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10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
https://t.me/medicina_free
Sleep consult submitted
Oximetry/ABG obtained
Call requesting service
What’s the issue?
Previous evaluation?
Discharge pending?
Patient refusing CPAP?
203
Follow-up as outpatient:
Sleep lab or home study
Sleep lan follow-up:
Outpatient return visit
scheduled
*Criteria
1. Bad overnight oxygenation
• 4% desaturation index > 20
• Saturation ≤ 75% or
• Mean saturation ≤ 88% or
• Saturation ≤ 90% ≥ 15% of study
2. Or coronary artery disease+
3. Or congestive heart failure+
4. Or arrhythmia
5. Or reason to delay PSG
Patient agrees
APAP (min/max 4/20 cm H
• Heated humidification
• Repeat oximetry on APAP
• If initial oximetry on O
• If initial oximetry on room ari, then APAP alone
BPAP for Paco
Heated humidification (1 or 2 setting)
Oxygen decided as above
Setting per ICU or previous use
Continue CPAP/BPAP
• Order standard fixed
CPAP, set at > 95%
time pressure off
• Download data
Discharge from hospital
Follow-up PSG scheduled
(No home CPAP)
> 50 mm Hg or pH < 7.35
2
Dowload
APAP and
oximetry
O)
2
then APAP on O
2
Patient non-adherent
or refuses to continus:
• Why?
Continue CPAP (prescription given)
with follow-up PSG scheduled in sleep lab
2
Perform consultation: based
on oximetry, comorbidities,
converience (eg, paraplegic)
Begin empirical CPAP/BPAP*:
Unit: start BPAP
Ward: CPAP, continue BPAP
Contact respiratory therapy
New CPAP introduction?
Auto-adjusting PAP
• Introduction: before 4 pm
• Fit with mask and pillows
• Assess patient’s willingness
Respiratory therapy
contacts sleep service
Patient intolerent
RT records why?
• Mask discomfort
• Pressure
• Claustrophobia
• Refusal
Sleep Service contacts
primary service:
• Recommend bed elevation
and avoid back position
• Minimize narcotics,
sedatives
• Follow-up scheduled in
sleep lab
Supplemental oxygen
Polysomnogram now: either
portable in-hospital (because
of medical issues) or in sleep
lab (bed availability)
Fig. 10.3 Obstructive apnea systematic intervention strategy (OASIS) for assessing postoperative
or medical patients for sleep-disordered breathing, with follow-through management algorithm
based on patients’ PAP willingness. ABG Arterial blood gas, CPAP continuous PAP, BPAP bi-level
PAP, PSG polysomnography, APAP auto-adjusting PAP, PSG polysomnography, RT respiratory
therapy. (Adapted from [107])
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pressure need may need to be titrated to meet the uctuating needs of the postoperative patient and to accommodate for increased time in the supine position, thoracic
pain, postoperative distortions in sleep architecture, and CNS depressant medications. Sleep-related breathing disturbances are typically the highest on the third
night postoperatively, likely due to “REM rebound,” or increased proportion of
REM sleep after the distortion in sleep architecture, (with decreased sleep efciency, slow wave sleep and REM sleep) which typically accompanies postoperative night one [110]. This uctuating severity of sleep disordered breathing in the
postoperative period reinforces the concept that PAP needs may also vary and
patients should be continuously monitored, and PAP adjusted appropriately. For
patients who do not have a prior pressure setting, use of APAP or manual bedside
titration may be more appropriate [111].
In those for which inpatient PAP initiation is desired, early assessment (prior to
4 p.m.) by the respiratory therapist mask t and patient willingness is recommended. Once PAP is initiated, close follow-up is needed to assess patient tolerance. In the case of intolerance, troubleshooting may be attempted, including mask
t, pressure setting, addressing claustrophobia, and assessing if the treatment aligns
with the patient’s wishes and values. Upon discharge, the patient may need a formal
sleep evaluation in the outpatient setting if continuation of PAP therapy is desired.
In certain institutions, the patient may be qualied for PAP therapy in the inpatient
setting and discharged with a prescription and routine sleep medicine follow up.
The recommended follow through of inpatient PAP initiation is outlined in the bottom half of Fig.10.3.
As there are no universal guidelines for discharge into an unmonitored setting,
patients with known or suspected OSA should be discharged at the discretion of the
inpatient care team when they are able to maintain oxygen saturation on room air
[3], taking into account severity of OSA, type of surgery performed, and postoperative course (Fig.10.2). Ambulatory surgical centers managing OSA patients should
have transfer agreements to inpatient facilities and should be equipped to manage
contingencies associated with OSA.
K. L. Dupuy-McCauley et al.
Positive Airway Pressure andPostoperative Risk Reduction
No consensus has emerged regarding the ability of PAP to reduce cardiopulmonary
complications in patients with OSA.It is difcult to assess this body of literature as
a whole due to its heterogeneous characteristics when it comes to the timing of PAP
initiation (i.e., was PAP used in the preoperative period leading up to surgery vs.
implementation during hospital admission), and low PAP compliance. Low PAP
compliance has been a consistent hinderance to assessing OSA outcomes associated
with PAP use in general, and PAP use tends to be even lower in the perioperative
period [112]. Nagappa and colleagues performed a systematic review and metaanalysis of the existing studies on outcomes in OSA patients undergoing surgery.
