Transcript OSA : Isn’t it about obese?

OSA : Isn’t it about obese?
Saowapark Chumpathong
Department of Anesthesiology
Siriraj Hospital
OSA : Isn’t it about obese?
Obstructive Sleep Apnea (OSA)
• Recurrent episodes of complete or partial
obstruction of the upper airway during
sleep, resulting in oxygen desaturation
and arousal
OSA : Isn’t it about obese?
Obstructive Sleep Apnea
Clinical criteria
• Apnea: complete cessation of breathing
≥ 10 seconds
• Hypopnea: marked reduction in airflow,
decreased SaO2 ≥ 4%
OSA: AHI score > 5
OSAS: AHI > 5 + excessive daytime sleepiness
OSA : Isn’t it about obese?
OSA at a glance
Prevalence
• OSA 11.4% (men 15.4%, women 6.3%)
• OSAS 4.4% (men 4.8%, women 1.9%)
Sleep Breath 2011;15:641-8.
OSA ⇆ Obesity
2
 BMI ≥ 30 kg/m : 40% prevalence
2
 BMI ≥ 40 kg/m : 98% prevalence
Arch Intern Med.2002;162:893-900.
Obes Res.2000;8:262-9.
OSA : Isn’t it about obese?
Risk factors for OSA
Variables
Male gender
Age > 45 years
Habitual smoking
Habitual drinking
Obesity
Hypertension
OR (95% CI)
8.7 (7.8-14.9)
2.7 (1.4-8.2)
2.1 (1.6-2.3)
3.2 (2.8-3.6)
4.8 (1.9-11.4)
3.4 (3.1-4.9)
Sleep Breath 2011;15:641-8.
OSA : Isn’t it about obese?
Why OSA matters
Health consequences of OSA
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Problems with daytime functioning
sleepiness, accident, quality of life
Cardiovascular, Cerebrovascular disease
HT, CAD, MI, AF, CHF, Stroke, Death
Diabetes, Metabolic syndrome
Cleveland Clinic Journal of Medicine. 2009;76:S98-103.
OSA : Isn’t it about obese?
Why OSA matter to us?
• Higher prevalence in the surgical population
 24% by Berlin questionnaire
 > 70% in obese bariatric surgery
• > 80% unrecognized OSA undergoing surgery
• Increases perioperative morbidity, mortality
Sleep.1997;20:705-6.
Am Surg.2008;74:834-8.
OSA : Isn’t it about obese?
Postoperative complications in
patients with OSA
Complications
AHI ≥ 5
(n=282)
Hypoxemia
35 (12.4)
4 (2.1)
7.9
0.009
ICU transfer
19 (6.7)
3 (1.6)
4.43
0.069
5 (2.6)
6.9
0.003
53 (28.0)
1.65
0.049
Any complication 40 (14.2)
LOS > 2 days
135 (48.2)
AHI < 5
(n=189)
Adjusted OR Adjusted p value
Chest.2011 Aug 25. [Epub ahead of print]
OSA : Isn’t it about obese?
Perioperative pulmonary outcomes
in patients with OSA
Pulmonary outcomes
Aspiration pneumonia
ARDS
Pulmonary embolism
Intubation/mechanical
ventilation
OR (95% CI)
1.37 (1.33,1.41)
1.58 (1.54, 1.62)
0.90 (0.84, 0.97)
1.95 (1.91, 1.98)
Anesth Analg.2011;112:113-21.
OSA : Isn’t it about obese?
Identify OSA patient
• Risk factors for OSA
• History : Sleep habits
: Symptoms and complaints

Snoring
Sleepiness
Night sweats
Impotence
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Morning headaches  Morning dry mouth or sore throat
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Personality change
Morning confusion
Physically restless sleep
Intellectual impairment
OSA : Isn’t it about obese?
Identify OSA patient
• Physical examination
 Obesity  HT  Large neck circumference
 Airway
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Nasal obstruction
Tonsil enlargement
Elongated uvula
Macroglossia
Retrognathia
Micrognathia
OSA : Isn’t it about obese?
Identify OSA patient
Screening tools
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Berlin questionnaire
ASA checklist
STOP questionnaire
STOP-BANG questionnaire
Nocturnal oximetry
Ann Intern Med.1999;131:485-91.
Anesthesiology.2006;104:1081-93.
Anesthesiology.2008;108:812-21.
Curr Opin Anaesthesiol.2009;22:405-11.
STOP-Bang scoring model
Curr Opin Anaesthesiol. 2009;22:405-11.
Questions
Snoring
Questions
Tired
Do you often feel tired, fatigued, or
Do you snore loudly
(louder than talking or loud enough to be heard
through closed doors)?
Answer
Yes / No
Yes / No
sleepy during daytime?
Has anyone observed you stop
Observed
Yes / No
breathing during your sleep?
P blood pressure
Do you have or are you being
Yes / No
treated for high blood pressure?
BMI
Age
BMI more than 35
Neck circumference
Neck circumference greater than 40 cm
Gender
Male
Age over 50 years
Yes / No
Yes / No
Yes / No
Yes / No
High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items
STOP-Bang scoring model
Questions
Snoring
Curr Opin Anaesthesiol. 2009;22:405-11.
