Peri-operative Management of Obstructive Sleep Apnoea. Matthew T. Naughton MD FRACP Alfred Hospital, Melbourne, Australia
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1 Peri-operative Management of Obstructive Sleep Apnoea Matthew T. Naughton MD FRACP Alfred Hospital, Melbourne, Australia
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3 Fritz Kahn
4 Fritz Kahn
5 Fritz Kahn
6 Fritz Kahn Fearless Felix
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8 Case: 46yo male, BMI=35, smoker, single, loud snorer, 2 drug hypertension, myocardial infarct 12 mths ago, Presents for semi-urgent CAGS?
9 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation
10 OSA Contributes to Post-Operative Complicatons Surgery type RxOSA LOS & Complications General OP 5 yes N N Ortho 3 no 33% x 6 General IP 4,7,8 no N/Y x 2 Bariatric 6 85% - Y CAGS 1,2 no 8% x 2 (& AF) 1. Mooe Cor Art Dis 1996;7:475-78; 2. Zarbock et al. Chest 2009;135: Gupta et al. Mayo Clin Proc 2001;76: Hwang et al. Chest 2008;133: Sabers et al Anesth & Analg 2003;96: NEJM 2009;361: Kaw et al. Chest 2012;141: Memtsoudis et al. Anesth & Analg 2011;112:113
11 OSA Contributes to Post-Operative Complicatons Surgery type RxOSA LOS & Complications General OP 5 yes N N Ortho 3 no 33% x 6 General IP 4,7,8 no N/Y x 2 Bariatric 6 85% - Y CAGS 1,2 no 8% x 2 (& AF) 1. Mooe Cor Art Dis 1996;7:475-78; 2. Zarbock et al. Chest 2009;135: Gupta et al. Mayo Clin Proc 2001;76: Hwang et al. Chest 2008;133: Sabers et al Anesth & Analg 2003;96: NEJM 2009;361: Kaw et al. Chest 2012;141: Memtsoudis et al. Anesth & Analg 2011;112:113
12 General surgery & unrx ed OSA Hwang et al. Chest 2008;133: consecutive pts awaiting surgery with 2 features of OSA underwent oximetry study Features of OSA Regular snoring Excessive sleepiness Witnessed apnoeas Crowded oro-pharynx
13 Major Non-Cardiac Surgery-unRx OSA Kaw et al. Chest 2012;141: No Apnea (n=282) Apnea (n=189) Atrial Fibrillation ** Myocardial Ischemia ** Delerium ** CHF ** Post hyopoxemia ** Respiratory Failure ** ICU ** Any Complication ** LOS > 2days ** LOS mean (range) 1 (0-3) 2 (0-4) *
14 Bariatric Surgery & OSA NEJM 2009; 361: outcome: 30D Death / DVT / re-intervention / failure to discharge 4776 / 5648 pts Results-1 LAGB LRYGB ORYGB N (%) Death (%) outcome (%) OSA Dx (%) UnRxOSA (%) Results-2 RISKS: Type of procedure, BMI, WD<60M, past DVT, OSA
15 OSA Contributes to Post-Operative Complicatons Surgery type RxOSA LOS & Complications General OP 5 yes N N Ortho 3 no 33% x 6 General IP 4,7,8 no N/Y x 2 Bariatric 6 85% - Y CAGS 1,2 no 8% x 2 (& AF) 1. Mooe Cor Art Dis 1996;7:475-78; 2. Zarbock et al. Chest 2009;135: Gupta et al. Mayo Clin Proc 2001;76: Hwang et al. Chest 2008;133: Sabers et al Anesth & Analg 2003;96: NEJM 2009;361: Kaw et al. Chest 2012;141: Memtsoudis et al. Anesth & Analg 2011;112:113
16 OSA Contributes to Post-Operative Complicatons Anesth Analg 2011;112: AHRQ (Agency for Healthcare Research & Quality, USA) N = 6,051,703 43% orthopaedic 57% general surgical * * * * * * *
17 Mechanisms OSA Respiratory Failure Obesity and lung function OSA & cardiovascular disease OSA & ventilatory drive (O2 sensitive) Drugs Positioning Peri-operative care (esp at night) OSA & Upper airway (aka Difficult airway)
18 Difficult airway is associated with OSA Hiremath et al. Br J Anaesthesiology 1998;80:606. Difficult intubation= no glottic structure visible on laryngoscopy (Cormack & Lehane Grade 4). N= 17 of 32 in 3 years
19 UnRx OSA -> $ Hospital Complications Dimick et al. J Am Coll Surgeons 2004;199: $1000x Infective 1.3 Cardiovascular 8 18 Thomboembolic Respiratory Failure
20 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation
21 Speech -> Snoring Primate Human
22 Closed Apnoea Airway collapsibility Hypopnoea Snoring Open + Surfactant Size of airway UAW muscle tone (+/- oscillation=lg) Weight
23 Snoring Snoring with arousals Hypoponeas Obstructive Apnoeas Hypoventilation & high CO 2 Advanced LV Heart failure Hyperventilation & low CO 2 Cheyne Stokes Respiration
24 OSA & Cardiovascular Disease Shamsuzzaman JAMA 2003;290:
25 Prevalence of Adult OSA in the Community Young. NEJM Baldwin & Young Snore AHI >5 AHI >5 & EDS 28% 9 25* 2 ~6% 44% 24 33** 4 ~8% 1993 Young Q =3513; PSG = 602; 2004 Baldwin F= 3398 & BMI=28.5 M= 3042 & BMI=28.5
