSA if the patient There is a significant probability of OSA if the patient

has signs or symptoms in 2 or more of the above has signs or symptoms in 2 or more of the above categoriescategories

Severity of OSA is ideally determined by a sleep studySeverity of OSA is ideally determined by a sleep study

If sleep study not available then treat as if patient has If sleep study not available then treat as if patient has moderate OSAmoderate OSA

If 1 or more of the signs or symptoms above is severely If 1 or more of the signs or symptoms above is severely abnormal then treat patient as a severe OSA patientabnormal then treat patient as a severe OSA patient


Preoperative Recommendations: Estimating risk for the OSA patient

A patient’s perioperative risk depends on the severity A patient’s perioperative risk depends on the severity of the OSA, the invasiveness of the procedure and the of the OSA, the invasiveness of the procedure and the requirement for postoperative analgesicsrequirement for postoperative analgesics

The OSA Scoring System incorporates these measures The OSA Scoring System incorporates these measures and can be used as a guide to estimate risk for the and can be used as a guide to estimate risk for the patient who presumably has OSA or has a diagnosis of patient who presumably has OSA or has a diagnosis of OSA OSA

ASA Practice Guidelines for the OSA Patient: Anesthesiology 2006;1084ASA Practice Guidelines for the OSA Patient: Anesthesiology 2006;1084

OSA Scoring System(modified from ASA Guidelines Table 2)

A.A. Severity of Sleep ApneaSeverity of Sleep Apnea(based on sleep study or clinical (based on sleep study or clinical indicators)indicators)

NoneNone 00

MildMild 11

ModerateModerate 22

SevereSevere 33ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083


B. Invasiveness of surgery and anesthesiaB. Invasiveness of surgery and anesthesia

Superficial surgery under local or peripheral nerve block Superficial surgery under local or peripheral nerve block anesthesia without sedation(0 points)anesthesia without sedation(0 points)

Superficial surgery with moderate sedation or general Superficial surgery with moderate sedation or general anesthesia(1 point)anesthesia(1 point)

Peripheral Surgery with spinal or epidural anesthesia(with no Peripheral Surgery with spinal or epidural anesthesia(with no more than moderate sedation) (1point) more than moderate sedation) (1point)

ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083


B. Invasiveness of surgery and anesthesiaB. Invasiveness of surgery and anesthesia

Peripheral surgery with general anesthesia Peripheral surgery with general anesthesia (2 (2 points)points)

Airway surgery with moderate sedation(2 Airway surgery with moderate sedation(2 points)points)

Major surgery, general anesthesia(3 points)Major surgery, general anesthesia(3 points)

Airway surgery, general anesthesia(3 points)Airway surgery, general anesthesia(3 points)ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083


C. Requirement for postoperative opioidsC. Requirement for postoperative opioids

NoneNone 00

Low-dose oral opioidsLow-dose oral opioids 11

High-dose oral opioids,High-dose oral opioids, 33

parenteral or neuraxial parenteral or neuraxial

opioidsopioidsASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083ASA Practice Guidelines for the OSA patient:Anesthesiology2006;1083

OSA Scoring System:D. Estimation of perioperative risk(modified from ASA Guidelines Table 2)

Overall score Overall score = score for A= score for A(severity) (severity) plus the plus the greater of the score for either Bgreater of the score for either B(invasiveness) (invasiveness) or Cor C(opioid (opioid requirement)requirement). Point score is 0 to 6.. Point score is 0 to 6.

