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Perioperative
Screening in Sleep
Apnea Patients
Marietta Bellamy Bibbs, BA,
RPSGT
Morton Plant Mease Healthcare
Clearwater, FL
Presentation Content
Undiagnosed
OSA Statistics
Consequences
of Untreated
OSA
Identifying
the At-Risk
Patient
The Surgical
Patient
Postoperative
catastrophes
Screening
Tools and
Preventive
Measures
Untreated Obstructive
Sleep Apnea
Risk of Dying
Population Percentage
Percent Undiagnosed
Predisposing
Characteristics
Clinical Signs and
Symptoms
BMI
BMI 35
35 kg/m2
kg/m2
Pediatric
patients
95
percentile
Pediatric patients 95 percentile for
for age
age and
and gender
gender
Hypertension
Hypertension (difficult
(difficult to
to
manage
and
manage and treat)
treat)
th
th
Large
(>17 inches
Large Neck
Neck (>17
inches in
in men
men and
and >16
>16
inches
inches in
in women
women
Tonsils
Tonsils nearly
nearly touching
touching or
or
touching
touching in
in the
the midline
midline
Craniofacial
Craniofacial abnormalities
abnormalities
Anatomical
Frequent
Anatomical Nasal
Nasal Obstruction
Obstruction
Frequent and
and Loud
Loud Snoring
Snoring
Awakens
Awakens with
with choking
choking sensation
sensation
from
from sleep
sleep
Frequent
Frequent arousals
arousals
from
from sleep
sleep
Excessive
Excessive
Sleepiness
Excessive sleepiness
sleepiness or
or fatigue
fatigue despite
despite
adequate
adequate sleep
sleep
Pauses
Pauses in
in breathing
breathing during
during sleep
sleep
Restless
Restless sleep,
sleep, difficulty
difficulty breathing
breathing
or
increased
respiratory
or increased respiratory effort
effort
during
during sleep
sleep
Falls
Falls asleep
asleep easily
easily in
in sedentary
sedentary (non(nonstimulating)
situations
stimulating) situations
Parent
Parent or
or teacher
teacher notes
notes child
child is
is sleepy
sleepy during
during day,
day, easily
easily distracted
distracted and
and overly
overly
aggressive
and
difficulty
concentrating
aggressive and difficulty concentrating
Child
Child is
is difficult
difficult to
to arouse
arouse at
at usual
usual awakening
awakening
time
time
Prevalence of OSA
18 -20 million adults suffer from
symptomatic OSA or severe asymptomatic
OSA
It is estimated that 90% of those suffering
from OSA are still undiagnosed and
untreated
4% of the US population affected
Frequently goes unrecognized and
undiagnosed in the medical community
Affects all aspects of life
OSA patients have a higher risk of postoperative complications
Healthcare Utilization
and OSA
Healthcare Utilization
A Canadian study on a targeted group
of OSA patients revealed that they:
used 25-50% more medical resources in
the 5 years prior to diagnosis
had more physician office visits
spent more nights in the hospital
Had higher physician costs than matched
controls
Risk Factors
Obesity
Enlarged adenoids, tonsils, and soft
palate tissues including large uvula,
low lying soft palate and excessive
pharyngeal tissue
Jaw malformations
Large tongue
Common Symptoms
Snoring
Waking up from
snoring
Witnessed apnea
Frequent nocturnal
awakenings
Sleep maintenance
insomnia
Waking unrefreshed
in the mornings or
following naps
Commonly
Recognized
Symptoms
Waking up choking,
short of breath or
gasping for breath
Excessive daytime
sleepiness
Chronic
fatigue/tiredness
Falling asleep or
nodding off at
inappropriate times
Unrecogniz
ed
Symptoms
Nighttime
sweating
Nighttime GE
reflux
Automatic
behaviors
Sleep
drunkenness
OSA Complications
Hypertension
Untreated OSA is
associated with
hypertension in 40 % of
patients
30 % of patients with
idiopathic hypertension
have OSAS
OSA Complications
Heart attacks
Stroke
Type 2 Diabetes Mellitus
The Importance of
Screening for
Obstructive Sleep
Apnea Prior to
Surgery
Patient Safety
OSA patients have a higher rate of
Difficult Intubation
Difficult Extubation
Hypercapnia
Oxygen desaturations
Cardiac insults
Anesthesiologists know
the Dangers
American Society
of Anesthesiology
published
guidelines
recommending
that patients
should be
screened for OSA
before surgery.
Goal:
Identify patients
undiagnosed OSA
patients prior to surgery.
Diagnose and treat prior
to surgery when
possible.
