Sleep Apnea Maki Morimoto, MD

Sleep Apnea Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops during sleep. There are three types of sleep apnea 1.) Obstructive sleep apnea, which occurs when your throat muscles intermittently relax and block the airway during sleep. 2.) Central, which is a neurological disorder 3.) Mixed

Sleep Apnea Obstructive Sleep Apnea most common form of sleep apnea 12 million people are affected 1 in 25 middle aged male 1 in 50 middle aged female Only 50% are obese Males > Females Older > Younger African American, Hispanics and Pacific Islanders Only 20% is diagnosed (Helder et al - BMJ. 2004 Oct 23; 329(7472): 955–959)

Sleep Apnea Which patient has OSA? Harley – 53 yo male Ursula – 54 yo female Burton – 66 yo male Helju – 37 yo female Eric – 53 yo male Lionel – 39 yo male Answer: (New York Times – May 14, 2009)

Sleep Apnea How do we diagnose OSA? Why do we need to know if the patients have/do not have OSA? What can happen to the patients with OSA? How do we care for these patients? What should be monitored? Can we send these patients home?

Sleep Apnea - Diagnosis STOP-BANG Score - Do you Snore? - Do you feel Tired? - Has anyone Observed you with apnea? - Do you have high blood Pressure? - BMI more than 35kg/m2? - Age over 50 years old? - Neck circumference > 16 inches (40cm)? - Gender: Male? Score: 5-8 (High), 3-4 (Mid), 0-2 (Low) 88% sensitivity of identifying severe OSA (F. Chung et al.) Obes Surg. 2013 Dec;23(12):2050-7.

Sleep Apnea - Diagnosis For the definitive diagnosis, the patients must do a sleep study (Polysomnogram) The followings are recorded during the study: brain activity eye movements heart rate blood pressure the amount of oxygen in your blood air movement through your nose snoring chest movements

Sleep Apnea and surgery Why is important to know if the patient has OSA? - Patients are at a increased risk from anesthesia and sedation - Higher rate of cardiopulmonary and respiratory complications - Higher likelihood of “difficult” intubation - Higher rate of death (e.g. twofold for hip/knee surgeries)!

Sleep apnea and Surgery “A woman dies after a routine knee surgery” – Boston, 2013 “A patient dies after a shoulder surgery” – unknown location, 2007 “48 years old female patient dies after an eye surgery” – Texas, 2008 “There's this huge problem out there, and really no good answer,” Dr. Stavros G. Memtsoudis

Sleep Apnea and Surgery Common factors: - Patients had obstructive sleep apnea - Had received general anesthesia - Received opioid medications for pain - Were not monitored

Sleep Apnea and Surgery In 2014, Center for Medicare and Medicaid Services (CMS) issued a statement: “Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.”

Sleep Apnea and Surgery In 2014, American Society of Anesthesiologists (ASA) issued a practice guideline for OSA patients Anesthesiology. 2014 Feb;120(2):268-86.

Sleep Apnea and Surgery Pre-operative evaluation: - Protocol should be developed - Patient should be seen before the day of the surgery - Evaluation should be comprehensive - Sleep Study is encouraged, if suspected of OSA - Clinical criteria should be inclusive - Establish scoring system for peri- operatative risk from OSA - Inform the patient of the risks

Sleep Apnea

Sleep Apnea and Surgery Pre-operative preparation (surgical day) - Initiation of CPAP should be considered - Use of mandibular advancement should be considered - Weight loss should be encouraged - A Patient who has had corrective surgery should still be assumed to remain at risk unless a normal sleep study has been documented - Difficult airway may be suspected

Sleep Apnea and Surgery Intraoperative management - Because of their propensity for airway collapse, they are especially susceptible to the respiratory effects of sedatives, opioids, and inhalational anesthetics - Consider local, regional, or neuraxial anesthesia techniques, if possible - Should be monitored by capnography - Consider using CPAP or other devices - General anesthesia with endotracheal tube is preferred over deep sedation - Extubate while awake - Full reversal should be documented - If possible, extubate in non-supine position

Sleep Apnea and Surgery Post-operative Management - Try to avoid systemic opioid use - If PCA is to be used, avoid basal rate - Multi-modal pain management is encouraged - Be careful with sedative medications - Supplemental oxygen should be administered - Encourage CPAP use - Continuous pulse oximeter use

Sleep Apnea and Surgery Criteria for discharge to unmonitored settings: - Once they are no longer at risk of postoperative respiratory depression - May take twice as long for discharge - Observe patients in an unstimulating environment, preferably while a sleep, to assess adequate oxygen saturation levels with room air

Sleep Apnea Lifestyle modifications (e.g. weight loss and regular sleep) Avoid alcohol and certain medications Special pillows/beds Mandibular advancement devices (e.g. dental gum and mouth guard) Mechanical therapy (e.g. CPAP and BiPAP) Surgery (e.g. Stimulator implants, UPPP and tonsillectomy)

Sleep Apnea How do we diagnose OSA? Why do we need to know if the patients have/do not have OSA? What can happen to the patients with OSA? How do we care for these patients? What should be monitored? Can we send these patients home?

The End