26 Mortality α OSA in USA (SHHS) n=6300 x 10 years. Punjabi et al. PLOS Medicine 2009;6:1-9.
27 OSA Assessment Clinical Anaesthetic or Dental: Difficult airway Snore (without alcohol) with witnessed apnoeas Mallampati 3-4 Neck Circumference (shirt collar > 43cm & 2 α HT drugs) BMI >30 Questionnaires STOP-BANG BERLIN Investigation APNEALINK = finger oximetry, airflow & respiratory effort POLYSOMNOGRAPHY Home vs Laboratory
28 Mallampati classification Original (Anaesthetists) Freidman (Sleep physicians) Seated patient with head in neutral position Mouth wide open Protruded tongue No phonation No tongue depressor
29 OSA Severity AHI Minimum SpO2 (events/hour) (%) Normal < Mild Moderate Severe
30 Snoring vs AHI Maimon et al JCSM 2010;6:475-78
31 STOP-Bang Questionnaire for OSA Chung et al. Anesthesiology 2008;108: Score >3 = high risk AHI (#/hr) >5 >15 >30 Sensitivity Specificity PPV NPV AUC
32 Berlin Questionnaire (+ve 2 categories) Netzer et al. Ann Int Med 1999;131:
33 OSA Management Age Child: Adult: Elderly: Management Surgery > Dental > Lifestyle Lifestyle > CPAP > Dental CPAP >> Dental & Lifestyle
34 OSA Treatment: Conservative - Lifestyle Weight loss Cautious alcohol One pillow (avoid neck flexion) Raise head of bed 10-15cm (avoid UAW oedema) Sleep in lateral (recovery) position (chin extension) Reduce nasal resistance (HDM, Nasal Steroids) Minimize medications (steroids, sedatives, antiseizure) Avoid sleep deprivation Avoid fluid accumulation in legs
35 Medical & Surgical Wt loss Greenburg, Littieri & Eliasson. Am J Med 2009;122: Chang, Marshall, Yee & Grunstein. Eur Resp Monograph Dec 2010, p302. Method Weight* AHI Surgical: Medical: * Assume height 174 cm 80-90% of patients still have AHI > 5
36 SURGERY? Tonsils and adenoids Sinus and turbinectomy Maxillary restriction Retrognathia UPPP High Arched Palate
37 Dental Mandibular Advancement Maxillary Expansion
38 CPAP Family
39 Long term adherence to CPAP McArdle AJRCCM 1999;159:1108 N=1211 Symptom & AHI >5 (?) Mean f-up 22 months 8 cmh2o x 5.6hrs BMI 30
40 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation
41 1. Cardiac Surgery & Post-op CPAP [OSA undefined] oxygen toxicity diaphragm weakness trauma bypass
42 1.Methods-Cardiac Surgery & Post-op CPAP Zarbock et al. Chest 2009;135: LATE EXTUBATION = 6 hours later CONTROL= CPAP 10 x 10 min 4 hourly STUDY = CPAP 10 > 6 hours Early extub = 14.6 hours Late extub = 9.1 hours
43 1.Results-Cardiac Surgery & Post-op CPAP Zarbock et al. Chest 2009;135: CPAP Control Complications Pulmonary * Cardiac ICU Readmission * 7 14 LOS ICU (hrs) Hospital (d) 13 14
44 2.NIV for High Risk Resp Failure Post-Extubation Author KEENAN ESTERBAN NAVA FERRER Year NIV delayed delayed prophylactic <48hrs <48hrs immediate Outcome negative negative positive positive N Centres Age Days MV NIV 10/5x12 ns 13/5x16 14/5x19 Vision ns Vision Vision RR HR ph PaCO PaO2/FiO2 150 (75) Acute surg-med Past COPD-CHF (%)
45 2. NIV for High Risk Resp Failure Post-Extubation Author KEENAN ESTERBAN NAVA FERRER Year NIV delayed delayed prophylactic <48hrs <48hrs immediate Outcome negative negative positive positive N Centres Age Days MV NIV 10/5x12 ns 13/5x16 14/5x19 Vision ns Vision Vision RR HR ph PaCO PaO2/FiO2 150 (75) Acute surg-med Past COPD-CHF (%)
46 2. NIV for High Risk Resp Failure Post-Extubation Author KEENAN ESTERBAN NAVA FERRER Year NIV delayed delayed prophylactic <48hrs <48hrs immediate Outcome negative negative positive positive N Centres Age Days MV NIV 10/5x12 ns 13/5x16 14/5x19 Vision ns Vision Vision RR HR ph PaCO PaO2/FiO2 150 (75) Acute surg-med Past COPD-CHF (%)
47
48 Q: 46yo male, BMI=35, smoker, single, loud snorer, 2 drug hypertension, myocardial infarct 12 mths ago, Presents for semi-urgent CAGS?
49 Peri-operative Management? Pre-operative: if elective operation & on CPAP bring to hospital if drowsy & aspiration risk, change full face to nasal mask if moderate to severe untreated OSA & due for elective major surgery, refer for sleep assessment pre-op. Post operative: high risk untreated / undiagnosed OSA treat with CPAP monitor patient with educated staff (see table next slide) refer for sleep assessment if not previously diagnosed.
50 Post-operative Nursing - Alfred
51 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation
52 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation
53 Outline Evidence of OSA -> perioperative complications OSA pathophysiology & Rx Weaning from Intubation Archie Cochrane
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