1. 1 Reducing Risk/Liability Perioperative Program Aspects of OSA Reducing Risk/Liability While Enhancing Revenues Peter Allen, BS, RRT-NPS-SDS, RST, RPSGT

2. 2 Conflicts of Interest Philips Respironics ResMed Corp DeVilbiss Fisher & Paykel Healthcare MVAP Natus Main Line Health System

3. 3 Questions for Attendees How many Home Care How many Hospital RTs How many Hospital owned Sleep Center How many Private owned Sleep Center How many are directly involved with a Perioperative OSA Mangement Program

4. 4 Goals Brief Overview of Perioperative Aspects Review my Research of the Field Discussion of Attendees Experiences Case Histories Solutions One or Two Ideas for Each Attendee

5. 5 Learning Objectives Identification of the “At Risk” Patient Review of Adverse Outcomes Tools Why, Who, Where, What, How Supporting Perioperative Management Raising Questions for Discussion

6. 6 Why Perioperative Management? At Risk Population is Growing More Post-Op Complications Respiratory Failure Re-Intubation Unexpected ICU Admissions Increased PACU Time Increased Suffering/Liability/Cost

7. 7 Raising Questions How often do you see respiratory emergencies in the hospital? How many could OSA have been factor? Unexpected Deaths in the PACU Unexpected Deaths 24 hrs after Surgery Within one week of Surgery?

8. 8 Payment for Performance Value-Based Purchasing Rewards Disincentives Quality-Payment Alignment http://www.ahrq.gov/qual/qpayment.htm http://www.ahrq.gov/qual/qpayment.htm Implementation Timelines http://healthreform.kff.org/timeline.aspx http://healthreform.kff.org/timeline.aspx

9. 9 American Society of Anesthesiologists 2006 Commissioned a Task Force that Identified the Importance of Pre-Screening surgery patients for the presence of Obstructive Sleep Apnea (OSA). Purpose: Prevent Post-Surgical Respiratory Events Anesthesiology 2006; 104:1081-93

10. 10 2008 National Patient Safety Goals Proposed Goal 17 from Task Force Reduce Risk of Post-Operative Complications for Patients with Obstructive Sleep Apnea Organization screens potential OSA patients prior to surgical procedures involving centrally acting anesthetic and/or analgesic agents.

11. 11 Epidemiology of OSA It is estimated that 75% to 95% of patients with OSA are not yet diagnosed. Many who are diagnosed are not being treated effectively. Body Mass Index>30 Estimates are that 26% of Adults are at Risk 80%-Bariatric/60%-Diabetic/40%-CHF

12. 12 Pathophysiology of OSA Awake: Airway Patent/Neuromuscular Compensation Sleep Onset Neuromuscular compensation is lost Airway Collapses Apnea Occurs Hypoxia & Hypercapnia ensue Ventilatory effort increases Arousal from sleep Pharyngeal muscle tone increases Patent airway restored Hypoxia and Hypercapnia improved by hyperventilation

13. 13 OSA Increasing Obesity is increasing at epidemic proportions which is only adding to the problem of increasing numbers of at risk patients presenting for surgery. Obesity Maps

14. 14 Associated OSA Conditions Obesity Hypertension Depression Coronary Artery Disease Accidents Arrhythmias Diabetes Left side heart enlargement GERD LV Dysfunction Stroke Congestive Heart Failure(CHF)

15. 15 Anesthesia Concerns with OSA OSA patients are more susceptible to airway collapse without anesthesia. OSA can affect all three phases of perioperative period. Anesthesiologists role in identification of the at risk OSA patient. Upper airway dilator muscles impaired. Effect may last for hours Eikermann, et. Al., AmJRespirCritCareMed 2007 175:9-15

16. 16 Anesthesia Impairs airway patency Increases difficulty of intubation Brain response less effective Narcotics decrease sensitivity to CO2 Respiratory drive/rate depressed Anesthetic gases almost eliminate hypoxic drive in most all patients.

17. 17 Anesthesia Upper airway muscle tone reduced with opiates, sedatives and volatile agents. Perpheral control of O2 inhibited Recovery rooms Local and regional nerve block options Malampatti Scores 1-4 Patients encouraged to bring PAP

18. 18 Anesthesia Unexpected Risks during Administration of Conscious Sedation: Previously Undiagnosed Obstructive Sleep Apnea Annals of Internal Medicine, 2003;139: 707-708 Pressman, et. Al.

19. 19 Case Reports 1of 6 Male 65 years of age-Radical prostatectomy History showed Positive OSA Profile Not diagnosed/treated Morphine 5 mg, epidural 8 hours later found unresponsive Apneic with Cyanosis Patient recovered

20. 20 Case Report 2 of 6 Male 38 years of age-Emergent mastoidectomy History of loud snoring Diagnosed with OSA, but never treated Upon extubation patient airway collapses Reintubated

21. 21 Case Report 3 of 6 Male 41 years of age-Orthopedic surgery Diagnosed, but not treated Epidural opiods Post-op day 2 found unresponsive Irregular respiratory pattern Cardiac arrest lead to death

22. 22 Case Report 4 of 6 Female 42 years of age-Laproscopic surgery Diagnosed with OSA, but not treated Post-op prolonged heart block during sleep

23. 23 Case Report 5 of 6 Obese male, 42 years of age-Surgery Diagnosed with OSA, not treated IM Morphine Cardiac arrest Severe hypoxia followed by cerebral silence

24. 24 Case Report 6 of 6 101 OSA patients and 101 matched controls Hip & knee surgery OSA patients diagnosis prior to or after surgery Controls did not get PSG-???? Post-op complications greater in OSA patients Hospital reported longer stays for OSA group Hospital reported more ICU transfers/OSA pts.

