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10/9/18
1
PerioperativeUpperAirwayConsiderationsinPediatricObstructiveSleepApnea
KimmoMurto MD,FRCPC
DepartmentofAnesthesiology&PainMedicine,CHEOAssociateProfessor,UniversityofOttawa,FacultyofMedicine
Email:[email protected]
ConflictofInterest
• Nonetodeclare
OBJECTIVESAttheendofthissessionaudiencememberswillbeableto:
• UnderstandhowOSArelatedupperairwaystructure,functionandrelatedpathophysiologyimpactanestheticmanagementinchildren.
• ListkeylimitationsofpublishedpediatricOSAassociatedmanagementguidelines.
• Appreciatearoleforanti-inflammatoryagentstomodulate perioperativerespiratoryadverseevents(PRAEs)inchildrenwithOSA.
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PerioperativeCare&Anesthesiology
PreoperativeOptimization
PostoperativeRecovery:DaycareorIn-patient
LAI=LocalAnestheticInfiltration;PNB=peripheralnerveBlock
Sedation&LAI
RegionalAnesthesia:NeuroaxialorPNB
Ketamine GeneralAnesthesia
&LAI
General&Regional
Anesthesia
IntraoperativeCare:Anxiolysis
UnconsciousAmnesiaAnalgesia
MuscleRelaxation“OSA:RiskStratification&Diagnosis” “Monitoring”&
“Analgesia”
AnxiolysisUnconsciousAnalgesia
MuscleRelaxation
Murto K.Anesth Analg 2018
ObstructiveSleepDisorderedBreathing(SDB)
• “Asyndromeofupperairwaydysfunctionduringsleepcharacterizedbysnoringand/orincreasedrespiratoryeffortthatresultfromincreasedupperairwayresistanceandpharyngealcollapsibility”
Kaditis AGEur Respir J2016
SDBSpectrum
Normal PrimarySnoring
UpperA/WResistanceSyndrome(UARS)
ObstructiveHypoventilation
(OH)
ObstructiveSleepApnea(OSA)
NormalUAR,nosnoring
Habitualsnoring,no
abnormalities
↑workofbreathing,arousals,
cognitive/behaviorsymptoms
noobviousobstructiveevents,but↑ExpCO2
Partial/totalobstructive
events,arousals,AbnO2/CO2,
end-organeffects
PediatricOSAPrototype=Adenotonsillar hyperplasia
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PediatricOSAS&SocietalImpact
• Common• 1-5%ofchildren;↑ with obesity• ?Surgicalprevalence• M>F&agephenotypes• Secondary&associatedmorbidity
• ↓ socioeconomicstatus• Expensive• ↓Schoolandjobperformance• ↑healthcareutilization• AlteredCVShealthtrajectory
• Shorterlifespan• Treatment&healthtrajectory
Jennum Petal.Thorax 2013
Pediatricmortalityafteradenotonsillectomy
Source Years 15-30DayDeathRate(per10,000)
Adenotonsillectomy
US(BrownKAnesth Analg 2014) 1970s 0.3-0.6
USout-patient(ShaySLaryngoscope2015) 2010 0.6
USin-patient(Allareddy VClin Pediatr 2016) 2001-10 4
Canadain/out-patient(MurtoKCanJAnesth 2017) 2002-13 0.2
Swedenin/out-patient(Østvoll EEur ArchOtorhinolaryngol 2015) 2004-11 0.24PediatricPredictionToolsforPerioperativeMorbidity&Mortality:
“PulmonaryorRespiratoryDisease”(SubramanyamRAnesth Analg 2015;NasrVGAnesth Analg 2017)
TheElephantintheRoom:LethalApneaatHomeafterATBrownKAnesth Analg June2014
Laryngoscope2013
Pediatr Anesth 2014
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OSAassociatedwithincreasedrespiratorycomplications&dose-responseevident
Pediatrics 2015
OSASyndromeOxidativeStress+ ↑Pco2InflammatoryCascadeAutonomicDysfunctionFrequentMicro-arousals
Environment
CardiovascularMorbidity MetabolicMorbidity Neuro-cognitive&BehaviorMorbidity
↑BP&LVStrain
EndothelialDisruption
AssociatedObesity→Insulin
Resistance
Athero-ScleroticLipidProfile
↓Memory,IQ&ExecutiveFunction
Hyperactive,Impulsive,↓Attention&Concentrat’n
GeneticPredisposition
End-OrganDysfunction