Questions
คุณนอนกรนดังหรื อไม่ ?
(ดังกว่าเสียงพูด หรื อ ดังพอที่จะได้ ยินออกไปนอกห้ อง)
คุณมักจะรู้สกึ อ่อนเพลีย ล้ า หรื อ ง่วงนอนในระหว่าง
กลางวันบ่อย ๆ หรื อไม่ ?
Answer
ใช่ / ไม่ใช่
Observed
มีคนเคยสังเกตเห็นว่าคุณหยุดหายใจขณะที่คณ
ุ หลับ
อยู่หรื อไม่ ?
ใช่ / ไม่ใช่
P blood pressure
คุณมีความดันโลหิตสูง หรื อกาลังรักษาโรคความดัน
โลหิตสูงอยู่ หรื อไม่ ?
ดัชนีมวลกายมากกว่า 35 หรื อไม่ ?
ใช่ / ไม่ใช่
Neck circumference
อายุมากกว่า 50 ปี หรื อไม่ ?
เส้ นรอบวงคอมากกว่า 40 ซม. หรื อไม่ ?
ใช่ / ไม่ใช่
ใช่ / ไม่ใช่
Gender
เป็ นเพศชายหรื อไม่ ?
ใช่ / ไม่ใช่
Tired
BMI
Age
ใช่ / ไม่ใช่
ใช่ / ไม่ใช่
High risk of OSA: answering yes ≥ 3 items Low risk of OSA: answering yes < 3 items
OSA : Isn’t it about obese?
Identify level of OSA
• Polysomnography (PSG) : gold standard
Severity of OSA
Mild
Moderate
Severe
AHI
5-15
15-30
> 30
American Academy of Sleep Medicine 2007
• If no study available
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positive in two categories of signs/symptoms moderate OSA
any severe abnormality on the list presume severe OSA
Anesthesiology.2006;104:1081-93.
Obstructive sleep Apnea : Preoperative Assessment
Suspected OSA patient
Known OSA patient
Screening using STOP or
STOP –Bang questionnaire
High risk of OSA
Low risk of OSA
Severity Assessment from
history or Polysomnography
Mild OSA
Moderate or
Severe OSA
Comorbidities and
Major Elective
Surgery
Yes
No
Consider
preoperative
Sleep Medicine
referral
Assume possibility of
moderate OSA.
Perioperative OSA
precautions
Routine perioperative
management.
No preoperative PAP
therapy required
Preoperative PAP
therapy.
Perioperative
OSA precautions.
Anesthesiology Clin.2010;28:199-215.
Can J Anesth.2010;57:849-64.
OSA : Isn’t it about obese?
Perioperative OSA precautions
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Anticipating possible difficult airway
Use of short-acting anesthetic agent
Opioid- minimization
Full reversal of neuromuscular blockade
Extubation in a non-supine position
Anesthesiology Clin.2010;28:199-215.
Can J Anesth.2010;57:849-64.
OSA : Isn’t it about obese?
Intraoperative Management
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Avoid sedating premedication
Consider gastroesophageal reflux
Regional, multimodal analgesia
Use of intraoperative capnography
Resume use of PAP device
Anesthesiology Clin.2010;28:199-215.
Can J Anesth.2010;57:849-64.
Prolonged stay in the PACU
Known OSA
Suspected OSA
• Non-compliant with PAP therapy
• Severe OSA
• Recurrent PACU Respiratory Event
No
Sao2 <90% (x3)
Bradypnea < 8/min (x3)
Apnea ≥10 sec (x1)
Pain sedation mismatch
Recurrent PACU
Respiratory Event
Yes
Yes
No
• Moderate OSA
• Postoperative opioids
No
Discharge to
home if minor
surgery.
Yes
Postoperative
care on the
surgical ward.
Postoperative PAP
therapy and care in
a monitored bed
with continuous
oximetry.
Discharge to home if
minor surgery or
postoperative care on
the surgical ward.
Anesthesiology Clin.2010;28:199-215.
Can J Anesth.2010;57:849-64.
OSA : Isn’t it about obese?
OSA & Ambulatory surgery
Estimation of perioperative risk
• Severity of OSA
• Invasive of surgery and anesthesia
• Requirement for postoperative opioids
• OSA scoring system > 4: increased risk
Anesthesiology.2006;104:1081-93.
OSA : Isn’t it about obese?
OSA & Ambulatory surgery
• Mild-moderate OSA patients
optimized comorbid conditions
not requiring postoperative opioids  safely
undergo surgery
• Severe OSA patients
requiring postoperative opioids  not safe to
undergo surgery
Current Opinion in Anesthesiology. 2011;24:605-11.
OSA : Isn’t it about obese?
Take Home Message
• OSA is strongly associated with obesity.
• Higher prevalence & unrecognized OSA are
undergoing surgery.
• Patients with OSA are at an increased risk of
perioperative complications.
• Identification,risk stratification of patients with
OSA is essential in preventing postoperative
complications.