9/30/13. PAP Therapy for OSA in the Perioperative Setting: Is There a Best Approach? Financial Disclosures

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1 PAP Therapy for OSA in the Perioperative Setting: Is There a Best Approach? Dennis Auckley MD Director, Center for Sleep Medicine MetroHealth Medical Center Associate Professor of Medicine Case Western Reserve University Financial Disclosures Research Funding: - Teva: Perioperative survey study Medical inpatient PSG study Research Equipment: - ResMed: Perioperative study Perioperative PAP Therapy: Known OSA on Treatment 1

2 Case # 1 52 y/o M with known OSA - PSG 18 months prior: AHI of 38.7 and CPAP 12 cm H2O resulted in an optimal titration - Reports CPAP compliance, denies OSA symptoms, and has gained 1.5 kg since his sleep study PMHx: HTN, hyperlipidemia, current smoker Planned right total knee replacement in 1 week Case # 1 You: A. Proceed with surgery, using his CPAP at current setting, no special monitoring B. Proceed with surgery, using his CPAP at current setting, monitor postoperatively with oximetry C. Repeat his PSG preoperatively to ensure CPAP is still effective, delaying surgery if needed D. Place on autoadjusting CPAP perioperatively E. Other? ASAA OSA Patient s Rights and Responsibilities To be adequately treated for OSA during all surgical procedures whether in-hospital or outpatient To be adequately treated for OSA while hospitalized for surgery, other medical conditions, or having same day surgery To use your own mask and headgear, and your own CPAP equipment set at your prescribed pressure ASAA website 2

3 CPAP in the Perioperative Management of Known OSA 2 pts with OSA had postop complications - Not initially treated with CPAP - 1 died Next 14 pts with OSA received pre / postop CPAP Variety of operations (CABG, gastroplasty, thyroidectomy, AAA repair) No significant complications occurred in any of the patients on CPAP Rennotte et al, Chest 1995 CPAP in the Perioperative Management of Known OSA N-CPAP allows us to freely use sedative, analgesic and anesthetic drugs without major complications. Rennotte et al, Chest 1995 % * * * * P < 0.05 IB, no hcpap = 2/32 CPAP postop IB, hcpap = 12/33 CPAP postop Gupta et al, Mayo Clinic Proc

4 CPAP in the Perioperative Management of Known OSA Retrospective analysis of 284 pts with PSG confirmed OSA who underwent Roux-en-Y GBS: were using CPAP/BPAP preoperatively were not using CPAP/BPAP preoperatively - Postoperatively, pts were monitored with oximetry while on supplemental O 2 at 2-4 l/m to keep saturations >92% - None were treated with CPAP/BPAP postoperatively Results: PAP No PAP Complication rate 0.7% 2.1% not SS Jensen et al, Surg Obes Relat Dis 2008 Is CPAP Use Enough During the Postoperative Period? CPAP at the usual home-setting may not prevent upper airway collapse postoperatively - Lowered threshold for upper airway collapse - Increased time in supine position - REM rebound Consequently may still have respiratory events and hypoxia No data available looking at this Example of Postoperative Hypoxia on CPAP Pulse Oximetry Dx PSG 6/2006 CPAP 9 cm H 2 0 6/2006 Ist PostOP night CPAP 9 cm H 2 O 9/2007 4

5 Postoperative Oximetry Study of OSA Patients on CPAP: Methods Observational cohort study (n=38) Patients with known OSA well-controlled (not hypoxemic) on CPAP therapy Elective surgery at our institution Monitored with an overnight pulse-oximeter for approximately 8 hour period on the first night after surgery Brar et al, J Sleep Dis and Therapeutics, in press Postoperative Oximetry Study of OSA Patients on CPAP: Results Brar et al, J Sleep Dis and Therapeutics, in press Postoperative Oximetry Study of OSA Patients on CPAP: Conclusions Significant hypoxia (n=7, 18%) was associated with: - baseline AHI and supine AHI - Average SpO 2 on diagnostic PSG - Fluid balance - IV MEQ dose The etiology of the hypoxia not always clear It is uncertain if the hypoxia increases the risk of other complications Monitoring would be required to detect the hypoxia Brar et al, J Sleep Dis and Therapeutics, in press 5

6 OSA, Narcotics and CPAP Home OSA, Narcotics and CPAP Admitted, IV dilaudid x 2 Perioperative PAP Therapy: Known OSA on Treatment We need better data! - Is PAP assessment prior to surgery needed? - Is there a role for ACPAP in this setting? - Should postop monitoring be recommended for OSA pts on PAP therapy? In the meantime, my thoughts: - PreOp assessment with history +/- machine download +/- oximetry - Consider repeat titration or ACPAP before surgery* - Monitor (oximetry) those at high-risk for problems - Severe OSA, high narcotic requirement, co-morbidities 6