One point may be subtracted if a patient has been One point may be subtracted if a patient has been on CPAP or NIPPV before surgery and will be using on CPAP or NIPPV before surgery and will be using the appliance consistently in the perioperative the appliance consistently in the perioperative periodperiod

One point should be added if a patient with mild or One point should be added if a patient with mild or moderate OSA has a resting Pamoderate OSA has a resting PaCOCO2 2 > 50 mmHg> 50 mmHg


OSA Scoring System:D. Estimation of perioperative risk(modified from ASA Guidelines Table 2)

Patients with a score of 4 may be at increased Patients with a score of 4 may be at increased perioperative risk and patients with scores of perioperative risk and patients with scores of 5 or 6 may be at a significantly increased 5 or 6 may be at a significantly increased perioperative risk from OSAperioperative risk from OSA


OSA check in

So now we have So now we have identifiedidentified OSA(STOP BANG OSA(STOP BANG & ASA Table 1), & ASA Table 1), assessed severity assessed severity of of OSA(sleep study with AASM AHI or ASA Table OSA(sleep study with AASM AHI or ASA Table 1) and 1) and estimated perioperative risk estimated perioperative risk (ASA’s (ASA’s OSA Scoring-Table 2)OSA Scoring-Table 2)

Before we go on to preoperative preparation a Before we go on to preoperative preparation a decision must be made on whether or not the decision must be made on whether or not the patient is a candidate(if type of surgery patient is a candidate(if type of surgery allows)for ambulatory surgery allows)for ambulatory surgery

Inpatient vs. Outpatient Surgery for OSA

patients-- ASA Task Force recommends considering:

1.1. Sleep apnea statusSleep apnea status

2.2. Anatomical and physiological abnormalitiesAnatomical and physiological abnormalities

3.3. Status of coexisting diseasesStatus of coexisting diseases

4.4. Nature of surgeryNature of surgery

5.5. Type of anesthesiaType of anesthesia

6.6. Need for postoperative opioidsNeed for postoperative opioids

7.7. Patient agePatient age

8.8. Adequacy of post-discharge observationAdequacy of post-discharge observation

9.9. Capabilities of the outpatient facilityCapabilities of the outpatient facility

ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087 ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087

Inpatient vs. Outpatient Surgery for OSA patients

““The availability of emergency airway equipment, The availability of emergency airway equipment, respiratory care equipment, radiology facilities, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer clinical laboratory facilities, and a transfer agreement with an inpatient facility should be agreement with an inpatient facility should be considered…”considered…”

ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087 ASA Practice Guidelines for the OSA patient: Anesthesiology 2006;1087

Inpatient vs. Outpatient Surgery for OSA patients

Consultant opinions regarding procedures that Consultant opinions regarding procedures that may be performed safely on an outpatient may be performed safely on an outpatient basis for patients at increased risk from OSAbasis for patients at increased risk from OSA

Table 3 in the ASA Practice guidelines for the Table 3 in the ASA Practice guidelines for the OSA patient modified on the following slidesOSA patient modified on the following slides

Consultants agree…

Superficial surgery/local or regional anesthesiaSuperficial surgery/local or regional anesthesia

Minor orthopedic surgery/local or regional Minor orthopedic surgery/local or regional anesthesiaanesthesia

LithotripsyLithotripsy

ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087 ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

Consultants disagree…

Airway surgery(e.g.,UPPP)Airway surgery(e.g.,UPPP)

Tonsillectomy in children less than 3 years oldTonsillectomy in children less than 3 years old

Laparoscopic surgery, upper abdomenLaparoscopic surgery, upper abdomen


Consultants are equivocal…

Superficial surgery/general anesthesiaSuperficial surgery/general anesthesia

Tonsillectomy in children greater than 3 years Tonsillectomy in children greater than 3 years oldold

Minor orthopedic surgery/general anesthesiaMinor orthopedic surgery/general anesthesia

Gynecologic LaparoscopyGynecologic Laparoscopy


Inpatient vs. OutpatientUpdate: Society for Ambulatory Anesthesia Task Force on Practice Guidelines

Developed a consensus statement addressing this Developed a consensus statement addressing this controversial issue as new evidence is availablecontroversial issue as new evidence is available

Patients with a known diagnosis of OSA and optimized Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a CPAP ambulatory surgery, if they are able to use a CPAP device in the postoperative period.device in the postoperative period.