↑BP&LVStrain
AssociatedObesity→Insulin
Resistance
AbnormalLipidProfile
MetabolicSyndrome
RespiratoryMorbidity(Asthma&URTI)
GutierrezMJ.Pediatri Pulmonl 2013Bhattacharjee R.PLoS Med2014
TanHLNatSci Sleep2013
?GIMorbidity(GERD)
Polysomnography(PSG)isdiagnostic“GoldStandard”
“DIAGNOSTIC”SEVERITYisbasedonthefollowing:• PSGdata-Apnea-hypopneaindex(AHI)andgasexchange.• Nocturnalanddaytimesymptoms• Age• Secondarycomorbidities• Associatedcomorbidities
• Interpretedbyasleepmedicinespecialist• Limitedaccessandexpensive
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Pediatricmanagementguidelinesareconfusing…
• ASAPracticeguidelinefortheperioperativemanagementofpatientswithobstructivesleepapnea2014• AAP Diagnosisandmanagementofchildhoodobstructivesleepapneasyndrome2012• AAOHNS FoundationClinicalpracticeguideline:Tonsillectomyinchildren2011• AAOHNSFoundationClinicalpracticeguideline:polysomnographyforsleep-disorderedbreathingpriortotonsillectomyinchildren2011• AASM Executivesummaryofrespiratoryindicationsforpolysomnographyinchildren:anevidencebasedreview2011
PSGIndications“Everyone”--------------------Prescriptive-----------Notreallynecessary
AHIDiagnosticThresholdfor“Severe”OSA=↑RiskforPRAE?Yes------------No----Whatdoes“severe”mean?----Notacknowledged
PSGAlternativesAcceptable?Yes----------------------------------No----------------Notacknowledged
OSASdiagnosisismovingoutofthesleeplab
Questionnaires• Symptomsnotdiagnostic
• Physicalfindings“unreliable”
• Researchbasedimpractical
• STBURand“ShortScale”
• Nopediatric“STOPBANG”
• Includeassociatedco-morbidities(defineendotype)
Otheroptions• Single-channelrecordings
• Oximetry+ airfloworECG
• Home-basedsleepstudies• PSGandpolygraphy
• BiologicalMarkers(DeLucaCantoGSleepMedRev2015)• Blood• Urinary-mostpromising• Salivary• Exhaledcondensate
GozalDCurr Opin Pulm Med2015
“RelevantAsthmaEndotype?”
“Typical”tonsillectomydispositionplanning
SchwengelDAAnesthesiologyClin 2014
Definition“Severe”OSAleadingto↑riskofPRAE:NOCONSENSUS
UnknownhowPRAEriskmodulatedbyassociatedpathophysiology,age,comorbidities,skillofproviders(andopioids)
Intensivecareunitadmissioncriteria:NOCONSENSUS
Monitoraccordingtolocalpractice
DoesriskforPRAEvarybyprocedure?
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OSAage-relatedairwayphenotypes
PediatricOSAEndotypes Infant(0-<2yrs)
Child(2-8yrs)
Pre-teen/Teen(9-21yrs)
Lymphoidhyperplasia(adenoids+/- tonsils) +/- +++ +Softtissue
Obesity +/- ++ +++“Genetic”(e.g.Hurler’s,Prader-Willi,Beckwith-Wiedemann)
++ +++ +
CraniofacialSyndromesVault&Mandible(e.g.Craniosynostosis&PRobin)
+++ ++ +/-
ForamenMagnum(e.g.Arnold-Chiarii) ++ ++ +/-Neuromuscular(e.g.Cpalsy&Trisomy21) + +++ ++Prematurity(<32wks) +++ + -Inflammatory(e.g.Asthma&SickleCellDis.) +/- +++ ++
SchwengelDAAnesthesiologyClin 2014
NasopharyngealAirway
Retroglossal Airway
Genioglossusmuscle
PROMOTEA/WCOLLAPSE
Negativepressureoninspiration
Extra-lumenPositivepressure:FatdepositionSmallmandible
Genioglossuscontraction
Lungvolume(longitudinaltrachealtraction)
PROMOTEA/WPATENCY
FactorscontributingtoairwaypatencyandcollapseinpediatricOSA
Rigid“Box”
ACollapsibleTube
SoftTissue
PlumenPTissue
Relationshipbetweenairflow&resistance
Q=ΔP/R Rɑ1/radius4
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Pharyngealwalltension,trachealtraction&abdominalpannus
Doesdysfunctionalneuro-motorcontroloftheupperairwayhavearole?