If unable to diagnose
prior to surgery, treat
patients as if they have
documented OSA in
order to avoid
Starting a Perioperative
Program
Questions for
Anesthesiologists
Perioperative Program
GoalFocused
Patient
Approach
3. Status unknown
Additional Surgical
Risk Factors
Why Perioperative
OSA Safety?
OSA is a major risk factor for perioperative adverse
events; however, no screening tool for OSA has
been validated specifically in surgical patients.
If you think someone might have sleep apnea, you
might not be correct. You cannot always pick out
OSA patients by looking at them.
The American Society of Anesthesiologists
screening guidelines recommend that OSA
screening should be done on every patient.
Perioperative Complications
Factors in OSA that could increase
perioperative complications:
Anatomical imbalance
Lung volume reduction (decreased FRC
and ERV)
Sympathetic nervous system activation
Ventilatory instability
Present
a
Sample
Case
Needs Assessment
Case #1:
A 40-year old male with history of mobid obesity
and prior laparoscopic cholecystectomy and
nephrolithiasis presented to the hospital for an
incisional hernia repair. He was noted to have a
difficult airway preoperatively, but was intubated
with a glide scope without difficulty and was
ventilated fairly easily through surgery.
Postoperatively the patient was extubated and it
was noted that he would drop his oxygen saturation
down into the 40% or less range, even with nasal
and high-flow mask O2. His baseline oxygen range
was 80% or less when awake. The patient was
reportedly aware of a diagnosis of obstructive sleep
Case 1 (Continued)
The Anesthesiologist became
concerned about releasing the patient
home with witnessed severe O2
desats.
This resulted in the patient being
admitted to the ICU with plans to
titrate him on the Vision BiPAP.
Pulmonary consult was ordered with
resulting impression that the patient
had severe obstructive sleep apnea
Case 1 (continued)
Patient was immediately placed on empirical
BiPAP settings in the ICU at pressures of
12/4 cmH2O (IPAP/EPAP). The consulting
Pulmonologist scheduled an emergency
sleep study on the patient which was
performed the next day as a split-night
procedure.
The diagnostic portion of the sleep study
confirmed sleep apnea with AHI of 115
events per hour, SpO2 nadir of 51% and
average SpO2 of 69% in absence of REM or
slow wave sleep.
Results
The patient failed CPAP and was changed to
Screening Tools
The Sleep
The STOP and
Apnea Clinical STOP-BANG
Score (SACS) Questionnaire
The ASA
Checklist
The Berlin
Questionnaire
33% -High
Risk
27% high
28% high
risk
risk
No significant difference in the questionnaires
ability to identify
patients with OSA)
Category 2
3 questions on tiredness and
fatigue
Category positive if score two
or more points
Category 3
positive if HTN or BMI > 30
kg/m2
High Risk
2 or more categories
positive
Low Risk
0-1 categories
positive
Sensitivity 0.89
Specificity 0.71
Netzer NC et al. Ann Internal Med 1999;
131:485-491
Four questions
combined with body
mass index, age, neck
size, and gender.
A high sensitivity,
especially for patients
with moderate to
severe OSA.
Two positive
questions on the STOP
indicates that the
patient may be at high
Discharge
(longitudinal
evaluation
and care)
Monitoring
(keeping the
patient safe)
Perioperative
Screening
(Identification
)
Clinical Management
Strategy
Clinical Management
Protocol
OSA
OSA focused
focused
history
history and
and
physical
physical
examination
examination
Perioperative
Perioperative
Screening
Screening
tool
tool (STOP(STOPBANG,
BANG, Berlin
Berlin
or
or ASA)
ASA)
Low
Low Risk
Risk for
for
OSA
OSA
Proceed
Proceed with
with
surgery
surgery
utilizing
utilizing usual
usual
perioperative
perioperative
care
care
High
High Risk
Risk for
for
OSA
OSA
Identify
Identify
Patient
Patient with
with
wrist
wrist alert
alert
band
band
Patient with
diagnosed
OSA
Intraoperative
Management in the
OSA Patient
Consider using regional anesthetic or peripheral nerve block with
minimal sedation
Postoperative Anesthesia
Recovery Management of
the OSA Patient
Focused attention to oxygen saturation and
hemodynamics in recovery
High
High Risk
Risk of
of OSA
OSA or
or known
known OSA
OSA and
and non-compliant
non-compliant prepreoperatively
or
known
OSA
but
PAP
pressures
unknown
operatively or known OSA but PAP pressures unknown
Date:
*Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D, Santhira
Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C.,
Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea.
Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc. 1
Make it Easy
PAT Scripting for Nurses:
Ensure Follow-up
Date:
Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D,
Santhira Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro,
F.R.C.P.C., Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea.
Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc.1
1