Patients with a presumed diagnosis of OSA with Patients with a presumed diagnosis of OSA with optimized comorbidities can be considered for optimized comorbidities can be considered for ambulatory surgery, if postoperative pain can be ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid techniquesmanaged predominantly with nonopioid techniques

Joshi et al.2012Joshi et al.2012

Inpatient vs. OutpatientUpdate: Society for Ambulatory Anesthesia Task Force on Practice Guidelines

OSA patients with nonoptimized comorbid OSA patients with nonoptimized comorbid conditions may not be good candidatesconditions may not be good candidates

Recommend use of STOP-BANG for OSA screenRecommend use of STOP-BANG for OSA screen

Current literature does not support the ASA recs. Current literature does not support the ASA recs. that upper abdominal procedures (on OSA that upper abdominal procedures (on OSA patients) are not appropriate for ambulatory patients) are not appropriate for ambulatory surgerysurgery

Joshi et al.2012Joshi et al.2012

What country has the most obese population?

A.A. NauruNauru

B.B. MexicoMexico

C.C. USAUSA

D.D. AustraliaAustralia

OSA check inagain

So now we have So now we have identifiedidentified OSA(STOP BANG & ASA OSA(STOP BANG & ASA Table 1), Table 1), assessed severity assessed severity of OSA(sleep study of OSA(sleep study with AASM AHI or ASA Table 1) and with AASM AHI or ASA Table 1) and estimated estimated perioperative risk perioperative risk (ASA’s OSA Scoring-Table 2)(ASA’s OSA Scoring-Table 2)

And we have made an educated decision(Table 3-And we have made an educated decision(Table 3-Consultant opinion. ASA Guidelines &/or SAMBA Consultant opinion. ASA Guidelines &/or SAMBA task force consensus statement) as to whether or task force consensus statement) as to whether or not the OSA patient is a candidate for ambulatory not the OSA patient is a candidate for ambulatory surgerysurgery

Now we can move on to preoperative preparation Now we can move on to preoperative preparation

Preoperative Preparation recommendations: ASA

GuidelinesConsider pre-op initiation of CPAP/NIPPV(Non-invasive positive pressure Consider pre-op initiation of CPAP/NIPPV(Non-invasive positive pressure ventilation)ventilation)

Consider having the patient use mandibular advancement devices or oral Consider having the patient use mandibular advancement devices or oral appliancesappliances

Preoperative weight loss if feasiblePreoperative weight loss if feasible

A patient who has had corrective airway surgery remains at risk for OSA A patient who has had corrective airway surgery remains at risk for OSA complications until a normalized sleep study is obtained and symptoms complications until a normalized sleep study is obtained and symptoms resolveresolve

Consider difficult airway probability Consider difficult airway probability

ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Preoperative PreparationBenefits of CPAP use

““Gupta et al found that patients who were using CPAP Gupta et al found that patients who were using CPAP preoperatively had a lower incidence of postoperative preoperatively had a lower incidence of postoperative complications and shorter hospital length of stay when complications and shorter hospital length of stay when compared with those who were not on CPAP.”compared with those who were not on CPAP.”

This “carryover protection” may be explained by This “carryover protection” may be explained by decreased inflammation and/or edema of the upper decreased inflammation and/or edema of the upper airway, decrease tongue size, and increased upper airway, decrease tongue size, and increased upper airway volume and stabilityairway volume and stability

Adebola et al. 2010 .Adebola et al. 2010 .

Intraoperative Management: ASA Guideline Recommendations

Consider the potential for postoperative respiratory Consider the potential for postoperative respiratory compromise when selecting intraoperative medicationscompromise when selecting intraoperative medications

Consider use of local anesthesia or peripheral nerve Consider use of local anesthesia or peripheral nerve blocks(with or without moderate sedation)blocks(with or without moderate sedation)

Continuously monitor ventilation with capnography if Continuously monitor ventilation with capnography if moderate sedation is usedmoderate sedation is used

Consider CPAP or dental appliance use on patients treated Consider CPAP or dental appliance use on patients treated with these devices preoperativelywith these devices preoperatively


Intraoperative Management: ASA Guideline Recommendations

General anesthesia with a secure airway is safer General anesthesia with a secure airway is safer than deep sedationthan deep sedation