7 Case # 2 52 y/o F with known OSA - PSG 4 weeks prior: AHI of 45.2 with REM worsening and REM desaturations - Just now being seen in clinic and has not been evaluated for PAP therapy yet - HCO3 - is normal PMHx: HTN, DM, morbid obesity Planned right total hip replacement in 1 week Case # 2 You: A. Do nothing preoperatively, proceed with surgery, no special postoperative monitoring B. Do nothing preoperatively, proceed with surgery, monitor postoperatively with oximetry C. Place on autoadjusting CPAP perioperatively, proceed with surgery, no special postoperative monitoring D. Place on autoadjusting CPAP perioperatively, proceed with surgery, monitor postoperatively with oximetry E. Arrange for urgent PAP titration study, delaying surgery if needed F. Other? ACPAP initiation for the Perioperative Management of Known OSA Case-control study of 45 pts with severe OSA undergoing upper airway surgery (uvula sparing): - 21 pts started on CPAP at least 7 days preop, then placed on ACPAP for 3 nights postop - 24 pts not treated with PAP therapy - All had a PSG on night 2 following their surgery Results (Cases): Dx study PAP titration PostOp AHI Low O 2 Sat 65.0% 94.5% 93.7% Lin et al, Zhonghua Er Bi Yan Hou Ke Za Zhi

8 CPAP Adherence in the Perioperative Management of Known OSA Retrospective observational study of 138 pts who underwent preop PSG, found to have an AHI > 15 and started on PAP therapy preop: - PSGs were split nights - ACPAP started (max +3 cm H 2 O, min 2 H 2 O best PSG CPAP pressure) on average 4 days preop - All had RT instruction, mask fitting and MD phone contact Results - at 30 days after starting ACPAP - Average use = 2.5 hrs / night - Use > 4 hrs / night = 33% Guralnick et al, J Clin Sleep Med 2012 Perioperative PAP Therapy: Known OSA not on Treatment We need better data! - Should ACPAP (or other PAP) be started preop / postop? - What can be done to improve compliance with therapy? - Should postop monitoring be recommended for OSA pts initiated on PAP therapy perioperatively? In the meantime, my thoughts: - PreOp assessment with history, exam and review of PSG - Consider ACPAP before surgery if can ensure quality instruction - Monitor (oximetry) those at high-risk for problems - Severe OSA, high narcotic requirement, co-morbidities Case # 3 58 y/o M screens positive for OSA during preop assessment (STOP-Bang score is 4) - You are called by the presurgical clinic regarding how to proceed PMHx: HTN, TIA, obesity Planned for lower abdominal surgery in 1 week 8

9 Case # 3 You: A. Do nothing preoperatively, proceed with surgery, no special postoperative monitoring B. Do nothing preoperatively, proceed with surgery, monitor postoperatively with oximetry C. Place on autoadjusting CPAP perioperatively, proceed with surgery, no special postoperative monitoring D. Place on autoadjusting CPAP perioperatively, proceed with surgery, monitor postoperatively with oximetry E. Arrange for urgent PSG, delaying surgery if needed F. Other? PostOp ACPAP initiation for the Management of Suspected OSA 86 pts at-risk for OSA (positive SACs questionnaire) undergoing TKR or THR randomized to ACPAP + UC vs UC alone - Those randomized to ACPAP all had video/verbal instruction, mask fitting and minute practice preop - ACPAP was initiated postop, preferrably in the PACU - ACPAP were set at 5-15 cm H2O - Primary outcome was LOS with a secondary outcome of complication rates Gorman et al, Chest 2013 PostOp ACPAP initiation for the Management of Suspected OSA Results: - No difference in LOS (primary) - 1 day longer LOS in those with AHI > 15 placed on ACPAP - No difference in postoperative complications (secondary) - CPAP compliance: 6 hrs night 1, 3 hrs for LOS Issues: Screened 2075 to enroll 138 Study ended up being underpowered Median AHI was 13.5 on ACPAP ACPAP initiated postop Gorman et al, Chest

10 Perioperative PAP Therapy: Suspected OSA not on Treatment We need more data! - Should these pts get a preop PSG or PM? - Should ACPAP (or other PAP) be started preop vs postop or at all? - Should postop monitoring be recommended for suspected OSA pts with or without PAP therapy? In the meantime, my thoughts: - There may be a role for PM/ preop ACPAP - ACPAP initiation would require quality instruction - Monitor (oximetry) those at high-risk for problems - Severe OSA, high narcotic requirement, co-morbidities PAP Therapy for OSA in the Perioperative Setting: Is There a Best Approach? Known OSA pts already on PAP therapy should be clinically reassessed preop: - Consider need for repeat testing - Consider need for postop monitoring Known OSA pts not on PAP therapy should be clinically assessed preop: - Consider PAP titration vs ACPAP trial - Consider the need for postop monitoring Suspected OSA pts should be placed in the clinical context PAP Therapy for OSA in the Perioperative Setting: Lots of Questions Who is considered highest risk for complications? Who should be monitored postop? And how? - oximetry? - CO 2 monitoring? - other? Is there a role for autoadjusting Bilevel PS? Data, Data, Data, Data, Data, Data, Data, Data 10

11 Thank You! 11