25. 25 OSA – Diagnosis Clinical examination(history and physicial examination) carries a diagnostic sensitivity and specificity of only 50 to 60% even when performed by experienced sleep physicians Clinics oF Chest Med 1998; 19:1-19 If it walks like, talks like, looks like a …. Its OSA

26. 26 Preoperative screening for OSA Stop Bang Questionaire with H&P Preoperative diagnosis Referral to sleep disorder center Preoperative treatment if possible PAP Treatment prior to surgery PAP Treatment documented prior to surgery

27. 27 Identifying the Problem

28. 28 Stop-Bang Stop-Bang Stop-Bang 1. Do you Snore loudly? 2. Do you often feel Tired during the daytime? 3. Has anyone Observed you stop breathing during your sleep? 4. Do you have or are you being treated for high blood Pressure? Stop 5. BMI more than 35 kg/m ? 6. Age over 50? 7. Neck circumference greater than 40cm? 8. Gender male? Bang High Risk of OSA=Yes to 3 or more items Low Risk of OSA= Yes to less than 3 items

29. 29 American Society of Anesthesiology Recommendations Anesthesiologists need to work with Surgeons Develop Protocols Get suspected OSA patients diagnosed and treated prior to surgery whenever possible If diagnosis of OSA is made on the day of the surgery, then patient and family needs to be informed of the potential implications of OSA on the perioperative course.

30. 30 ASA Recommendations Continued Be prepared for difficult intubation Choice of anesthetic technique Oximetry and end-tidal CO2 monitoring Full reversal of neuromuscular blocking agents Consider non-supine extubation w awake patient General anesthesia preferable to deep sedation Spinal epidural considerations vs IV Use of opioids vs regional anesthesia Discharge delay a consideration

31. 31 Perioperative Program Awareness Contact these areas all at the same time All medical staff members Grand Rounds Presentations Lunch and Learn AMA CEUs Community Outreach Programs Allied Healthcare Staff Home Care Companies Manufacturers Implement Outcome Tracking Protocols

32. 32 Perioperative Management of OSA, Budget Questions to Ask: What is it going to cost to implement or to increase awareness? What will it cost if we do not implement or promote?

33. 33 Hospital Implications At risk patients not served Safety Hospital revenue Hospital reputation Hospital recognition Physician revenues Surgical Risk Liability and Schedules

34. 34 HME Considerations Perioperative program will: Drive PAP business higher Drive O2 business higher Increase your referral base Improved relations with area medical and surgi-centers

35. 35 Sleep Disorder Centers Additional Revenue Increase Referral Base Reinforces the fact that to survive sleep disorder centers need to diversify/change their sales and marketing focus on more complex patients and new opportunities.

36. 36 Working Together Primary Care Physicians Surgeons Anesthesiologists Allied Health, Nursing, Respiratory Care Sleep Disorder Centers Home Care Companies Hospital Administration

37. 37 Helpful Organizations American Society of Anesthesiology ASA Society of Anesthesia & Sleep Medicine SASM American College of Chest Physicians ACCP American Academy of Sleep Medicine AASM

38. 38 Summary Patients with OSA Make up a significant portion of the surgical population and will only increase as obesity trends move upward. Most are not identified before surgery Have an increased risk for perioperative complications Can be screened diagnosed and treated to manage perioperatively to reduce risks. Programs can be implemented to identify and treat these patients without substantial increases in costs, resulting in risk reduction, improved patient safety and better outcomes.

39. 39 Sources Stop Bang Questionaire, Anesthesiology, V 108, No 5 May Chung, et al. Anesthesiolgy News Guide to Airway mangement-Obstructive Sleep Apnea Anesthesia, and Ambulatory Surgery, Bishop, et. al Perioperative Screening for and Mangement of Patients with Obstructive sleep Apnea-Beth Israel Deaconess Medical Center, Boston, MA, Sundar, et. al Avoiding adverse outcomes in patients with obstructive sleep apnea(OSA); development and implementation of a perioperative OSA protocol, Bolde, et. al. Postoperative Complications in Patients With Obstructive Sleep Apnea, CHEST 2012; 141;436-44, Kaw, et. Al. Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature, Journal of Clinical Medicine, Vol. 8, NO. 2 2012, Vasu, et. Al Postoperative Complications in Patients with Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study 2001 Mayo Foundation, Mayo Clin Proc. 2001;76:897-905 Gupta, et.al.

40. 40 petersleep@comcast.net