Consider spinal or epidural anesthesiaConsider spinal or epidural anesthesia

Proceed with extubation after patient is awake and Proceed with extubation after patient is awake and has full reversal of neuromuscular blockadehas full reversal of neuromuscular blockade

Lateral and semi-upright positions(not supine) for Lateral and semi-upright positions(not supine) for extubation and recovery extubation and recovery


Intraoperative Management

Regional anesthesia benefits

““Regional anesthesia obviates the need for Regional anesthesia obviates the need for airway manipulation and reduces the need for airway manipulation and reduces the need for intraoperative sedatives and opioids…these intraoperative sedatives and opioids…these techniques provide postoperative analgesia, techniques provide postoperative analgesia, and reduce postoperative opioid and reduce postoperative opioid requirements.” requirements.” Joshi.2007Joshi.2007

Intraoperative ManagementPreoxygenation with CPAP

CPAP acts as a pneumatic splint to keep the CPAP acts as a pneumatic splint to keep the airway openairway open

Preoxygenation with 100% oxygen and CPAP Preoxygenation with 100% oxygen and CPAP at 10cm Hat 10cm H22O is a good recommendationO is a good recommendation


Postoperative management

Patients with OSA have post-op complications more frequentlyPatients with OSA have post-op complications more frequently

Common post-op complications:Common post-op complications:

• Airway obstructionAirway obstruction

• Oxygen desaturationOxygen desaturation

• ReintubationReintubation

• Systemic hypertensionSystemic hypertension

• Cardiac dysrhythmias Cardiac dysrhythmias

• Admission to ICUAdmission to ICU

Joshi.2007.Joshi.2007.

Postoperative managementRespiratory depression

Postoperative respiratory depression risk factors:Postoperative respiratory depression risk factors:

• Systemic and neuraxial administration of opioidsSystemic and neuraxial administration of opioids

• Administration of sedativesAdministration of sedatives

• Site and invasiveness of surgical procedureSite and invasiveness of surgical procedure

• Underlying severity of sleep apneaUnderlying severity of sleep apneaASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

Postoperative managementRespiratory depression

““REM rebound” occurs on the third or fourth REM rebound” occurs on the third or fourth post-operative day as sleep patterns are re-post-operative day as sleep patterns are re-established exacerbating respiratory established exacerbating respiratory depression depression ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1085

REM rebound(the lengthening & increasing REM rebound(the lengthening & increasing frequency & depth of REM sleep which occurs frequency & depth of REM sleep which occurs after periods of sleep deprivation) further after periods of sleep deprivation) further increasing the risk of obstruction and apnea increasing the risk of obstruction and apnea

Postoperative ManagementASA Guideline recommendationsPostoperative Pain

Consider regional analgesic techniques to reduce or Consider regional analgesic techniques to reduce or eliminate requirement for systemic opioidseliminate requirement for systemic opioids

Neuraxial analgesia benefits are improved analgesia Neuraxial analgesia benefits are improved analgesia and decreased need for systemic opioidsand decreased need for systemic opioids

Neuraxial analgesia risk is rostral spread causing Neuraxial analgesia risk is rostral spread causing respiratory depressionrespiratory depression

Consider these in choosing an opioid, opioid-local Consider these in choosing an opioid, opioid-local mixture or local anesthetic alonemixture or local anesthetic alone


Postoperative ManagementASA Guideline recommendationsPostoperative pain

Continuous background infusions with patient Continuous background infusions with patient controlled systemic opioids(PCA) should be used with controlled systemic opioids(PCA) should be used with extreme caution or avoidedextreme caution or avoided

To reduce opioid requirement consider NSAIDS and To reduce opioid requirement consider NSAIDS and other modalities(e.g., ice, transcutaneous electrical other modalities(e.g., ice, transcutaneous electrical nerve stimulation) nerve stimulation)

Be aware of the increased risk of respiratory depression Be aware of the increased risk of respiratory depression and airway obstruction with concurrent use of and airway obstruction with concurrent use of sedatives(e.g.,benzodiazepines, barbiturates)sedatives(e.g.,benzodiazepines, barbiturates)


Postoperative ManagementOpioid requirement…good news!