• Dayvsnighttimeobstruction• ↑EMGgenioglossusactivity• NotallchildrenwithanatomicalobstructionhaveOSA• VariableOSAcureratefollowingadenotonsillectomy
PathophysiologyofpediatricOSA:StructurallabmodelIsonoS.EncyclopediaSleep2013
TransmuralPressure=Plumen-Ptissue(cmH2O)
0 20-5
(cm2)5
Pediatric
-15
Cross-SectionofRigidBox&CollapsibleTube
Non-OSA=Pclose <0cmH20 OSA=Pclose >0cmH20
OSA
Adult
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OSAandupperairwayneuromotor control
UpperAirwayFindings Receptor(Location)
OSAPhenotypesInfant
(0-<2yrs)Child
(2-8yrs)Pre-teen/Teen(9-21yrs)
Collapsibility(genioglossus) CO2(BrainStem)
Mechano (airway)High High High
Ventilatory drive O2(Peripheral)CO2(BrainStem) ? Normal ?
Arousibility“AirwaySelf-Rescue”
O2(Peripheral)CO2(BrainStem)Mechano (airway)
Blunted Blunted Bluntedtohigh
VentilatoryControlinstability-“LoopGain”
O2(Peripheral)CO2(Peripheral&BrainStem)
?High ?High ?High
Arens R&MarcusC.Sleep 2004
O2administrationimprovesventilatory controlinstability
Upperairwaycollapsibility:Anestheticagents&opioids
GenericDrugName
AirwayCollapse
MechanismofAction
Midazolam + CNSGABAA,?α doseSevoflurane +++ CNSGABAA,α doseDesflurane +++ CNSGABAA
Propofol ++ CNSGABAA/NMDA,α doseDexmedetomidine +/- CNSα2 adrenergicagonistKetamine +/- NMDAreceptorantagonist;↑EMGgenioglossus(rats)TopicalLidocaine + ↓Dilator/tensormusclespharynx/larynxOpioids ++ ↓ventilatory &pharyngealneuromotor drive
EhsanZLaryngoscope 2016
GABAA receptors-stimulationleadstomyo-relaxation
Anestheticagentsenhance GABAA receptoractivityCampagnaJANEJMMay2003
GABAA receptoractivityaugmentedbyanestheticagentsinpresenceofIL-1
CellReports2,September2012
Anesth Analg April2012
PreventionofPRAEsinOSApatients:IstherearoleforsteroidsorNSAIDs?
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Perioperativesteroidadministrationimprovingadenotonsillectomyoutcomes
NEng JMed2013
CaulfieldHMClin Otolaryngol 2012
Oxidativestress&sensitivitytoopiatesinpediatricOSAS
Anesth Analg 2010
Anesthesiology 2006
Anesthesiology 2006
Pediatr Anesth 2010;20:1078-83
Musclerelaxants,reversalagents&theupperairway
Anesthesiology 2014
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Summary:PerioperativeUpperAirwayConsiderationsinChildrenwithOSA
• PATIENT• Pronetoimpairedairwayneuro-motorfunctionduetodrugs• SpectrumofcomorbiditiessecondarytoOSAor“age-specific”
• PREOPERATIVE• RiskStratificationforPRAE
• Age<3yrs&“significant”comorbidities• “Severe”OSAbyHx/Px,PSGorOvernightPulseOximetry• “PrescriptivePSG”needed?• “Invasiveness”ofsurgery&anesthesia• Needforpostoperativeopioids
• POSITION• Headup“TrachealTethering”,avoidbeingsupine
Summarycontinued
• PROCEDURE• Goals-preparefor“challenging”airway&PRAEs• Noone“best”anesthetictechnique;• “Pharyngealsparing”approach• Emergeawakeandconsidernasopharyngealairway
• POSTOPERATIVE• Monitoring
• ContinuousSpO2preferablyonroomairandasleep• Appropriatedurationunknown(2-6hrs)• Significanceofminor/majorPRAEsduringrecoveryunknown
(WeingartenGAnesth Analg 2015)• Analgesia
• Multimodalandavoidopioidinfusionsor“around-the-clock“• Optimalapproachunknown(AndersonBJPediatr Anesth 2011)
• ParentPreparation• 2019AAOHNSTonsillectomyGuideline
KimmoMurtoMD,FRCPC
DepartmentofAnesthesiology&PainMedicine,CHEOAssociateProfessor,UniversityofOttawa,FacultyofMedicine
Email:[email protected]
Thankyou!