They examined six studies of 904 patients and found that use of perioperative CPAP
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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205
did not decrease postoperative complications but it did lower the AHI and provided
a trend toward decrease length of hospital stay [62]. A large cohort study by Mutter
etal. deduced that CPAP decreased cardiovascular complications by demonstrating
increased risk in patients who had undiagnosed OSA (versus diagnosed OSA), and
patients who had a preoperative diagnosis of OSA and a CPAP prescription [40]. A
smaller retrospective case–control study suggested that despite CPAP use being low
in general, those who had been using CPAP prior to admission were at less risk of
serious postoperative complications, total ICU length-of-stay, unplanned ICU
admission, and length of hospital stay [35].
More recently, a large retrospective database study of over 28,000 patients was
performed to assess differences in postoperative outcomes between those with previously diagnosed OSA and preoperatively suspected OSA.The rate of adverse
perioperative outcomes (reintubation, mechanical ventilation, direct ICU admission
after surgery, prolonged hospital length-of-stay, and all-cause 30-day mortality) was
higher in those with suspected OSA after adjusting for potential confounders. But a
subgroup analysis did not nd any link between those who were diagnosed with
OSA and compliant with CPAP versus those who were diagnosed and who were not
compliant with CPAP, suggesting that PAP may not inuence postoperative outcomes. However, this was based on self-reported PAP compliance, which can be
inaccurate [113].
A review of perioperative CPAP use by Chung and colleagues highlighted several studies examining the perioperative benets of CPAP and while some of the
case series and cohort studies showed benets from CPAP including decreased
postoperative complications, and decreased length of hospital admission and ICU
stay, the two RCTs did not show the same benet [114].
The bariatric population offers an exceptional opportunity to study CPAP-related
postoperative outcomes due to the high prevalence of OSA.A retrospective study of
53 patients undergoing bariatric surgery found no differences in postoperative complications, or hospital length of stay; however, similar to other literature on the
subject, there were signicant limitations including retrospective nature of the
study, small sample size, use of oxygen desaturation index from pulse oximetry to
dene OSA presence and severity, and lack of CPAP adherence data [115].
Additionally, all patients with moderate-to-severe OSA were treated with CPAP,
which may be a major confounder, being that other studies have shown varying
postoperative risk based upon severity of OSA [22].
Although many of the studies suggesting benet from perioperative CPAP use
have signicant limitations, they appear to be building the foundation of a body of
evidence that may eventually show denitive reduction in postoperative complications as a result of PAP use.
And looking beyond the OSA population, there are compelling RCTs in patients
without OSA that show a more conclusive postoperative PAP benet. A metaanalysis of 9 RCTs of abdominal surgery patients without OSA found that CPAP
reduced postoperative pulmonary complications when used perioperatively [116].
Similar benets have been shown when prophylactic CPAP is used after cardiothoracic surgery [117, 118].
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Although the data surrounding risk reduction afforded by CPAP in OSA patients
is inconclusive, it’s important to acknowledge the lack of large, prospective data,
and also to consider some of the roadblocks such as poor adherence that have limited this type of investigation. Therefore, it’s reasonable to consider the possibility
that we simply do not have all the information at this point in time to make a fair
assessment and it therefore may be reasonable to advocate for perioperative PAP
use in patients with OSA when possible.
K. L. Dupuy-McCauley et al.
Conclusion
While it is clear that patients with OSA are at increased risk of postoperative cardiopulmonary complications, there is less certainty when it comes to what perioperative interventions might mitigate these risks. Emphasis has been placed on
preoperative screening for suspect OSA and minimizing risk for known and suspected OSA patients by optimizing management of comorbidities and initiating
OSA treatment preoperatively. The better question to ask is not who has OSA but
who has an OSA phenotype that will result in postoperative complications. Our
institution his implemented in-hospital sleep consultative services in combination
with OASIS with a close follow-through protocol to aid workup and initial management of perioperative inpatients with suspected OSA.Many hospitals throughout
the country have adopted their own approaches in screening and monitoring suspected and known OSA patients perioperatively, and have developed in-hospital
sleep consultative services. But more evidence-based guidelines will need to be
established before there can be a single algorithm to manage patients within the
OSA population presenting for surgery.
OSA is a common entity and will likely continue to increase in prevalence in the
coming years. We must strive to develop best practices to manage and monitor
patients with OSA from the preoperative period to their discharge home from the
hospital with the aim of reducing unnecessary postoperative risk. By combining
preoperative screening, perioperative optimization of comorbidities, and identication of recurrent postoperative and PACU events, optimal risk identication,
prevention, and intervention strategies will hopefully be achieved as we pursue
more robust prospective outcomes data.
Summary of Key Points
• OSA is a common, chronic health condition associated with increased risk
of cardiopulmonary complications in the post-surgical period.
• Several organizations have developed recommendations for management
of patients with OSA presenting for surgery.
• Questionnaires have been validated for use in the preoperative setting to
assess for risk of OSA and provide an opportunity for sleep medicine referral if deemed necessary.
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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• When additional factors were included, the STOP-Bang Questionnaire had
the highest sensitivity in detecting those at risk for OSA, especially
moderate- to-severe disease.
• Algorithms developed to minimize perioperative risk in those with known
or suspected OSA consider the patients’ risk of suspected OSA, severity of
known OSA, type of surgery, comorbidities, and changes in OSA status.
• Early identication of patients with OSA may forewarn the clinician of
potential difculty with airway maintenance intra- and postoperatively,
perhaps inuencing choice of anesthetic/sedation/analgesia technique and
postoperative monitoring environment.
• We advocate an algorithm using recurrent PACU events as a predictive
indicator to guide postoperative disposition of the known or suspected
OSA patient.
• For those with previously undiagnosed but suspected OSA in the postoperative or medical inpatients setting, our institution has developed an
OASIS protocol.
• More prospective data is needed to guide recommendations for perioperative strategies to reduce postoperative risk in this patient population
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