““Brown et al found that total analgesic opiate Brown et al found that total analgesic opiate dose in patients with OSA and recurrent dose in patients with OSA and recurrent hypoxemia was half that required in patients hypoxemia was half that required in patients without such a history and attributed this without such a history and attributed this finding to upregulation of central opioid finding to upregulation of central opioid receptors due to recurrent hypoxemia.” receptors due to recurrent hypoxemia.” Adebola et al. 2010 Adebola et al. 2010

Postoperative ManagementASA Guideline recommendations

““Supplemental oxygen should be administered continuously to all Supplemental oxygen should be administered continuously to all patients who are at increased perioperative risk from OSA until they patients who are at increased perioperative risk from OSA until they are able to maintain their baseline oxygen saturation while breathing are able to maintain their baseline oxygen saturation while breathing room air.”room air.”

Supplemental OSupplemental O22 should be used with caution as it may reduce should be used with caution as it may reduce hypoxic respiratory drive. Treat recurrent hypoxemia with CPAP & hypoxic respiratory drive. Treat recurrent hypoxemia with CPAP & oxygen. oxygen. Joshi 2006.Joshi 2006.

““The task force cautions that supplemental oxygen may increase the The task force cautions that supplemental oxygen may increase the duration of apneic episodes and may hinder detections of atelectasis, duration of apneic episodes and may hinder detections of atelectasis, transient apnea, and hypoventilation by pulse oximetry.”transient apnea, and hypoventilation by pulse oximetry.”


Postoperative ManagementCPAP -- ASA Guideline recommendations

Unless contraindicated by the surgical procedure Unless contraindicated by the surgical procedure continuous use of CPAP or NIPPV should be used by continuous use of CPAP or NIPPV should be used by patients who were using these devices preoperativelypatients who were using these devices preoperatively

Patients should bring their own equipment(CPAP/NIPPV) Patients should bring their own equipment(CPAP/NIPPV) to the hospital to improve complianceto the hospital to improve compliance

Consider postoperative initiation of CPAP or NIPPV for Consider postoperative initiation of CPAP or NIPPV for frequent or severe airway obstruction and hypoxemiafrequent or severe airway obstruction and hypoxemia

ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086-1087. ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1086-1087.

Postoperative ManagementCPAP

““Prophylactic CPAP for 24-48 h after extubation Prophylactic CPAP for 24-48 h after extubation have been reported to reduce major complications have been reported to reduce major complications despite unrestricted opioid use.”despite unrestricted opioid use.”Joshi.2007Joshi.2007

““Another study showed that the rate of Another study showed that the rate of postoperative CPAP use was relatively low (58%-postoperative CPAP use was relatively low (58%-63%) even in patients on established home CPAP, 63%) even in patients on established home CPAP, reflecting a lack of hospital policy guiding the reflecting a lack of hospital policy guiding the consistent use of CPAP…” consistent use of CPAP…” Adebola et al. 2010 Adebola et al. 2010

Postoperative ManagementASA Guideline recommendations

OSA patients should be placed in nonsupine positions OSA patients should be placed in nonsupine positions throughout the entire recovery periodthroughout the entire recovery period

Continuous pulse oximetry and monitoring should follow Continuous pulse oximetry and monitoring should follow the OSA patient from the recovery room(PACU) to the next the OSA patient from the recovery room(PACU) to the next level of care in the hospital. An appropriately trained level of care in the hospital. An appropriately trained professional observer in the patients room should be used professional observer in the patients room should be used to monitor if patient is not in a telemetry or critical care to monitor if patient is not in a telemetry or critical care areaarea

““Intermittent pulse oximetry or continuous bedside Intermittent pulse oximetry or continuous bedside oximetry without continuous observation does not provide oximetry without continuous observation does not provide the same level of safety.” the same level of safety.”


Postoperative ManagementDischarge from PACU with or without continuous pulse oximetry and monitoring

Patients that exhibit respiratory events such Patients that exhibit respiratory events such as apnea, bradypnea, desaturations, and pain-as apnea, bradypnea, desaturations, and pain-sedation mismatch in PACU(recovery room) sedation mismatch in PACU(recovery room) should be admitted to a monitored bed with should be admitted to a monitored bed with continuous oxygen saturation monitoring continuous oxygen saturation monitoring


Postoperative ManagementASA Guideline recommendations Criteria for discharge to unmonitored settings

The most significant postoperative complications in OSA patients The most significant postoperative complications in OSA patients usually occur within 2 hours after surgery usually occur within 2 hours after surgery Joshi.2007.Joshi.2007.

OSA patients should be monitored for a median of 3 hours longer OSA patients should be monitored for a median of 3 hours longer than their non-OSA counterparts before discharge from the than their non-OSA counterparts before discharge from the facility facility ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087

OSA patients should continue to be monitored for a median of 7 OSA patients should continue to be monitored for a median of 7 hours after the last episode of obstruction or hypoxemia while hours after the last episode of obstruction or hypoxemia while breathing room air in an unstimulating environment breathing room air in an unstimulating environment ASA Practice Guidelines for ASA Practice Guidelines for the OSA patient:Anesthesiology 2006;1087the OSA patient:Anesthesiology 2006;1087

These recommendations may play a part in deciding suitability These recommendations may play a part in deciding suitability for ambulatory surgery, especially in a free standing ASCfor ambulatory surgery, especially in a free standing ASC

Postoperative managementDischarge Instructions

Continued use of CPAP at home should be Continued use of CPAP at home should be included in post-discharge instructions for included in post-discharge instructions for patients who use CPAP preoperatively patients who use CPAP preoperatively Joshi. 2007.Joshi. 2007.

Remember the rebound!Remember the rebound!

What perioperative protocol system do we use here for OSA patients?

A.A. Stop-BangStop-Bang

B.B. ASA GuidelinesASA Guidelines

C.C. Gambit’s best of N.O.Gambit’s best of N.O.

D.D. NoneNone

Summary OSA

OSA definition, diagnosis, risk factorsOSA definition, diagnosis, risk factors

Increased perioperative risks & adverse Increased perioperative risks & adverse outcomesoutcomes

Pre-operative management: OSA screening, Pre-operative management: OSA screening, estimating risk, inpatient vs. estimating risk, inpatient vs. outpatient(ambulatory suitability)outpatient(ambulatory suitability)

Intra-op & post-op managementIntra-op & post-op management

Bibliography:

1.1. Practice Guidelines for the Perioperative Management of Patients Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. with Obstructive Sleep Apnea. AnesthesiologyAnesthesiology. 2006; 104:1081-. 2006; 104:1081-10931093

2.2. Joshi G., MD. The Patient with Sleep Apnea for Ambulatory Joshi G., MD. The Patient with Sleep Apnea for Ambulatory Surgery. Surgery. ASA Refresher Courses in AnesthesiologyASA Refresher Courses in Anesthesiology. 2007; . 2007; 35(1):97-10635(1):97-106

3.3. Spector R.,MD and Ryan R. Obstructive Sleep Apnea for All Spector R.,MD and Ryan R. Obstructive Sleep Apnea for All Specialties: Reducing Perioperative Risk. A CME Monograph. Specialties: Reducing Perioperative Risk. A CME Monograph. 2011.2011.

4.4. Adebola A., MD, FCCP; Lee W, MD; Greilich N., MD; Joshi G., MD. Adebola A., MD, FCCP; Lee W, MD; Greilich N., MD; Joshi G., MD. Perioperative Management of Obstructive Sleep ApneaPerioperative Management of Obstructive Sleep Apnea. . CHESTCHEST. 2010;138(6):1489-1498.. 2010;138(6):1489-1498.

Bibliography:5.5. Joshi G.,MD, Ankichetty S.,MD, Gan T.,MD, Chung F. Society for Ambulatory Anesthesia Consensus Joshi G.,MD, Ankichetty S.,MD, Gan T.,MD, Chung F. Society for Ambulatory Anesthesia Consensus

Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery. Ambulatory Surgery. Anesthesia & AnalgesiaAnesthesia & Analgesia. 2012. 2012

6.6. Memstoudis S, Liu SS, Ma Y, Chiu YL., Walz JM,Gaber-Baylis LK, Mazumdar M, Perioperative Memstoudis S, Liu SS, Ma Y, Chiu YL., Walz JM,Gaber-Baylis LK, Mazumdar M, Perioperative Outcomes in Patients with Sleep Apnea after Noncardiac Surgery. Outcomes in Patients with Sleep Apnea after Noncardiac Surgery. Anesth. Analg.Anesth. Analg. 2011;112:113-121 2011;112:113-121

7.7. Benumof JL. Summary of the prototypical OSA malpractice law case. Paper presented at: Challenges Benumof JL. Summary of the prototypical OSA malpractice law case. Paper presented at: Challenges in the perioperative management of OSA patients symposium;October 15,2010;San Diego, CA.in the perioperative management of OSA patients symposium;October 15,2010;San Diego, CA.

8.8. Gupta RM, Parvizi J, Hanssen AD, Gay PC; Postoperative complications in patients with Gupta RM, Parvizi J, Hanssen AD, Gay PC; Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study, Mayo obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study, Mayo Clin Proc 2001 769 897-905 Clin Proc 2001 769 897-905

9.9. Brown KA, Laferrière A, Lakheeram I, Moss IR; Recurrent hypoxemia in children is associated with Brown KA, Laferrière A, Lakheeram I, Moss IR; Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates, Anesthesiology 2006 1054 665-669increased analgesic sensitivity to opiates, Anesthesiology 2006 1054 665-669

Bibliography:

10. Hwang D, Shakir N, Limann B; et al. Association of sleep- disordered 10. Hwang D, Shakir N, Limann B; et al. Association of sleep- disordered breathing with postoperative complications, Chest 2008 1335 1128-1134breathing with postoperative complications, Chest 2008 1335 1128-1134

11. Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N, Walker E; 11. Kaw R, Golish J, Ghamande S, Burgess R, Foldvary N, Walker E; Incremental risk of obstructive sleep apnea on cardiac surgical outcomes, J Incremental risk of obstructive sleep apnea on cardiac surgical outcomes, J Cardiovasc Surg (TorinoCardiovasc Surg (Torino) 2006 476 683-689) 2006 476 683-689

12. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F; 12. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F; Postoperative complications in patients with obstructive sleep apnea: a Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study,retrospective matched cohort study, Can J Anaesth Can J Anaesth 2009 5611 819-828 2009 5611 819-828

13. Chong C, Tey J, Leow S; et al. Management Plan to Reduce Risks in 13. Chong C, Tey J, Leow S; et al. Management Plan to Reduce Risks in Periopeerative Care of Patients with Obstructive Sleep Apnoea Averts the Periopeerative Care of Patients with Obstructive Sleep Apnoea Averts the Need for Presurgical Polysomnography, Need for Presurgical Polysomnography, Ann Acad of Med Singapore Ann Acad of Med Singapore 2013;42:110-92013;42:110-9

Bibliography:

14. Society of anesthesia and sleep medicine: 14. Society of anesthesia and sleep medicine: proceedings of 2012 meeting.proceedings of 2012 meeting.

15. Memstoudis S., Besculides M., Mazumdar M. 15. Memstoudis S., Besculides M., Mazumdar M. et. al. A Rude Awakening—The Perioperative et. al. A Rude Awakening—The Perioperative Sleep Apnea Epidemic, Sleep Apnea Epidemic, NEJMNEJM 2013; 368;25:2352- 2013; 368;25:2352-2353.2353.

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OBSTRUCTIVE SLEEP APNEA